Community-Based Complementary and Alternative Medicine: An Integrative Approach to Confronting...

Running head: PREVENTING HEART DISEASE 1

Community-Based Complementary and Alternative Medicine:

An Integrative Approach to Confronting America’s Leading Killers

Myrna Davis Washington

University of the Rockies

Preventing Heart Disease 2

Community-Based Complementary and Alternative Medicine:

An Integrative Approach to Confronting America’s Leading Killers

Taking an integrative approach to health is nothing new.

Since the days of ancient Greek medicine, Plato, and Hippocrates;

physicians have approached healing by balancing the four ‘humors’

(blood, phlegm, black bile, and yellow bile) and modifying

lifestyle behaviors, such as diet and exercise. In recent years,

however, conventional medicine’s original goal of ‘alleviating

suffering’ (based on the Hippocratic Oath taken by every

physician) has been reshaped by a paradigmatic shift in thinking

ushered in by a deeper understanding of anatomy and physiology,

the emergence of new scientific evidence bases (i.e.,

neurobiology, molecular biology, genetics, infectious disease,

etc.), revolutionary medical and technological advances, a

shrinking globe and an increasingly diverse and aging population,

a fledgling economy, and a growing dissatisfaction with the


costly and curative, aggressively invasive, disease-focused,

treatment-only approach of conventional Western biomedicine.

Medicine’s ‘new’ model, an Integrative Medicine (IM),

refines traditional Western medicine’s original goal with a

holistic, preventative, person-centered, healing-oriented

approach committed to solving health problems with an

understanding of the profound implications of biopsychosocial-

spiritual interconnectedness in the healing process and the use

of evidence-based, non-invasive, natural and therapeutic

interventions (i.e., botanical medicine, lifestyle modification,

therapeutic touch, diet, exercise, community-based organizations,

etc.) whenever possible (Kligler & Lee, 2004). This paper

explores the impact that IM can have on attenuating medicine’s

revised goal by examining the impact of community-based

organizations (CBOs) and complementary and alternative medicine

(CAM) strategies on alleviating the suffering caused by two of

the leading causes of morbidity and mortality in the United

States today: heart disease and stroke; discussed herein as

Cardiovascular Disease (CVD).

What Are The Leading ‘Killers’ in the United States?


In 2010, the U.S. National Vital Statistics System (NVSS, as

cited in CDC, 2013) recorded nearly 2.5 million deaths in the

United States and listed the ten leading causes of morbidity and

mortality as: 1) heart disease, 2) cancer, 3) chronic lower

respiratory diseases, 4) stroke, 5) unintentional injuries, 6)

Alzheimer’s disease, 7) diabetes, 8) nephritis/ nephrotic

syndrome/ nephrosis, 9) influenza and pneumonia, and 10) suicide.

As the number one and number four ‘killers’ in the United States,

heart disease and stroke are combined as one chronic disease:

Cardiovascular Disease (CVD).

Cardiovascular Disease: What Is It and What IS Its Impact?

As stated above, CVD is made up of heart disease (myocardial

infarction, cardiac failure, coronary artery disease, heart

attack, angina, and arrhythmias) and stroke (a ‘brain attack’

occurring when a clot blocks the blood supply to the brain or

when a blood vessel in the brain bursts). In describing the

‘suffering’ caused by CVD, evidence indicates that heart disease

can lead to heart attacks/myocardial infarctions (MI),

arrhythmia, atherosclerosis, and death; and that stroke can cause

death (immediate in approximately 6% of cases), paralysis,


significant disability, speech and motor disabilities, emotional

problems (CDC, 2013; Oberg et al., 2009). However, the overall

effects of CVD are indicated by multilevel and catastrophic

‘suffering’. According to the 2010 NVSS findings, CVD accounts

for one in three deaths (nearly 800 thousand), costs Americans an

estimated $444 billion in direct and indirect health care costs,

accounts for one of every six American dollars spent on health

care, and promises to have an even more devastating economic

impact on the nation’s healthcare system as the U.S. population

continues to diversify and age (CDC, 2013).

Other, more telling, CVD statistics include the following:

1) More than one out of three (83 million) U.S. adults currently

lives with one or more types of CVD; 2) An estimated 935,000

heart attacks and 795,000 strokes occur each year; 3) Nearly 68

million adults have high blood pressure, and about half do not

have this condition under control; 4) An estimated 71 million

adults have high cholesterol (i.e., high levels of low-density

lipoprotein cholesterol); and 5) Nearly 2 of 3 do not have this

condition under control (CDC, 2013). Despite these statistics,

CVD deaths have continued to decline over the past 40 years, due


in large part to risk factor reductions (e.g., reducing high

blood pressure and high cholesterol) and modifying lifestyle and

health behaviors (i.e., smoking cessation, regular moderate

activity, and adopting balanced, healthful eating habits) (CDC,

2013).

Who is Most at Risk of Experiencing CVD?

While anyone who fails to adopt preventative lifestyle

modifications can put themselves at risk of contracting CVD, data

from the 2009 Behavioral Risk Factor Surveillance System (BRFSS,

as cited in CDC, 2013) suggests that at-risk individuals can most

readily be identified by correlating individual heart health with

seven heart health risk factors (high blood pressure, high

cholesterol, smoking, overweight, diabetes, lack of physical

activity, and less than 5 servings of fruit and vegetable a day),

with ideal heart health being associated with having ideal values

for each heart-health risk measure and poor heart health having

ideal values for two or less of the seven factors. According to

findings from this survey, of the nearly 10% of Americans

reporting poor cardiovascular health: 1) those 65 years or older

have the lowest heart health and the highest percentage of poor


heart health; 2) adults aged 18 to 34 years have the lowest

percentage of poor health; 3) those aged 35 to 54 years have the

highest percentage of ideal heart health; 4) women had better

heart health than men across all categories; 5) Non-Hispanic

whites and Asian/Pacific Islanders had consistently better heart

health than Hispanics; 6) Non-Hispanic African Americans and

American Indian/Alaska Natives had poorer heart health than their

counterparts in the other three groups; 7) and adults who had

received college or postgraduate degrees had consistently higher

levels of ideal heart health (CDC, 2013).

How Are The Social Determinants of Health Associated with CVD?

In addition to the above findings, results from the 2009

BRFSS suggested that the pressing issue of dealing with health

disparities across racial, cultural, and ethnic lines was

compounded by the social determinants of health (the social

circumstances in which people are born, grow up, live, work, and

age, as well as the systems put in place to deal with illness)

and a wider set of forces, including economics, social policies

and politics, population differences in environmental exposures,

health care access, utilization or quality, health status, health


outcomes, and access to digital technology (the “digital divide”)

(Gibbons, 2005; CDC, 2013). Research supports this with evidence

of consistent lower health care quality and poorer CDV outcomes

in ethnic minorities or patients in the lower socioeconomic

status (SES) (Oberg, Fitzpatrick, Lafferty, and LoGerfo, 2009).

According to one study (Oberg et al., 2009), while health

care disparities along racial lines has been documented in all

aspects of care, and the rate of CDV-related deaths has

differentiated little at one year (39.7% for blacks and 37.6% for

whites; P = .001), evidence shows that minorities are

disproportionately represented in lower SES strata and that,

compared with lower-SES patients, more affluent and better-

educated patients are more likely to receive cardiac

rehabilitation (43.9% vs 25.6%, P < .001) or to be seen by a

cardiologist (56.7% vs 47.8%, P < .001) (Oberg et al., 2009).

These studies also show that while some health disparities may be

attributable to underlying differences in access to care (e.g.,

privately insured vs Medicare or Medicaid; associated stigma),

the ratio of minorities enrolled in Medicaid is substantially

higher than in the general population (Oberg et al., 2009). What


this suggests and reinforces is the idea that the solution to

disparities in health care may be solved, for the most part, by

making health care more affordable, and, therefore, more

accessible to everyone; an economic problem most likely best

addressed at the community or local level.

How Should CVD Be Addressed?

Despite being one of the most widespread and costly health

problems facing the country today, CVD has been shown to be one

of the most preventable chronic diseases. Yet, research

demonstrates that despite the significant progress in

understanding its pathophysiology and declining rates of

occurrence and frequency, CVD continues to be the major cause of

mortality and morbidity in the US and the world today (CDC, 2013;

Weiner & Rabbani, 2010). Based on this information, the answer to

how CVD should be addressed appears logically simple: a

preventable disease, such as CVD, should be addressed by using a

preventative intervention. A rapidly expanding body of research

concurs by demonstrating high efficacy in CVD prevention with the

use of integrative, preventative, absolute-risk-based therapies

that deviate from the traditional “treatment only” approach of


conventional Western medicine by emphasizing self-care, lifestyle

modifications, and, in some cases, taking medication (CDC, 2013).

To put the above findings into action, the U.S. Department

of Health and Human Services’ Healthy People 2020 (the third set of

ten-year health objectives released to assist federal, state, and

local governments in promoting health, preventing disease, and

improving the health of every U.S. citizens) has devised a

blueprint for improving cardiovascular health and quality of life

through prevention, detection, and treatment of risk factors for

heart attack and stroke; and the American Heart Association (AHA)

has defined its 2020 cardiovascular health goal as a 20%

improvement in the cardiovascular health of all Americans and a

20% reduction in deaths from CVD (CDC, 2013; MedicineZine, 2011).

Can Community-Based Organizations Be Utilized for CVD Risk

Reduction?

Firstly, what is a community and what are community-based

organizations (CBOs)? According to MacQueen et al. (2001), a

community is “a group of people with diverse characteristics who

are linked by social ties, share common perspectives, and engage

in joint action in geographical locations or settings” (para. 3).


Working from this definition, a community can be a church, a

school, an organization, the workplace, the Internet, or a public

organization; and can be based on culture, ethnicity, gender,

sexual preference, interests, skills, occupation, beliefs, or

values. According to the American Academy of Pediatrics (AAP,

2005), a CBO is a locally controlled and consumer-oriented agency

that fosters self-reliance and self-sufficiency in the overall

advancement of human welfare and reflects the values of the

community in which it resides (AAP, 2005).

What Are the Strengths and Weaknesses of Using a CBO to Address

CVD?

According to the AAP (2005), CBOs have expert knowledge in

community needs, community credibility, resources, the culture of

the clients they serve, funding streams, and unique advocacy

opportunities. In addition, each CBO has a mission to serve a

defined group of individuals with a set of programs or services

to meet some of the needs of the community (AAP, 2005). Moreover,

most CBOs, by their nature, are flexible and resourceful in

assisting individuals in crisis and have the infrastructure to

partner with other community organizations and tap into community


opinion, despite having a narrow or broad focus of the human

services they provide (AAP, 2005).

An increasing number of studies show community-based risk

reduction strategies to be highly efficacious in preventing the

incidence of CVD (Cobiac, Magnus, Barendregt, Carter, & Vos,

2012; Weiner & Rabbani, 2012). One study (Weiner & Rabbani, 2010)

examined the value of adhering to evidence-based secondary

prevention therapies (i.e., exercise, smoking cessation,

controlling diabetes, diet and weight reduction, cardiac

rehabilitation, influenza vaccination, environmental issues, and

depression screening) for CVD prevention. As these are evidence-

based, non-pharmacological, non-invasive, preventative,

integrative strategies that can be implemented at the state,

local, and community levels, CBOs and complementary and

alternative medicine (CAM) strategies appear to be ‘tailor-made’

for monitoring and educating people on how to modify their

lifestyles and behaviors to reduce the risk of future

confrontations with heart disease and possible heart attacks

(Weiner & Rabbani, 2012).

What is Complementary and Alternative Medicine (CAM)?


The National Center for Complementary and Alternative

Medicine (NCCAM, as cited in Georgetown University Law Library’s

“Complementary & Alternative Medicine Research Guide”, 2013)

defines Complementary and Alternative Medicine (CAM) as “a group

of diverse medical and health care systems, practices, and

products that are not presently considered to be part of

conventional medicine.” NCCAM also divides CAMs into four major

areas: 1) natural products (herbs/ botanicals, vitamins and

minerals, and probiotics; widely marketed, readily available to

consumers, and often sold as dietary supplements); 2)

manipulative and body-based practices (i.e., Acupuncture,

healing/therapeutic touch, Reiki, massage therapy, spinal

manipulation, etc.); 3) mind-body medicine (i.e., mindfulness or

transcendental meditation, guided imagery, and relaxation

techniques such as breathing exercises, guided imagery, and

progressive muscle relaxation); and 4) movement therapies,

traditional healers, energy medicine and whole medical systems

(i.e., a broad range of Eastern and Western movement-based

approaches, including yoga, Feldenkrais method, Alexander


technique, Pilates, Rolfing Structural Integration, and Trager

psychophysical integration) (NCCAM, 2013).

According to NCCAM (2013), the ten most common CAM

approaches in 2007 were natural products (17%), deep breathing

(12.7%), meditation (9.4%), chiropractic and osteopathic (8.6%),

massage (8.3%), yoga (6.1%), diet-based therapies (3.6%),

progressive relaxation (2.9%), guided imagery (2.2%) and

homeopathic treatment (1.8%). Other CAM approaches presented by

NCCAM (2013) include the practices of traditional healers,

Ayurvedic medicine, traditional Chinese medicine, homeopathy, and

naturopathy. Although definitive evidence on the efficacy of

using CAM approaches to address CVD is lacking, evidence of

increasing interest and utilization of CAM approaches can be seen

in the fact that 40% of Americans now use some form of CAM

therapy to address their health problems, due primarily to rising

and costly health care costs.

Despite Their Effectiveness, Are CBOs and CAMs Cost-effective?

As stated above, as recent research indicates that 40% of

the U.S. population already use CAM therapies, based to a large

degree on the costliness of pharmaceuticals and technological


procedures; the answer to this question would appear to be ‘yes’.

However, in light of a 2012 study conducted by Cobiac et al.,

that answer might be premature. Cobiac et al. (2012) examined the

cost-effectiveness of changing cardiovascular disease prevention

from pharmaceutical treatment for everyone with hypertension or

elevated cholesterol, to absolute risk-based prevention. After

evaluating the cost-effectiveness of statins, diuretics, ACE

inhibitors, calcium channel blockers and beta-blockers, for

Australian men and women (35 to 84 years) who had never

experienced a heart disease or stroke event; the authors found

that despite demonstrating cost-effectiveness that could free up

health dollars for more important health issues, changing to

pure, absolute risk-based prevention intervention will neither

lead to substantial changes in the number of patients eligible

for treatment nor produce substantial net differences in

population health effects between conventional and integrative

approaches (Cobiac et al., 2012). Although this clearly

necessitates the need for an integrative approach and for more

studies in the future, what this most readily obviates is a case


for using community-based CAM approaches and lifestyle management

approaches for CVD prevention.

What Is the Role of CAM Approaches in Addressing CVD?

Sullivan (2001) researched the role of CAM approaches (i.e.,

nutrition, herbs, mind-body-spirit, acupuncture/oriental

medicine, lifestyle changes, nutritional supplements/vitamins,

and massage) and lifestyle management in managing patients with

coronary artery disease. Findings based on preliminary studies in

the areas of CAM indicated that because CAM focuses on patient-

centered lifestyle choices, comprehensive lifestyle interventions

(i.e., diet, exercise, relaxation, and stress management) may

benefit patients with cardiac disease (Sullivan, 2001). At the

very least, says Sullivan (2001), the surge in interest in CAM

modalities warrants further investigation and will promote

research, education, and clinical application of CAM strategies

in U.S. medical school curricula; and provide a novel venue for

the promotion of CAM as appropriate rehabilitation strategies in

CVD patients.

Is There a Place for Alternative Medicine in Addressing CVD?


As he predicted, Sullivan’s research did spark an interest in

using CAM approaches in CVD prevention and rehabilitation.

However, prevention and rehabilitation are not the only areas

where community-based organizations and CAMs have shown efficacy.

In fact, although CAM approaches have demonstrated high efficacy

in reducing the occurrence of CDV, the most significant impact

can be seen in preventing recurrent CVD occurrences with the use

of aggressive risk factor reduction strategies, including a

combination of pharmacologic and lifestyle recommendations

(Oberg, Fitzpatrick, Lafferty, and LoGerfo, 2009). In a study of

372 myocardial infarction (MI) patients (50 of whom died and 144

of whom were rehospitalized), Oberg et al.’s findings indicated

that using combined pharmacologic and lifestyle recommendations

demonstrated a 20% improvement in one-year survival rates, from

74.7% with no care to 95.7% with optimal care (2009). Therefore,

the answer to the question of whether there is a place for

alternative medicine in addressing CVD is: Complementary (or

adjunctive),Yes; Alternative: No; and neither should be used

unless supported by valid scientific research. With this in mind,


the following section presents a case for the use of community-

based CAM approaches for CVD prevention and rehabilitation.

How Can Community-based CAM Approaches Be Used to Address CVD?

According to Oberg et al. (2009), a number of organizations

(i.e., the American Heart Association [AHA], American College of

Cardiology [ACC], and European Society of Cardiology) have

published guidelines that specify the evidence-based components

of optimal secondary prevention of CVD. This is based in part,

posit Oberg et al. (2009), on evidence suggesting that because

discharge planning and outpatient secondary prevention have not

demonstrated improvement as rapidly as processes of optimal

inpatient care, guidelines associated with nonpharmacologic

interventions (cardiac rehabilitation, smoking cessation,

physical activity, weight reduction) should be considered (Oberg

et al., 2009). One example is the AHA’s Get with the Guidelines,

a community-based quality improvement program. Recent results

from facilities implementing Get With the Guidelines demonstrate

that, compared with drug recommendations that are made 86% to 93%

of the time, nonpharmacologic interventions are recommended only

26% to 54% of the time and that, in addition to secondary


prevention of CVD, lifestyle modifications reduce the risk for

many other chronic diseases and have been prioritized as a common

agenda by the CDC, the AHA, the American Diabetes Association,

and American Cancer Society (Oberg et al., 2009).

Another community-based CAM intervention that has

demonstrated efficacy is the AHA’s “My Heart My Life” (MHML; AHA,

2013). Although racial disparities have been reported in access

to computers and the Internet, MHML has shown effectiveness in

addressing CVD as an interactive web-based intervention with the

goal of educating and informing anyone on the Internet or in the

global community on a heart-healthy lifestyle. The seven sub-

sections (accessible from the drop-down menu) include: 1) a

nutrition center (healthy diet, shopping, cooking, recipes,

dining out, cookbooks, and health guides); 2) physical activity

(Start Walking, National Walking Day); 3) healthier kids

(programs, tips on making healthy homes, activities for kids, and

teaching gardens); 4) weight management (BMI, losing weight, and

obesity); 5) stress management (stress-fighting habits, proactive

stress techniques, four ways to deal with stress); 6) fats & oils

(fats 101, meet the fats, the dish with Dr. Eckel, Restaurant


Resources); and 7) quitting smoking (resources and tips for

quitting smoking). These mirror the previously-cited BRFSS risk

factors and align with community-based, preventative, risk-based

CAM strategies outlined by BRFSS and referenced above (Cobiac

et al., 2012; Oberg et al., 2009; Sullivan, 2001; Weiner &

Rabbani, 2012). And, while racial disparities in computer

accessibility may retard or impede deliverance of this strategy

to ethnic minorities or those in the lower SES bracket, this

writer does not believe the disparity to be disproportionate (at

least, not with respect to ethnicity).

One final exploration of community-based CAM intervention is

the CDC’s “Reducing Out-of-Pocket Costs (ROPC)” program for

patients with high blood pressure and high cholesterol, two of

the most evidenced risk antecedents for CVD (CDC, 2013). ROPC is

based on a systemic review of five studies reviewing its economic

impact and fourteen studies demonstrating a reduction of out-of-

pocket medical costs for patient costs to be positively

associated with improvements in adherence to blood pressure (a

decrease in systolic and diastolic blood pressure) and

cholesterol-lowering medications (increased by a median of 3.2


percentage points: 2.0 to 4.6) and blood pressure (decreased by a

median of 8.7mmHg; 1.9 to 10.9) and cholesterol outcomes (a

decrease in total cholesterol, low-density lipoprotein, and

triglycerides) (CDC, 2013). Results from these two groups of

studies are applicable to adults (aged 18 to 64), women and men,

low income patients, Hispanic, white, and African-American

patients (CDC, 2013); rendering this program an effective CAM

strategy for addressing CVD prevention and health disparities.

In a nutshell, ROPC involves program and policy changes that

reduce or cover the costs of CVD preventive services such as

medications, behavioral counseling (e.g., nutrition counseling),

and behavioral support (e.g., community-based weight management

programs, gym membership) by providing new or expanded treatment

coverage and lowering or eliminating patient out-of-pocket

expenses (i.e., copayments, coinsurances, deductibles) (CDC,

2013). Additionally, ROPC is coordinated through the community’s

health care system and preventive services are delivered in

clinical and non-clinical settings; can be implemented alone or

in conjunction with other interventions to enhance patient-

provider interaction (i.e., team-based care, medication


counseling, and patient education); and communicates program and

policy changes using targeted health messages (i.e., supporting

materials, publications, promotional materials, etc.) to increase

awareness and use of covered services (CDC, 2013).

Is Integrative Medicine More Effective In Treating CVD than

Conventional Medicine?

As stated previously, despite the ‘best efforts of

conventional medicine’ and a more profound understanding of the

disease pathophysiology of CVD, CVD continues to affect one in

three Americans. While the strengths and weakness of conventional

medicine were addressed in the introduction as the logic behind

the current paradigmatic shift in medicine and in thinking, in

general, it is clear from a preponderance of the evidence

presented in this paper, that CVD is most appropriately addressed

by using risk-based, preventative, community-based CAM approaches

because they are evidence-based, non-invasive, ‘natural’,

holistic, patient-centered, empowering, healing-centered, based

on patient-centered lifestyle choices, and, in most cases, cost-

effective and, therefore, accessible. If “the CVD numbers”

presented in this paper indicate anything, they demonstrate that


if conventional medicine continues to do what it has done in the

past, it will garner the same results. They also admonish that

if a change in outcome is desired, then a change in interventions

must be affected (the definition of insanity). That change must

necessarily come in the form of community-based CAM approaches

that prevent, rehabilitate, and restore; three of the fundamental

principles underlying the foundations of Integrative Medicine.

In conclusion, as an integrative approach was actually

identified in the original Hippocratic Oath (e.g., respect for

hard-won scientific gains, use any measures requires to treat,

warmth, sympathy, and understanding; respect for patient privacy;

patient-centeredness, and the use of disease prevention whenever

possible) taken by every U.S. physician, preventative, risk-

based, community-based CAM approaches, used in conjunction with

cholesterol-lowering and blood pressure-reducing medicine (an

integrative approach), appear to be tailor-made for addressing

CVD as one of the nation’s most urgent and pressing health

problems. This way, no one is left out. While the evidence does

not definitively support their efficacy in addressing the number

one and the number four causes of death in the U.S., it does


promote interest in CAM approaches and, therefore, provides

opportunities for new research to refine and deepen our

understanding of the world around and within us by validating or

refuting accepted anecdotal evidence of what worked in the very

distant and not-so-distant past. As Jung asserted, healing and

therapy should consist of “whatever works.” As diversity aligns

itself along individual, rather than racial, ethnic, community,

or national lines; it is important for health and health

approaches to ‘fit’ the individual needs of every person; a feat

requiring little more than preparation, tenacity, an open and

inquisitive mind, a willingness to view things from multiple

perspectives, and the opportunity to pull it all together. In

the words of Henry Hartman: “Success happens when preparation

meets opportunity.” The question is, are we ready?


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