Integrative Medicine and the Health of the Public A Summary of the February 2009 Summit (2009) / Chapter Skim
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Pages 77-110
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From page 77... ...
Bruce McEwen of the Rockefeller University, with panelists offering their perspectives and priorities surrounding the development and advancement of the evidence base for integrative medicine. Topics reviewed focused on the complex interplay of biology, behavior, psychosocial factors, and environment shaping health and disease.
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From page 78... ...
Dr. Nancy Adler noted that people in lower socioeconomic strata are particularly vulnerable to the effects of stress, which is reflected in their lower health status and premature aging at the cellular level.
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Integrative medicine contrasts with that of conventional medicine, where, Ornish said, clinicians spend a great deal of time mopping up the floor around an overflowing sink instead of just turning off the faucet. Evidence in integrative medicine accumulates, not through studies involving one independent variable and one dependent variable, but rather through studies of the effects of multiple factors working together in systematic ways.
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From page 80... ...
The third example Ornish gave of synergy in integrative medicine research was a 1989 study in which a group of women was treated with chemotherapy, radiation, and surgery for metastatic breast cancer. One study cohort, randomly assigned to a support group that met 1 hour a week, exhibited a 5-year survival rate twice as high as that of control subjects who did not participate in a support group (Spiegel et al., 1989)
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From page 81... ...
Ornish and his team use high-tech, state-of-the-art measurement techniques to show the benefits of low-tech, low-cost, and, in some cases, ancient interventions and forms of disease prevention. Comprehensive lifestyle changes -- including changing what we eat, how we respond to stress, moderate exercise, and greater love and intimacy -- can yield remarkable improvements in health.
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. In later randomized trials, patients who made comprehensive lifestyle changes showed a significant reduction in coronary artery blockages (atherosclerosis)
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. In contrast, Ornish said that comprehensive lifestyle changes are dynamic, and often cause people to feel so much better, so quickly, that it reframes the reason for changing lifestyle from risk factor reduction (which is boring)
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The Gene Expression Modulation by Intervention with Nutrition and Lifestyle (GEMINAL) studies found beneficial effects in 501 genes within 3 months after comprehensive lifestyle changes, including meditation.
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In contrast, comprehensive lifestyle changes led to almost 30 percent increases in telomerase, and thus telomere length, within 3 months, as shown in Figure 4-3 (Ornish et al., 2008b)
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than from all forms of transportation combined. Limitations of Conventional Medicine and Traditional Research Diet and lifestyle changes that have already proved effective could prevent 95 percent of heart disease (Yusuf et al., 2004)
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Unlike a drug study, in which access to a new drug can be limited to experimental group participants, researchers cannot prevent the control group from making positive lifestyle changes on their own, which will confound the study's results. The study of integrative medicine cannot easily be limited to the study of only one independent variable and one dependent variable, noted Ornish.
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From page 88... ...
The language of behavioral change, unfortunately, often has a moralistic quality -- or what he termed a fascist quality: "I cheated on my diet" and "I ate bad food, so I'm a bad person." Willpower and patient compliance are based on restricting and manipulating behavior, which is not sustainable. The mechanisms that respond to comprehensive lifestyle changes are much more dynamic than had once been realized,
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From page 89... ...
All rights reserved. and, as described earlier, they allow patients to experience significant improvements in how they feel in a relatively short time.
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The brain is the central organ of stress; it perceives and decides what is threatening, producing physiologic responses that lead to adaptation and behavior that promotes or damages health, as shown in Figure 4-5. Although the body has a formidable capacity to defend itself against stress, this capacity is compromised by allostatic load -- the cumulative, damaging effects of the overuse or disregulation of stress response systems over time -- that results from chronic stress and behavior associated with experiencing stress, such as overeating, poor sleep, and lack of physical activity.
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Nancy Adler offered the perspective that, even though many types of risk occur in all socioeconomic groups, the ability to make lifestyle changes and to engage in healthy lifestyles is often patterned by social status. She reminded the summit participants that the people most
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More than 3 in 10 adults living below the federal poverty level 1 rate their health as fair or poor, whereas less than 7 percent of adults in the highest income group rate their health fair or poor (Robert Wood Johnson Foundation, 2008)
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35 30.9 24 30 25 18 21.2 20 13.9 12 11.0 15 14.0 10.1 10 5.8 6 6.6 5 0 0 Family income Educational attainment (Percent of federal poverty level) Less than high school <100% FPL High-school graduate 100–199% FPL Some college 200–299% FPL College graduate 300–399% FPL > 400% FPL – FIGURE 4-6a and 4-6b Relationship between income and education and reported adult health status.
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4.4 4.3 4 4 3 3 2.4 2.4 2 2 1.7 1.4 1.0 1 1 0.7 0.6 0 0 Family income Educational attainment (Percent of federal poverty level) Less than high school <100% FPL High-school graduate 100–199% FPL Some college 200–299% FPL College graduate 300–399% FPL > 400% FPL – FIGURE 4-7a and 4-7b Relationship between income and education and reported child health status.
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The current model of health focuses on the individual, involving efforts to promote behavior change, reduce stress, and increase patient empowerment. However, to improve health, it may be more effective to attempt broader strategies, suggested Adler.
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Sternberg, National Institute of Mental Health Biologic pathways mediated by the brain provide the central connection between the external environmental factors described by Adler and health status. Sternberg described these pathways, particularly those related to the immune response to stress.
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However, elegantly designed studies are beginning to shed light on brain mechanisms underlying such interventions. These include activation of the brain's positive emotional centers, with release of dopamine and endogenous opiates, and activation of the vagus nerve and parasympathetic nervous system, with resulting down-shifting of the stress response.
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From page 98... ...
Many of these diseases were eradicated through integrative approaches that began with basic science, including the development of vaccines for prevention, targeted therapies for specific infections, and improvements in public health and sanitation. The current status of genomic and predictive medicine reflects 150 years of progress in the basic sciences, starting with Gregor Mendel's 1865 recognition of genetic factors and Thomas Hunt Morgan's 1910 discovery that genes lie on chromosomes.
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From page 99... ...
A variety of study designs can be used to harness the knowledge resident in the genome, including the single-gene mutations that produce large effects and suggest therapeutic targets; acquired somatic mutations in cancer; and comprehensive measurement of gene expression in diseased and healthy tissues, in order to identify underlying disease pathways. Additionally, scientists increasingly can resequence large portions of the genome, which will soon enable identification of important mutations.
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From page 100... ...
Examples of the latter approach could be used to address both behavioral and environmental factors, such as reducing salt intake in order to control blood pressure and reducing cholesterol levels in order to prevent heart disease. Lifton said that realizing both visions require a fundamental, science-based understanding of the causes of disease.
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A geneticist at the University of Washington has found that women born with the BRCA1 or BRCA2 mutation before 1940 had a 24 percent risk of breast cancer, whereas such women born after 1940, as endocrine disruptors have become more prevalent in the environment, have a 67 percent risk. Simultaneously, the risk of ovarian cancer doubled for BRCA1 carriers, and increased 23 percent for BRCA2 carriers (King et al., 2003)
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Gaynor suggested a close relationship between environmental public policy and personalized medicine, saying that often "The environment outside us is the same as the environment inside us." Intervention Evaluation and Outcomes Measures Lawrence W Green, University of California, San Francisco Green indicated that he approaches integrative medicine from the opposite end of the biopsychosocial spectrum than the previous panelists.
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Moderating variables are reflected in the types of questions a clinician asks patients in order to learn about their identity, values, lifestyle, and life conditions. Green offered two strategic suggestions for meeting the postCochrane challenge.
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NCCAM's mission is to build the evidence base for complementary and alternative medicine interventions. The NIH core principles that govern this mission include rigorous peer review, investigator-initiated science, and partnerships.
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For example, these investigations so far have found: no impact of Echinacea on the severity or frequency of head colds; positive substantial impacts of fish oil and omega-3 fatty acids on cardiovascular risk factors; and mostly negative results for ginkgo biloba, glucosamine and chondroitin, and St.-John's-wort. The results of these studies tend to affect consumer use of the products; for example, St.-John's-wort, which was widely used in 2002, is no longer among the top 20 nonvitamin, nonmineral, natural products used by adults, as reported by the 2007 National Health Interview Survey.
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From page 106... ...
Several panelists responded to a related question regarding the lack of research on the effects of environmental risk factors and toxins on low-SES communities, where risks are often prevalent. Gaynor observed that African American women face an increased incidence of breast cancer as a result of increased exposure to endocrine-disrupting chemicals,
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She noted that high-tech methods can be used to assess the effects and health outcomes of lifestyle changes. Adler commented that skyrocketing health care costs create incentives to seek relatively inexpensive, lowtech interventions.
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For example, much time was lost in accepting the tobacco industry's persistent claim that cigarettes were not proven to cause cancer. Adler added that a market model is lacking for making disease prevention profitable, and a better alignment of incentives is needed.
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Progress is also needed in the development of evidence-based interventions for effective behavior change. Behavior change is a key strategy for preventing a very large number of diseases, but strategies for accomplishing it lack a great deal of empirical evidence.
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From page 110... ...
The group also noted that, while the biomedical research workforce has a strong basis, it requires more training in integrative human biology, behavior, and physiology. This additional training would show researchers how their work can apply to individual patients.
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