Chapter 8: CAM in Wellness and Health Promotion
In recent years, people have come to recognize that a healthy lifestyle can promote wellness and prevent illness and disease, allowing them to enjoy a long, high-quality life. To achieve this goal, many people have used various approaches, including complementary and alternative medicine (CAM).
Wellness is defined in many different ways, but all agree that it is more than the absence of disease. For some it is the achievement of one's fullest potential, for others it is an integration of body, mind, and spirit. Wellness can include a broad array of activities and interventions that focus on the physical, mental, spiritual, and emotional aspects of one's life.
Since the publication of Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention in 1979,1 the U.S. Public Health Service has led an initiative to define goals and objectives for the health of the U.S. population and to direct resources for improving the Nation's health. The goals and objectives are updated periodically, along with a progress report on their attainment, and have been published as Healthy People 20002 and 2010.3 Long-range goals and objectives for Healthy People 2020 are currently being developed.
As the Healthy People 2000 and 2010 reports illustrate, approaches to improving health and wellness, preventing illness and disease, and managing disabilities and chronic conditions require the involvement of a wide range of disciplines and social institutions. The effectiveness of the health care delivery system in the future will depend upon its ability to make use of all approaches and modalities that provide a sound basis for promoting optimal health. People with better health habits have been shown to survive longer and to postpone and shorten disability.4 CAM practices such as acupuncture, biofeedback, yoga, massage, and tai chi, as well as certain nutritional and stress reduction practices, may be useful in contributing to the achievement of the nation's health goals and objectives.
Helping people achieve a healthy, meaningful, and long life is the fundamental purpose of all health care systems. In the United States, great strides have been made in conquering disease and extending life, and the health care system reflects these remarkable scientific advances. Yet in the quest to conquer illness and disease, national wellness and prevention efforts have been focused primarily on immunizations, disease screening and monitoring (e.g., pap smears blood pressure checks), and services offered in response to an already identified illness or condition (e.g., physical therapy after stroke, nutritional counseling for diabetics). With some notable exceptions, wellness and health promotion have, for the most part, been left to the initiative and discretion of the individual. The Commission believes that it is time for wellness and health promotion to be a national priority and for the role of CAM in these efforts to be explored further.
The concomitant rise of interest in CAM and in wellness and prevention presents many new and exciting opportunities for the health care system. There is evidence that certain CAM practices, when administered by properly trained practitioners, may be beneficial. Evaluating safe and effective CAM practices and products to determine their applicability to wellness and health promotion activities presents new and exciting areas to explore in the quest to improve health outcomes and quality of life.
The Role of Safe and Effective CAM Practices and Products in Promoting Wellness and Helping to Achieve the Nation's Health Promotion and Disease Prevention Goals
The most recent Federal government report on the health status of the nation, Healthy People 2010, is designed to further two overarching goals: 1) increasing the quality and years of healthy life and 2) eliminating disparities in health. These goals and objectives are the blueprint for the nation's health promotion and disease prevention activities, and they influence data collection, national health policy, and program development and implementation. Healthy People 2010 addresses clinical, behavioral, environmental, and health system issues that affect health, and it emphasizes on health education and changing the health-related behaviors of individuals and communities.
The principles that underlie CAM practices are consistent with the two overarching goals of Healthy People 2010. Several CAM practices have shown promise in addressing some of the specific objectives outlined in Healthy People 2010, such as massage therapy to reduce the limited activity caused by chronic low back pain (Objective 2-11), meditation or biofeedback to reduce high blood pressure (Objectives 12-9 through 12-12), and tai chi to increase physical activity and flexibility (Objectives 22-1 through 22-5). These and other CAM practices and products that have been shown to be safe and effective should be evaluated to determine their potential for helping to achieve the nation's health promotion and disease prevention goals and objectives.
The Healthy People Consortium, which includes over 600 Federal, state, and national organizations, should form a working group to evaluate the potential impact of safe and effective CAM practices and products on the nation's leading health indicators (physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunization, and access to health care). Strategies, including demonstration projects, should be developed to incorporate CAM practices and products found to have potential benefit to address these indicators and promote healthy lifestyles.
Wellness and Health Promotion for Children
For no other group is the learning and adoption of healthy behaviors and lifestyle choices more important than for children and young people. Although many programs address some of the pressing issues facing American youth, the statistics remain sobering, with unintentional injuries, homicides, and suicides accounting for the majority of deaths between the ages of 1 and 24.3 Serious, chronic conditions are beginning earlier in life, as shown by the recently released The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity.5 This report highlights many of the health issues facing children who are overweight, including heart disease, diabetes, and depression, and states that risk factors for heart disease (e.g., high cholesterol and high blood pressure) occur with increased frequency among overweight children. Numerous reports have cited the dramatic increase of Type II diabetes in children and adolescents in recent years, which is also strongly associated with being overweight.6,7
Early interventions that promote the development of good health habits and attitudes could help prevent many of the negative behaviors and lifestyle choices that begin early in life. Poor dietary habits, lack of exercise, smoking, suicide, substance abuse, homicide, and depression are a silent epidemic among young people and should be considered a national priority.
While many individual programs address these problems, safe and effective CAM principles and practices should be evaluated to determine their potential role in transforming the unhealthy behavior responsible for U.S. youths' dismal health statistics. Those CAM principles and practices that have been shown to be appropriate for children and young people should be included as part of a national effort and involve all sectors of the community, especially the schools.
Parents, schools, communities, businesses, influential individuals, and the media should become part of a national campaign to heighten children's interest in and awareness of health issues, including how their behavior affects their life and environment and how they can establish good habits for coping with life's stresses. This effort could be similar to other national initiatives, such as those to increase seat belt use, decrease alcohol consumption when driving, and modify other behaviors that impact on public health.
Schools are a particularly important part of any strategy. Schools provide activities and services to promote students' physical, emotional, and social development and they usually require that some form of health education be taught. The teaching of safe and effective CAM practices in schools to improve nutrition, reduce stress, resolve conflicts, and develop healthy lifestyles should be evaluated to determine if it can complement the efforts already under way to improve the health and well-being of young people. School programs are locally designed and implemented, and what works in one community may not work in another. Therefore, it is essential that members of the local community (children, parents, teachers, school boards, and others) be involved in these activities.
The Centers for Disease Control and Prevention has developed guidelines for schools to use to increase physical activity, promote healthy eating, prevent tobacco use and addiction, and prevent HIV infection.14 The Health Resources and Services Administration, in conjunction with the American Academy of Pediatrics, is developing guidelines for schools that address comprehensive physical and mental health and safety programs. Other Federal organizations, such as the Department of Agriculture, also produce information to assist schools in promoting health. A public-private working group should be established to evaluate the applicability of safe and effective CAM practices and products to existing guidelines. In addition to representatives from Federal organizations, CAM professionals, and parent and teacher groups should be included, and the guidelines should reflect the cultural diversity in school systems.
Innovative programs that are successfully addressing wellness promotion and disease prevention in schools should be identified so that other schools can learn from them and, if appropriate, adapt them for use in developing their own programs. For example, a group of middle schools in the Minneapolis-St. Paul metropolitan area has developed school nutrition advisory councils to promote the nutritional health of students. This is part of the Teens Eating for Energy and Nutrition at Schools (TEENS) program, which encourages adolescents to adopt good dietary habits to reduce their risk of cancer risk.15 Some elementary, middle, and high schools in New York and California are offering yoga classes as part of their health or physical education curricula. The reported benefits include increased concentration, reduced impulsive behavior, and increased self-esteem.16
Wellness and Health Promotion in the Workplace
Most adults in the United States spend a large part of their lives in the workplace, and employers spend an average of $2,400 per employee for single coverage and $6,900 for family coverage annually.17 Premiums rose an average of 11 percent from 2000 to 2001, with small firms bearing a disproportionate share of that increases.17 Data consistently show that high levels of stress, excessive body weight, and multiple risk factors are associated with increased health care costs and absenteeism, and that health promotion programs in the workplace can lower health care and insurance costs and decrease absenteeism.18
The Department of Health and Human Service's Division of Federal Occupational Health helps Federal organizations improve the health, safety, and productivity of their workforce. It provides comprehensive medical, nursing, and wellness and fitness services at Federal workplaces around the country and serves more than 300 agencies with 1.6 million employees. Other Federal organizations may offer their employees wellness programs as well.
Many health promotion programs in the workplace focus on reducing risk factors for illness by encouraging weight loss, smoking cessation, and stress reduction. Studies have shown that stress reduction techniques such as yoga and meditation are beneficial. Evaluations should be conducted to determine the role of safe and effective CAM practices and products in the workplace, and incentives should be developed to encourage those found to be beneficial.
Incentives to include CAM in wellness programs and health coverage will vary with the size of the business. For example, larger companies that negotiate health plans through a union will require a different set of incentives than small companies that may only offer limited or no coverage. Some incentives currently exist but have not been evaluated for their effectiveness. Any additional programs or services will have start-up costs that may deter some companies from offering them.
Recommendation 26: The Department of Health and Human Services and other Federal agencies and public and private organizations should evaluate CAM practices and products that have been shown to be safe and effective to determine their potential to promote wellness and help achieve the nation's health promotion and disease prevention goals. Demonstration programs should be funded for those determined to have benefit.
26.1 The Healthy People Consortium should evaluate the role of safe and effective CAM practices and products in addressing the10 leading health indicators and develop strategies, including demonstration programs, to encourage the use of CAM practices and products found to be beneficial in addressing these indicators.
26.2 Questions on the extent and use of CAM products and practices should be included in national surveys and other assessment tools including the National Health Interview Survey, the National Health and Nutrition Examination Survey, and the Medical Expenditure Panel Survey. Where appropriate, information from these sources should be incorporated into the Healthy People 2020 goals and objectives.
26.3 The Department of Health and Human Services, as part of the Healthy People 2010 initiative, should support the development of a national campaign to teach and encourage behaviors that focus on improving nutrition, promoting exercise, and teaching stress management for all Americans, especially children. This campaign should include safe and effective CAM practices and products where appropriate.
26.4 The Federal government, in partnership with public and private organizations, should evaluate safe and effective CAM practices and products to determine their applicability to improving nutrition, promoting exercise, and teaching stress management to children. Demonstration programs should be funded for those found to be applicable to children.
26.5 The Health Resources and Services Administration, the Centers for Disease Control and Prevention, the Department of Agriculture, the Department of Education, and other Federal agencies that develop school health guidelines should evaluate the potential applicability of safe and effective CAM practices and products to these school health guidelines. Those found to have benefits should be included in the guidelines.
26.6 Federal agencies, in partnership with the business community, should develop incentives for schools to make lunches and snacks healthful, and to limit the sale-and eliminate the advertising-of high-fat snacks, soft drinks, and other products that do not contribute to healthy lifestyles
26.7 The Department of Health and Human Services and the Department of Labor should evaluate safe and effective CAM practices and products to determine their potential role in workplace wellness and prevention activities, and include them in Federal workplace wellness and health promotion programs and Federal health coverage plans when appropriate.
26.8 Federal agencies, in conjunction with the business community, should develop incentives for employers to include CAM practices and products found to be beneficial in wellness and prevention activities in their workplace wellness programs and health coverage.
The Role of Safe and Effective CAM Practices and Products in Health Care Delivery Systems and Health-Related Programs to Help Promote Wellness and Health and Prevent Disease
Federal/State Programs and Systems
The Federal government funds many programs that serve vulnerable populations. Among them are Head Start; Meals on Wheels; Special Supplemental Nutrition Program for Women, Infants and Children; Healthy Mothers/Healthy Babies; the State Children's Health Insurance Program, and programs for people with disabilities. These programs have a direct impact on the health and quality of life of the people they serve and may benefit from a wellness and prevention component that includes safe and effective CAM practices and products.
The agencies that administer these programs should evaluate safe and effective CAM practices and products to determine their applicability to these programs and fund demonstration programs for those found to be applicable. An example of CAM practices and products that might be considered is teaching children in Head Start programs to breathe deeply as a relaxation technique. The State Children's Health Insurance Program might consider whether chiropractic services would be appropriate for this population, and Meals on Wheels might re-evaluate the type of food being served. Appropriately trained CAM providers should be part of the evaluation and decision-making process.
Federally funded health care delivery programs should also evaluate the applicability of CAM wellness and prevention activities into their services. This includes the Department of Veterans Affairs, which has 172 hospitals and more than 500 other health care facilities serving 25 million persons; the Indian Health Service, serving 1.5 million American Indians and Alaskan Natives; community and migrant health centers, serving more than 10 million people who otherwise would not have access to care; maternal and child health programs; and school health programs. Demonstration programs should be funded for those CAM practices and products found to benefit these populations.
Public and Private Programs and Systems
Much of the research, education, training, services, reimbursement, and information development and dissemination activities of the health care system is directed toward identifying and treating diseases and conditions. Although many hospitals have begun to offer community programs that focus on wellness and prevention, these activities often occur outside the system of primary health care and rely upon consumers' knowing that these activities exist, belief in their potential benefit, ability to pay for them out-of- pocket, and ability to access them.
Public and private health care programs and systems should evaluate safe and effective CAM practices and products to determine their role in wellness and prevention activities for individuals and communities. The Department of Health and Human Services should help bring together organizations from the private and public sectors for this purpose and help to develop strategies to promote the use of those found to be beneficial. Representatives of national, state, and local organizations of clinicians, administrators, health plans, pharmacists, nurses, mental health professionals, consumers, and others from hospitals, long-term care facilities, and programs serving the aging, the dying, and those with disabilities or chronic illness should be included with CAM professionals and institutions in this process.
Recommendation 27: Federal, state, public, and private health care delivery systems and programs should evaluate CAM practices and products to determine their applicability to programs and services that help promote wellness and health. Demonstration programs should be funded for those determined to be beneficial.
27.1 The Secretaries of Health and Human Services, Agriculture, Veterans Affairs, and Defense and the Commissioner of the Administration for Children and Families, should evaluate safe and effective CAM practices and products that contribute to wellness and health and determine their applicability to Federal health systems and programs.
27.2 The Secretary of Health and Human Services should facilitate the bringing together of public and private health care organizations to evaluate safe and effective CAM practices and products that contribute to wellness and health and determine their applicability to health systems and programs, especially in the nation's hospitals and long-term care facilities and in programs serving the aging, those with chronic illness, and those at the end of life.
27.3 CAM and conventional health professional training programs should consider offering training and educational opportunities for students in self-care and lifestyle decision-making to improve practitioners' health and to enable practitioners to impart this knowledge to their patients or clients.
The Role of Safe and Effective CAM Practices and Products in Wellness and Health Promotion and the Application of CAM Principles and Practices to the Management of Chronic Disease
Although a significant percentage of people who use CAM practices and products do so to prevent disease and promote health, more information is needed on how CAM approaches can improve wellness and promote health. A related but largely unexplored area is the application of CAM wellness and prevention practices to the management of chronic disease. CAM principles and practices may be useful not only in preventing some of these diseases and conditions, but also in enhancing recovery and preventing further illness. Increased research in this area will help to determine how CAM principles and practices can best be used to meet the goals of the health care system.
The core philosophy and orientation of many CAM systems is to support and stimulate the inherent healing capacities of the individual. For example, Traditional Chinese Medicine practitioners focus on maintaining the flow of "qi" and "blood" to balance "yin" and "yang" for the maintenance of good health. Ayurvedic medicine emphasizes early detection and balancing of "doshas" to prevent disease and pathology. Other CAM modalities, such as chiropractic and naturopathic medicine, seek to enhance the body's natural healing system to prevent, treat, and cure disease. A significant portion of the adult population takes supplements and herbs to maintain health.
Although many CAM systems and practitioners emphasize the health-promoting nature of their approaches and interventions, research is needed to determine which ones are or might be useful for improving overall health and preventing disease. A systematic review of research to evaluate CAM approaches to health promotion would help identify promising areas for further research and development. In addition to the Federal government, private organizations such as the Institute of Medicine and the American Public Health Association should provide leadership in this area, including assistance in determining how CAM may contribute to the goals of Healthy People 2010 and the development of Healthy People 2020.
Recommendation 28: Research on the role of CAM in wellness and health promotion, the application of CAM principles and practices, and the role of CAM practitioners in the management of chronic disease should be expanded.
28.1 The Department of Health and Human Services should fund demonstration projects to evaluate the clinical and economic impact of comprehensive health promotion programs that include CAM. These studies should include underserved and special populations.
28.2 The Federal government and private health organizations should evaluate CAM practices and products that are currently being used for wellness and health promotion to determine their effectiveness and applicability to the management of chronic disease. Funding should be provided for demonstration projects in the Centers for Medicare and Medicaid Services, the Department of Veterans Affairs, the Department of Defense, the Health Resources and Services Administration, and other Federal agencies for those CAM practices and products found to have benefit in the management of chronic disease, end of life such as hospice.