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Following an Evidence Based Approach to Integrative Care (Part I)

By Craig Tanio, MD, FACP, IFMCP

In a famous critique of alternative medicine in the New England Journal of Medicine in 1998, Drs. Marcia Angell and Jerome Kassirer, the former editors-in-chief of The New England Journal of Medicine wrote the following[1]

“There cannot be two kinds of medicine – conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work. Once a treatment has been tested rigorously it no longer matters whether it was considered alternative at the beginning. If it is found to be reasonably safe and effective, it will be accepted.”

At Rezilir Health our objective is to implement an integrative clinical model that combines traditional medicine with a functional medicine approach. We embrace the evidence-based approach articulated by Drs. Angell and Kassirer as the basis for our approach.

However, we first observe that the way traditional medicine is being practiced today does not follow the evidence-base standard either.

There is strong evidence that changes in lifestyle behaviors are far more powerful than most individual pharmacologic therapies. The Nurse’s Health Study has followed over 81,000 female nurses in the US for over 30 years. Sudden cardiac death (SCD) accounts for more than half of the deaths in these women. The researchers looked at four lifestyle factors: smoking, body mass index (BMI), diet score (compared to Mediterranean diet) and amount of regular physical activity. [2] Scoring as low risk behavior in just one of the four categories reduced the risk of SCD by 40%. However, women who maintained a low risk lifestyle in all four categories had a 92% decrease in their risk of SCD. No pharmacologic drug can come close to this type of impact!

Current medical system is not effective at changing behavior. Just to give a recent example, there was an article in the January 2016 Mayo Clinic Proceedings showed that only 7% of US adults had all four healthy lifestyle characteristics tracked by the Nurse’s Health Study above. Very little time is spent in medical practice on how to implement those changes effectively[3]. Innovations in health coaching, such as Dean Ornish’s intensive cardiac rehabilitation program Medicare’s new reimbursement of diabetes coaching based on principles in the Diabetes Prevention program are promising developments. A quantum leap forward in this area is needed, one that promotes the power of groups, systems and the community to change behavior.

Commercial bias in favor of pharmaceuticals and expensive technologies. The pharmaceutical companies have been extraordinarily effective at promoting both a silver bullet solution to particular remedies and expanding the markets to fit diseases. To give an example, over the last 20 years’ proton pump inhibitors have consistently been in the top 10 drugs used accounting for $13 billion in annual sales in 2009. Up to 70% of patients taking the drugs have no appropriate long term indication[4].

Older paradigms of medicine and public health are slow to change based on new evidence. Probably the best historical example and a significant contributor to today’s obesity epidemic is the public health tradeoff made in promoting the dangers of saturated fat versus the underappreciation of the dangers of simple sugars and fructose well documented in Gary Taubes’ Good Calories Bad Calories.

To have a truly evidence based and effective system, we need to get the foundation right. In our integrative model we will ensure we get the foundation of care right based on evidence based principles. In this foundation we will:

Start with a foundation of promoting effective changes in lifestyle behaviors – purpose, diet, activity, recovery and environment / habits.
Continue to build on this foundation when adding additional therapeutics
Review the literature carefully and not depend on consensus guidelines subject to commercial bias

[1] Angell M, Kassirer JP. Alternative Medicine – The Risks of Untested and Unregulated Remedies. NEJM 1998 339 839-943.

[2] Chiuve SE, Fung TT et al. Adherence to a low-risk, healthy lifestyle and risk of sudden cardiac death among women. JAMA 2011; 306(1): 62-69

[3] Loprinzi PD, Branscum A. Healthy Lifestyle Characteristics and their Joint Association with Cardiovascular Disease Biomarkers in US Adults. Mayo Clinic Proceedings 2016; 91 432-442.

[4] Forgacs I, Lognanyagam A. Overprescribing proton pump inhibitors. BMJ 2008 ; 336 (7634) 2-3.

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