Adjunctive naturopathic care for type 2 diabetes: patient-reported and clinical outcomes after one year

A review of whole-medical systems and holistic care approach for type 2 diabetes and associated metabolic syndrome

Whole-person care and holistic care approach has been proposed for complementary and integrative health care for type 2 diabetes mellitus. However, some doubts still exist on the feasibility of replicating processes followed in clinical trials and observational studies in real-world settings. This narrative literature review summarized and assessed existing clinical evidence (clinical trials, observational studies, and case reports) describing holistic and integrated care approach in adult and adolescent individuals with type 2 diabetes mellitus in clinical practice. The goal was to highlight existing evidence for implementation and outcomes of whole-medical systems and holistic integrated care approach for type 2 diabetes mellitus. A nonsystematic literature search was performed on Google Scholar, PubMed, Web of Science, ProQuest and ScienceDirect to identify clinical evidence from different parts of the world, evaluating the use of whole-medical systems and/or holistic care interventions in clinical practice for management of type 2 diabetes mellitus. Relevant keywords were used in the search. Data were analyzed using content analysis and simple descriptive statistics (percentages). Most of the studies (64%) were mainly conducted in Eastern countries (India, China and Israel) while 36% of the studies were conducted in the Western countries (USA, Netherlands, Canada and Mexico). Lifestyle medicine and integrated naturopathy were shown to be the commonly used whole-medical systems for type 2 diabetes mellitus management. Significant improvements in type 2 diabetes parameters, medication use, other symptoms, and overall feeling of wellness were observed in all studies. This review study revealed limited utilization and/or documentation of whole-medical systems or holistic care treatments for type 2 diabetes mellitus in regions of the world other than eastern countries. Lifestyle medicine, naturopathy, yoga, Ayurveda and traditional Chinese medicine were shown to be effective for type 2 diabetes mellitus, either as an alternative or as a complementary therapy. Please cite this article as: Makoni L, Manduna IT, Mbiriri AL. A review of whole-medical systems and holistic care approach for type 2 diabetes and associated metabolic syndrome. J Integr Med. 2024; Epub ahead of print.

Assessing the Feasibility of Rural Residency Training for Licensed Naturopathic Physicians in the Northwest: A Qualitative Study

Objectives

Naturopathic physicians (ND) are uniquely situated to address areas of unmet health care need as primary care providers (PCPs). In several states, NDs have a broad scope of practice and are licensed as independent practitioners regardless of residency training. However, with a larger role in the health care system, the need for post-graduate medical training becomes more important for clinical success and patient safety. Our study aimed at assessing the feasibility of developing residencies for licensed NDs in rural federally qualified health centers (FQHCs) of Oregon and Washington.

Methods

We conducted interviews with leadership from a convenience sample of eight FQHCs. Six centers were rural, two of which already employed NDs. Two urban centers that employed NDs as PCPs were included for their valuable insights related to study design. Two investigators independently reviewed and coded site visit notes for prominent themes through inductive reasoning analysis.

Results

Consensus was met identifying the following themes: onboarding and mentorship; diversity of clinical training; financial structure; length of residency; and addressing health care needs in the community. We identified several opportunities for the development of primary care residencies for NDs, including the need for PCPs in rural communities, the ability of NDs to manage chronic pain with prescription drugs, and the prevention of morbidity from complex conditions such as diabetes and cardiovascular disease. Potential barriers to residency development include lack of Medicare reimbursement, mixed awareness of the ND scope of practice, and scarcity of dedicated mentors.

Conclusion

These results may serve as guideposts for the future development of naturopathic residencies in rural community health centers.

Naturopathic patient care during different life stages: an international observational study of naturopathic practitioners and their patients

BACKGROUND

An individual's health status varies with age, with most health problems increasing through different life stages. Yet, a key feature of the majority of conditions contributing burden to society globally, irrespective of life stage, is the predominance of chronic, non-communicable diseases (NCDs). An important response to this growing burden is the increasing recognition of addressing NCD prevention through a life-course perspective through primary care and public health. Naturopathy is a traditional medicine system originating from Europe, and its practitioners commonly provide primary care and focus on prevention and wellness. However, little is known about naturopathic practitioners (NPs) contribution to health care across different life stages.

METHODS

This secondary analysis of a cross-sectional study aimed to describe the approach to the care of NPs based on the life stage of their patients. The primary study recruited NPs from 14 regions or countries, who were invited to complete a short survey about 20 consecutive patients. The multilingual survey included the following domains: patient demographics, reason for visit, prescribed or recommended treatments, and naturopathic interpretation of the health conditions. Descriptive statistics were tabulated as frequencies and percentages and chi square tests were used to test associations and compare groups. Effect size was determined by Cramer's V.

RESULTS

Participant NPs (n = 56) provided consultation details for 854 patients encounters. There were differences in the patient's primary reason for visiting, the additional physiological systems the NP considered important in the management of the patient's health, and the treatments prescribed across all life stages. However, diet (45.1-70.0%) and lifestyle (14.3-60.0%) prescription were the most common categories of treatments across all patient groups.

CONCLUSION

NPs provide care to patients across all life stages, and diverse conditions pertinent to those life stages while also demonstrating a holistic approach that considers broader health concerns and long term treatment practices. While there may be emerging evidence supporting and informing NP clinical outcomes, the breadth and diversity of health conditions, populations and treatments within the scope of naturopathic practice underscores a need for urgent and widescale research investigating naturopathic care across the life course.

Community education and health promotion activities of naturopathic practitioners: results of an international cross-sectional survey

BACKGROUND

Health promotion and patient education are crucial to improved population health and are also among the core principles that define naturopathy. Yet, the activities of naturopathic practitioners (NPs) with regards to health promotion and community education have not been widely studied.

METHODS

A cross-sectional online survey of an international convenience sample of NPs was conducted through disseminating a 15-item questionnaire prepared in five languages. Correlates of most frequently mentioned NP activities were studied.

RESULTS

The survey was completed by 813 NPs representing all world regions. Almost all participants (98%) reported at least one health promotion activity. Most reported were information sheets and handouts (92.7%) or social and professional network communications (91.8%) and information talks presented to community members (84.9%). The majority of NPs (79.5%) indicated that the 'health issues individuals in NPs' community have said they need help with' were a 'very important' consideration when they designed health promotion activities. NP characteristics associated with the likelihood of engaging in specific health promotion activities varied between activities but include gender, time since first qualification, factors considered to identify need when designing an activity, and stakeholder involvement in activity design.

CONCLUSIONS

Health promotion is a key activity of the global naturopathic profession. There are a wide range of patient education tools utilized by NPs.

The utilisation of public and private health care among Australian women with diabetes: Findings from the 45 and Up Study

Aim

To describe the prevalence of health care utilisation and out-of-pocket expenditure associated with the management of diabetes among Australian women aged 45 years and older.

Design

Cross-sectional survey design.

Methods

The questionnaire was administered to 392 women (a cohort of the 45 and Up Study) reporting a diagnosis of diabetes between August and November 2016. It asked about the use of conventional medicine, complementary medicine (CM) and self-prescribed treatments for diabetes and associated out-of-pocket spending.

Results

Most women (88.3%; n = 346) consulted at least one health care practitioner in the previous 12 months for their diabetes; 84.6% (n = 332) consulted a doctor, 44.4% (n = 174) consulted an allied health practitioner, and 20.4% (n = 80) consulted a CM practitioner. On average, the combined annual out-of-pocket health care expenditure was AU$492.6 per woman, which extrapolated to approximately AU$252 million per annum. Of this total figure, approximately AU$70 million was spent on CM per annum.

Conclusions

Women with diabetes use a diverse range of health services and incur significant out-of-pocket expense to manage their health. The degree to which the health care services women received were coordinated, or addressed their needs and preferences, warrants further exploration. Limitations of this study include the use of self-report and inability to generalise findings to other populations.

Raising burden of non-communicable diseases: importance of integrating Yoga and Naturopathy at primary care level

Primary health care is a vital component in health care delivery. Non-communicable diseases (NCD's) are rising like a major threat to human survival, which is expected to account for 75% of the total mortality by 2030. Lifestyle and behavioural changes are reckoned as the way ahead. Yoga and Naturopathy, a drugless system of medicine has intersecting paradigms which addresses all planes of health effectively. Yoga and Naturopathy through its holistic approach educate and make the people responsible for their own health. It has shown its efficacy in alleviating and preventing various NCD's. A systematic approach should be initiated, which can channelize the integration of Yoga and Naturopathy at the primary care level considering its cost-effectiveness and efficacy over NCD's.

Integrating Traditional and Complementary Medicine Recommendations into Clinical Practice Guidelines for People with Diabetes in Need of Palliative and End-of-Life Care: A Scoping Review

Objectives: This study was conducted before an evidence review on Traditional and Complementary Medicine (TCM) to update the clinical practice guidelines (CPGs): "Deciding palliative and end-of-life (P/EoL) care for people with diabetes." The aim was to frame the PICO (population/problems, interventions/comparisons, and outcomes), ascertain their importance, and identify other modifying factors for grading recommendations. Design: A systematic scoping review mapped information about diabetes P/EoL problems and outcomes, TCM use, provision, benefits and risks, and stakeholder preferences and values. Thirteen electronic databases were searched in 2017/18 until no new information was identified. Relevant data were extracted, rated for quality, directness, and relevance, and synthesized using triangulation methods. Excluded was diabetes prevention or treatment, as this is not an important P/EoL problem. Results: Of the 228 included articles, except for diabetes P/EoL problems, insufficient direct evidence led to data being extrapolated from either adults with diabetes or any P/EoL diagnosis. The findings affirmed that caring for people with diabetes in need of P/EoL care is complex due to multiple fluctuating needs that are influenced by the P/EoL trajectories (stable, unstable, deteriorating, terminal, or bereaved), multimorbidity, and difficult-to-manage chronic and acute problems. The only problem specific to diabetes P/EoL care, was unstable glycemia. Over 50 TCM interventions commonly used by patients and/or provided by services were identified, of which, many might simultaneously address multiple problems and 18 had been appraised in systematic reviews. Physical and psychologic symptom reliefs were most often evaluated; however, these were only one aspect of a "good death." Other important outcomes were the quality and location of care, personal agency, relationships, preparations for the dying process, spirituality, and affirmation of the whole person. Other important modifying factors included opportunity costs, affordability, availability, preferences, cultural appropriateness, and alignment with beliefs about the meaning of illness and death. Conclusions: There is a role for TCM in the multidisciplinary holistic P/EoL care of people with diabetes. Due to the paucity of evidence specific to this population, the generalizability of some of these results is broader and the updated CPG will also need to consider indirect evidence from other patient groups. Along with recommendations about indications for TCM use, the CGP should provide guidance on ceasing unnecessary interventions, reducing polypharmacy and managing unstable glycemia is required. Before ceasing a TCM, a broader risk-benefit analysis is recommended, as unlike many conventional therapies, there may be multiple benefits warranting its continuation.

Overview of international naturopathic practice and patient characteristics: results from a cross-sectional study in 14 countries

Background

Naturopathy is a distinct system of traditional and complementary medicine recognized by the World Health Organization and defined by its philosophic approach to patient care, rather than the treatments used by practitioners. Worldwide, over 98 countries have practicing naturopaths, representing 36% of all countries and every world region. The contributions of naturopaths to healthcare delivery services internationally has not been previously examined. Thus, the primary intention of this research was to conduct an international survey of naturopathic practice and patient characteristics in order to gain insight to the breadth of their practices and the type of clinical conditions routinely encountered.

Methods

The cross-sectional study was conducted in naturopathic clinics in 14 countries within 4 world regions including the European (Portugal, United Kingdom, Switzerland, Spain), Americas (Canada, United States, Chile, Brazil), Western Pacific (Hong Kong, Australia, New Zealand) and African (South Africa). Naturopathic practitioners in each country were invited to prospectively complete an online survey for 20 consecutive cases. The survey was administered in four languages.

Results

A total of 56 naturopaths from 14 countries participated in the study, providing a mean of 15.1 cases each (SD 7.6) and 851 cases in total. Most patients were female (72.6%) and all age categories were represented with a similar proportion for 36–45 years (20.2%), 46–55 years (19.5%), and 56–65 years (19.3%). A substantial majority (75%) of patients were considered by the participant to be presenting with chronic health conditions. The most prevalent category of health conditions were musculoskeletal (18.5%), gastrointestinal (12.2%), and mental illness (11.0%). The most common treatment categories prescribed or recommended to patients by the participants were dietary changes (60.5%), lifestyle and behaviour changes (56.9%), herbal medicines (54.2%) and nutritional supplements (52.1%). Many patients were known by participants to be receiving care from a general practitioner (43.2%) or a specialist medical practitioner (27.8%).

Conclusions

Naturopathic practitioners provide health care for diverse health conditions in patients in different age groups. The global population would benefit from researchers and policy makers paying closer attention to the potential risks, benefits, challenges and opportunities of the provision of naturopathic care within the community.

Effect of an Integrated Naturopathy and Yoga Program on Long-Term Glycemic Control in Type 2 Diabetes Mellitus Patients: A Prospective Cohort Study

Aim

Lifestyle is an important risk factor for increasing the prevalence of diabetes in the Indian population. In this study, we evaluate the effects of naturopathy treatment, salt-restricted low-calorie diets, and yoga in long-term glycemic control in patients with type 2 diabetes mellitus.

Methods

In this prospective, longitudinal, two-arm cohort study, patients with type 2 diabetes mellitus referred from a tertiary care center undergoing a 3-month residential naturopathy treatment were compared with those undergoing only conventional management on glycemic control. Both fasting and postprandial blood glucose (PPBG) levels were assessed at baseline, 3 months following intervention, at 6 months, and 12 months from the study start. Data were analyzed using repeated-measures ANOVA with post hoc Bonferroni correction.

Results

Naturopathy and yoga intervention significantly reduced PPBG levels (P < 0.001), glycated hemoglobin levels (P < 0.001), and reduced requirement for antidiabetic medications (P < 0.008) in the intervention group compared to controls. The effects were more profound immediately following intervention and lasted up to 6 months from the start of the study.

Conclusion

The results suggest benefit with an intensive residential naturopathy-based lifestyle intervention program. Randomized controlled trials are needed to further validate the findings.

Naturopathy as a Model of Prevention-Oriented, Patient-Centered Primary Care: A Disruptive Innovation in Health Care

Background and Objective: The concept of a "disruptive innovation," recently extended to health care, refers to an emerging technology that represents a new market force combined with a new value system, that eventually displaces some, or all, of the current leading "stakeholders, products and strategic alliances." Naturopathy is a distinct system of traditional and complementary medicine recognized by the World Health Organization (WHO), emerging as a model of primary care. The objective here is to describe Naturopathy in the context of the criteria for a disruptive innovation. Methods: An evidence synthesis was conducted to evaluate Naturopathy as a potentially disruptive technology according to the defining criteria established by leading economists and health technology experts: (1) The innovation must cure disease; (2) must transform the way medicine is practiced; or (3) have an impact that could be disruptive or sustaining, depending on how it is integrated into the current healthcare marketplace. Results: The fact that Naturopathy de-emphasizes prescription drug and surgical interventions in favor of nonpharmacological health promotion and self-care could disrupt the present economic model that fuels health care costs. The patient-centered orientation of Naturopathy, combined with an emphasis on preventive behaviors and popular complementary and integrative health services like natural products, mind and body therapies, and other therapies not widely represented in current primary care models increase the likelihood for disruption. Conclusions: Because of its patient-centered approach and emphasis on prevention, naturopathy may disrupt or remain a durable presence in healthcare delivery depending on policymaker decisions.

A Hierarchy of Healing: Origins of the Therapeutic Order and Implications for Research

The philosophy, principles, and theories of naturopathic medicine include the six Principles of Naturopathic Medicine and the Therapeutic Order. Together these constructs, describe the core principles of the practice of naturopathic medicine, as established by thought leaders throughout the formation and development of the profession. The naturopathic medicine research agenda (NMRA) set forth recommendations for the codification of the foundational theories of naturopathic medical practice. The "Therapeutic Order, Whole-systems, Evidence-based Research Standards" (TOWERS) initiative is proposed with the primary objective to conduct the rigorous evaluation of the Principles of Naturopathic Medicine and the Therapeutic Order constructs. It is envisioned that this initiative will result in the development of an evidence-base concerning the clinical theory, philosophy and principles of whole-systems naturopathic medicine. After over one hundred years of professional organization and formal practice, there is a need to translate these empirically derived constructs into an evidence-informed theory of naturopathic medicine.

Convergent Points for Conventional Medicine and Whole Systems Research: A User's Guide

CONTEXT

Value-based health care has emerged as a manifestation of the conventional medicine community's awareness of the overlapping needs to both better incorporate patient centeredness into practice and research paradigms and further develop a systemic approach to cost reduction.

BACKGROUND

The origins of the whole systems research (WSR) movement date to the late 1990s, when the U.S. Congress legislated appropriation of funds to stimulate the U.S. National Institutes of Health to evaluate popular traditional, complementary, and integrative medicine (TCIM) practices. Questions immediately arose over how well these forms of practice could be measured through standard randomized controlled trials, and the WSR community began to articulate and adapt innovative methodologies for evaluating TCIM interventions.

DISCUSSION

This column explores the potential impact of WSR methods and exemplars on the clinical practice and research communities seeking to successfully implement and measure the complexities of value-based health care. Four potentially cross-talking themes are specifically discussed: complex behaviorally focused interventions, patient-centered outcomes, team-based care, and resilience and well-being.

CONCLUSION

The time is ripe for clinicians and investigators to capitalize on methodologies, exemplars, and learnings from the WSR literature toward improving care, developing more robust research strategies, and furthering the dialogue between the TCIM and conventional medicine communities.

Whole Systems Research Methods in Health Care: A Scoping Review

Objectives: This scoping review evaluates two decades of methodological advances made by “whole systems research” (WSR) pioneers in the fields of traditional, complementary, and integrative medicine (TCIM). Rooted in critiques of the classical randomized controlled trial (RCT)'s suitability for evaluating holistic, complex TCIM interventions, WSR centralizes the principle of “model validity,” representing a “fit” between research design and therapeutic paradigm.

Design: In consultation with field experts, 41 clinical research exemplars were selected for review from across 13 TCIM disciplines, with the aim of mapping the range and methodological characteristics of WSR studies. Using an analytic charting approach, these studies' primary and secondary features are characterized with reference to three focal areas: research method, intervention design, and outcome assessment.

Results: The reviewed WSR exemplars investigate a wide range of multimodal and multicomponent TCIM interventions, typified by wellness-geared, multitarget, and multimorbid therapeutic aims. Most studies include a behavioral focus, at times in multidisciplinary or team-based contexts. Treatments are variously individualized, often with reference to “dual” (biomedical and paradigm-specific) diagnoses. Prospective and retrospective study designs substantially reflect established biomedical research methods. Pragmatic, randomized, open label comparative effectiveness designs with “usual care” comparators are most widely used, at times with factorial treatment arms. Only two studies adopt a double-blind, placebo-controlled RCT format. Some cohort-based controlled trials engage nonrandomized allocation strategies (e.g., matched controls, preference-based assignment, and minimization); other key designs include single-cohort pre–post studies, modified n-of-1 series, case series, case report, and ethnography. Mixed methods designs (i.e., qualitative research and economic evaluations) are evident in about one-third of exemplars. Primary and secondary outcomes are predominantly assessed, at multiple intervals, through patient-reported measures for symptom severity, quality of life/wellness, and/or treatment satisfaction; some studies concurrently evaluate objective outcomes.

Conclusions: Aligned with trends emphasizing “fit-for-purpose” research designs to study the “real-world” effectiveness of complex, personalized clinical interventions, WSR has emerged as a maturing scholarly discipline. The field is distinguished by its patient-centered salutogenic focus and engagement with nonbiomedical diagnostic and treatment frameworks. The rigorous pursuit of model validity may be further advanced by emphasizing complex analytic models, paradigm-specific outcome assessment, inter-rater reliability, and ethnographically informed designs. Policy makers and funders seeking to support best practices in TCIM research may refer to this review as a key resource.

The effectiveness of integrative healthcare for chronic disease: A systematic review

BACKGROUND

The past few decades have witnessed a surge in consumer, clinician and academic interest in the field of integrative healthcare (IHC). Yet, there is still uncertainty regarding the effectiveness of IHC for complex, long-term health conditions.

OBJECTIVE

To assess the effectiveness of IHC for the management of any chronic health condition.

METHODS

Seven databases and four clinical trial registries were searched from inception through to May 2018 for comparative/controlled clinical trials investigating the effectiveness of IHC for any chronic disease, and assessing any outcome. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias tool.

RESULTS

The search yielded 6,926 results. Eight studies met the inclusion criteria. All studies had at least three design features that carried an uncertain/high risk of bias. Differences in physiological, psychological and functional outcomes, and quality of life between patients receiving IHC and patients receiving conventional/usual care were varied and inconsistent. Changes in patient satisfaction with care were inconclusive. No studies reported the effectiveness of IHC on workforce- or administration-related parameters. Evidence from one trial suggested IHC may be more cost-effective than conventional care.

CONCLUSIONS

The findings indicate some promising effects for the use of IHC to manage chronic disease. However, the uncertain/high risk of bias across multiple domains, diverse and inconsistent findings, and heterogeneity of outcome measures and study populations prevents firm conclusions from being reached. Along with conducting further well-designed, long-term studies in this field, there is a need to ensure interventions closely align with the definition/principles of IHC.

Lessons from Outside and Within: Exploring Advancements in Methodology for Naturopathic Medicine Clinical Research

Introduction: Naturopathy is a mixture of both traditional and complementary medicine. It incorporates a broad set of health care practices that may or may not be traditional to that country or conventional medicine and are not fully integrated into the dominant health care system. Research required to evaluate or substantiate naturopathic medicine may not fall under the testing of randomized clinical trials, which opens up discussions on what is the best practice for research in naturopathic medicine.

Discussion: Not only do advances in health research methodology offer important opportunities to progress naturopathic research, there are also areas where the unique characteristics of naturopathic philosophy and practice can impact other areas of health research. Some of the new advances in health research methodology involve whole-system research, pragmatic trials, template for intervention description and replication protocols for complex interventions, patient-centered care models, and the pragmatic-explanatory continuum indicator summary tool for designing pragmatic trials. Discussion and critique of these health-related methodologies shows that these research methods are more suited for the philosophy and treatment options that naturopathy is based on.

Conclusions: Successful implementation of naturopathic research methodologies, and translation and dissemination of research will require a substantial paradigm shift in which naturopathic practitioners adopt a greater level of responsibility for developing an evidence base for naturopathic medicine.

The State of the Evidence for Whole-System, Multi-Modality Naturopathic Medicine: A Systematic Scoping Review

Objective: To summarize the current state of the research evidence for whole-system, multi-modality naturopathic medicine.

Design: A systematic search for research articles from around the world was undertaken using MEDLINE, Embase, CINAHL, AMED, and WHO regional indexes. Naturopathic journals and gray literature were hand searched. No language restrictions were imposed.

Interventions: All human research evaluating the effectiveness of naturopathic medicine, where two or more naturopathic modalities are delivered by naturopathic clinicians, were included in the review. Case studies of five or more cases were included.

Results: Thirty-three published studies (n = 9859) met inclusion criteria (11 American; 4 Canadian; 6 German; 7 Indian; 3 Australian; 1 United Kingdom; and 1 Japanese) across a range of mainly chronic clinical conditions. The studies predominantly showed evidence for the efficacy of naturopathic medicine for the conditions and settings in which they were based.

Conclusions: To date, research in whole-system, multi-modality naturopathic medicine shows that it is effective for treating cardiovascular disease, musculoskeletal pain, type 2 diabetes, polycystic ovary syndrome, depression, anxiety, and a range of complex chronic conditions.

Advancing Research on Traditional Whole Systems Medicine Approaches

While the intention of Integrative Medicine (IM) is whole person medicine, it has for the most part remained driven by individual modalities. Like the practice of IM itself, IM research too has been driven primarily by studies on individual modalities. There are significant challenges to moving research on whole systems medicine forward, with funding being at the top of the list. Historically, NIH has not been receptive to supporting research on whole systems, preferring instead to support studies that are more individual modality driven so that mechanisms can be identified. Purely mechanistic research, however, assumes unidirectional causality and linear responses yet clinical responses to whole systems approaches are more often multidirectional and dynamically unpredictable. The concept of emergence is applicable here. Whole systems approaches suggest that by incorporating therapies into holistic treatment programs we not only treat symptoms but accomplish more by activating the body's inherent self-organizing healing mechanisms and treat the root cause of illnesses as well as associated symptoms. Given that interest in integrative therapies with the general public and medical community is steadily increasing, there is need for more research that explores intact whole systems approaches to elucidate the relevant system-wide effects and dynamic interactions related to these practices.

Assessing quality of life in diabetes: II - Deconstructing measures into a simple framework

A growing number of instruments measuring diabetes-specific health-related quality of life (HRQOL) have been identified in previous systematic reviews, the most recent being published in 2008. The purpose of this paper is report on an updated systematic review of diabetes-specific HRQOL measures highlighting the time period 2006-2016; to deconstruct existing diabetes-specific HRQOL measures into a simple framework for evaluating the goodness-of-fit between specific research needs and instrument characteristics; and to present core characteristics of measures not yet reported in other reviews to further facilitate scale selection. Using the databases Medline, Pubmed, CINAHL, OVID Embase, and PsycINFO, we identified 20 diabetes-specific HRQOL measures that met our inclusion criteria. For each measure, we extracted eight core characteristics for our measurement selection framework. These characteristics include target population (type 1 vs. type 2), number and type of HRQOL dimensions measured and scored, type of score and calculation algorithm, sensitivity to change data reported in subsequent studies, number of survey items, approximate time length to complete, number of studies using the instrument in the past 10years, and specific languages instruments is translated. This report provides a way to compare and contrast existing diabetes-specific HRQOL measures to aid in appropriate scale selection and utilization.

Is adjunctive naturopathy associated with improved glycaemic control and a reduction in need for medications among type 2 Diabetes patients? A prospective cohort study from India

BACKGROUND

With an estimated 65 million Diabetes Mellitus (DM) patients, India ranks second in the world in terms of DM burden. The emphasis of current medical practice has been on pharmacotherapy but, despite the best combination therapies, acheiving glycaemic control (reduction of blood sugar to desirable levels) is a challenge. 'Integrated Naturopathy and Yoga'(INY) is an alternative system of medicine that lays emphasis on the role of diet and physical exercise. We assessed the short term effect of INY as an adjunct to pharmacotherapy on glycaemic control among type 2 DM patients.

METHODS

In this prospective cohort study with a 3 month follow-up, DM patients consecutively admitted to a hospital in India from May-October 2014 for either 15 or 30 days were offered INY - a package of vegetarian diet with no added oil, sugar and salt, yoga-based exercise, patient counselling and rest. A 'favourable outcome' was defined as glycaemic control (glycosylated hemoglobin (HbA1c) < 7 % or absolute reduction by 1 %) along with at least 50 % reduction in antidiabetes medication at 3 months relative to baseline. Compliance to diet was scored by self-report on a scale of 0-10 and categorized into poor (0-5), moderate (6-8) and excellent (9-10).

RESULTS

Of 101 patients with 3-month follow-up data, 65(65 %) achieved a favourable outcome - with 19(19 %) stopping medication while sustaining glycemic control. Factors associated with favourable outcome were baseline HbA1c and compliance to diet, which showed a significant linear relationship with mean HbA1c reductions of 0.4 %, 1.1 % and 1.7 % in relation to poor, moderate and excellent dietary compliance respectively.

CONCLUSION

INY, adjunctive to pharmacotherapy, was associated with a significant beneficial effect on glycaemic control and reduced the overall need for antidiabetes medications. These early results are promising. Further studies with long-term follow-up and using more rigorous randomized controlled trial designs are needed.

Disease Prevention and Health Promotion: How Integrative Medicine Fits

As a discipline, preventive medicine has traditionally been described to encompass primary, secondary, and tertiary prevention. The fields 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.

Self-directed Mindfulness Training and Improvement in Blood Pressure, Migraine Frequency, and Quality of Life

Background:

Interest in case studies has undergone a resurgence concurrent with increasing prioritization of illustrations of patient-centered care. However, substantial inclusion of the patient in these reports remains limited. Here, a doctor and patient collaborate to present her case report of self-directed mindfulness training and the subsequent changes in blood pressure, migraine frequency, and quality of life.

Methods:

After receiving encouragement from her naturopathic doctor, the patient initiated an 8-week program in mindfulness training following the Kabat-Zinn protocol and logged her daily blood pressure and symptoms before and after meditation sessions over an 11-week period.

Results:

Patient-reported outcomes included decreased perceived stress, increased focus, and a newfound sense of centeredness and calm. Changes in objective outcomes were clinically and statistically significant, including reductions in mean systolic and diastolic blood pressure between week 1 and week 11 (P = .0001 and P = .0004 for systolic and diastolic, respectively, by paired, 2-sided t-tests). Self-reported frequency of chronic migraine was also reduced. Critical to the patient's success was that mindfulness training was first approached in a simple, accessible manner prior to embarking on a deeper, extended experience.

Discussion and Conclusion:

Self-directed mindfulness training can have a meaningful impact on both subjective and objective health outcomes. It may take years of encouragement from a healthcare provider before a patient is ready to adopt a mind-body practice; it is important to recognize and counsel patients with messages appropriate to their stage of change and self-efficacy. Additionally, case studies that combine the voice of the clinician and the patient can provide useful illustrations of truly patient-centered care.

Assessing the Utility of an Electronic Research Database to Capture Whole Systems Practice at Two Naturopathic Outpatient Teaching Clinics

This observation study assessed the utility of an electronic Naturopathic Patient Database at 2 naturopathic teaching clinics as a research and educational tool. Focusing on the whole systems practice of naturopathic medicine using individualized treatment protocols, patients from the Canadian College of Naturopathic Medicine outpatient teaching clinic and the Boucher Institute of Naturopathic Medicine outpatient teaching clinic were assessed. Data were collected on patient demographics, laboratory values, physical measures, treatment protocols, and validated questionnaires. Results showed the Naturopathic Patient Database was able to capture both standardized and individualized measures of care for research purposes. A number of substudies were generated by student interns using the database. Limitations identified included limited resources for training faculty, interns, and administrators on program use and data entry; also, data quality and completeness were problematic. However, the Naturopathic Patient Database captured data on the individualized nature of naturopathic care and had the ability to collect and compare large amounts of data.

Patient-reported experiences with first-time naturopathic care for type 2 diabetes

Differences in the effectiveness of diverse healthcare providers to promote health behavior change and successful diabetes self-care have received little attention. Because training in naturopathic medicine (NM) emphasizes a patient-centered approach, health promotion, and routine use of clinical counseling on wellness and prevention, naturopathic physicians (NDs) may be particularly well-prepared for promoting behavior change. However, patients' experiences with NM have not been well studied. This study provides the first report of the perceptions of persons with type 2 diabetes of their first experiences with naturopathic care for their diabetes. Following their participation in a one-year prospective cohort study of adjunctive naturopathic care for diabetes, twenty-two patients were interviewed about their experiences working with a naturopathic physician. Using a content analysis approach, nine dominant themes were identified. Three themes characterized the nature of the ND-patient interaction: 1) patient-centered, 2) holistic health rather than diabetes focused, and 3) collaborative. Five themes characterized the content of the clinical encounter: 1) individualized and detailed health promotion, 2) counseling that promoted self-efficacy, 3) pragmatic and practical self-care recommendations, 4) novel treatment options that fostered hopefulness, and 5) patient education that addressed both diabetes self-care and general health. A ninth theme was cross-cutting: the contrast between ND care and conventional medical care. Results indicate that the routine clinical approach used by NDs is consistent with behavior change theory and clinical strategies found most effective in promoting self-efficacy and improving clinical outcomes.