Integrative Medicine and Womens Health

Anastasia Rowland-Seymour, MD Fellow, Program in Integrative Medicine University of Arizona

Priester National Extension Health Conference Phoenix, AZ April 22, 2003
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Health Issues for Women

Heart Disease Cancers

Lung Cancer number one for deaths per year Breast Cancer number one for diagnoses per year

Stroke Diabetes Asthma Osteoporosis HIV/AIDS Domestic Violence

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Chronic Diseases

Women report a higher number of chronic conditions and have higher rates of disability and activity limitations than men. While 67% of women between the ages of 18 and 64 reported their health as excellent or very good, only 36.9% of women aged 65 and over did so.
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So how can we make a difference for Women even if money is an issue?

Nutrition

1996 Data from the USDA indicate that 9% of US women over the age of 20 ate less than one serving of vegetables per day, and only 47% of women consumed at least 2 servings of vegetables a day. Only 26% of adult women ate two fruit serving daily, and nearly half of U.S. women received less than one serving of fruit per day.
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Physical Activity

Preliminary data from early 2001 show that 36% of women aged 18-24 reported exercising regularly, with the proportion continually decreasing with advancing age. Among persons 18-64 years and 75 years and older, men were more likely than women to participate in regular exercise.
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Mental Health

Depression and anxiety disorders disproportionately affect women. 12% of women reported having between 3-7 poor mental health days as compared to 9% of men.
5% of women reported being in poor mental health for the entire month.
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Integrative Medicine Definition

Integrative Medicine is healing-oriented medicine that takes account of the whole person (body, mind and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.
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Integrative Medicine CAM

Integrative Medicine seeks to combine the best ideas and practices of conventional and alternative medicine into cost-effective treatments that will be in the best interest of patients and that aim to stimulate the bodys natural healing potential. It neither rejects conventional medicine nor embraces alternative practices uncritically.
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Principles of Integrative Medicine

1. 2. 3. 4. 5.

The conviction that it is better to prevent disease than to have to treat it later. Recognition of the interaction between body, mind, spirit, and environment. A desire to integrate the best of conventional and unconventional medicine. The belief that bodies respond uniquely, so treatment must be customized. A belief in the innate healing powers of the body.
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The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.
Thomas A. Edison
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Prevention Oriented

It is safer, cheaper, and more effective to prevent disease before it starts. Innumerable studies illustrate the healthprotective effects of good food, plenty of water, regular exercise, and stress reduction, even vitamins (JAMA 2002). Focus on education about lifestyle interventions that improve and maintain health.
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Principles of Integrative Medicine

1.
2.

3.
4.

5.

The conviction that it is better to prevent disease than to have to treat it later. Recognition of the interaction between body, mind, spirit, and environment. A desire to integrate the best of conventional and unconventional medicine. The belief that bodies respond uniquely, so treatment must be customized. A belief in the innate healing powers of the body.
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Environmental Factors

No health problem exists in isolation. Environment can be defined in so many ways, physical, cultural, mental, spiritual, etc. There are many studies looking at cultural competency in medicine and its importance in providing effective health care.
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Interaction between body, mind, spirit, and environment

Role of the environment in illness and healing: how the patient eats, if they exercise, how they relate to their environment, what stressors are present and how one reacts to them Knowing the importance (and having the time) to not just look at symptoms but also to listen for deeper issues that might be contributing to an illness
Dealing with issues of mind and spirit, recognizing that Medicine and Spirit are not incompatible, that combining one with the other creates potential for healing that goes far beyond the potential of either one used independently
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Principles of Integrative Medicine

1.
2.

3.

4. 5.

The conviction that it is better to prevent disease than to have to treat it later. Recognition of the interaction between body, mind, spirit, and environment. A desire to integrate the best of conventional and unconventional medicine. The belief that bodies respond uniquely, so treatment must be customized. A belief in the innate healing powers of the body.
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Integrate the best of conventional and unconventional medicine

An Integrative Physician is conventionally trained An Integrative practitioner employs a wide-ranging set of tools: Conventional: vaccines, antibiotics, pain medications, diagnostic tests, and surgery Unconventional: mind/body techniques, botanicals, nutritional interventions, manipulation, massage, movement therapies, homeopathy, and other alternatives Embrace technology, understand its usefulness, understand its limitations, and use it when appropriate

Antibiotics for Sepsis, Surgery for Acute Injury, etc. Other Modalities for Viral Illnesses, Autoimmune disorders, etc.
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Not every alternative therapy is effective!

Consider that 43% of Americans spent $21.2 billion in 1997 on unconventional therapies, such as chiropractic, massage, herbal remedies, and dietary supplements, and the majority of these patients did not disclose this info to their physicians.
The concern is that not every modality used is effective, there isnt evidence to support a good number of the therapies being used. We recommend therapies for which there is good evidence.
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Principles of Integrative Medicine

1. 2. 3. 4. 5.

The conviction that it is better to prevent disease than to have to treat it later. Recognition of the interaction between body, mind, spirit, and environment. A desire to integrate the best of conventional and unconventional medicine. The belief that bodies respond uniquely, so treatment must be customized. A belief in the innate healing powers of the body.
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Patient Centered Customized Treatment

Many conditions have different triggers in different people, so it makes sense that different people may need different approaches to healing- e.g. asthma. People vary in their biochemistry, genetics, digestion, hormonal levels, attitudes, values, age and gender, all of which can influence what works and what doesnt - e.g. idiosyncratic reactions.
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Genetic Polymorphisms

A small study published in the Lancet studied 57 patients on Coumadin looking for the presence of genetic variants of the CYP2C9 allele and its effect on elevated INRs. In the low dose coumadin group 29 of 36 (81%) had one or more variant alleles. 20 of the 36 patients had an elevated INR. 3-10% of Caucasians are deficient in CYP2C9. CYP2C9 is responsible for 15% of drug metabolism therefore increased susceptibility to Accolate, Diclofenac, Ibuprofen, Losartan, Phenytoin, Warfarin, etc.
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Drug Metabolism

Even the types of foods that we eat can affect our metabolism. Weve all heard about grapefruit and how we shouldnt eat it with many drugs because it decreases metabolism of many drugs and raises drug levels. Additionally, liver metabolism is improved by in Phase I by milk thistle and cruciferous veggies, and in Phase II by cruciferous veggies, green tea, fish oils, folic acid, vitamins B6, B12, and C, glutathione and selenium.
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Adverse Drug Events

It is well documented that there are detrimental outcomes from the right drug at the right time to the right person.
In 1998, JAMA published a meta-analysis of studies about inpatient adverse drug events that estimated in 1994 more than 1 million Americans were hospitalized due to adverse drug events, accounting for 4.7% of all admissions.
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Adverse Events

Last week lead article in New England Journal of Medicine on Adverse Drug Events in Ambulatory Care. Of 661 patients who responded, 162 (25%) had adverse drug events. Of the respondents 66% were women. Drugs most often involved: SSRIs, Bblockers, ACEs, Ca channel blockers, Corticosteroids, NSAIDs, Non-narcotic analgesics.
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Principles of Integrative Medicine

1. 2. 3. 4. 5.

The conviction that it is better to prevent disease than to have to treat it later. Recognition of the interaction between body, mind, spirit, and environment. A desire to integrate the best of conventional and unconventional medicine. The belief that bodies respond uniquely, so treatment must be customized. A belief in the innate healing powers of the body.
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Homeostasis

In grade school biology we learn about the bodys ability to maintain constant conditions homeostasis.
We seek to help re-establish and maintain homeostasis.
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Innate healing power of the body

Healing comes from within (not outside) the patient.

The body is designed with an excellent system of defense. Integrative physicians attempt to work with and support this natural healing capacity. Goal: to strengthen and enhance the functioning of a

persons innate healing capacity, not take over for it.

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So What Modalities Might We Recommend?

Nutritional Interventions Mind-Body Medicine Manual Medicine Movement Therapies Traditional Chinese Medicine acupuncture alone or plus herbs Supplements Homeopathy Energy Medicine
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So Where Do We Find This Approach?

Fellowship Programs at:

University of Arizona Albert Einstein-Continuum Center University of Maryland Harvard Columbia Scripps Medical Center

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Medical School Education

JAMA study in 1998 looked at CAM electives in medical schools. Of 125 medical schools 117 replied to survey. Of those 75 (64%) offered an elective in Med School curriculum.

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The Consortium of Academic Health Centers for Integrative Medicine includes:

University of Arizona UCLA UCSF Columbia Duke Albert Einstein Georgetown Harvard University of Hawaii

Thomas Jefferson University of Maryland U Mass University of Minnesota UMDNJ U Penn University of Pittsburgh U Texas Medical Branch U Washington
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References

Womens Health USA 2002. U.S. Department of Health and Human Services. http://mchb.hrsa.gov/data/women.htm. KM Fairfield, et al. Vitamins for Chronic Disease Prevention in Adults. JAMA 2002;287:3116-3126. D Eisenberg, et al. Trends in Alternative Medicine Use in the United States, 1990-1997: Results of a Follow-up National Survey. JAMA 1998;280(18):1569-75. GP Aithal, et al. Association of polymorphisms in the sytochrome P450 CYP2C9 with warfarin dose requirement and risk of bleeding complications. Lancet 1999;353:717-9. T Gandhi, et al. Adverse Drug Events in Ambulatory Care. NEJM 2003;348:1556-64. J Lazarou, et al. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998;279(15):1200-1205. MS Wetzel, et al. Courses Involving Complementary and Alternative Medicine at US Medical Schools. JAMA 1998;280:784-787.
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