Good evening, I have a paper due on Thursday and instructions for the paper is attached. I chose the number 5a and the paper will talk about "interventions to enhance adherence to dietary advice for

Disease Prevention and Health Promotion How Integrative Medicine Fits Ather Ali, ND, MPH, MHS, 1David L. Katz, MD, MPH 2 As a discipline, preventive medicine has traditionally been described to encompass primary, secondary, and tertiary prevention. Theﬁelds of preventive medicine and public health share the objectives of promoting general health, preventing disease, and applying epidemiologic techniques to these goals. This paper discusses a conceptual approach between the overlap and potential synergies of integrative medicine principles and practices with preventive medicine in the context of these levels of prevention, acknowledging the relative deﬁciency of research on the effectiveness of practice-based integrative care. One goal of integrative medicine is to make the widest array of appropriate options available to patients, ultimately blurring the boundaries between conventional and complementary medicine. Both disciplines should be subject to rigorous scientiﬁc inquiry so that interventions that are efﬁcacious and effective are systematically distinguished from those that are not. Furthermore, principles of preventive medicine can be infused into prevalent practices in complementary and integrative medicine, promoting public health in the context of more responsible practices. The case is made that an integrative preventive approach involves the responsible use of science with responsiveness to the needs of patients that persist when conclusive data are exhausted, providing a framework to make clinical decisions among integrative therapies.

(Am J Prev Med 2015;49(5S3):S230–S240)&2015 American Journal of Preventive Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Introduction T he dividing line between preventive medicine and public health practice is far from distinct, as is that between prevention and treatment. The purview of preventive medicine has traditionally been described to encompass primary, secondary, and tertiary prevention in the construct usually attributed to Leavell and Clark. 1Others have expanded on this construct; quaternary prevention focuses on reducing overmedical- ization and protecting patients from unnecessary or excessive invasive interventions, 2 whereas primordial prevention focuses on the alteration of societal (i.e., environmental, economic, social, behavioral, cultural) structures that affect disease risk. 3 This paper discusses a conceptual approach between the overlap and potential synergies of integrative medicine and preventive medicine in the context of these levels of prevention, and represents an update of a prior paper on this topic commissioned by the then IOM (now National Academy of Medicine), and placed in the public domain. 4 Integrative Medicine and Nomenclature Integrative medicine, a concept developed over the past few decades, 5refers to the fusion—by various means, and to varying degrees—of conventional medical practice and some of the practices that fall under the complementary and alternative medicine (CAM) rubric. 5,6 Integrative medicine thus offers, in theoryatleast,theopportunityto combine the“best”of the conventional healthcare system and practices and providers commonly considered to be CAM, 7and thereby produce better outcomes, measured in terms of symptom relief, functional status, patient satisfac- tion, and perhaps cost effectiveness. 8Integrative medicine is necessarily“holistic”in the sense that somatic, emotional, and spiritual health are considered integral to overall health. 9These deﬁnitions are inherently problematic; what exactly comprises spiritual health, or whether this is the appropriate realm of the physician, is debated. 10,11 Further, integrative medicine advocates are accused of creating a forced dichotomy between anidealized patient-centered biopsychosocial approach 12incorporating CAM and“good conventional medicine.” 13 A rationale for integrative med- icine depends largely on a rationale for CAM, as CAM tends to be the limiting element in efforts to advance integrative care.

The term CAM is used to describe diverse medical practices not routinely taught in mainstream medical education. 6“Alternative”denotes that such practices are From the 1Yale School of Medicine, New Haven, Connecticut; and 2Yale University Prevention Research Center, Derby, Connecticut Address correspondence to: Ather Ali, ND, MPH, MHS, Yale Uni- versity School of Medicine, 2 Church Street South, Suite 300C, New Haven CT 06519. E-mail: [email protected].

0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2015.07.019 S230Am J Prev Med 2015;49(5S3):S230–S240&2015 American Journal of Preventive Medicine Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). deﬁned by what they are not, and that they are exclusive of mainstream health care.“Complementary”implies that these practices are supplemental to conventional health care. The discrepancy in suggesting that such practices are both alternative and complementary to mainstream care has been noted. 4,14,15 Such challenges to the nomenclature notwithstanding, CAM has been the most widely used academic appellation, its primacy conveyed by its incorporation into the title of the NIH National Center for Complementary and Alter- native Medicine, recently renamed to the National Center for Complementary and Integrative Health, acknowledg- ing that pure“alternative medicine”is rare, and that “integrative”better conveys prevalent practice patterns. 6 Despite institutionalization of this terminology, this broad- based categorization overlooks necessary nuance.“CAM” and“integrative”thus encompass practices and practi- tioners inside and outside of the mainstream, as well as approaches rooted in historic or cultural contexts, uncon- ventional diagnostics and diagnoses, new and untested approaches, and off-label use of conventional therapies.

These terms also encompass therapies and approaches that have historically been embraced by CAM clinicians but are recently becoming mainstream (such as some mind–body therapies and interest in the human microbiome beyond gastrointestinal conditions). 16–18 Interest in and use of complementary health approaches has remained constant in recent years in adults 19 and children 20 after a rise in use between 1990 and 1997. 21 One third of the adult population 19 and 12% of children 20 have used at least one CAM therapy. The majority of patients seek CAM approaches to comple- ment rather than substitute for conventional care most often for pain and chronic musculoskeletal conditions. 22 Americans spent an estimated $33.9 billion on CAM services in 2007. 23 The use of CAM is more prevalent among female, better-educated, higher-income popula- tions 21,22 with chronic and degenerative condi- tions. 20,24,25 Predictors of CAM use include a holistic philosophical orientation to health and life, a chronic health condition, environmentalism, feminism, and an interest in spirituality and personal growth psychology. 25 Other studies show a relationship to health-promoting lifestyle choices: Regular physical activity, infrequent to moderate alcohol consumption, and being a former smoker are associated with CAM use. 26 Although researchﬁndings vary, common reasons that people choose CAM include dissatisfaction with conventional care; a desire to avoid side effects of conventional medicine and treatments; an interest in and greater knowledge of how nutritional, emotional, and lifestyle factors affect health; and a broader focus on disease prevention and overall health. 21,24,25 Despite prevalent CAM usage, fewer than 40% of CAM patients disclose this information to their main- stream physicians, indicating an important disconnect between patient preferences and comfort in sharing these views. 21,25,27–30 This salient deﬁciency in provider– patient communication 28–30 might reﬂect mistrust, dis- satisfaction with the conventional healthcare system, 25or a response to the perceived receptivity of conventional providers. 4 Therefore, a case may be made to responsibly guide patients in CAM therapies based on interest and in accordance with scientiﬁc evidence. Because this guid- ance should by no means supplant conventional treat- ments, an argument for an integrative approach emerges:

Patients should ideally receive expert guidance across the availability of treatments that may result in improved health. 4 Integrative Medicine Across the Prevention Spectrum As behavioral and lifestyle choices account for the majority of premature mortality in the U.S., 31 target- ing these areas can potentially provide the greatest beneﬁt. In 2010, the leading cause of death in the U.S.

was tobacco use, which resulted in some 435,000 deaths, or 18.1% of total deaths. Closely following was diet and lack of physical activity, resulting in 400,000 deaths. 31 The following sections discuss the potential for inte- grative medicine across the prevention spectrum. By and large, the effectiveness of integrative approaches in health promotion or disease prevention is not fully elucidated; data derived from direct tests of integrative care models are promising but preliminary. 32–35 Integrative Medicine in Primary Prevention Among the means to promote lifestyle change is model- ing (i.e., being an exemplar of) healthy behavior, notably diet and physical activity. Physicians that practice healthy behaviors tend to emphasize these behaviors in patient care; consequently, patients of these physicians generally receive stronger, more pronounced, and more speciﬁc advice regarding lifestyle change. 36,37 Physicians who exercise regularly are more likely to counsel their patients to do so; nonsmokers are more likely to emphasize the risks of smoking. 38 A number of integrative health organizations encour- age members to model healthy lifestyle behaviors, including the Academy of Integrative Health & Medi- cine 39 and the American Association of Naturopathic Physicians. 40Among some integrative health educational Ali and Katz / Am J Prev Med 2015;49(5S3):S230–S240S231 November 2015 institutions, a culture of wellness exists, where healthy food choices are readily (if not exclusively) available and faculty model healthy behaviors.

Furthermore, a number of CAM whole systems con- sider dietary habits and therapeutic nutrition as a cornerstone of health, including Traditional Chinese Medicine, 41 Ayurveda, 42,43 and naturopathy. 40,44 Some dietary guidance is consistent with current mainstream recommendations for chronic disease prevention, 45 whereas some traditional recommendations conﬂict.

Challenges (and opportunities) also exist in synergiz- ing primary prevention with integrative healthcare. A sizable proportion of patients oriented toward CAM tend to be skeptical of preventive interventions, especially childhood vaccination. 46,47 Anti-vaccine views 48 and increases in vaccine-preventable illnesses are associated with care from CAM providers. 49 An evidence-based integrative approach in the context of“holistic preven- tion,”emphasizing the patient–provider relationship, 50 with a sympathetic understanding of parental concerns can potentially increase immunization rates in parents that would otherwise be mistrustful of more- conventional clinicians, 46 thus protecting public health in the context of providing care that is responsive to the needs of CAM-oriented patients. Secondary Prevention and Integrative Medicine Integrative medicine has the potential to improve rates of screening and uptake of preventive services through an emphasis on a strong therapeutic alliance, prevention, teaching, interprofessional, and holistic care. 51 Nation- ally, screening rates for preventive services are consid- erably lower than ideal 52; much of the blame can be placed on lack of emphasis and training in health promotion and disease prevention as well as the burdens of a healthcare system that constrain primary care visits to suboptimal levels. 53–55 Abbreviated primary care encounters, coupled with barriers to access, tend to compromise continuity of care as well. 55 As prevention and population health activities occur in almost all healthcare settings, 56 clinicians can potentially improve screening rates and utilization of preventive services and enhancing risk-reduction efforts for chronic diseases with strong diet and lifestyle associations, namely, cardiovascular disease, diabetes, and certain cancers. 57 Despite this potential, the authors are not aware of evidence of enhanced screening and preventive services in integrative medicine.

Many CAM approaches have demonstrated promise in treating early disease or risk factors such as improving the lipid proﬁle, 58 reducing inﬂammation, 59 controlling serum glucose, and reducing blood pressure. 60–64 By usingthese in combination with comprehensive lifestyle change, mind–body interventions, and mainstream preventive recommendations 65 with a strong therapeutic alliance, the potential to improve outcomes rationally follows.

In certain instances, an integrative approach can be used to enhance adherence with conventional therapies, such as using the nutritional supplement coenzyme Q10 to reduce statin-induced myopathy 66 (though other studies demonstrate a lack of beneﬁt)67; probiotics to reduce antibiotic-associated diarrhea 68–70 ; licorice and its derivatives to potentiate the effects of cortisone 71 and reduce non-steroidal anti-inﬂammatory drug–associated gastropathy 72; and a variety of integrative approaches to improve quality of life and adverse effects associated with cancer chemotherapy. 73 Tertiary Prevention and Integrative Medicine Many lifestyle programs demonstrate effectiveness for tertiary prevention of cardiometabolic disease. 74–76 Though aspects of such programs have now arguably been conventionalized (i.e., diet and lifestyle), the blend- ing of lifestyle, dietary supplements, and mind–body interventions is certainly representative, if not diagnostic, of integrative care. 4 Integrative healthcare approaches for chronic disease can improve functionality, reduce morbidity, improve quality of life, and directly inﬂuence disease processes.

The quality of evidence for CAM therapies is mixed for treating chronic conditions with signiﬁcant public health impact. 77 Nutritional supplements such asﬁsh oil, 78 chromium, 79 alpha-lipoic acid, 80 herbal medicines, 81 and mind–body techniques 82 have been used to treat Type 2 diabetes mellitus. Hyperlipidemia can be treated with therapeutic diets consisting of functional foods, 83,84 nutri- tional supplements, and herbal medicines. 58Manual thera- pies such as massage can be useful for osteoarthritis, 85 as well as acupuncture, 86 and nutritional and herbal supple- ments. 87An anti-inﬂammatory diet, 59,88 nutritional supple- ments, manual therapies, and other CAM therapies have shown promise in the management of rheumatoid arthritis. 89 The public health impact of obesity and its related sequelae is unparalleled in the U.S., while the prevalence is quickly rising throughout the rest of the world. 90 Integrative medicine has the potential to add to obesity prevention and control efforts by emphasizing nutrition, stress reduction, 91 and exercise. 92 There also tends to be an emphasis on dietary supplements, although the scientiﬁc evidence underlying such recommendations has long been suspect. 93,94 At least 13% of outpatient visits are attributable to medically unexplained symptoms 95,96 (also known as Ali and Katz / Am J Prev Med 2015;49(5S3):S230–S240 S232 www.ajpmonline.org somatoform disorders) such as chronic fatigue syn- drome, irritable bowel syndrome,ﬁbromyalgia, chronic Lyme disease, 97 and chronic unexplained pain, 98 which are often complicated by concurrent psychological dis- tress and strong emotions. 97,99 Mainstream care for patients with these conditions is often frustrating, usually resulting in extensive diagnostic workups and signiﬁcant iatrogenic complication rates. 95,100 In one study, a majority of primary care physicians described attitudes toward patients as negative and dismissing, 101 and another study found substantial discordance between patient and physician treatment goals. 102 As is true of many health conditions that are poorly understood and often resistant to conventional treat- ments, medically unexplained conditions often compel patients to seek CAM. 97,103–107 The holistic nature of integrative care, with an emphasis on mind–body med- icine, often results in recommendations incorporating psychological and somatic therapies. 9,108,109 CAM therapies for pain control vary in demonstrated efﬁcacy, spanning mind–body therapies such as medita- tion 110,111 and biofeedback, 112 to tai chi, 113 acupuncture, yoga, hypnosis, chiropractic, nutritional interventions, 114 herbal medicines, massage, 85 or combinations thereof. 115 In recent years, a number ofwhole-practice outcomes studies demonstrate beneﬁt of integrative approaches, particularly in chronic pain, 32,34,35,116–118 Type 2 diabetes, 33 and cardiovascular risk markers. 119 Theseﬁndings suggest public health beneﬁts as well as possible cost savings. 8,119 Stress and Mind–Body Medicine Integrative medicine tends to emphasize the importance of psychological stress and its impact on overall health. 51 The evidence is robust and broad-based; psychological stress leads to poorer health outcomes—encompassing infectious and chronic disease, morbidity and mortality, and developing illness as well as recovery. 120 Psychological states can also be beneﬁcial; the presence of“positive emotions”has been shown to predict better health and outcomes. 121–123 Personality aspects such as commitment to self, an attitude of concern for the environment, a sense of meaningfulness, and an internal locus of control are all associated with decreased illness in high-stress environments. 124 Contextual factors and the therapeutic relationship are important factors in the overall effectiveness of a therapy, especially with subjective outcomes such as in chronic pain syndromes, 125,126 and perhaps stronger with CAM approaches associated with elaborate rituals and distinct contexts. 127 There is an ethical imperative to provide therapeutic options that are safe and effective for symptomatic relief, with appropriate informed consent,without endorsing approaches that are unsafe or ineffec- tive. 128 There is an emerging literature on the psycho- biology of the placebo effect, with clinically signiﬁcant effects demonstrated in a variety of contexts. 127,129,130 Intentional use of placebo in clinical practice is rou- tine, 131 with complex ethical implications. 127 Integrative medicine offers a framework that incorpo- ratespsychoemotionalfactorsasintegraltooverallhealth with the resultant emphasis on mind–body therapies. 132 These factors are often perceived to be overlooked in conventional clinical practice and medical education, 133–136 or challenging to practicallyaddress in hurried medical visits resulting fromﬁnancial constraints of the current health delivery system. 53–55 Evidence and Integrative Medicine As integrative medicine often incorporates approaches outside of mainstream care where evidence is weak or speculative, a systematic method in addressing“uncon- ventional therapies”is warranted. 4Where strong evi- dence supporting a particular approach exists, that should be recommended in preference to others. The more ambiguous it is as to which might be the most appropriate therapeutic choice, the more important it is to consider a hierarchy of evidence, incorporating safety, effectiveness, alternatives, and the evidence supporting each Tables 1 and 2). For some medically unexplained syndromes, such asﬁbromyalgia or chronic fatigue syndrome, a deﬁnitive therapy does not exist, and the best available treatments are those safe and possibly effective. Integrative medicine expands patient options at this end of the evidence hierarchy, where options are generally most needed. Any therapy that a patient refuses to use is ineffective, regardless of the evidence supporting its use. 4 A common framework to assess the clinical appropri- ateness of a particular CAM intervention has been published in multiple venues. 128,137,138 Therapies that are both safe and effective are generally recommended, whereas those that are unsafe and ineffective are avoided and discouraged. Areas where either (but not both) safety or efﬁcacy is questioned should be approached with Table 1.Beneﬁt and Risk Ratio and Selection of Therapies a Effective Safe Yes No Yes Use Tolerate No Monitor Avoid aFrom Cohen and Eisenberg 128 Ali and Katz / Am J Prev Med 2015;49(5S3):S230–S240S233 November 2015 caution. A rational expectation of beneﬁt, based on weak clinical trial evidence or biological plausibility, may be desirable in cases where more evidence-based treatment options are unavailable or undesirable, or when patient preference drives the consideration of a particular intervention. Table 1 illustrates this decision framework.

The authors 4have also developed a similar framework to guide clinical recommendations in the context of indeﬁnite research. The expanded Clinical Applications of Research Evidence construct, in Table 2, highlights the practical, and practice-oriented, implications of this interface. These frameworks serve as guides to system- atically assess treatment options; clearly, clinical judg- ment is much more nuanced. Furthermore, there may be challenges in implementing an evidence-based frame- work for providers that believe therapeutic choice is intuitive and uncompromisingly individualized. 139,140 This framework suggests that clinical application of “evidence”depends on six considerations: the relative safety of a given intervention; its relative effectiveness; the quality and quantity of the supporting evidence; the availability of other treatment options for the condition; cost/accessibility (including insurance coverage, out-of- pocket expense, practicality, availability of reliable pro- viders); and patient preferences. When a treatment approach is unsafe, ineffective, poorly supported by science, less effective than other options, cost prohibitive, and not uniquely compatible with patient preference, it should never be used. When a treatment is safe, effective, supported decisively by science, better than any other therapeutic option, readily accessible, and preferred by a patient, it should always be used. Challenges occur when options reside in between, such as when the approaches supported by the best science have all been tried, and have all failed. What remains is a treatment that is apparently safe, possibly effective, cost neutral, and desired by the patient, but not deﬁnitively supported by the available research evidence. 4 When evaluating any potential clinical intervention, there is an implicit (or explicit) assessment of risk versusbeneﬁt. Efﬁcacy is generally the major component of the beneﬁt assessment (but not the only beneﬁt; for example, psychological beneﬁt can occur even in the absence of other clinical effects), whereas safety concerns are the primary risk (but not the only risk; for example, there is economic harm when using a safe but ineffective intervention). Conclusions The overlap of integrative medicine with preventive medicine is noteworthy. At the level of primary pre- vention, a number of approaches can contribute to health promotion. Minimally, these encompass lifestyle counseling, dietary guidance, stress mitigation techni- ques, interventions to improve sleep quality, and use of natural products for health promotion. At the level of secondary prevention, approaches such as stress man- agement and lifestyle interventions are germane, as are interventions that facilitate use of conventional therapies for risk attenuation. At the level of tertiary prevention, the full range of complementary health approaches pertain to such goals as pain management, symptom control, stress relief, disease management, and risk reduction.

To some extent, a conventional medical system that has emphasized the diagnosis and treatment of disease with ever-increasing degrees of specialization has margi- nalized both preventive medicine and the holistic view that is central to integrative medicine. The importance of disease prevention/health promotion is gaining increas- ing recognition, due in part to economic forces molding the evolution of modern health care. 141–144 As integrative medicine tends to be philosophically aligned toward environmentalism 25 and social justice, 145 as well as being particularly concerned with iatrogenesis (adverse effects of medical treatment), 146 the interface of integrative medicine and primordial and quaternary prevention becomes apparent. Integrative medicine thus offers the promise of more-expansive means to achieve Table 2.The Clinical Applications of Research Evidence Construct a Safety Efﬁcacy ScienceOther therapeutic optionsPatient preferenceCost / accessibilityUtilization frequency of treatment in question High High Decisive None that is superiorPrefers recommended approachNot a concernAlways Probable Possible Unclear None/few Anything that will workNeeds considerationOften Low Low Absent/ opposedMany that are superiorAnything that will workProhibitive Never aAdapted and expanded from Katz and Ali. 4 Ali and Katz / Am J Prev Med 2015;49(5S3):S230–S240 S234 www.ajpmonline.org the desired ends of preventive medicine, but also imposes the challenges of assessing evidence across that broader expanse.

With patients increasingly interested in complemen- tary and integrative approaches and conventional practi- tioners often uninformed or reticent, a system of unintegrated or, worse, disintegrated health care prevails in the U.S. Some conventional physicians actively dis- courage the use of CAM wholesale, without considering the differences in approaches or practitioners—or the potential value of integrative care. CAM-oriented practi- tioners may be just as apt to discourage the use of standard preventive interventions of conventional med- icine, citing its reliance on pharmaceuticals and invasive procedures, a failure to respect nature, a systemic lack of compassion and patient centeredness, andﬁnancial conﬂicts of interest. 147,148 It is noteworthy that conﬂicts of interest (ﬁnancial and non-ﬁnancial) and ethical challenges are prevalent in a number of CAM arenas such as providers proﬁting from dietary supplement sales and laboratory testing. 149–151 There is real danger here of patients toppling into the divide, with attendant squan- dering of the potential for disease prevention and health promotion.

The Integrative Medicine in Preventive Medicine Education project was designed to introduce preventive medicine residents to integrative medicine to enhance the education and practice of preventive medicine, 152 implying a unidirectional positive inﬂuence of integrative medicine. This is also an opportune time to encourage a bidirectional exchange of ideas where preventive medi- cine can enhance integrative medicine. In particular, fundamentals of preventive medicine training and prac- tice—biostatistics, epidemiology, research into causes of disease in population groups, the practice of prevention in clinical medicine, and planning and evaluation of health services 153 —can improve aspects of CAM and integrative medicine in such areas as childhood vaccines and encourage the critical evaluation of prevalent prac- tices. Indeed, recent national initiatives to limit pharma- ceutical industry inﬂuence in medical education (PharmFree), 154 better disclosure ofﬁnancial conﬂicts of interest (Sunshine Act), 155 and purging low-value practices from medical specialties (Choosing Wisely) 156 can serve as models to improve CAM and integrative health care. Implementing U.S. Food and Drug Admin- istration good manufacturing practices for dietary sup- plements can mitigate risk of contamination and poor quality control. 157 Incorporating emergingﬁndings from clinical and neurobiological 158 research of contextual and placebo effects can enhance the delivery 159 and under- standing of some CAM approaches. Overall, the appli- cation of preventive medicine principles and recentquality improvement initiatives can strengthen integra- tive medicine in the context of a healthcare system moving to value-based care. 144 Recent outcomes research on models (or“whole systems”) of integrative care 32–35,116–118 demonstrate promise and innovation, as well as potential cost savings, 8,119 despite a lack of large-scale funding 160,161 and methodologic challenges. 162–164 Practice-based research networks of integrative medicine centers are now adding to the literature on community effectiveness of integrative medicine for chronic pain 116 and cancer care. 165 Initiatives in integrative practices in underserved communities 166–168 demonstrate a public health orienta- tion beyond the more educated and afﬂuent demographics historically associated with CAM. Furthermore, the Patient-Centered Outcomes Research Institute, established by Congress in the Patient Protection and Affordable Care Act of 2010, 169 is focused on patient-centered comparative clinical effectiveness research and includes explicit stipula- tions for research on“integrative health practices.” 169 Relevant PCORI-funded research focused on chronic pain in underserved communities include studies in acupunc- ture 170 and integrative group visits. 171 Some posit that these emergingﬁndings can inﬂuence the current health- care system to be both more value driven and more aligned to integrative principles. 172 The ultimate goal of integrative medicine should be to make the widest array of appropriate options available to patients. Appropriateness should be predicated on fun- damental considerations that pertain equally to conven- tional and CAM practice: treatment safety and treatment effectiveness. Treatment safety and treatment effective- ness must, in turn, be interpreted in light of the available evidence.

Evaluating the current state of integrative medicine and preventive medicine leads to a number of funda- mental research questions that can address essential gaps.

The role of integrative medicine in areas germane to primary and secondary prevention needs to be better assessed in terms of rates of uptake of clinical preventive services, as well as the ability to demonstrably improve diet, physical activity, and smoking-cessation efforts. The question of whether integrative clinicians model healthy behavior and inﬂuence their patients in comparison to other clinicians is relevant, as well as cost-effectiveness studies of integrative practices in high-priority areas such as pain management and adjunctive cancer care. 173 But even in the absence of evidence, health care is not advanced by failing to adequately treat symptoms, engage patients in a therapeutic alliance, control disease progres- sion, or produce satisfaction. 4 The simple argument supporting integrative care is that modern medical science and knowledge, despite profound successes, comprises Ali and Katz / Am J Prev Med 2015;49(5S3):S230–S240S235 November 2015 far less than patient need. Integrative care is not a comprehensive solution, but does expand the array of patient options, and can increase the likelihood of success that can be assembled across the stages of prevention. 4 Publication of this article was supported by the Health Resources and Services Administration (HRSA-12-182).

The authors would like to thank Asim A. Jani, MD, MPH, for contributing insights and expertise in preparing this manuscript.

The authors are grateful for the funding support from the Health Resources and Services Administration (HRSA) of the USDHHS, and their Integrative Medicine Program, HRSA Grant No. IMOPH25100. This information or content and conclusions are those of the authors and should not be construed as the ofﬁcial position or policy of, nor should any endorsements be inferred by, the HRSA, DHHS, or U.S.

Government.

The project was supported by the HRSA of the USDHHS under Grant No. UE1HP25094 and from the National Center for Complementary and Integrative Health at the National Institutes of Health under Grant No. K23AT006703.

Noﬁnancial disclosures were reported by the authors of this paper.

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