E-Pub Ahead of Print

From Dick Benson, Publisher:
We are publishing this editorial electronically ahead of the Sep/Oct issue of Alternative Therapies in

Health and Medicine. This article title "A Proposed Conceptual Model for Studying the Use of Complementary and Alternative Medicine" describes the interrelated factors that dictate and influence 

complementary and alternative medicine (CAM) use in the United States.

Matthew A. Davis,

DC, MPH,

, MD, MBA, is an associate professor and core-faculty member at The Dartmouth Institute forHealth Policy and Clinical Practice. Ian D Coulter, PhD, is a professor at the University of California, Los Angeles; RAND/

Samueli Chair for Integrative Medicine and Senior HealthPolicy Researcher, RAND Corporation, Santa Monica, California; and on the research faculty at Southern CaliforniaUniversity of Health Sciences, Whittier.

A Proposed Conceptual Model for Studying the Use of Complementary and Alternative Medicine

Matthew A. Davis, DC, MPH; William B. Weeks, MD, MBA; Ian D. Coulter, PhD

A conceptual model has the ability to combine theories, illustrate relationships, and describe behaviors. We propose a conceptual model to describe the interrelated factors that dictate and influence complementary and alternative medicine (CAM) use in the United States based on sociologic theories including Parson's Sick Role and Suchman's Stages of Illness as well as the Andersen Sociobehavioral Model of health services utilization. In our conceptual model, we distinguish CAM use by symptomatic vs asymptomatic individuals, practitioner-based CAM services from products and self-administered CAM therapies, and the two ultimate endpoints: either the conclusion of CAM treatment or continuous CAM treatment. The development of our model underscores the importance of classifying CAM therapies based on the decision process of the CAM consumer rather than mechanism of action or CAM belief system in studying CAM health services utilization. (Altern Ther Health Med. 2011;17(5):##-##.)

[End of abstract]

                Cross-sectional studies conducted in the 1990s were the first to demonstrate the high rates of utilization of unconventional health care, now commonly referred to as complementary and alternative medicine (CAM), in the United States.^1,2 These early reports found that approximately one in three respondents used some form of CAM defined as "interventions not taught widely at US medical schools or generally available at US hospitals." Adults were asked if they used CAM therapies in the past 12 months and, if so, which therapies they used. If group CAM therapies are excluded, the most common practitioner-based CAM therapies used were chiropractic care, massage, energy healing, and acupuncture. The most common nonpractitioner-based CAM therapies included relaxation techniques, herbal medicine, and megavitamins. National estimates were that 427 million visits were made to CAM providers in 1990, and this increased to 629 million in 1997, exceeding annual estimates of total provider visits to all US medical physicians.^1,2

                Larger studies that investigated US CAM use have documented lower rates of practitioner-based CAM use and higher rates for nonpractitioner-based CAM services.^3-6 The most consistent and largest-scale data collection was from a repeat supplement questionnaire of the National Health Interview Survey (NHIS) conducted by National Center for Health Statistics in 2002 and 2007.^5,6 According to the NHIS data, the best and most current estimate is that four out of 10 individuals in the United States use one form of CAM.⁵ In this data, the definition of CAM is broad and encompasses practitioner-based CAM therapies (eg, chiropractic, acupuncture, and massage), natural products, deep breathing exercises, personal meditation, and diet-based therapies. Recent reviews of the many cross-sectional CAM utilization studies have found considerable variation in the definitions of CAM with little consistency throughout the literature.^7,8 This is not surprising considering the extensive diversity of CAM practices and products. Inconsistencies in the definition^9,10 and the classification of CAM subtypes continue to impair our ability to draw meaningful inferences regarding utilization.

                The high prevalence of CAM use in the United States has sparked interest in the development and use of conceptual models and theories to explain and predict CAM use.¹¹ While theories and models are sometimes used interchangeably, these terms are distinct in meaning and practice.¹² Theories are typically specific to another discipline (originate from sociology, psychology, etc) and function to describe, explain, or predict limited properties of reality. Therefore, a theory addresses an aspect of reality by stating what something is, how something happens, or why it happens. Conceptual models, on the other hand, tend to identify and describe specific types of behavior in specific situations or contexts.¹² Conceptual models have the ability to draw on numerous theories simultaneously while illustrating the causal linkages between elements.

                Broadly, the previous applications of theories and models originating from medical sociology, psychology, and marketing research to CAM can be separated into either health care utilization models or health behavior theories.¹¹ The most common theories and models used to date in the CAM literature include the Andersen Sociobehavioral Model,^13-21 Health Locus of Control,^14,22-24 and Self-regulatory Model.^25,26 Given the diversity of CAM practices, the unique underlying drivers of utilization, and ultimate endpoints of CAM use, a conceptual model that addresses these various aspects would be valuable to CAM education and future inquiry. In this article, we propose a conceptual model that describes the factors involved in CAM use.

DEVELOPMENT OF THE CONCEPTUAL MODEL

                To construct our conceptual CAM utilization model, we built upon prominent theories and health utilization models from the sociology and psychology literature base. Here we briefly describe the theories and models that most influenced the development of our conceptual model, which include Parson's Sick Role Theory, Suchman's Stages of Illness Theory, and the Andersen Sociobehavioral Model of health care utilization.

Parson's Sick Role Theory

                In our conceptual model, we delineate the transition from wellness (asymptomatic) to sickness as a driver of CAM use. A central construct of health service utilization theory is the "sick role concept" first introduced by Talcott Parsons in 1951. The sick role concept suggests that the experience of being sick extends beyond physical and physiological symptoms to include the impact of sociocultural factors. The sick role concept outlines the transition from the presence of symptoms to sickness and the interplay between the culture and ill person. Parson's sick role has four major tenets: (1) when an individual becomes sick, society excuses him or her temporarily from social duties; (2) a sick person is not expected to heal him/herself and thus requires assistance; (3) there exists general agreement that becoming sick is an undesirable state; and (4) to get well, the sick individual must seek medical treatment. The sick role concept channels the sick into seeking medical treatment, so the sick individual relinquishes self-responsibility to enter into a relationship of dependency with the health care provider. Though the sick role concept was instrumental to later medical sociological work, it fell under considerable scrutiny, including its application to CAM.²⁷

Suchman's Stages of Illness Theory

                Another seminal health services utilization theory is Suchman's Stages of Illness.²⁸ This theory details a linear relationship between five different points in the individual's decision process to utilize health care. According to Suchman, the five stages of the decision process are (1) the symptom experience stage, (2) the assumption of the sick role stage, (3) the medical care contact stage, (4) the dependent-patient role stage, and (5) the recovery or rehabilitation stage. During the initial stage, the individual weighs the severity of symptoms including pain, discomfort, and emotion. This includes the acknowledgment that something is wrong. Similar to Parson's Sick Role, the individual then assumes the role of being sick and proceeds to seek health care and explores their personal lay referral system. During the fourth stage, the individual may take on a dependent role; however, there are significant factors that impact this transition that relate to physical, social, and psychological facets. This is a critical point in the model where the patient-practitioner relationship may impact health care consumption and is a particularly important aspect in CAM utilization. The fourth stage can also be disrupted if the sick individual's beliefs clash with the practitioner's. This tipping point is also relevant to explaining the crossover between conventional health care and CAM use, as alignment with personal beliefs is an important factor in CAM use.^8,29 The final stage involves the relinquishment of the sick role by the individual except when a condition is incurable and entails ongoing treatment. Interestingly in CAM, continuous treatment may ensue among asymptomatic individuals.

The Andersen Sociobehavioral Healthcare Utilization Model

                The sociobehavioral model most often used to predict health care utilization is the Andersen Model initially developed in 1968.³⁰ Since its original iteration, the Andersen Model has been revised multiple times. The first version included three primary determinants of health service utilization: (1) predisposing characteristics (demographics, position within the social structure, and health beliefs, attitudes, knowledge, and values); (2) enabling resources (financial and physical access to health care services); and (3) need (both self-perceived and evaluated health status). The perception of need is a large constituent overriding the utilization of health services in this model and is based within social context. In the 1970s, the model was expanded to include aspects of the health care delivery system (policy, availability of resources, and its organization) as well as a component of the individual's satisfaction with the health care services such as convenience, availability, provider characteristics, and quality. Again in the 1980s and 1990s, the model was modified and now includes the impacts of health in a linear fashion with determinant subsets including (1) primary determinants (population characteristics, the health care system, and external environment); (2) health behaviors (personal health characteristics and the use of health services); and (3) health outcomes (perceived health status, evaluated health status, and consumer satisfaction). The Andersen Sociobehavioral Model has been used with two slight modifications for the study of CAM: (1) factors added to predisposing, enabling, and need factors specific to CAM and (2) health services was expanded to include nonpractitioner-based therapies and products.^20,21 Of particular relevance to our conceptual model was the impact of evaluated health status (diagnostics employed by health practitioners) on health service utilization.

THE CONCEPTUAL MODEL

Factors Pertaining to the Use of Complementary and Alternative Medicine

                The proposed conceptual model describes the use of CAM and how the various factors influencing utilization may interact (Figure). A unique feature of our proposed model is that we delineate CAM services used as treatment for a specific medical condition vs for other reasons (asymptomatic use).³¹ The decision to make this distinction was influenced by the early sociological work of Parson and Suchman. Use of CAM while asymptomatic may include uses for prevention, general health maintenance, or mere curiosity. Therefore, the assumption of a "sick role" as described by Parson and Suchman does not necessarily have to occur in order to utilize CAM. Although seeking health care services asymptomatically is not entirely unique to CAM (for instance, an individual may seek a general checkup under medical care), we theorize that the prevalence of asymptomatic use is higher among CAM therapies as CAM users are more likely to be philosophically committed to holistic values²⁹ and disease prevention.

                However, individuals may transition into the "sick role" before using CAM services. An interesting point is that the transition to a "sick role" state is influenced by other factors that may accelerate or decelerate the transition process. This transition may be influenced by cues from the media and culture as described in Rosenstock's Health Belief Model.³² For example, if an individual experiences aches from osteoarthritis and encounters an advertisement suggesting that these symptoms are somehow abnormal and could be alleviated with a nutritional supplement, this may encourage the transition to the role of being sick, thus leading one to take action (ie, use the nutritional supplement). Additionally, this transition may be facilitated by interaction with a CAM practitioner. In this regard, the diagnosis, whether it is based on conventional diagnosis or on CAM philosophy and practice, may perpetuate the individual's view of him/herself as sick and in need of health services. The CAM practitioner may legitimize the individual who has been rejected by the medical profession as a "malingerer." This may be especially common for conditions such as low back pain, a common condition treated by CAM practitioners.³³ Such enablement by a CAM practitioner may promote and facilitate further care either intra- or interprofessionally.

Other factors, as in the Andersen Sociobehavioral Model, included in our conceptual model that predispose one to use CAM include (1) demographics (age, gender); (2) social structure (educational background, occupation, ethnicity, support of friends and family); and (3) health beliefs and behaviors. A recent systematic review of the characteristics of CAM users found that being female of middle age with a higher educational background are proclivities of CAM use⁷; however, many of the studies focused on different types of CAM services and products. We theorize that these factors may differ dramatically based on whether the individual uses CAM for treatment of a specific medical condition vs use for some other reason.

Access to CAM Services

                A theoretical model to explain the use of CAM would be incomplete without addressing access to CAM services. Barton describes five dimensions to the access of health care services: (1) financial, (2) geographic, (3) sociocultural, (4) temporal, and (5) physical.³⁴ Many studies investigating CAM use have uncovered that use is higher among more affluent populations, specifically with higher incomes.⁷ We define financial access to CAM services as the ability to pay for the CAM services or have access through a health insurance plan. The original version of the Andersen Sociobehavioral Model considers financial access as an enabling factor.³⁰ The ability to either pay directly for a CAM service (out-of-pocket) or indirectly through a health insurance premium will dictate an individual's use of CAM. A considerable portion of expenditures on CAM continue to be from out-of-pocket payments³⁵ despite a trend of increased coverage by government and private insurers.³⁶ The state of Washington serves as an interesting example; in 1996, private insurers covered CAM practitioner-based services, and consequently, a substantial portion of health insurance beneficiaries have used the service (in 2002, of 600 000 enrollees, 13.7% had made a claim for a CAM service).³⁷ The increase in access to CAM services has encouraged utilization by reducing the financial barrier. Among the uninsured, it is possible that a higher barrier of financial access to traditional medical care may lead an individual to seek a less expensive CAM service. Geographic access is having CAM services available in a given area. For instance, the number of chiropractors per county differs dramatically throughout the United States.³⁸ Undoubtedly, there will be areas where there is limited access to CAM services because services are not available in a given area. Conversely, access or lack of access to medical physicians may influence CAM use.^39,40

                Access to CAM services may also be affected by personal sociocultural, temporal, and physical factors as well. Sociocultural factors include potential barriers in communication or rituals across groups. Temporal and physical factors relate to a patient's ability to see a CAM practitioner (for instance an appointment time conducive to one's work schedule) and physically have access to a practitioner's office.

Differentiation of Complementary and Alternative Medicine Services

                The National Institute of Health's National Center for Complementary and Alternative Medicine (NCCAM) classifies CAM practices into five domains: (1) whole medical systems, (2) mind-body medicine, (3) biologically-based systems, (4) manipulative and body-based practices, and (5) energy medicine.⁴¹ The five domains as described by NCCAM differentiate CAM services by mechanism of action which is applicable for directing study; however, the NCCAM system may not be feasible parameters for studying CAM utilization.

                We separate CAM practices into two categories, either practitioner-based products or services (eg, chiropractic, acupuncture, massage therapy, osteopathy, Reiki practitioners) and self-practice CAM therapies. Self-practice therapies include products such as natural supplements (megavitamins, herbals, and minerals) as well as self-practice CAM activities such as yoga, meditation, and deep breathing. Our decision to separate CAM practices in this fashion is based on the process of selecting a CAM therapy. In other words, a patient's decision to either self-treat with a CAM product or therapy is very different than a decision to consult a CAM practitioner. Previous authors have suggested the creation three categories of CAM: (1) CAM providers, (2) CAM products, and (3) self-practices.²¹ Although it could be argued that a CAM product is dissimilar to self-practice therapy such as yoga, our rationale in combining these into one category stems from control to self-treat using the modality. The difference in either self-treatment or consulting a CAM practitioner may be based in part on perception of control.

                The "locus of control" concept is a psychological theory that differentiates individuals who perceive having greater control over their actions and fate (high internal locus of control) vs those individuals who perceive lower personal control (high external locus of control).⁴² Thirteen different cross-sectional studies have examined CAM vs non-CAM users' locus of control metrics with little consistency of findings.⁸ In these studies, definitions of CAM varied, and perhaps an interesting study would be to compare users of different service types within the CAM realm. We illustrate the gradient between our two categories of CAM therapy based on perceived control in our model; we theorize that CAM users with a high internal locus of control are more likely to utilize CAM products or self-practice therapies as opposed to practitioner-based CAM services.

                We describe the two categories of CAM as potentially impacting each other's use. For example, a CAM practitioner may recommend either a CAM product or self-therapy intervention.

The Endpoints of Complementary and Alternative Medicine Use

                The two ultimate endpoints of CAM use are either the conclusion of treatment or the continuation of treatment. The concept of continuous treatment is in part a unique aspect of CAM services. Continuous treatment may occur in the case of CAM use as a preventive modality or as ongoing symptom relief for a chronic condition.

                The divergence between the two ultimate endpoints of care is dictated by the individual's personal characteristics and health status, as well as the outcomes of the CAM experience (the perceived effectiveness of addressing their personal goals, the associated costs, and satisfaction with CAM). In cases where treatment is concluded for a specific treatment episode, the experience with CAM will then in turn influence future use of CAM services.

FUTURE USES OF THE CONCEPTUAL MODEL

                Our proposed conceptual model may serve as a reference for future CAM education as well as help direct future research inquiry. The paradigms used to describe medical service utilization in public health texts and the health sociology literature are not necessarily applicable to CAM use. The proposed conceptual CAM utilization model is aimed at describing the unique ways in which individuals come to use CAM, the interaction of different CAM practices, and the ultimate endpoints. Although the model is subject to future changes, it provides an initial framework to conceptualize CAM utilization and potentially form more quantitative models.

                Informal review of our conceptual model suggests a number of new areas of new CAM inquiry. These may include (1) investigation of the sociodemographic characteristics of individuals who use CAM either for medical condition management vs those who use CAM for other reasons, (2) examination of the impact of the media as a driver of CAM use, (3) investigation of CAM practitioner treatment enablement, (4) investigation of the relationship between use of CAM practitioners and CAM products or self-treatment therapies, (5) examination of personal locus of control based on the type of CAM use, and (6) evaluation of the factors that result in continuous CAM treatment.

                However, there exist a number of inherent limitations of our conceptual model. First, our model demonstrates potential linear relationships of factors related to CAM use based largely in theory. Some authors argue that linear paradigms to explain health service utilization altogether are flawed, as human behavior might best be explained using chaos theory.⁴³ Second, our model does not predict or quantitatively measure CAM use. Lastly, our model is focused on CAM utilization and neglects to incorporate the impact of concurrent medical care or referral to CAM practices by practitioners of conventional medicine.

                As CAM health services research further develops, a conceptual model that describes CAM use may be valuable. We propose a conceptual model that combines prominent sociologic and psychological theories that specifically addresses the unique aspects of CAM use, which may help direct future research and educational activities.

REFERENCES

1.         Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280(180):1569-1575.

2.         Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med. 1993;328(4):246-252.

3.         Ni H, Simile C, Hardy AM. Utilization of complementary and alternative medicine by United States adults: results from the 1999 national health interview survey. Med Care. 2002;40(4):353-358.

4.         Paramore LC. Use of alternative therapies: estimates from the 1994 Robert Wood Johnson Foundation National Access to Care Survey. J Pain Symptom Manage. 1997;13(2):83-89.

5.         Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. 2008 Dec 10;(12):1-23.

6.         Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002. Adv Data. 2004 May 27;(343):1-19.

7.         Bishop FL, Lewith GT. Who uses CAM? A narrative review of demographic characteristics and health factors associated with CAM use. Evid Based Complement Alternat Med. 2008 Mar 13. [Epub ahead of print]

8.         Bishop FL, Yardley L, Lewith GT. A systematic review of beliefs involved in the use of complementary and alternative medicine. J Health Psychol. 2007;12(6):851-867.

9.         No authors listed. Defining and describing complementary and alternative medicine. Panel on Definition and Description, CAM Research Methodology Conference, April 1995. Altern Ther Health Med. 1997;3(2):49-57.

10.       Zollman C, Vickers A. What is complementary medicine? BMJ. 1999;319(7211):693-696.

11.       Lorenc A, Ilan-Clarke Y, Robinson N, Blair M. How parents choose to use CAM: a systematic review of theoretical models. BMC Complement Altern Med. 2009 Apr 22;9:9.

12.       Earp JA, Ennett ST. Conceptual models for health education research and practice. Health Educ Res. 1991;6(2):163-171.

13.       Yussman SM, Ryan SA, Auinger P, Weitzman M. Visits to complementary and alternative medicine providers by children and adolescents in the United States. Ambul Pediatr. 2004;4(5):429-435.

14.       Sirois FM, Gick ML. An investigation of the health beliefs and motivations of complementary medicine clients. Soc Sci Med. 2002;55(6):1025-1037.

15.       Upchurch DM, Burke A, Dye C, Chyu L, Kusunoki Y, Greendale GA. A sociobehavioral model of acupuncture use, patterns, and satisfaction among women in the United States, 2002. Womens Health Issues. 2008;18(1):62-71.

16.       Hildreth KD, Elman C. Alternative worldviews and the utilization of conventional and complementary medicine. Socio Inq. 2007;77(1):76-103.

17.       Kelner M, Wellman B. Health care and consumer choice: medical and alternative therapies. Soc Sci Med. 1997;45(2):203-212.

18.       Tsao JC, Dobalian A, Myers CD, Zeltzer LK. Pain and use of complementary and alternative medicine in a national sample of persons living with HIV. J Pain Symptom Manage. 2005;30(5):418-432.

19.       Hendrickson D, Zollinger B, McCleary R. Determinants of the use of four categories of complementary and alternative medicine. Compl Health Pract Rev. 2006;11(1):3-26.

20.       Fouladbakhsh JM, Stommel M. Comparative analysis of CAM use in the U.S. cancer and noncancer populations. J Compl Integr Med. 2008;5(1):article 19.

21.       Fouladbakhsh JM, Stommel M. Using the behavioral model for complementary and alternative medicine: the CAM healthcare model. J Compl Integr Med. 2007;4(1):article 11.

22.       Testerman JK, Morton KR, Mason RA, Ronan AM. Patient motivations for using complementary and alternative medicine. Compl Health Pract Rev. 2004;9(2):81-92.

23.       Henderson JW, Donatelle RJ. The relationship between cancer locus of control and complementary and alternative medicine use by women diagnosed with breast cancer. Psychooncology. 2003;12(1):59-67.

24.       Hedderson MM, Patterson RE, Neuhouser ML, et al. Sex differences in motives for use of complementary and alternative medicine among cancer patients. Altern Ther Health Med. 2004;10(5):58-64.

25.       Bishop FL, Yardley L. Why do people use different forms of complementary medicine? Multivariate associations between treatment and illness beliefs and complementary medicine use. Psychol Health. 2006;21(5):683-698.

26.       Montbriand MJ. Decision tree model describing alternate health care choices made by oncology patients. Cancer Nurs. 1995;18(2):104-117.

27.       Coulter ID. Sociological studies of the role of the chiropractor: an exercise in ideological hegemony? J Manipulative Physiol Ther. 1991;14(1):51-58.

28.       Suchman EA. Stages of illness and medical care. J Health Hum Behav. 1965;6(3):114-128.

29.       Astin JA. Why patients use alternative medicine: results of a national study. JAMA. 1998;279(19):1548-1553.

30.       Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(1):1-10.

31.       Bishop FL, Yardley L, Lewith GT. Treat or treatment: a qualitative study analyzing patients' use of complementary and alternative medicine. Am J Public Health. 2008;98(9):1700-1705.

32.       Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the Health Belief Model. Health Educ Q. 1988;15(2):175-183.

33.       Cherkin DC, Deyo RA, Sherman KJ, et al. Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. J Am Board Fam Pract. 2002;15(6):463-472.

34.       Barton PL. Understanding the U.S. Health Services System. 4th ed. Chicago, IL: Health Administrations Press; 2009.

35.       Bridevaux IP. A survey of patients' out-of-pocket payments for complementary and alternative medicine therapies. Complement Ther Med. 2004;12(1):48-50.

36.       Steyer TE, Freed GL, Lantz PM. Medicaid reimbursement for alternative therapies. Altern Ther Health Med. 2002;8(6):84-88.

37.       Lafferty WE, Tyree PT, Bellas AS, et al. Insurance coverage and subsequent utilization of complementary and alternative medicine providers. Am J Manag Care. 2006;12(7):397-404.

38.       Smith M, Carber L. Chiropractic health care in health professional shortage areas in the United States. Am J Public Health. 2002;92(12):2001-2009.

39.       Yesalis CE 3rd, Wallace RB, Fisher WP, Tokheim R. Does chiropractic utilization substitute for less available medical services? Am J Public Health. 1980;70(4):415-417.

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41.       National Institutes of Health, National Center for Complementary and Alternative Medicine. CAM basics: what is CAM?  Available at: http://nccam.nih.gov/health/whatiscam/overview.htm. 2007. Accessed March 5, 2010.

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43.       Resnicow K, Page SE. Embracing chaos and complexity: a quantum change for public health. Am J Public Health. 2008;98(8):1382-1389.

LIFESTYLE MEDICINE: TREATING THE CAUSES OF DISEASE

Mark A. Hyman, MD; Dean Ornish, MD; Michael Roizen, MD 

Recently, at a small gathering in Martha’s Vineyard in support of the Robert F. Kennedy Center for Justice and Human Rights, Larry Summers, PhD, economist and director of the White House’s National Economic Council, spoke about our narrow escape from economic depression. Dr Summers also addressed the even larger impending risks to our economy if the costs of healthcare are not successfully addressed now. He was asked how we could control these costs without tackling the root causes of the problem, the fact that most of the chronic diseases that affect 160 million Americans and account for 78% of our healthcare costs are caused by lifestyle and environmental factors—namely our diet, sedentary lifestyle, smoking, chronic stress, and environmental toxins.

But most believe that doctors don’t “do” lifestyle. Dr Summers dismissed “lifestyle” as a community and public health issue that was already included in the current plan. He didn’t understand that physicians can and must practice clinical lifestyle medicine to effectively treat disease and dramatically reduce healthcare costs. Lifestyle factors leading to chronic diseases such as heart disease, diabetes, obesity, and cancer are the domain of doctors and not merely a “public health problem.”

Lifestyle is not only a public health issue; it is also a medical and clinical care issue. Lifestyle medicine is not just about preventing chronic disease but also about treating it, often more effectively and less expensively than relying only on drugs and surgery. Nearly all the major medical societies recently joined in publishing a review of the scientific evidence for lifestyle medicine both for the prevention and treatment of chronic disease.1 There is strong evidence that this approach works and saves money. Unfortunately, insurance doesn’t usually pay for it. No one profits from lifestyle medicine, so it is not part of medical education or practice. It should be the foundation of our healthcare system.

For example, the recent “EPIC” study published in the Archives of Internal Medicine studied 23 000 people’s adherence to 4 simple behaviors (not smoking, exercising 3.5 hours a week, eating a healthy diet [fruits, vegetables, beans, whole grains, nuts, seeds, and limited amounts of meat], and maintaining a healthy weight [BMI <30]). In those adhering to these behaviors, 93% of diabetes, 81% of heart attacks, 50% of strokes, and 36% of all cancers were prevented.2

This study is only one among a large evidence base documenting how lifestyle intervention is often more effective in reducing cardiovascular disease, hypertension, heart failure, stroke, cancer, diabetes, and all-cause mortality than almost any other medical intervention.1 It is because lifestyle addresses not only risk factor modification or reduction. Our lifestyle and environment influence the fundamental biological mechanisms leading to disease: changes in gene expression, which modulate inflammation, oxidative stress, and metabolic dysfunction.

The distinction between risk factors and causes is an important one.3 High blood pressure, dyslipidemia, and elevated C-reactive protein or glucose are not in and of themselves the real causes of chronic disease but simply surrogate markers that are the effects of environmental toxins, what we eat, how much we exercise, and how we respond to stress.

The future of medical care must be to transform the general lifestyle guidance (eat a healthy diet, exercise regularly) that many physicians try to provide to their patients in individually tailored lifestyle prescriptions for both prevention and treatment of chronic diseases. Lifestyle is the best medicine when applied correctly.

“Prevention” therapies as written into current healthcare bills are public health– and community-based wellness initiatives or payment for early detection of disease with mammograms, colonoscopies, and other screening tests. As the Congressional Budget Office recently indicated, early detection without treating the major underlying causes of chronic diseases—our lifestyle choices—may actually add to costs.

For example, a mammogram does not prevent breast cancer; it may find it sooner, when it is more easily treated, but hundreds or thousands of women must be tested to find 1 incidence of cancer. The argument for this type of “prevention” is necessary and moral but not economic.

Health insurance reform is important, but it is insufficient. We need healthcare reform. We need to change the content and not just the financing and coverage of healthcare. We must change not only the way we do medicine, but the medicine we do.

The center of the healthcare debate must change to what is covered, not just who is covered, if we are to make current treatments more effective and less costly.

The lifestyle factors leading to chronic disease are the domain of doctors and not just a “public health problem.” Doctors must “do” lifestyle medicine and receive adequate reimbursement; otherwise, the cost of chronic disease will bankrupt Medicare by 2017.4

Treating Causes Rather than Risk Factors
Let’s circle back to the flaw in treatment of risk factors and not causes. Typically doctors treat “risk factors” for disease such as giving a lifetime’s worth of medications to lower high blood pressure, elevated blood sugar, and high cholesterol. These, however, do not treat the underlying causes of those risk factors: what and how much we eat, whether we smoke, how often we exercise, how we manage stress, and the effects of environmental toxins. Disregarding the underlying causes and treating only risk factors is somewhat like mopping up the floor around an overflowing sink instead of turning off the faucet, which is why medications usually have to be taken for a lifetime. When the underlying lifestyle causes are addressed, patients often are able to stop taking medication (under their doctor’s supervision, of course). Likewise, they often can avoid surgery as well.

Presently, according to the American Heart Association, 1.3 million coronary angioplasty and 448 000 coronary bypass operations are performed annually at a cost of more than $100 billion.5 Despite these costs, many studies, including one last month in The New England Journal of Medicine, reveal that angioplasties and stents do not prolong life or even prevent heart attacks in stable patients (ie, 95% of those who receive them6). Coronary bypass surgery prolongs life in less than 2% to 3% of patients who receive it.7

In contrast, the INTERHEART study, published in The Lancet in 2004, followed 30 000 people and found that changing lifestyle could prevent at least 90% of all heart disease.8

Think about it. Heart disease accounts for more premature deaths and costs Americans more than any other illness and is almost completely preventable simply by changing diet and lifestyle. The same lifestyle changes that can prevent or even reverse heart disease can prevent or reverse many other chronic diseases as well.

Medicare and insurance companies currently pay billions of dollars every year for surgical procedures such as angioplasties and bypass surgeries. These are high-risk, invasive, expensive procedures fraught with complications, and they are largely ineffective.

In the large ACCORD study of more than 10 000 diabetics, aggressive blood sugar lowering with medication actually caused deaths.9 High blood sugar is a side effect of poor lifestyle choices. The treatment isn’t insulin to lower blood glucose, but healthy dietary choices, exercise, stress management, and not smoking. The Diabetes Prevention Program Research Group study showed that lifestyle changes are even more effective than diabetes drugs such as metformin in reducing the incidence of diabetes in people at high risk, with lower costs and fewer side effects.10

Lifestyle medical treatment, including personalized, science-based prescriptions for diet, exercise, and stress management, however, are not reimbursed or are only partially reimbursed. These therapies are low-risk and effective in reversing and preventing chronic diseases.

If we train and pay for doctors to learn how to help patients address the real causes of disease with lifestyle medicine and not just treat disease risk factors (simply the effects of poor lifestyle choices) with medications or surgery, we can save almost $1.9 trillion over 10 years for just 5 major diseases: heart disease, diabetes, “pre-diabetes” or metabolic syndrome, and prostate and breast cancer.*

Our nation is actively debating whether we can provide access to healthcare for all Americans and reduce costs at the same time. We cannot do either if we continue to provide the same type of healthcare based primarily on treating disease with medications and surgery rather than lifestyle medicine. Giving 47 million more people access to our current methods of treatment for chronic disease will surely cost more and offer less.

Many, including the head of the American Medical Association, argue that lifestyle medicine is a social, community, and public health issue, not a medical care issue. Real doctors don’t “treat” patients with lifestyle medicine. While community wellness programs and public health education do work (tobacco use decreased by two-thirds since the 1950s; Americans reduced dietary fat by 4% and increased carbohydrate consumption by 6% on the urging of the misguided US Dietary guidelines of 1977; and more people use seatbelts, sunscreen, and helmets),11 they only go part way. Doctors need to go the rest of the way.

Doctors Must Learn and Practice Lifestyle Medicine
The fundamental flaw in thinking in healthcare right now is that doctors don’t “do” lifestyle medicine and that people don’t change. In part that is true. Only 50% of patients take the drugs their doctors recommend. The food and drug industry, however, has been very successful in changing our habits for the worse. The typical American now eats 680 more calories per day than 30 years ago, and 81% of the adult population takes at least 1 medication.12 Established financial interests drive research and delivery of care based on medication and surgery. There are no incentives to drive doctors to treat disease with lifestyle medicine. Changes in policy, reimbursement, research, education, and clinical care encouraging doctors to “do” lifestyle medicine must take center stage in healthcare reform.

You might argue that doing this for everyone may cost more (and it might), so let’s begin with those who already have chronic disease. Integrated healthcare teams led by physicians practicing lifestyle medicine can save our healthcare system. Presently, however, physicians lack training and financial incentives to help people learn how to eat a healthy diet, exercise, stop smoking, manage their weight, or address the effects of environmental toxins. So they continue to do what they know how to do: prescribe medication and perform surgery.

Personalized lifestyle medicine is a high-science, high-touch, low-tech, low-cost treatment that is more effective for the top 5 chronic diseases than our current approaches. Yet is it not taught in medical schools, practiced by physicians, or delivered in hospitals or healthcare settings. In fact, this treatment, if applied to all the patients with cardiovascular disease, diabetes, metabolic syndrome (obesity), prostate cancer, and breast cancer could reduce net health care expenditures $930 billion over 5 years and result in dramatically better health and quality of life.*

Opportunities for Change
On August 6, 2009, Senator Ron Wyden (D, Oregon) introduced new legislation, theTake Back Your Health Act (S. 1640) that includes payment for intensive lifestyle medicine as treatments, not just prevention. This legislation has bipartisan co-sponsorship by Senators John Cornyn (R, Texas) and Tom Harkin (D, Iowa). We worked closely with these senators to help craft this initiative. This pending legislation, or changes in Medicare policy, can make it feasible for intensive lifestyle treatments to take hold in medical care. It will reinvigorate primary care medicine and drive the transformation of existing healthcare institutions, medical schools, postgraduate education, and insurers to meet the demand for interventional lifestyle treatment of chronic disease. It will induce doctors to learn and practice lifestyle medicine both because it works better for their patients and physicians will be paid to do it. It will support the development of a wellness- and health-based economy rather than one based on sickness and chronic disease.

If lifestyle medicine becomes central to the practice of medicine, our sick care system will be transformed into a healthcare system.

References
1. American College of Preventive Medicine. Lifestyle Medicine—Evidence Review. June 30, 2009. Available at: http://www.acpm.org/LifestyleMedicine.htm. Accessed September 18, 2009.
2. Ford ES, Bergmann MM, Kröger 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. Arch Intern Med. 2009;169(15):1355-1362.
3. Mozaffarian D, Wilson PW, Kannel WB. Beyond established and novel risk factors: lifestyle risk factors for cardiovascular disease. Circulation. 2008;117(23):3031-3038.
4.Samuelson RJ. Let them go bankrupt, soon. Solving Social Security and Medicare. Newsweek. 2009 Jun 1;153(22):23. Available at: http://www.newsweek.com/id/199167. Accessed September 23, 2009.
5. Ornish D. Intensive lifestyle changes and health reform. Lancet Oncol. 2009;10(7):638-639.
6. Boden WE, O’Rourke RA, Teo KK, et al; COURAGE Trial Investigators. Impact of optimal medical therapy with or without percutaneous coronary intervention on long-term cardiovascular end points in patients with stable coronary artery disease (from the COURAGE Trial). Am J Cardiol.
7. Morrison DA, Sacks J. Balancing benefit against risk in the choice of therapy for coronary artery disease. Lesson from prospective, randomized, clinical trials of percutaneous coronary intervention and coronary artery bypass graft surgery. Minerva Cardioangiol. 2003;51(5):585-597.
8. Yusuf S, Hawken S, Ounpuu S, et al; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet.
9. Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, Byington RP, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358(24):2545-2559
10. Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.
11. Mozaffarian D, Wilson PW, Kannel WB. Beyond established and novel risk factors: lifestyle risk factors for cardiovascular disease. Circulation.
12. Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA. Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey. JAMA. 2002;287(3):337-344. 2009;104(1):1-4. 2008;117(23):3031-3038. 2004;364(9438):937-952

CLINICAL RESEARCH IN ANTHROPOSOPHIC MEDICINE

Harald Johan Hamre, Dr med; Helmut Kiene, Dr med; Gunver Sophia Kienle, Dr med

Harald Johan Hamre, Dr med, and Gunver Sophia Kienle, Dr med, are senior research scientists at and Helmut Kiene, Dr med, is the director of the Institute for Applied Epistemology and Medical Methodology, Freiburg, Germany.

Abstract
Anthroposophic medicine includes special medications and special artistic and physical therapies. More than 200 clinical studies of varying design and quality have been conducted on anthroposophic treatment. Half of these studies concern anthroposophic mistletoe therapy for cancer. Clinical effects of mistletoe products include improvement of quality of life, reduction of side effects from chemotherapy and radiation, and possibly increased survival.

Apart from cancer therapy, the largest studies of anthroposophic treatment have been 2 naturalistic system evaluations: In German outpatients with mental, musculoskeletal, respiratory, and other chronic conditions, anthroposophic treatment was followed by sustained improvements of symptoms and quality of life. In primary care patients from 4 European countries and the United States treated for acute respiratory and ear infections by anthroposophic or conventional physicians, anthroposophic treatment was associated with reduced use of antibiotics and antipyretics, quicker recovery, and fewer adverse reactions; these differences remained after adjustment for relevant baseline differences. (Altern Ther Health Med. 2009;15(6):52-55.)

Anthroposophic medicine (AM) is a complementary therapy system founded in the 1920s by Rudolf Steiner and Ita Wegman1 and provided by specially trained physicians in 56 countries worldwide.2 AM acknowledges a spiritual-existential dimension in humanity, which is assumed to interact with psychological and somatic levels in health and disease. AM therapy includes special treatment modalities (eurythmy movement exercises, art therapy, rhythmical massage therapy) and special medications.3,4

Eurythmy therapy is an artistic exercise therapy involving cognitive, emotional, and volitional elements. In eurythmy therapy sessions, patients are instructed to exercise specific movements with the hands, the feet, or the whole body. Eurythmy movements are related to the sounds of vowels and co