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Disease Prevention and Health Promotion

How Integrative Medicine Fits
      As a discipline, preventive medicine has traditionally been described to encompass primary, secondary, and tertiary prevention. The fields of preventive medicine and public health share the objectives of promoting general health, preventing disease, and applying epidemiologic techniques to these goals. This paper discusses a conceptual approach between the overlap and potential synergies of integrative medicine principles and practices with preventive medicine in the context of these levels of prevention, acknowledging the relative deficiency of research on the effectiveness of practice-based integrative care. One goal of integrative medicine is to make the widest array of appropriate options available to patients, ultimately blurring the boundaries between conventional and complementary medicine. Both disciplines should be subject to rigorous scientific inquiry so that interventions that are efficacious and effective are systematically distinguished from those that are not. Furthermore, principles of preventive medicine can be infused into prevalent practices in complementary and integrative medicine, promoting public health in the context of more responsible practices. The case is made that an integrative preventive approach involves the responsible use of science with responsiveness to the needs of patients that persist when conclusive data are exhausted, providing a framework to make clinical decisions among integrative therapies.

      Introduction

      The dividing line between preventive medicine and public health practice is far from distinct, as is that between prevention and treatment. The purview of preventive medicine has traditionally been described to encompass primary, secondary, and tertiary prevention in the construct usually attributed to Leavell and Clark.
      • Leavell H.
      • Clark E.
      Textbook of Preventive Medicine.
      Others have expanded on this construct; quaternary prevention focuses on reducing overmedicalization and protecting patients from unnecessary or excessive invasive interventions,
      • Jamoulle M.
      Quaternary prevention, an answer of family doctors to overmedicalization.
      whereas primordial prevention focuses on the alteration of societal (i.e., environmental, economic, social, behavioral, cultural) structures that affect disease risk.

      Porta MS. International Epidemiological Association. A Dictionary of Epidemiology. 5th ed. Oxford: Oxford University Press; 2008.

      This paper discusses a conceptual approach between the overlap and potential synergies of integrative medicine and preventive medicine in the context of these levels of prevention, and represents an update of a prior paper on this topic commissioned by the then IOM (now National Academy of Medicine), and placed in the public domain.

      Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for IOM Summit on Integrative Medicine and the Health of the Public; February 2009.

      Integrative Medicine and Nomenclature

      Integrative medicine, a concept developed over the past few decades,
      • Jonas W.B.
      • Eisenberg D.
      • Hufford D.
      • Crawford C.
      The evolution of complementary and alternative medicine (CAM) in the USA over the last 20 years.
      refers to the fusion—by various means, and to varying degrees—of conventional medical practice and some of the practices that fall under the complementary and alternative medicine (CAM) rubric.
      • Jonas W.B.
      • Eisenberg D.
      • Hufford D.
      • Crawford C.
      The evolution of complementary and alternative medicine (CAM) in the USA over the last 20 years.

      National Center for Complementary and Integrative Health. Frequently asked questions: name change. https://nccih.nih.gov/news/name-change-faq. Published 2014.

      Integrative medicine thus offers, in theory at least, the opportunity to combine the “best” of the conventional healthcare system and practices and providers commonly considered to be CAM,
      • Ring M.
      • Brodsky M.
      • Low Dog T.
      • et al.
      Developing and implementing core competencies for integrative medicine fellowships.
      and thereby produce better outcomes, measured in terms of symptom relief, functional status, patient satisfaction, and perhaps cost effectiveness.
      • Herman P.M.
      • Poindexter B.L.
      • Witt C.M.
      • Eisenberg D.M.
      Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations.
      Integrative medicine is necessarily “holistic” in the sense that somatic, emotional, and spiritual health are considered integral to overall health.
      • Goldstein M.S.
      • Sutherland C.
      • Jaffe D.T.
      • Wilson J.
      Holistic physicians and family practitioners: similarities, differences and implications for health policy.
      These definitions are inherently problematic; what exactly comprises spiritual health, or whether this is the appropriate realm of the physician, is debated.
      • Luster L.
      • Hines B.
      Debate question: should physicians incorporate spirituality into the care of patients?.
      • Scheurich N.
      Reconsidering spirituality and medicine.
      Further, integrative medicine advocates are accused of creating a forced dichotomy between an idealized patient-centered biopsychosocial approach
      • Smith R.C.
      • Fortin A.H.
      • Dwamena F.
      • Frankel R.M.
      An evidence-based patient-centered method makes the biopsychosocial model scientific.
      incorporating CAM and “good conventional medicine.”
      • McLachlan J.C.
      Integrative medicine and the point of credulity.
      A rationale for integrative medicine depends largely on a rationale for CAM, as CAM tends to be the limiting element in efforts to advance integrative care.
      The term CAM is used to describe diverse medical practices not routinely taught in mainstream medical education.

      National Center for Complementary and Integrative Health. Frequently asked questions: name change. https://nccih.nih.gov/news/name-change-faq. Published 2014.

      “Alternative” denotes that such practices are defined by what they are not, and that they are exclusive of mainstream health care. “Complementary” implies that these practices are supplemental to conventional health care. The discrepancy in suggesting that such practices are both alternative and complementary to mainstream care has been noted.

      Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for IOM Summit on Integrative Medicine and the Health of the Public; February 2009.

      • Druss B.G.
      • Rosenheck R.A.
      Association between use of unconventional therapies and conventional medical services.
      • Katz D.L.
      Conventional medical care and unconventional therapies.
      Such challenges to the nomenclature notwithstanding, CAM has been the most widely used academic appellation, its primacy conveyed by its incorporation into the title of the NIH National Center for Complementary and Alternative Medicine, recently renamed to the National Center for Complementary and Integrative Health, acknowledging that pure “alternative medicine” is rare, and that “integrative” better conveys prevalent practice patterns.

      National Center for Complementary and Integrative Health. Frequently asked questions: name change. https://nccih.nih.gov/news/name-change-faq. Published 2014.

      Despite institutionalization of this terminology, this broad-based categorization overlooks necessary nuance. “CAM” and “integrative” thus encompass practices and practitioners inside and outside of the mainstream, as well as approaches rooted in historic or cultural contexts, unconventional diagnostics and diagnoses, new and untested approaches, and off-label use of conventional therapies. These terms also encompass therapies and approaches that have historically been embraced by CAM clinicians but are recently becoming mainstream (such as some mind–body therapies and interest in the human microbiome beyond gastrointestinal conditions).

      Hur KY, Lee MS. Gut microbiota and metabolic disorders. Diabetes Metab J. 2015;39(3):198–203. http://dx.doi.org/10.4093/dmj.2015.39.3.198.

      • Giorgetti G.
      • Brandimarte G.
      • Fabiocchi F.
      • et al.
      Interactions between innate immunity, microbiota, and probiotics.
      • Zhou L.
      • Foster J.A.
      Psychobiotics and the gut-brain axis: in the pursuit of happiness.
      Interest in and use of complementary health approaches has remained constant in recent years in adults
      • Clarke T.C.
      • Black L.I.
      • Stussman B.J.
      • Barnes P.M.
      • Nahin R.L.
      Trends in the use of complementary health approaches among adults: United States, 2002-2012.
      and children
      • Black L.I.
      • Clarke T.C.
      • Barnes P.M.
      • Stussman B.J.
      • Nahin R.L.
      Use of complementary health approaches among children aged 4-17 years in the United States: National Health Interview Survey, 2007-2012.
      after a rise in use between 1990 and 1997.
      • Eisenberg D.M.
      • Davis R.B.
      • Ettner S.L.
      • et al.
      Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey.
      One third of the adult population
      • Clarke T.C.
      • Black L.I.
      • Stussman B.J.
      • Barnes P.M.
      • Nahin R.L.
      Trends in the use of complementary health approaches among adults: United States, 2002-2012.
      and 12% of children
      • Black L.I.
      • Clarke T.C.
      • Barnes P.M.
      • Stussman B.J.
      • Nahin R.L.
      Use of complementary health approaches among children aged 4-17 years in the United States: National Health Interview Survey, 2007-2012.
      have used at least one CAM therapy. The majority of patients seek CAM approaches to complement rather than substitute for conventional care most often for pain and chronic musculoskeletal conditions.
      • Barnes P.M.
      • Bloom B.
      • Nahin R.L.
      Complementary and alternative medicine use among adults and children: United States, 2007.
      Americans spent an estimated $33.9 billion on CAM services in 2007.
      • Nahin R.L.
      • Barnes P.M.
      • Stussman B.J.
      • Bloom B.
      Costs of complementary and alternative medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007.
      The use of CAM is more prevalent among female, better-educated, higher-income populations
      • Eisenberg D.M.
      • Davis R.B.
      • Ettner S.L.
      • et al.
      Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey.
      • Barnes P.M.
      • Bloom B.
      • Nahin R.L.
      Complementary and alternative medicine use among adults and children: United States, 2007.
      with chronic and degenerative conditions.
      • Black L.I.
      • Clarke T.C.
      • Barnes P.M.
      • Stussman B.J.
      • Nahin R.L.
      Use of complementary health approaches among children aged 4-17 years in the United States: National Health Interview Survey, 2007-2012.
      • Barnes P.M.
      • Powell-Griner E.
      • McFann K.
      • Nahin R.L.
      Complementary and alternative medicine use among adults: United States, 2002.
      • Astin J.A.
      Why patients use alternative medicine: results of a national study.
      Predictors of CAM use include a holistic philosophical orientation to health and life, a chronic health condition, environmentalism, feminism, and an interest in spirituality and personal growth psychology.
      • Astin J.A.
      Why patients use alternative medicine: results of a national study.
      Other studies show a relationship to health-promoting lifestyle choices: Regular physical activity, infrequent to moderate alcohol consumption, and being a former smoker are associated with CAM use.
      • Nahin R.L.
      • Dahlhamer J.M.
      • Taylor B.L.
      • et al.
      Health behaviors and risk factors in those who use complementary and alternative medicine.
      Although research findings vary, common reasons that people choose CAM include dissatisfaction with conventional care; a desire to avoid side effects of conventional medicine and treatments; an interest in and greater knowledge of how nutritional, emotional, and lifestyle factors affect health; and a broader focus on disease prevention and overall health.
      • Eisenberg D.M.
      • Davis R.B.
      • Ettner S.L.
      • et al.
      Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey.
      • Barnes P.M.
      • Powell-Griner E.
      • McFann K.
      • Nahin R.L.
      Complementary and alternative medicine use among adults: United States, 2002.
      • Astin J.A.
      Why patients use alternative medicine: results of a national study.
      Despite prevalent CAM usage, fewer than 40% of CAM patients disclose this information to their mainstream physicians, indicating an important disconnect between patient preferences and comfort in sharing these views.
      • Eisenberg D.M.
      • Davis R.B.
      • Ettner S.L.
      • et al.
      Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey.
      • Astin J.A.
      Why patients use alternative medicine: results of a national study.
      • Eisenberg D.M.
      • Kessler R.C.
      • Foster C.
      • Norlock F.E.
      • Calkins D.R.
      • Delbanco T.L.
      Unconventional medicine in the United States. Prevalence, costs, and patterns of use.
      • Elder N.C.
      • Gillcrist A.
      • Minz R.
      Use of alternative health care by family practice patients.
      • Feldman M.K.
      Patients who seek unorthodox medical treatment.
      • McKee J.
      Holistic health and the critique of Western medicine.
      This salient deficiency in provider–patient communication
      • Elder N.C.
      • Gillcrist A.
      • Minz R.
      Use of alternative health care by family practice patients.
      • Feldman M.K.
      Patients who seek unorthodox medical treatment.
      • McKee J.
      Holistic health and the critique of Western medicine.
      might reflect mistrust, dissatisfaction with the conventional healthcare system,
      • Astin J.A.
      Why patients use alternative medicine: results of a national study.
      or a response to the perceived receptivity of conventional providers.

      Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for IOM Summit on Integrative Medicine and the Health of the Public; February 2009.

      Therefore, a case may be made to responsibly guide patients in CAM therapies based on interest and in accordance with scientific evidence. Because this guidance should by no means supplant conventional treatments, an argument for an integrative approach emerges: Patients should ideally receive expert guidance across the availability of treatments that may result in improved health.

      Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for IOM Summit on Integrative Medicine and the Health of the Public; February 2009.

      Integrative Medicine Across the Prevention Spectrum

      As behavioral and lifestyle choices account for the majority of premature mortality in the U.S.,
      • Mokdad A.H.
      • Marks J.S.
      • Stroup D.F.
      • Gerberding J.L.
      Actual causes of death in the United States, 2000.
      targeting these areas can potentially provide the greatest benefit. In 2010, the leading cause of death in the U.S. was tobacco use, which resulted in some 435,000 deaths, or 18.1% of total deaths. Closely following was diet and lack of physical activity, resulting in 400,000 deaths.
      • Mokdad A.H.
      • Marks J.S.
      • Stroup D.F.
      • Gerberding J.L.
      Actual causes of death in the United States, 2000.
      The following sections discuss the potential for integrative medicine across the prevention spectrum. By and large, the effectiveness of integrative approaches in health promotion or disease prevention is not fully elucidated; data derived from direct tests of integrative care models are promising but preliminary.
      • Johnson J.R.
      • Crespin D.J.
      • Griffin K.H.
      • Finch M.D.
      • Dusek J.A.
      Effects of integrative medicine on pain and anxiety among oncology inpatients.
      • Bradley R.
      • Sherman K.J.
      • Catz S.
      • et al.
      Adjunctive naturopathic care for type 2 diabetes: patient-reported and clinical outcomes after one year.
      • Johnson J.R.
      • Crespin D.J.
      • Griffin K.H.
      • et al.
      The effectiveness of integrative medicine interventions on pain and anxiety in cardiovascular inpatients: a practice-based research evaluation.
      • Szczurko O.
      • Cooley K.
      • Busse J.W.
      • et al.
      Naturopathic care for chronic low back pain: a randomized trial.

      Integrative Medicine in Primary Prevention

      Among the means to promote lifestyle change is modeling (i.e., being an exemplar of) healthy behavior, notably diet and physical activity. Physicians that practice healthy behaviors tend to emphasize these behaviors in patient care; consequently, patients of these physicians generally receive stronger, more pronounced, and more specific advice regarding lifestyle change.
      • Oberg E.B.
      • Frank E.
      Physicians’ health practices strongly influence patient health practices.
      • Maheux B.
      • Pineault R.
      • Lambert J.
      • Beland F.
      • Berthiaume M.
      Factors influencing physicians’ preventive practices.
      Physicians who exercise regularly are more likely to counsel their patients to do so; nonsmokers are more likely to emphasize the risks of smoking.
      • Frank E.
      • Kunovich-Frieze T.
      Physicians’ prevention counseling behaviors: current status and future directions.
      A number of integrative health organizations encourage members to model healthy lifestyle behaviors, including the Academy of Integrative Health & Medicine

      Academy of Integrative Health & Medicine. Academy Values. http://aihm.org/about/academy-values/. Published 2015.

      and the American Association of Naturopathic Physicians.
      • Hough H.
      • Dower C.
      • O’Neil E.
      Profile of a Profession: Naturopathic Practice.
      Among some integrative health educational institutions, a culture of wellness exists, where healthy food choices are readily (if not exclusively) available and faculty model healthy behaviors.
      Furthermore, a number of CAM whole systems consider dietary habits and therapeutic nutrition as a cornerstone of health, including Traditional Chinese Medicine,
      • Kaptchuk T.
      The Web That Has No Weaver: Understanding Chinese Medicine.
      Ayurveda,

      National Center for Complementary and Integrative Health. Ayurvedic Medicine: An Introduction. Bethesda, MD: USDHHS, NIH, National Center for Complementary and Alternative Medicine; 2013.

      Chopra A, Doiphode VV. Ayurvedic medicine. Core concept, therapeutic principles, and current relevance. Med Clin North Am. 2002;86(1):75–89, vii. http://dx.doi.org/10.1016/S0025-7125(03)00073-7.

      and naturopathy.
      • Hough H.
      • Dower C.
      • O’Neil E.
      Profile of a Profession: Naturopathic Practice.

      National Center for Complementary and Integrative Health. Naturopathy: An Introduction. https://nccih.nih.gov/health/naturopathy/naturopathyintro.htm. Published 2012.

      Some dietary guidance is consistent with current mainstream recommendations for chronic disease prevention,
      • Katz D.L.
      • Meller S.
      Can we say what diet is best for health?.
      whereas some traditional recommendations conflict.
      Challenges (and opportunities) also exist in synergizing primary prevention with integrative healthcare. A sizable proportion of patients oriented toward CAM tend to be skeptical of preventive interventions, especially childhood vaccination.
      • Benin A.L.
      • Wisler-Scher D.J.
      • Colson E.
      • Shapiro E.D.
      • Holmboe E.S.
      Qualitative analysis of mothers’ decision-making about vaccines for infants: the importance of trust.
      • Stokley S.
      • Cullen K.A.
      • Kennedy A.
      • Bardenheier B.H.
      Adult vaccination coverage levels among users of complementary/alternative medicine—results from the 2002 National Health Interview Survey (NHIS).
      Anti-vaccine views
      • Ali A.
      • Calabrese C.
      • Lee R.
      • Salmon D.
      • Zwickey H.
      Vaccination attitudes and education in naturopathic medicine students.
      and increases in vaccine-preventable illnesses are associated with care from CAM providers.
      • Downey L.
      • Tyree P.T.
      • Huebner C.E.
      • Lafferty W.E.
      Pediatric vaccination and vaccine-preventable disease acquisition: associations with care by complementary and alternative medicine providers.
      An evidence-based integrative approach in the context of “holistic prevention,” emphasizing the patient–provider relationship,

      Academic Consortium for Integrative Medicine & Health. About us. www.imconsortium.org/about/home.cfm. Published 2015.

      with a sympathetic understanding of parental concerns can potentially increase immunization rates in parents that would otherwise be mistrustful of more-conventional clinicians,
      • Benin A.L.
      • Wisler-Scher D.J.
      • Colson E.
      • Shapiro E.D.
      • Holmboe E.S.
      Qualitative analysis of mothers’ decision-making about vaccines for infants: the importance of trust.
      thus protecting public health in the context of providing care that is responsive to the needs of CAM-oriented patients.

      Secondary Prevention and Integrative Medicine

      Integrative medicine has the potential to improve rates of screening and uptake of preventive services through an emphasis on a strong therapeutic alliance, prevention, teaching, interprofessional, and holistic care.
      • Snyderman R.
      • Weil A.T.
      Integrative medicine: bringing medicine back to its roots.
      Nationally, screening rates for preventive services are considerably lower than ideal; much of the blame can be placed on lack of emphasis and training in health promotion and disease prevention as well as the burdens of a healthcare system that constrain primary care visits to suboptimal levels.
      • McGlynn E.A.
      • Asch S.M.
      • Adams J.
      • et al.
      The quality of health care delivered to adults in the United States.
      • Mangione-Smith R.
      • DeCristofaro A.H.
      • Setodji C.M.
      • et al.
      The quality of ambulatory care delivered to children in the United States.
      • Bodenheimer T.
      Coordinating care—a perilous journey through the health care system.
      Abbreviated primary care encounters, coupled with barriers to access, tend to compromise continuity of care as well.
      • Bodenheimer T.
      Coordinating care—a perilous journey through the health care system.
      As prevention and population health activities occur in almost all healthcare settings,
      • Zenzano T.
      • Allan J.D.
      • Bigley M.B.
      • et al.
      The roles of healthcare professionals in implementing clinical prevention and population health.
      clinicians can potentially improve screening rates and utilization of preventive services and enhancing risk-reduction efforts for chronic diseases with strong diet and lifestyle associations, namely, cardiovascular disease, diabetes, and certain cancers.
      • Ford E.S.
      • Bergmann M.M.
      • Kroger J.
      • Schienkiewitz A.
      • Weikert C.
      • Boeing H.
      Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study.
      Despite this potential, the authors are not aware of evidence of enhanced screening and preventive services in integrative medicine.
      Many CAM approaches have demonstrated promise in treating early disease or risk factors such as improving the lipid profile,
      • Nies L.K.
      • Cymbala A.A.
      • Kasten S.L.
      • Lamprecht D.G.
      • Olson K.L.
      Complementary and alternative therapies for the management of dyslipidemia.
      reducing inflammation,

      Kohatsu W. The antiinflammatory diet. In: Rakel DP, ed. Integrative Medicine. 3rd ed., Philadelphia, PA: Elsevier, 2012:795–802.

      controlling serum glucose, and reducing blood pressure.
      • Lee T.
      • Dugoua J.J.
      Nutritional supplements and their effect on glucose control.
      • Li G.Q.
      • Kam A.
      • Wong K.H.
      • et al.
      Herbal medicines for the management of diabetes.
      • Houston M.
      Nutrition and nutraceutical supplements for the treatment of hypertension: part I.
      • Yeh G.Y.
      • Eisenberg D.M.
      • Kaptchuk T.J.
      • Phillips R.S.
      Systematic review of herbs and dietary supplements for glycemic control in diabetes.
      • Brook R.D.
      • Jackson E.A.
      • Giorgini P.
      • McGowan C.L.
      When and how to recommend “alternative approaches” in the management of high blood pressure.
      By using these in combination with comprehensive lifestyle change, mind–body interventions, and mainstream preventive recommendations

      U.S. Preventive Services Task Force; Agency for Healthcare Research and Quality. The Guide to Clinical Preventive Services 2014: Recommendations of the U.S. Preventive Services Task Force. Rockville, MD: Agency for ealthcare Research and Quality; 2014.

      with a strong therapeutic alliance, the potential to improve outcomes rationally follows.
      In certain instances, an integrative approach can be used to enhance adherence with conventional therapies, such as using the nutritional supplement coenzyme Q10 to reduce statin-induced myopathy
      • Skarlovnik A.
      • Janic M.
      • Lunder M.
      • Turk M.
      • Sabovic M.
      Coenzyme Q10 supplementation decreases statin-related mild-to-moderate muscle symptoms: a randomized clinical study.
      (though other studies demonstrate a lack of benefit)
      • Taylor B.A.
      • Lorson L.
      • White C.M.
      • Thompson P.D.
      A randomized trial of coenzyme Q10 in patients with confirmed statin myopathy.
      ; probiotics to reduce antibiotic-associated diarrhea
      • Floch M.H.
      Recommendations for probiotic use in humans—a 2014 update.
      • McFarland L.V.
      Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease.
      • Johnston B.C.
      • Supina A.L.
      • Ospina M.
      • Vohra S.
      Probiotics for the prevention of pediatric antibiotic-associated diarrhea.
      ; licorice and its derivatives to potentiate the effects of cortisone
      • Teelucksingh S.
      • Mackie A.D.
      • Burt D.
      • McIntyre M.A.
      • Brett L.
      • Edwards C.R.
      Potentiation of hydrocortisone activity in skin by glycyrrhetinic acid.
      and reduce non-steroidal anti-inflammatory drug–associated gastropathy
      • Russell R.I.
      • Morgan R.J.
      • Nelson L.M.
      Studies on the protective effect of deglycyrrhinised liquorice against aspirin (ASA) and ASA plus bile acid-induced gastric mucosal damage, and ASA absorption in rats.
      ; and a variety of integrative approaches to improve quality of life and adverse effects associated with cancer chemotherapy.
      • Greenlee H.
      • Balneaves L.G.
      • Carlson L.E.
      • et al.
      Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer.

      Tertiary Prevention and Integrative Medicine

      Many lifestyle programs demonstrate effectiveness for tertiary prevention of cardiometabolic disease.
      • Ornish D.
      • Scherwitz L.W.
      • Billings J.H.
      • et al.
      Intensive lifestyle changes for reversal of coronary heart disease.
      • Knowler W.C.
      • Barrett-Connor E.
      • Fowler S.E.
      • et al.
      Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
      • de Lorgeril M.
      • Salen P.
      • Martin J.L.
      • Monjaud I.
      • Delaye J.
      • Mamelle N.
      Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study.
      Though aspects of such programs have now arguably been conventionalized (i.e., diet and lifestyle), the blending of lifestyle, dietary supplements, and mind–body interventions is certainly representative, if not diagnostic, of integrative care.

      Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for IOM Summit on Integrative Medicine and the Health of the Public; February 2009.

      Integrative healthcare approaches for chronic disease can improve functionality, reduce morbidity, improve quality of life, and directly influence disease processes. The quality of evidence for CAM therapies is mixed for treating chronic conditions with significant public health impact.

      Ward BW, Schiller JS. Prevalence of multiple chronic conditions among US adults: estimates from the National Health Interview Survey, 2010. Prev Chronic Dis. 2013;10:E65. http://dx.doi.org/10.5888/pcd10.120203.

      Nutritional supplements such as fish oil,
      • Hartweg J.
      • Perera R.
      • Montori V.
      • Dinneen S.
      • Neil H.A.
      • Farmer A.
      Omega-3 polyunsaturated fatty acids (PUFA) for type 2 diabetes mellitus.
      chromium,
      • Balk E.M.
      • Tatsioni A.
      • Lichtenstein A.H.
      • Lau J.
      • Pittas A.G.
      Effect of chromium supplementation on glucose metabolism and lipids: a systematic review of randomized controlled trials.
      alpha-lipoic acid,
      • Singh U.
      • Jialal I.
      Alpha-lipoic acid supplementation and diabetes.
      herbal medicines,
      • Bradley R.
      • Oberg E.B.
      • Calabrese C.
      • Standish L.J.
      Algorithm for complementary and alternative medicine practice and research in type 2 diabetes.
      and mind–body techniques
      • Kligler B.
      The role of the optimal healing environment in the care of patients with diabetes mellitus type II.
      have been used to treat Type 2 diabetes mellitus. Hyperlipidemia can be treated with therapeutic diets consisting of functional foods,
      • Becker D.J.
      • Gordon R.Y.
      • Morris P.B.
      • et al.
      Simvastatin vs therapeutic lifestyle changes and supplements: randomized primary prevention trial.
      • Jenkins D.J.
      • Kendall C.W.
      • Faulkner D.A.
      • et al.
      Assessment of the longer-term effects of a dietary portfolio of cholesterol-lowering foods in hypercholesterolemia.
      nutritional supplements, and herbal medicines.
      • Nies L.K.
      • Cymbala A.A.
      • Kasten S.L.
      • Lamprecht D.G.
      • Olson K.L.
      Complementary and alternative therapies for the management of dyslipidemia.
      Manual therapies such as massage can be useful for osteoarthritis,
      • Perlman A.I.
      • Sabina A.
      • Williams A.L.
      • Njike V.Y.
      • Katz D.L.
      Massage therapy for osteoarthritis of the knee: a randomized controlled trial.
      as well as acupuncture,
      • Berman B.M.
      • Lao L.
      • Langenberg P.
      • Lee W.L.
      • Gilpin A.M.
      • Hochberg M.C.
      Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial.
      and nutritional and herbal supplements.
      • Ernst E.
      Complementary or alternative therapies for osteoarthritis.
      An anti-inflammatory diet,

      Kohatsu W. The antiinflammatory diet. In: Rakel DP, ed. Integrative Medicine. 3rd ed., Philadelphia, PA: Elsevier, 2012:795–802.

      • Adam O.
      • Beringer C.
      • Kless T.
      • et al.
      Anti-inflammatory effects of a low arachidonic acid diet and fish oil in patients with rheumatoid arthritis.
      nutritional supplements, manual therapies, and other CAM therapies have shown promise in the management of rheumatoid arthritis.

      Muller D. Rheumatoid arthritis. In: Rakel DP, ed. Integrative Medicine. 3rd ed, Philadelphia, PA: Elsevier; 2012:456–463

      The public health impact of obesity and its related sequelae is unparalleled in the U.S., while the prevalence is quickly rising throughout the rest of the world.
      • Ng M.
      • Fleming T.
      • Robinson M.
      • et al.
      Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013.
      Integrative medicine has the potential to add to obesity prevention and control efforts by emphasizing nutrition, stress reduction,
      • O’Reilly G.A.
      • Cook L.
      • Spruijt-Metz D.
      • Black D.S.
      Mindfulness-based interventions for obesity-related eating behaviours: a literature review.
      and exercise.

      Nicolai J, Lupiani J, Wolf A. An integrative approach to obesity. In: Rakel DP, ed. Integrative Medicine. 3rd ed, Philadelphia, PA: Elsevier; 2012:364–375.

      There also tends to be an emphasis on dietary supplements, although the scientific evidence underlying such recommendations has long been suspect.
      • Vaughan R.A.
      • Conn C.A.
      • Mermier C.M.
      Effects of commercially available dietary supplements on resting energy expenditure: a brief report.

      Allison DB, Fontaine KR, Heshka S, Mentore JL, Heymsfield SB. Alternative treatments for weight loss: a critical review. Crit Rev Food Sci Nutr. 2001;41(1):1–28; discussion 39–40. http://dx.doi.org/10.1080/20014091091661.

      At least 13% of outpatient visits are attributable to medically unexplained symptoms
      • Ring A.
      • Dowrick C.F.
      • Humphris G.M.
      • Davies J.
      • Salmon P.
      The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms.
      • van der Weijden T.
      • van Velsen M.
      • Dinant G.J.
      van Hasselt CM, Grol R. Unexplained complaints in general practice: prevalence, patients’ expectations, and professionals’ test-ordering behavior.
      (also known as somatoform disorders) such as chronic fatigue syndrome, irritable bowel syndrome, fibromyalgia, chronic Lyme disease,
      • Ali A.
      • Vitulano L.
      • Lee R.
      • Weiss T.R.
      • Colson E.R.
      Experiences of patients identifying with chronic Lyme disease in the healthcare system: a qualitative study.
      and chronic unexplained pain,
      • Hatcher S.
      • Arroll B.
      Assessment and management of medically unexplained symptoms.
      which are often complicated by concurrent psychological distress and strong emotions.
      • Ali A.
      • Vitulano L.
      • Lee R.
      • Weiss T.R.
      • Colson E.R.
      Experiences of patients identifying with chronic Lyme disease in the healthcare system: a qualitative study.
      • McEwen B.S.
      Physiology and neurobiology of stress and adaptation: central role of the brain.
      Mainstream care for patients with these conditions is often frustrating, usually resulting in extensive diagnostic workups and significant iatrogenic complication rates.
      • Ring A.
      • Dowrick C.F.
      • Humphris G.M.
      • Davies J.
      • Salmon P.
      The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms.
      • Smith R.C.
      • Lein C.
      • Collins C.
      • et al.
      Treating patients with medically unexplained symptoms in primary care.
      In one study, a majority of primary care physicians described attitudes toward patients as negative and dismissing,
      • Salmon P.
      • Peters S.
      • Clifford R.
      • et al.
      Why do general practitioners decline training to improve management of medically unexplained symptoms?.
      and another study found substantial discordance between patient and physician treatment goals.
      • Nordin T.A.
      • Hartz A.J.
      • Noyes Jr, R.
      • et al.
      Empirically identified goals for the management of unexplained symptoms.
      As is true of many health conditions that are poorly understood and often resistant to conventional treatments, medically unexplained conditions often compel patients to seek CAM.
      • Ali A.
      • Vitulano L.
      • Lee R.
      • Weiss T.R.
      • Colson E.R.
      Experiences of patients identifying with chronic Lyme disease in the healthcare system: a qualitative study.
      • Pioro-Boisset M.
      • Esdaile J.M.
      • Fitzcharles M.A.
      Alternative medicine use in fibromyalgia syndrome.
      • Paterson C.
      • Taylor R.S.
      • Griffiths P.
      • et al.
      Acupuncture for “frequent attenders” with medically unexplained symptoms: a randomised controlled trial (CACTUS study).
      • Dimmock S.
      • Troughton P.
      • Bird H.
      Factors predisposing to the resort of complementary therapies in patients with fibromyalgia.
      • Sarac A.J.
      • Gur A.
      Complementary and alternative medical therapies in fibromyalgia.
      • Jones J.F.
      • Maloney E.M.
      • Boneva R.S.
      • Jones A.B.
      • Reeves W.C.
      Complementary and alternative medical therapy utilization by people with chronic fatiguing illnesses in the United States.
      The holistic nature of integrative care, with an emphasis on mind–body medicine, often results in recommendations incorporating psychological and somatic therapies.
      • Goldstein M.S.
      • Sutherland C.
      • Jaffe D.T.
      • Wilson J.
      Holistic physicians and family practitioners: similarities, differences and implications for health policy.
      • Ali A.
      • McCarthy P.L.
      Complementary and integrative methods in fibromyalgia.
      • Mist S.D.
      • Firestone K.A.
      • Jones K.D.
      Complementary and alternative exercise for fibromyalgia: a meta-analysis.
      CAM therapies for pain control vary in demonstrated efficacy, spanning mind–body therapies such as meditation
      • Goyal M.
      • Singh S.
      • Sibinga E.M.
      • et al.
      Meditation programs for psychological stress and well-being: a systematic review and meta-analysis.
      • Hsu M.C.
      • Schubiner H.
      • Lumley M.A.
      • Stracks J.S.
      • Clauw D.J.
      • Williams D.A.
      Sustained pain reduction through affective self-awareness in fibromyalgia: a randomized controlled trial.
      and biofeedback,
      • Morone N.E.
      • Greco C.M.
      Mind-body interventions for chronic pain in older adults: a structured review.
      to tai chi,
      • Wang C.
      • Schmid C.H.
      • Rones R.
      • et al.
      A randomized trial of tai chi for fibromyalgia.
      acupuncture, yoga, hypnosis, chiropractic, nutritional interventions,
      • Ali A.
      • Njike V.Y.
      • Northrup V.
      • et al.
      Intravenous micronutrient therapy (Myers’ Cocktail) for fibromyalgia: a placebo-controlled pilot study.
      herbal medicines, massage,
      • Perlman A.I.
      • Sabina A.
      • Williams A.L.
      • Njike V.Y.
      • Katz D.L.
      Massage therapy for osteoarthritis of the knee: a randomized controlled trial.
      or combinations thereof.
      • Little P.
      • Lewith G.
      • Webley F.
      • et al.
      Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain.
      In recent years, a number of whole-practice outcomes studies demonstrate benefit of integrative approaches, particularly in chronic pain,
      • Johnson J.R.
      • Crespin D.J.
      • Griffin K.H.
      • Finch M.D.
      • Dusek J.A.
      Effects of integrative medicine on pain and anxiety among oncology inpatients.
      • Johnson J.R.
      • Crespin D.J.
      • Griffin K.H.
      • et al.
      The effectiveness of integrative medicine interventions on pain and anxiety in cardiovascular inpatients: a practice-based research evaluation.
      • Szczurko O.
      • Cooley K.
      • Busse J.W.
      • et al.
      Naturopathic care for chronic low back pain: a randomized trial.
      • Abrams D.I.
      • Dolor R.
      • Roberts R.
      • et al.
      The BraveNet prospective observational study on integrative medicine treatment approaches for pain.
      • Ritenbaugh C.
      • Hammerschlag R.
      • Calabrese C.
      • et al.
      A pilot whole systems clinical trial of traditional Chinese medicine and naturopathic medicine for the treatment of temporomandibular disorders.
      • Sundberg T.
      • Petzold M.
      • Wandell P.
      • Ryden A.
      • Falkenberg T.
      Exploring integrative medicine for back and neck pain—a pragmatic randomised clinical pilot trial.
      Type 2 diabetes,
      • Bradley R.
      • Sherman K.J.
      • Catz S.
      • et al.
      Adjunctive naturopathic care for type 2 diabetes: patient-reported and clinical outcomes after one year.
      and cardiovascular risk markers.
      • Herman P.M.
      • Szczurko O.
      • Cooley K.
      • Seely D.
      A naturopathic approach to the prevention of cardiovascular disease: cost-effectiveness analysis of a pragmatic multi-worksite randomized clinical trial.
      These findings suggest public health benefits as well as possible cost savings.
      • Herman P.M.
      • Poindexter B.L.
      • Witt C.M.
      • Eisenberg D.M.
      Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations.
      • Herman P.M.
      • Szczurko O.
      • Cooley K.
      • Seely D.
      A naturopathic approach to the prevention of cardiovascular disease: cost-effectiveness analysis of a pragmatic multi-worksite randomized clinical trial.

      Stress and Mind–Body Medicine

      Integrative medicine tends to emphasize the importance of psychological stress and its impact on overall health.
      • Snyderman R.
      • Weil A.T.
      Integrative medicine: bringing medicine back to its roots.
      The evidence is robust and broad-based; psychological stress leads to poorer health outcomes—encompassing infectious and chronic disease, morbidity and mortality, and developing illness as well as recovery.
      • Schneiderman N.
      • Ironson G.
      • Siegel S.D.
      Stress and health: psychological, behavioral, and biological determinants.
      Psychological states can also be beneficial; the presence of “positive emotions” has been shown to predict better health and outcomes.
      • Ryff C.D.
      • Singer B.H.
      • Dienberg Love G.
      Positive health: connecting well-being with biology.
      • Kok B.E.
      • Coffey K.A.
      • Cohn M.A.
      • et al.
      How positive emotions build physical health: perceived positive social connections account for the upward spiral between positive emotions and vagal tone.
      • Giltay E.J.
      • Geleijnse J.M.
      • Zitman F.G.
      • Hoekstra T.
      • Schouten E.G.
      Dispositional optimism and all-cause and cardiovascular mortality in a prospective cohort of elderly dutch men and women.
      Personality aspects such as commitment to self, an attitude of concern for the environment, a sense of meaningfulness, and an internal locus of control are all associated with decreased illness in high-stress environments.
      • Kobasa S.C.
      Stressful life events, personality, and health: an inquiry into hardiness.
      Contextual factors and the therapeutic relationship are important factors in the overall effectiveness of a therapy, especially with subjective outcomes such as in chronic pain syndromes,
      • Miller F.G.
      • Colloca L.
      • Kaptchuk T.J.
      The placebo effect: illness and interpersonal healing.
      • Hauser W.
      • Sarzi-Puttini P.
      • Tolle T.R.
      • Wolfe F.
      Placebo and nocebo responses in randomised controlled trials of drugs applying for approval for fibromyalgia syndrome treatment: systematic review and meta-analysis.
      and perhaps stronger with CAM approaches associated with elaborate rituals and distinct contexts.
      • Finniss D.G.
      • Kaptchuk T.J.
      • Miller F.
      • Benedetti F.
      Biological, clinical, and ethical advances of placebo effects.
      There is an ethical imperative to provide therapeutic options that are safe and effective for symptomatic relief, with appropriate informed consent, without endorsing approaches that are unsafe or ineffective.
      • Cohen M.H.
      • Kemper K.J.
      • Stevens L.
      • Hashimoto D.
      • Gilmour J.
      Pediatric use of complementary therapies: ethical and policy choices.
      There is an emerging literature on the psychobiology of the placebo effect, with clinically significant effects demonstrated in a variety of contexts.
      • Finniss D.G.
      • Kaptchuk T.J.
      • Miller F.
      • Benedetti F.
      Biological, clinical, and ethical advances of placebo effects.
      • Kam-Hansen S.
      • Jakubowski M.
      • Kelley J.M.
      • et al.
      Altered placebo and drug labeling changes the outcome of episodic migraine attacks.
      • Kaptchuk T.J.
      • Miller F.G.
      Placebo effects in medicine.
      Intentional use of placebo in clinical practice is routine,
      • Tilburt J.C.
      • Emanuel E.J.
      • Kaptchuk T.J.
      • Curlin F.A.
      • Miller F.G.
      Prescribing "placebo treatments": results of national survey of US internists and rheumatologists.
      with complex ethical implications.
      • Finniss D.G.
      • Kaptchuk T.J.
      • Miller F.
      • Benedetti F.
      Biological, clinical, and ethical advances of placebo effects.
      Integrative medicine offers a framework that incorporates psychoemotional factors as integral to overall health with the resultant emphasis on mind–body therapies.

      National Center for Complementary and Integrative Health. Complementary, Alternative, or Integrative Health: What’s In a Name? Bethesda, MD: NCCIH; 2014.

      These factors are often perceived to be overlooked in conventional clinical practice and medical education,
      • Roter D.L.
      • Hall J.A.
      • Kern D.E.
      • Barker L.R.
      • Cole K.A.
      • Roca R.P.
      Improving physicians’ interviewing skills and reducing patients’ emotional distress. A randomized clinical trial.
      • Kligler B.
      • Maizes V.
      • Schachter S.
      • et al.
      Core competencies in integrative medicine for medical school curricula: a proposal.
      • Abbo E.D.
      • Zhang Q.
      • Zelder M.
      • Huang E.S.
      The increasing number of clinical items addressed during the time of adult primary care visits.
      • Teutsch C.
      Patient-doctor communication.
      or challenging to practically address in hurried medical visits resulting from financial constraints of the current health delivery system.
      • McGlynn E.A.
      • Asch S.M.
      • Adams J.
      • et al.
      The quality of health care delivered to adults in the United States.
      • Mangione-Smith R.
      • DeCristofaro A.H.
      • Setodji C.M.
      • et al.
      The quality of ambulatory care delivered to children in the United States.
      • Bodenheimer T.
      Coordinating care—a perilous journey through the health care system.

      Evidence and Integrative Medicine

      As integrative medicine often incorporates approaches outside of mainstream care where evidence is weak or speculative, a systematic method in addressing “unconventional therapies” is warranted.

      Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for IOM Summit on Integrative Medicine and the Health of the Public; February 2009.

      Where strong evidence supporting a particular approach exists, that should be recommended in preference to others. The more ambiguous it is as to which might be the most appropriate therapeutic choice, the more important it is to consider a hierarchy of evidence, incorporating safety, effectiveness, alternatives, and the evidence supporting each Tables 1 and 2). For some medically unexplained syndromes, such as fibromyalgia or chronic fatigue syndrome, a definitive therapy does not exist, and the best available treatments are those safe and possibly effective. Integrative medicine expands patient options at this end of the evidence hierarchy, where options are generally most needed. Any therapy that a patient refuses to use is ineffective, regardless of the evidence supporting its use.

      Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for IOM Summit on Integrative Medicine and the Health of the Public; February 2009.

      A common framework to assess the clinical appropriateness of a particular CAM intervention has been published in multiple venues.
      • Cohen M.H.
      • Kemper K.J.
      • Stevens L.
      • Hashimoto D.
      • Gilmour J.
      Pediatric use of complementary therapies: ethical and policy choices.

      Deng G, Weber W, Sood A, Kemper K. Integrative medicine research: context and priorities. Commissioned paper for the IOM Summit on Integrative Medicine and the Health of the Public; February 2009.

      • Cohen M.H.
      • Eisenberg D.M.
      Potential physician malpractice liability associated with complementary and integrative medical therapies.
      Therapies that are both safe and effective are generally recommended, whereas those that are unsafe and ineffective are avoided and discouraged. Areas where either (but not both) safety or efficacy is questioned should be approached with caution. A rational expectation of benefit, based on weak clinical trial evidence or biological plausibility, may be desirable in cases where more evidence-based treatment options are unavailable or undesirable, or when patient preference drives the consideration of a particular intervention. Table 1 illustrates this decision framework.
      Table 1Benefit and Risk Ratio and Selection of Therapies
      From Cohen and Eisenberg128
      Effective
      SafeYesNo
      YesUseTolerate
      NoMonitorAvoid
      a From Cohen and Eisenberg
      • Cohen M.H.
      • Kemper K.J.
      • Stevens L.
      • Hashimoto D.
      • Gilmour J.
      Pediatric use of complementary therapies: ethical and policy choices.
      The authors

      Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for IOM Summit on Integrative Medicine and the Health of the Public; February 2009.

      have also developed a similar framework to guide clinical recommendations in the context of indefinite research. The expanded Clinical Applications of Research Evidence construct, in Table 2, highlights the practical, and practice-oriented, implications of this interface. These frameworks serve as guides to systematically assess treatment options; clearly, clinical judgment is much more nuanced. Furthermore, there may be challenges in implementing an evidence-based framework for providers that believe therapeutic choice is intuitive and uncompromisingly individualized.
      • Barrett B.
      • Marchand L.
      • Scheder J.
      • et al.
      What complementary and alternative medicine practitioners say about health and health care.
      • Barrett B.
      • Marchand L.
      • Scheder J.
      • et al.
      Themes of holism, empowerment, access, and legitimacy define complementary, alternative, and integrative medicine in relation to conventional biomedicine.
      Table 2The Clinical Applications of Research Evidence Construct
      Adapted and expanded from Katz and Ali.4
      SafetyEfficacyScienceOther therapeutic optionsPatient preferenceCost / accessibilityUtilization frequency of treatment in question
      HighHighDecisiveNone that is superiorPrefers recommended approachNot a concernAlways
      ProbablePossibleUnclearNone/fewAnything that will workNeeds considerationOften
      LowLowAbsent/opposedMany that are superiorAnything that will workProhibitiveNever
      a Adapted and expanded from Katz and Ali.

      Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for IOM Summit on Integrative Medicine and the Health of the Public; February 2009.

      This framework suggests that clinical application of “evidence” depends on six considerations: the relative safety of a given intervention; its relative effectiveness; the quality and quantity of the supporting evidence; the availability of other treatment options for the condition; cost/accessibility (including insurance coverage, out-of-pocket expense, practicality, availability of reliable providers); and patient preferences. When a treatment approach is unsafe, ineffective, poorly supported by science, less effective than other options, cost prohibitive, and not uniquely compatible with patient preference, it should never be used. When a treatment is safe, effective, supported decisively by science, better than any other therapeutic option, readily accessible, and preferred by a patient, it should always be used. Challenges occur when options reside in between, such as when the approaches supported by the best science have all been tried, and have all failed. What remains is a treatment that is apparently safe, possibly effective, cost neutral, and desired by the patient, but not definitively supported by the available research evidence.

      Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for IOM Summit on Integrative Medicine and the Health of the Public; February 2009.

      When evaluating any potential clinical intervention, there is an implicit (or explicit) assessment of risk versus benefit. Efficacy is generally the major component of the benefit assessment (but not the only benefit; for example, psychological benefit can occur even in the absence of other clinical effects), whereas safety concerns are the primary risk (but not the only risk; for example, there is economic harm when using a safe but ineffective intervention).

      Conclusions

      The overlap of integrative medicine with preventive medicine is noteworthy. At the level of primary prevention, a number of approaches can contribute to health promotion. Minimally, these encompass lifestyle counseling, dietary guidance, stress mitigation techniques, interventions to improve sleep quality, and use of natural products for health promotion. At the level of secondary prevention, approaches such as stress management and lifestyle interventions are germane, as are interventions that facilitate use of conventional therapies for risk attenuation. At the level of tertiary prevention, the full range of complementary health approaches pertain to such goals as pain management, symptom control, stress relief, disease management, and risk reduction.
      To some extent, a conventional medical system that has emphasized the diagnosis and treatment of disease with ever-increasing degrees of specialization has marginalized both preventive medicine and the holistic view that is central to integrative medicine. The importance of disease prevention/health promotion is gaining increasing recognition, due in part to economic forces molding the evolution of modern health care.
      • McGinnis J.M.
      • Williams-Russo P.
      • Knickman J.R.
      The case for more active policy attention to health promotion.
      • Hu P.
      • Reuben D.B.
      Effects of managed care on the length of time that elderly patients spend with physicians during ambulatory visits: National Ambulatory Medical Care Survey.
      • Freeman J.D.
      • Kadiyala S.
      • Bell J.F.
      • Martin D.P.
      The causal effect of health insurance on utilization and outcomes in adults: a systematic review of U.S. studies.
      • Burwell S.M.
      Setting value-based payment goals—HHS efforts to improve U.S. health care.
      As integrative medicine tends to be philosophically aligned toward environmentalism
      • Astin J.A.
      Why patients use alternative medicine: results of a national study.
      and social justice,
      • Fritts M.
      • Calvo A.
      • Jonas W.
      • Bezold C.
      Integrative medicine and health disparities: a scoping meeting.
      as well as being particularly concerned with iatrogenesis (adverse effects of medical treatment),
      GBD 2013
      Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.
      the interface of integrative medicine and primordial and quaternary prevention becomes apparent. Integrative medicine thus offers the promise of more-expansive means to achieve the desired ends of preventive medicine, but also imposes the challenges of assessing evidence across that broader expanse.
      With patients increasingly interested in complementary and integrative approaches and conventional practitioners often uninformed or reticent, a system of unintegrated or, worse, disintegrated health care prevails in the U.S. Some conventional physicians actively discourage the use of CAM wholesale, without considering the differences in approaches or practitioners—or the potential value of integrative care. CAM-oriented practitioners may be just as apt to discourage the use of standard preventive interventions of conventional medicine, citing its reliance on pharmaceuticals and invasive procedures, a failure to respect nature, a systemic lack of compassion and patient centeredness, and financial conflicts of interest.
      • Lexchin J.
      • Bero L.A.
      • Djulbegovic B.
      • Clark O.
      Pharmaceutical industry sponsorship and research outcome and quality: systematic review.
      • Bes-Rastrollo M.
      • Schulze M.B.
      • Ruiz-Canela M.
      • Martinez-Gonzalez M.A.
      Financial conflicts of interest and reporting bias regarding the association between sugar-sweetened beverages and weight gain: a systematic review of systematic reviews.
      It is noteworthy that conflicts of interest (financial and non-financial) and ethical challenges are prevalent in a number of CAM arenas such as providers profiting from dietary supplement sales and laboratory testing.
      • Ma B.
      • Guo J.
      • Qi G.
      • et al.
      Epidemiology, quality and reporting characteristics of systematic reviews of traditional Chinese medicine interventions published in Chinese journals.
      • Singh S.
      • Ernst E.
      Trick or Treatment: The Undeniable Facts about Alternative Medicine.

      Cohen M. Key points for physicians and other healthcare licensees to consider when selling dietary supplements to patients. http://michaelhcohen.com/2014/12/key-points-for-physicians-and-other-healthcare-licensees-to-consider-when-selling-dietary-supplements-to-patients/.

      There is real danger here of patients toppling into the divide, with attendant squandering of the potential for disease prevention and health promotion.
      The Integrative Medicine in Preventive Medicine Education project was designed to introduce preventive medicine residents to integrative medicine to enhance the education and practice of preventive medicine,

      Health Resources and Services Administration. Integrative Medicine Program (IMP) Announcement Number: HRSA-12-180. 2012.

      implying a unidirectional positive influence of integrative medicine. This is also an opportune time to encourage a bidirectional exchange of ideas where preventive medicine can enhance integrative medicine. In particular, fundamentals of preventive medicine training and practice—biostatistics, epidemiology, research into causes of disease in population groups, the practice of prevention in clinical medicine, and planning and evaluation of health services

      American College of Preventive Medicine. What is Preventive Medicine? www.acpm.org/?page=whatispm. Published 2015.

      —can improve aspects of CAM and integrative medicine in such areas as childhood vaccines and encourage the critical evaluation of prevalent practices. Indeed, recent national initiatives to limit pharmaceutical industry influence in medical education (PharmFree),
      • Moghimi Y.
      The “PharmFree” campaign: educating medical students about industry influence.
      better disclosure of financial conflicts of interest (Sunshine Act),
      • Steinbrook R.
      • Ross J.S.
      “Transparency reports” on industry payments to physicians and teaching hospitals.
      and purging low-value practices from medical specialties (Choosing Wisely)
      • Colla C.H.
      • Morden N.E.
      • Sequist T.D.
      • Schpero W.L.
      • Rosenthal M.B.
      Choosing wisely: prevalence and correlates of low-value health care services in the United States.
      can serve as models to improve CAM and integrative health care. Implementing U.S. Food and Drug Administration good manufacturing practices for dietary supplements can mitigate risk of contamination and poor quality control.
      • Whitsitt V.
      • Beehner C.
      • Welch C.
      The role of good manufacturing practices for preventing dietary supplement adulteration.
      Incorporating emerging findings from clinical and neurobiological
      • Benedetti F.
      Placebo effects: from the neurobiological paradigm to translational implications.
      research of contextual and placebo effects can enhance the delivery
      • Jonas W.B.
      Reframing placebo in research and practice.
      and understanding of some CAM approaches. Overall, the application of preventive medicine principles and recent quality improvement initiatives can strengthen integrative medicine in the context of a healthcare system moving to value-based care.
      • Burwell S.M.
      Setting value-based payment goals—HHS efforts to improve U.S. health care.
      Recent outcomes research on models (or “whole systems”) of integrative care
      • Johnson J.R.
      • Crespin D.J.
      • Griffin K.H.
      • Finch M.D.
      • Dusek J.A.
      Effects of integrative medicine on pain and anxiety among oncology inpatients.
      • Bradley R.
      • Sherman K.J.
      • Catz S.
      • et al.
      Adjunctive naturopathic care for type 2 diabetes: patient-reported and clinical outcomes after one year.
      • Johnson J.R.
      • Crespin D.J.
      • Griffin K.H.
      • et al.
      The effectiveness of integrative medicine interventions on pain and anxiety in cardiovascular inpatients: a practice-based research evaluation.
      • Szczurko O.
      • Cooley K.
      • Busse J.W.
      • et al.
      Naturopathic care for chronic low back pain: a randomized trial.
      • Abrams D.I.
      • Dolor R.
      • Roberts R.
      • et al.
      The BraveNet prospective observational study on integrative medicine treatment approaches for pain.
      • Ritenbaugh C.
      • Hammerschlag R.
      • Calabrese C.
      • et al.
      A pilot whole systems clinical trial of traditional Chinese medicine and naturopathic medicine for the treatment of temporomandibular disorders.
      • Sundberg T.
      • Petzold M.
      • Wandell P.
      • Ryden A.
      • Falkenberg T.
      Exploring integrative medicine for back and neck pain—a pragmatic randomised clinical pilot trial.
      demonstrate promise and innovation, as well as potential cost savings,
      • Herman P.M.
      • Poindexter B.L.
      • Witt C.M.
      • Eisenberg D.M.
      Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations.
      • Herman P.M.
      • Szczurko O.
      • Cooley K.
      • Seely D.
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      and methodologic challenges.
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      demonstrate a public health orientation beyond the more educated and affluent demographics historically associated with CAM. Furthermore, the Patient-Centered Outcomes Research Institute, established by Congress in the Patient Protection and Affordable Care Act of 2010,

      Office of the Legislative Counsel. Compilation of Patient Protection and Affordable Care Act: Extracted sections concerning Patient-Centered Outcomes Research and the Authorization of the Patient-Centered Outcomes Research Institute (PCORI). Subtitle D of Title VI, Sec. 6301. Patient-Centered Outcomes Research; 2010.

      is focused on patient-centered comparative clinical effectiveness research and includes explicit stipulations for research on “integrative health practices.”

      Office of the Legislative Counsel. Compilation of Patient Protection and Affordable Care Act: Extracted sections concerning Patient-Centered Outcomes Research and the Authorization of the Patient-Centered Outcomes Research Institute (PCORI). Subtitle D of Title VI, Sec. 6301. Patient-Centered Outcomes Research; 2010.

      Relevant PCORI-funded research focused on chronic pain in underserved communities include studies in acupuncture

      Patient-Centered Outcomes Research Institute. Acupuncture Approaches to Decrease Disparities in Outcomes of Pain Treatment—A Two Arm Comparative Effectiveness Trial (AADDOPT-2). www.pcori.org/research-results/2014/acupuncture-approaches-decrease-disparities-outcomes-pain-treatment-two-arm. Published 2014.

      and integrative group visits.

      Patient-Centered Outcomes Research Institute. Integrative Medicine Group Visits: A Patient-Centered Approach to Reducing Chronic Pain and Depression in a Disparate Urban Population. www.pcori.org/research-results/2013/integrative-medicine-group-visits-patient-centered-approach-reducing-chronic. Published 2013.

      Some posit that these emerging findings can influence the current healthcare system to be both more value driven and more aligned to integrative principles.

      Center for Optimal Integration. Project for Integrative Health and the Triple Aim (PIHTA). http://optimalintegration.org/project-pihta/pihta.php. Published 2013.

      The ultimate goal of integrative medicine should be to make the widest array of appropriate options available to patients. Appropriateness should be predicated on fundamental considerations that pertain equally to conventional and CAM practice: treatment safety and treatment effectiveness. Treatment safety and treatment effectiveness must, in turn, be interpreted in light of the available evidence.
      Evaluating the current state of integrative medicine and preventive medicine leads to a number of fundamental research questions that can address essential gaps. The role of integrative medicine in areas germane to primary and secondary prevention needs to be better assessed in terms of rates of uptake of clinical preventive services, as well as the ability to demonstrably improve diet, physical activity, and smoking-cessation efforts. The question of whether integrative clinicians model healthy behavior and influence their patients in comparison to other clinicians is relevant, as well as cost-effectiveness studies of integrative practices in high-priority areas such as pain management and adjunctive cancer care.
      • Mao J.J.
      • Cohen L.
      Advancing the science of integrative oncology to inform patient-centered care for cancer survivors.
      But even in the absence of evidence, health care is not advanced by failing to adequately treat symptoms, engage patients in a therapeutic alliance, control disease progression, or produce satisfaction.

      Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for IOM Summit on Integrative Medicine and the Health of the Public; February 2009.

      The simple argument supporting integrative care is that modern medical science and knowledge, despite profound successes, comprises far less than patient need. Integrative care is not a comprehensive solution, but does expand the array of patient options, and can increase the likelihood of success that can be assembled across the stages of prevention.

      Katz D, Ali A. Preventive Medicine, Integrative Medicine, and the Health of the Public. Commissioned paper for IOM Summit on Integrative Medicine and the Health of the Public; February 2009.

      Acknowledgments

      Publication of this article was supported by the Health Resources and Services Administration (HRSA-12-182).
      The authors would like to thank Asim A. Jani, MD, MPH, for contributing insights and expertise in preparing this manuscript.
      The authors are grateful for the funding support from the Health Resources and Services Administration (HRSA) of the USDHHS, and their Integrative Medicine Program, HRSA Grant No. IMOPH25100. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, the HRSA, DHHS, or U.S. Government.
      The project was supported by the HRSA of the USDHHS under Grant No. UE1HP25094 and from the National Center for Complementary and Integrative Health at the National Institutes of Health under Grant No. K23AT006703.
      No financial disclosures were reported by the authors of this paper.

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