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The Role of Complementary and Alternative Medicine in Integrative Preventive Medicine 

The Role of Complementary and Alternative Medicine in Integrative Preventive Medicine
Chapter:
The Role of Complementary and Alternative Medicine in Integrative Preventive Medicine
Author(s):

Farshad Fani Marvasti

DOI:
10.1093/med/9780190241254.003.0009
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date: 29 November 2020

Key Concepts

  • ■ Integrative preventive medicine (IPM) creates a new framework to integrate both conventional and complementary and alternative medicine (CAM) approaches in the practice of preventive medicine.

  • ■ Integrative preventive medicine identifies CAM as a key contributor to the shift from acute to chronic disease treatment and prevention with the goal of morbidity compression to extend the period of disease-free high-quality life throughout the lifespan.

  • ■ As an integral part of IPM, CAM empowers the patient to take an active role in their health, resulting in a shift away from passive screenings and treatment-centered approaches to prevention-focused care.

  • ■ Integrative preventive medicine identifies a broad range of CAM that can be amenable to self-care, is cost-effective, is minimally invasive, and has minimal potential for side effects.

  • ■ The role of CAM in IPM is to reemphasize the value of primary prevention as an underused level of prevention in our current approach to healthcare.

  • ■ Integrative preventive medicine redefines and expands the levels of prevention to include evidence-based CAM at each level of prevention alongside conventional approaches.

  • ■ Key components of CAM have been shown to be effective in treating the major risk factors for morbidity and mortality.

  • ■ Integrative preventive medicine affirms the value of evidence-based CAM and thereby contributes to better outcomes by engaging patients to share their CAM usage with their physicians as part of their treatment plan.

Introduction

Complementary and alternative medicine (CAM) has been defined as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.”1 When used in place of conventional treatments, CAM therapies are considered “alternative.” When used together with conventional treatments, CAM therapies are considered “complementary.”2 According to the National Center for Complementary and Integrative Health (NCCIH) most people who use CAM use them along with conventional approaches, making them complementary. Integrative health is defined by the NCCIH as bringing conventional and complementary approaches together in a coordinated way. Integrative preventive medicine (IPM) creates a new framework that integrates and brings together both conventional and CAM approaches in the prevention of disease and the promotion of health.

The New Framework of Integrative Preventive Medicine

The new framework created by IPM provides a shift in the focus of our healthcare system from acute disease management to chronic disease prevention. This shift is based on the change in disease epidemiology from acute to chronic disease. Over 100 years ago, acute infectious diseases such as tuberculosis or polio were the major sources of morbidity and mortality.3 Great success was achieved to eradicate these conditions through advances in public health and the establishment of an acute care model. A hundred years later, the burden of illness has shifted dramatically toward chronic disease. In fact, 7 out of every 10 deaths among Americans are from chronic diseases including cardiovascular disease, cancer, and diabetes.4 Despite these changes in disease epidemiology mandating a focus on chronic disease prevention, our current healthcare system focuses almost exclusively on acute care.5 Our acute care model continues to demonstrate success in treating acute conditions as well as acute exacerbations of chronic diseases such as myocardial infarction. However, we have poor success in preventing these episodes in the first place. Focusing on acute care without adequate prevention contributes to the ongoing costs of chronic disease that now account for nearly 75% of healthcare dollars spent each year.6 In fact, modifiable and preventable factors such as lifestyle choices and behavior account for the majority of premature mortality in the United States.7

To address our chronic disease epidemic and maximize the potential of prevention, IPM mandates a new focus on chronic disease prevention and health. In sync with the pathogenesis of chronic disease, IPM focuses on risk factor modification over time. Therefore IPM emphasizes ongoing prevention practices and risk factor modification instead of a narrow focus on episodic treatment and late-stage disease management. Prevention in IPM includes health promotion activities that encourage healthy lifestyles that prevent the progression of chronic disease. The goal of IPM is therefore aligned with the goals of health promotion and prevention. Instead of focusing on treatment and cure, IPM focuses on maintaining health by expanding the period of disease-free high-quality life for as long as possible. Therefore IPM espouses the concept of morbidity compression, first articulated by James Fries as the goal of prevention.8 In focusing on prevention and health as paramount, IPM seeks to vindicate the quote attributed to Hippocrates, “the function of protecting and developing health must rank even above that of restoring it when it is impaired.” The need for this shift in focus also reflects emerging public opinion. Survey data has shown that two-thirds of all adults believe that the US healthcare system should place more emphasis on chronic disease preventive care, with four in five Americans (84%) being in favor of funding for such prevention programs.9

CAM Usage and the Goals of IPM

Despite the pressing need and public desire for prevention and health promotion, estimates show that Americans receive only about half the preventive services recommended.10 Integrative preventive medicine identifies evidence-based CAM therapies as an underused tool in preventive medicine. Although representing a diverse array of modalities with varying levels of evidence, much of CAM inherently focuses on the importance of lifestyle. By emphasizing lifestyle and providing ongoing practices for daily maintenance of health, CAM is a key contributor to the IPM goal of prevention and health promotion. Being cost-effective and amenable to self-care on a large scale, CAM is critical in decreasing morbidity and mortality and controlling costs associated with the chronic diseases of our time. One reason CAM should be considered as a key part of the solution to our chronic disease epidemic is reflected in its continued popularity and widespread usage, which has increased and persisted over time. The 2012 National Health Interview Survey (NHIS) conducted by the National Center for Health Statistics found that 33.2% of adults and 11.6% of children used some form of complementary health approach.11 This same survey found that 59 million Americans spent over 30 billion dollars a year out-of-pocket on complementary health approaches. The latest 2012 NHIS data has found the following to be the 10 most common complementary health approaches among adults: natural products (dietary supplements other than vitamins and minerals), deep breathing, yoga or tai chi or qi gong, chiropractic or osteopathic manipulation, meditation, massage, special diets, homeopathy, progressive relaxation, and guided imagery.12

In sync with the goal of IPM that shifts the focus of our healthcare system to health promotion and wellness, NHIS data has shown the majority of individuals who use CAM do so to maintain wellness, with much smaller numbers using these approaches for treatment.13 In IPM, CAM provides the cost-effective tools to achieve the goals of health promotion and prevention throughout the lifespan. And CAM can be particularly useful in the modification of personal health behaviors and risk factors for chronic disease. National Health Interview Survey data has shown CAM users to present with risk factors that are a public health priority, making CAM encounters an opportunity to coordinate health promotion and prevention messages with their primary care providers.14 Furthermore, CAM practitioner visits may be ideal opportunities for behavior change counseling and lifestyle modification.15

CAM in IPM Empowers the Patient

In IPM, CAM empowers the patient to actively participate in their health and thereby prevent disease through daily activities and practices that are amenable to self-care, are cost-effective, are minimally invasive, and have limited side effects. One such practice area in CAM is mind body medicine. Mind body therapies are defined as “practices that focus on the interactions of the brain, mind, body and behavior, with the intent to use the mind to affect physical functioning and promote health.”16 Commonly practiced mind body therapies include yoga, tai chi, qi gong, deep breathing, guided imagery, hypnosis, meditation, and progressive relaxation. Several of these therapies are among the top 10 most commonly used CAM therapies. Yoga, for example has grown in popularity. Twice as many US adults were practicing yoga in 2012 as they were in 2002.17 The latest national health statistics data show that 9.5% or 21 million adults use yoga on a regular basis.12 Yoga has been shown to have a variety of therapeutic effects. A recent review article found yoga to support muscle strength and flexibility; improve respiratory and cardiovascular function; treat addiction; improve sleep patterns; reduce stress, anxiety, and depression; and enhance overall quality of life.18 Yoga is a great example of a CAM therapy that is now becoming mainstream. And IPM identifies mind body practices such as yoga to be amenable to self-care, minimally invasive, and cost-effective, with little to no negative side effects. Tai chi, originally practiced as a martial art, is another mind body therapy that is low impact and amenable to self-care. Instead of simply screening elderly populations for osteoporosis and treating osteoarthritis with pain medications, IPM recognizes tai chi as a CAM therapeutic alternative to addressing these conditions. Research on tai chi has shown it to be effective in the treatment of coronary disease, metabolic syndrome, back pain, chronic fatigue, stroke rehabilitation, pain, and osteoporosis.19,20–25 When considering the conventional care approaches that include addictive and harmful pain medications, the consequences of a pathologic fracture due to poor muscle strength and bone density and the costs associated with these, CAM therapies such as yoga and tai chi provide a safer alternative. In sync with the new framework of CAM in IPM, these therapies provide daily practices for patients to engage in and thereby play an active role in their health. Furthermore, both yoga and tai chi also provide effective ways to expand primary prevention in healthy individuals to maintain health and prevent the onset of disease.

IPM Emphasizes Primary Prevention and Expands the Levels of Prevention to Include Evidence-Based CAM

Integrative preventive medicine emphasizes the value of primary prevention and identifies CAM as a key contributor to this underused aspect of healthcare. Despite the fact that most of our chronic diseases are potentially preventable, most healthcare resources are concentrated on treatment services for advanced disease management and only 2%–3% of all healthcare dollars are spent on prevention.26 Integrative preventive medicine asserts that this reality is unacceptable and identifies CAM to provide great potential for expanding primordial prevention. Primary prevention is central to the new IPM framework, and CAM provides effective tools to maintain health throughout the lifespan as opposed to episodic, disjointed treatment of symptoms and conditions after they have progressed to higher levels of morbidity. Most people who engage in CAM therapies have health conditions such as hypertension or diabetes and sedentary lifestyles. These patients see their CAM providers as often as two to five times per year.27 This higher visit rate supports the success of high-intensity behavioral interventions to prevent disease, as these are most effective in settings where there is greater time spent with patients. Therefore, CAM presents an ideal setting whereby health promotion and primary prevention can take place. Engaging patients in this new paradigm enables physicians to have more support on all levels of prevention to increase access to care for their patients. This increased access and contact has the potential to better prevent disease progression and unnecessary hospitalizations that can lead to higher costs, morbidity, and ultimately death.

Integrative preventive medicine redefines and expands the levels of prevention to include evidence-based CAM at each level of prevention alongside conventional approaches. The concept of prevention in IPM comes from the Latin root praeventus, to anticipate.28 Taken together with this definition of prevention, disease prevention translates to activities intended to forestall or anticipate the development of disease. Prevention has traditionally been conceptualized to occur on three distinct levels: primary, secondary, and tertiary prevention.29 Prevention can occur in a variety of settings on an individual, community, or societal level. Integrative preventive medicine considers prevention to be a spectrum that encompasses a broader synergy between medicine and public health. In IPM, CAM expands the traditional levels of prevention and reemphasizes the value of primary or primordial prevention as an underused level of prevention in our current healthcare system. As demonstrated in Table 9.1, the levels of prevention in IPM can expand to include CAM and community components at each level. Primary prevention includes activities intended to forestall the development of a disease prior to its clinical diagnosis. As such, daily practices such as tai chi or yoga are a great way to enhance self-efficacy to prevent disease and maintain health.

Table 9.1 Conventional Approaches to Secondary Prevention

Primary Prevention

Secondary Prevention

Tertiary Prevention

Conventional

Generic advice on diet and exercise to maintain weight and glycemic control in patient at risk for type 2 diabetes mellitus

  • Medication

  • management for early stage diabetes, hypertension, or other diagnosed medical conditions

  • Treating advanced

  • Diabetes with neuropathy and chronic kidney disease with insulin to prevent renal failure and dialysis, anticoagulants in patients with coronary disease

CAM in IPM

  • Optimizing physical activity with daily practices such as tai chi or yoga, optimizing diet Mediterranean or anti-inflammatory (AI) diet, meditation for relaxation and

  • stress reduction, tonic herbs and functional foods

evidence-based dietary supplements, diet protocols AI diet, Functional foods for lowering blood glucose like apple cider vinegar, mind body practices such as meditation to lower blood pressure, manual medicine to prevent progression of arthritic disease

Ornish diet and lifestyle protocol to reverse coronary artery disease, tai chi for cardiac rehab, acupuncture for nausea post chemotherapy for better compliance

Community

  • Addressing the built

  • environment, e.g., safe sidewalks and recreation facilities, addressing food deserts and food policy to make healthy

  • food choices available

  • Diabetes Prevention

  • Programs in YMCAs and community centers, diabetes educators in communities, public service health education on coronary artery disease

  • Enhance access to

  • primary and specialty medical care for chronic conditions for all to avoid unnecessary hospitalizations and prevent death

As seen in Table 9.1, conventional approaches are limited to generic recommendations for healthy diet and exercise. Unfortunately, these recommendations are too vague and generalized. Consequently, most Americans do not meet intake recommendations. For example, fruit and vegetable intake information from the Behavioral Risk Factor Surveillance System (BRFSS) found that 76% of Americans did not meet recommended fruit intake of 1.5–2 cups per day and 87% of Americans did not meet vegetable intake recommended at 2–3 cups per day.30 Having more sophisticated and personalized dietary advice with CAM in IPM has greater potential for success in achieving dietary goals to maintain health and prevent disease. Dietary practices that are tailored to individual needs are part of many CAM therapies. Alternative health systems such as Ayurveda and traditional Chinese medicine emphasize diet and the use of herbs and spices as a cornerstone in the prevention and treatment of disease.31,32 A number of herbs in these alternative health systems are taken by healthy individuals as a tonic to maintain health. Emerging evidence has supported the usage of selected herbs for various conditions and more research is needed to validate claims and traditional practices. The new framework of CAM in IPM necessitates a new focus on the role of diet in disease prevention and the treatment of chronic disease. Furthermore, nutriceutical dietary supplements are another area requiring further investigation. While challenges remain in regulation of the nutriceuticals, there is mounting evidence of their potential role in maintaining health and preventing disease. Integrative preventive medicine identifies evidence-based dietary supplements as an important tool in the prevention of disease, and more attention is needed on reforming policies to regulate the industry and expand medical research on efficacy and safety. In support of these goals, CAM in IPM advocates for systematic training for current physicians to expand their knowledge of evidence-based nutritional protocols and supplements. Current educational resources for clinicians include a number of ongoing conferences and integrative medicine fellowships.33,34

Secondary prevention includes activities intended to forestall the further development of an existing disease while in its early stages before it results in significant morbidity. As shown in Table 9.1, conventional approaches to secondary prevention largely include pharmacological treatments such as medications for blood pressure or blood glucose control. In IPM, CAM expands this to include evidence-based natural products or dietary supplements, specific diet treatment protocols, and lifestyle practices that optimize secondary prevention to forestall disease progression, such as meditation for blood pressure control. Tertiary prevention includes activities intended to forestall end-stage sequelae of symptomatic clinical disease, including significant morbidity leading to functional impairment or death. Tertiary prevention is where the lion’s share of conventional medical care is focused. As seen in Table 9.1, CAM in IPM can provide added resources here as well. For example, the intensive lifestyle changes including specific dietary and stress-management protocols of the Ornish plan have been shown to result in regression of coronary atherosclerosis.35 These and other similar findings for the role of lifestyle and diet expand tertiary prevention to include nonpharmacological, minimally invasive modalities that are amenable to self-care and cost-effective with minimal side effects. These lifestyle interventions can be particularly useful in patients with advanced cardiovascular disease who may not be good candidates for anticoagulant treatment due to fall risk and other comorbidities.

The Evidence for CAM in Treating Chronic Disease and Its Risk Factors

In expanding the levels of prevention, CAM in IPM provides a broader range of options for patients and healthcare providers to consider. These complementary therapeutic options require further research into their efficacy and safety. As research in CAM expands, the principles of preventive medicine can be integrated more fully into CAM encounters to promote health and prevent disease.36 To date, research in CAM has been supported by the National Center for Complementary and Integrative Health, which has created over 14 research centers through the National Institutes of Health. Key components of CAM have been shown to be effective in treating the major risk factors for morbidity and mortality as well as chronic conditions ranging from cardiovascular disease to chronic pain.37,38 According to the White House Commission on Complementary and Alternative Medicine Policy, much more evidence for CAM exists than is commonly recognized, as the Cochrane Collaboration lists well over 4,000 randomized studies on CAM therapies.39 The Cochrane Complementary Medicine website presents a collaboration between the NCCIH and University of Maryland School of Medicine to provide links to summarize the evidence for or against CAM.40 Additional free resources for physicians and healthcare providers for evidence-based CAM therapies include the Dietary Supplements subset search database in Pub Med, the University of Maryland Medical Center CAM Guide that provides drug-herb interactions and dosage recommendations based on evidence for natural products, and the Dietary Supplements Labels Database at the National Library of Medicine.41,42,43 Using these resources for evidence on dietary supplements is increasingly important, as natural products were used by 17.7% of American adults in 2007, making these the most popular form of CAM.16 Natural products include herbal preparations or botanicals, vitamins or minerals in higher dosages than minimal daily nutritional requirements, and probiotics. The most commonly used natural product in adults is omega 3 fish oil, reported by 37.4% of all adults who said they used a natural product.16 Omega 3 fish oil is one example of a CAM natural product that has now been well established and incorporated into mainstream treatment of cardiovascular disease and its risk factors such as hypertriglyceridemia.44 Probiotics and fermented foods are an emerging area of CAM that is gaining increased recognition by conventional medicine, as new research programs are being expanded to understand and define the human microbiome. Evidence for probiotics in certain conditions are already well established. For example, probiotics have been shown to reduce antibiotic-associated diarrhea and effectively aid in the treatment and prevention of recurrence for Clostridium difficile infections.45 Integrative preventive medicine provides a framework and rationale to support the expansion of research in these areas of CAM that have demonstrated potential for better outcomes.

As shown in Table 9.2, CAM in IPM expands therapeutic options in the treatment of the chronic disease and its risk factors. For example, diabetes affects over 29 million people in the United States,46 and over 57 million American adults are estimated to have prediabetes.47 Lifestyle interventions for diabetes such as the Diabetes Prevention Program (DPP) have been shown to be more effective than first-line pharmacotherapy for diabetes.48 Furthermore, use of DPP has been shown to reduce the risk of developing type 2 diabetes by as much as 58%.48 Integrative preventive medicine recognizes these lifestyle-based CAM interventions as an integral part of its new framework for healthcare. As noted in the expansion of prevention levels to include CAM, CAM in IPM also recognizes the potential role of diet and micronutrients in the care and prevention of chronic disease. According to a recent epidemiological study by the CDC examining the major risk factors for death and disability-adjusted life-years in the United States, dietary risk factors were found to be associated with the highest percentage of morbidity and mortality.49 After dietary factors, the other major risk factors identified in the study included tobacco smoking, high blood pressure, high fasting plasma glucose, and physical inactivity and low physical activity. Despite the obvious role that dietary factors play in our current chronic disease epidemic, our current system continues to have inadequate nutrition in medical education, with an average of 19.6 contact hours of nutrition instruction for the entire 4 years of medical school.50 The new framework of IPM expands primary prevention to include more personalized nutrition and requires expanded nutrition education in medical school curriculum.

Table 9.2 Therapeutic Options in Treating Chronic Disease

Conventional Approaches

CAM in IPM

Cardiovascular Disease

Statins for hyperlipidemia, antihypertensive medications for hypertension

  • Omega 3 fish oil for hypertriglyceridemia, anti-Inflammatory diet, integrative lifestyle

  • intervention, e.g., Ornish Tx for coronary artery disease, meditation

Diabetes

  • Oral hypoglycemic

  • medication, insulin

  • therapy

Lifestyle intervention such as Diabetes Prevention Program, tailored specific dietary intervention such as glycemic index guide, functional foods

Chronic Pain

  • Nonsteroidal anti-

  • inflammatory drugs (NSAIDs), nerve blocks and interventional pain, steroids

  • Mind body therapies including tai chi, yoga, acupuncture, anti-inflammatory diet, Omega 3 fish oil, evidence-based

  • supplements

In the CDC study identifying the importance of diet, the most important dietary risks included our low intake of vegetables, fruits, nuts, and seeds and high intake of sodium, processed meats, and sources of trans fat.49 To address these risks, CAM approaches to dietary interventions are much more specific than generic advice and provide a rich source of potential for treating this major risk factor for chronic disease and death. For example, the concept of the glycemic index and glycemic load is more routinely included in CAM approaches to treating diabetes and metabolic syndrome. Additionally, studies on functional foods such as apple cider vinegar and cinnamon have shown promise in improving glycemic control in patients with insulin resistance or type 2 diabetes.51,52 More research is needed in these areas to validate CAM approaches. By providing a framework to expand this research, CAM in IPM becomes a key part of treating the chronic diseases of our time and should be further supported by insurance reimbursement so as to easily incorporate it into routine medical practice.

Another related area of CAM in IPM is manual medicine. Manipulative and body-based practices focus on the body’s systems and structures, including the bones and joints, soft tissues, and circulatory and lymphatic systems.16 Examples of this type of CAM therapy include spinal or joint manipulation as done by chiropractors, osteopathic physicians, and other practitioners. The latest statistical data show that 8.4% or 19.4 million people use chiropractic or osteopathic manipulation.12 A systematic review found good evidence for spinal manipulation in the treatment of chronic or subacute low-back pain.53 Given the preponderance of low-back pain as one of the most common diagnoses and the current burden of opioid addiction that often begins with treating musculoskeletal complaints such as low-back pain, IPM recognizes manual medicine to be a cost-effective, nonpharmacological intervention that is minimally invasive and is associated with minimal side effects. Massage therapy is also one form of manual medicine. References to massage therapy defined as the “the art of rubbing” by Hippocrates have been found in most ancient civilizations.16 Currently 6.9% or 15.4 million US adults used massage therapy.12 Massage therapy is another example of a mind body practice that has been shown to play a role in the management of chronic pain, although the evidence is not as strong as it is for manual medicine for chronic low-back pain.26

CAM in IPM Engages Patients and Physicians to Openly Discuss and Incorporate CAM in Routine Care Plans

Since the first major national surveys of CAM usage by Eisenberg et al, most patients who use CAM do not inform their physicians.54 Patients do not discuss CAM usage for a number of reasons. The most common reasons cited by the NCCIH survey on CAM usage include the physician never asked (42%), the patient did not know they should ask (30%), and there was not enough time during the visit (19%).54,55 These data suggest that simply asking about CAM in a routine visit will enable patients to share their usage with their physicians. IPM recognizes the lack of disclosure of CAM usage to be detrimental to the health of patients. Sharing this information can prevent the potential known side effects of certain CAM therapies and interactions with medications or other conventional treatments. By incorporating CAM into conventional approaches to prevention and chronic disease management, patients will be able to openly discuss their CAM usage with their doctors to optimize their care. Making these discussions a part of routine care will also serve as an opportunity to encourage and support patients’ self-efficacy in taking responsibility for their health. This, coupled with the potential of CAM to be incorporated into the activities of daily living, will expand primary prevention and health promotion. By validating the patient’s interest in evidence-based CAM as part of routine care, IPM encourages open dialogue with patients. These discussions can promote and reinforce positive behavior change to modify lifestyle to improve health outcomes. Motivational interviewing has been an effective tool for behavior change to modify risk factors for chronic disease. By including CAM in the intake for routine care, physicians have an opportunity to set lifestyle change goals with their patients that engage their CAM usage as part of their health action plan. This can be a more effective approach that will likely lead to better outcomes by enabling patients to be an active part of their treatment plans. This is particularly relevant when considering patients who have or are at risk for chronic disease. Chronic disease requires ongoing effort for management and prevention of progression. IPM provides an important tool to achieve success in chronic disease self-management by empowering patients to discuss CAM and empowering physicians to include it as part of the patient’s treatment plan.

Conclusions

“Complementary and alternative medicine” is an antiquated term. More patients are using CAM as an adjunct to their conventional therapies. In redefining our current system to address this reality, IPM creates a new framework where complementary approaches to health are integrated seamlessly into conventional medical practice. The new framework of IPM is focused on prevention and health promotion with the goal of morbidity compression or extending the period of high-quality life that is free of disease throughout the lifespan. The role of CAM in IPM is to provide the needed evidence-based nonpharmacological therapies that are safe, minimally invasive, amenable to self-care, and cost-effective. The inherent focus of CAM on lifestyle and daily practices lends itself well to the new focus in IPM on prevention and health promotion. In IPM, CAM expands the three established levels of prevention to include evidence-based complementary approaches with particular emphasis on empowering patients to engage in more profound primary prevention efforts than are currently afforded to them by a conventional system that relies on passive screening and tertiary prevention. Also CAM brings added value to IPM by providing tools to combat the major risk factors for morbidity and mortality. By actively integrating CAM into a new framework for prevention and treatment of disease, IPM engages patients and physicians to openly discuss and use evidence-based CAM as a routine part of medical practice. This integrative approach will ultimately lead to better outcomes by providing key therapies for primary prevention and health maintenance. Although requiring further outcomes-based research, the new approach of IPM to incorporate CAM into our system provides great potential to effectively address the human and financial costs of our current epidemic of chronic disease.

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