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


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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.
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Naturopathy as a Model of Prevention-Oriented,
Patient-Centered Primary Care: A Disruptive
Innovation in Health Care
Ryan Bradley 1,2,3,*, Joanna Harnett 3,4, Kieran Cooley 3,5,6, Erica McIntyre 3,
Joshua Goldenberg 1,3 and Jon Adams 3
1Helfgott Research Institute, National University of Natural Medicine, Portland, OR 97201, USA;
2Department of Family Medicine and Public Health, University of California, San Diego,
La Jolla, CA 92093, USA
3University of Technology Sydney, Australian Research Center in Complementary and Integrative
Medicine (ARCCIM), Ultimo NSW 2007, Australia; (J.H.); (K.C.); (E.M.); (J.A.)
Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney NSW 2006, Australia
5Department of Research and Clinical Epidemiology, The Canadian College of Naturopathic Medicine,
Toronto, ON M2K1E2, Canada
6Transitional Doctorate Department, Pacific College of Oriental Medicine, San Diego, CA 92108, USA
Received: 3 August 2019; Accepted: 10 September 2019; Published: 18 September 2019
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.
naturopathy; prevention; complementary medicine; chronic disease management;
policy implications
1. Introduction
The United States health care system is moderately eective in prolonging life, albeit at high
costs [
]. There is much room for improvement in health care delivery, and within developed
Medicina 2019,55, 603; doi:10.3390/medicina55090603
Medicina 2019,55, 603 2 of 14
countries, there is near universal agreement on aspirations to achieve the “triple aim” of health
care [
]—improved health and patient experience at a lower cost. Multiple tensions exist between
these three aims, which render them dicult to achieve. Trade-os between the delivery of the clinical
services patients want versus those services known to reduce costs is an example of one fundamental
tension [
]. Additional contextual tensions preventing achievement of these combined aims include
the unpopularity amongst patients for approaches that limit access and coverage for services [
and the unpopularity amongst providers for approaches that reduce insurance reimbursement [
Technological “innovations” (e.g., electronic health records, gene-based therapies, and advanced
imaging technologies) are perceived as holding great promise for achieving this triad of health
care aims, yet, in most cases, these innovations have increased costs and fail to improve clinical
outcomes [
]. This context of moderate outcomes and high-costs with dissatisfied stakeholders has
created an opportunity for “disruptive” innovations to emerge in health care delivery [
]. One such
disruptive innovation with the potential to transform health care is an eective model of primary care
less dependent on costly drugs and technological intervention, one which also explicitly promotes
improvements in health.
The concept of a “disruptive innovation” was introduced to the business community by the
Christensen Institute in respect to an emerging technology representing 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” [
]. This concept has more recently been extended to health care [
In order for a new technology to be considered a “disruptive innovation” in health care, the technology
must meet at least one of the following criteria: (1) It must cure disease; (2) transform the way medicine
is practiced; and/or (3) have an impact that could be disruptive or sustaining, depending on how it is
integrated into the current healthcare marketplace. Examples of candidate disruptive innovations in
health care are few, and none have yet proven to be fully disruptive, (e.g., gene-targeted therapies
and electronic health records have unmet promise) [
]. Little research or discussion has considered
innovative models of health care delivery or a re-shuing of therapeutic approaches to those with
lower costs as potential disruptors.
Naturopathy is a distinct system of traditional and complementary medicine (T and CM)
recognized by the World Health Organization (WHO) [
]. The educational model for naturopathy
is similar to that in allopathic medical training with its foundation in biomedical physiology and
diagnostics. However a unique attribute of naturopathy is a reprioritization of the order of therapeutics
(Figure 1), first emphasizing lifestyle-oriented self-care, preventive behaviors, nutrition, physical
activity, and stress-management counseling before moving on to clinical nutrition (i.e., targeting
pharmacologic actions by nutrients for specific diseases irrespective of nutrient status), herbal medicine,
homeopathy, and hands-on manual therapies—all rather than emphasizing over-the-counter and
prescription drug therapies or surgical interventions [
]. There are eight accredited colleges of
naturopathy in North America, all of which utilize a primary care foundation of medical education,
including outpatient pharmacy and pharmacology training [
]. In the United States, naturopathy
is licensed in 20 states, the Washington District of Columbia (D.C.) and the territories of Puerto Rico
and the U.S. Virgin Islands [
]. Third-party insurance coverage for naturopathy varies by state
jurisdiction and ranges from minimal coverage (e.g., California) to legislatively mandated coverage
(e.g., Washington State) [
]. Select states (e.g., Washington, Oregon, and Connecticut) include
some reimbursement to naturopathic doctors through Medicaid, and naturopathic doctors practice in
established community-care organizations and/or federally-qualified health centers.
An evidence-informed argument is made below that naturopathy is, or has the potential to become,
a disruptive innovation in health care in the United States by meeting all three of the Christensen
criteria. Table 1compares potential disruptive innovations from naturopathy and current conventional
biomedicine. As outlined below, a “naturopathic” model of primary care—focused on self-care, the
minimal use of costly prescription drugs, and being patient-centered—is a testing ground for achieving
the “triple aim” in health care and ultimately disrupting the status quo of the health system.
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Medicina 2019, 55, x FOR PEER REVIEW 3 of 14
Figure 1. Hierarchy of typical therapeutics applied in naturopathy practice.
An evidence-informed argument is made below that naturopathy is, or has the potential to
become, a disruptive innovation in health care in the United States by meeting all three of the
Christensen criteria. Table 1 compares potential disruptive innovations from naturopathy and
current conventional biomedicine. As outlined below, a “naturopathic” model of primary care—
focused on self-care, the minimal use of costly prescription drugs, and being patient-centeredis a
testing ground for achieving the “triple aim” in health care and ultimately disrupting the status quo
of the health system.
Table 1. Comparison of potential disruptive technologies in naturopathic and allopathic primary care.
Allopathy/Conventional Biomedicine
Naturopathy/Naturopathic Medicine
Genetic medicine, biologic therapies, gene
editing, robotic surgery, precision radiation
Chronic disease prevention, self-care and
“out-of-pocket” treatments
Electronic Health Records, medical homes,
evidence-based practice
Patient-centered, prioritization of patient
preferences, experts in complementary
Disrupt or
Integrated via guidelines and standards of
practice upon reaching a threshold of
evidence and provider acceptance
Integrated through insurance coverage,
“integrative” guideline development and co-
location of providers
Disruptive via marginalization but increased
consumer demand and market pressures
2. Criterion 1: A Disruptive Innovation Must Cure Disease
One of three potential criteria an innovation in healthcare must meet to be considered
“disruptive” is to cure disease. Though no clinical trials have been performed evaluating changes in
disease incidence from naturopathic practice or individual treatments, and naturopathy thus does
not meet this criterion as originally articulated, there are plentiful examples of therapeutics
commonly applied in naturopathic practice leading to robust changes in clinical status that could
alter the course of “incurable” chronic disease. Important for the potential disruption is that, in many
cases, the costs for the therapies recommended are outside of the prescriptive drug model and
typically include self-care and treatments classified as “dietary supplements” that are thus sold over
the counter or online. The disruption to health care is similar as to a cure because the costs previously
Patient Self-Management/Empowerment
Homeopathic Medicines
Legend Drugs
Active Clinical Health
Promotion Counseling
Figure 1. Hierarchy of typical therapeutics applied in naturopathy practice.
Table 1.
Comparison of potential disruptive technologies in naturopathic and allopathic primary care.
Criterion Allopathy/Conventional Biomedicine Naturopathy/Naturopathic Medicine
Genetic medicine, biologic therapies, gene
editing, robotic surgery, precision radiation
Chronic disease prevention, self-care and
“out-of-pocket” treatments
Electronic Health Records, medical homes,
evidence-based practice
Patient-centered, prioritization of patient
preferences, experts in complementary medicine
Disrupt or
Integrated via guidelines and standards of
practice upon reaching a threshold of
evidence and provider acceptance
Integrated through insurance coverage,
“integrative” guideline development and
co-location of providers
Disruptive via marginalization but increased
consumer demand and market pressures
2. Criterion 1: A Disruptive Innovation Must Cure Disease
One of three potential criteria an innovation in healthcare must meet to be considered “disruptive”
is to cure disease. Though no clinical trials have been performed evaluating changes in disease
incidence from naturopathic practice or individual treatments, and naturopathy thus does not meet
this criterion as originally articulated, there are plentiful examples of therapeutics commonly applied
in naturopathic practice leading to robust changes in clinical status that could alter the course of
“incurable” chronic disease. Important for the potential disruption is that, in many cases, the costs for
the therapies recommended are outside of the prescriptive drug model and typically include self-care
and treatments classified as “dietary supplements” that are thus sold over the counter or online.
The disruption to health care is similar as to a cure because the costs previously directed into the system
via pharmaceutical sales are diverted to other businesses, leading to lost revenue to pharmaceutical
companies and insurance-based care delivery centers. Dietary supplements and self-care practices
already account for an estimated $12.8 billion and $2.7 billion, respectively, for out-of-pocket health
care expenditures per year [
]. To illustrate this point, we will discuss two costly chronic diseases
significantly improved by therapies typically included in naturopathic practice: Depression and type
2 diabetes.
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Depression is another chronic condition that is not well treated by currently available drugs, that
drastically reduces health-related quality of life, and that carries an estimated economic cost in excess
of US $210 billion annually, with 50% of these costs attributable to work place losses [
]. Yoga and
St. John’s Wort, two typical naturopathic approaches for depression, have been extensively evaluated
for depression and meta-analyzed [
]. Findings for St. John’s Wort have specifically concluded
that it is eective, comparable to drug therapy, and safer than drug therapy [
]. In addition to
positive meta-analyses, yoga has been specifically evaluated in the workplace and appears ecacious
for depression [
], including in employees with chronic pain [
]. Thus, by oering guidance on
self-care and non-drug interventions, naturopathic practice models have the potential to disrupt the
current treatment paradigm and to reduce reimbursement for other primary care, pharmacy and
mental health services.
Type 2 diabetes is a costly drain on the health care system, with estimates from the United States
suggesting diabetes and its complications costs in excess of $400 billion per year, or approximately one
of every three health care dollars spent [
]. Notably, therapies typically recommended in naturopathic
practice [
], including yoga [
], omega-3 fatty acids [
], cinnamon [
], chromium [
and carbohydrate reduction [
], all have robust clinical trial and/or meta-analysis support for ecacy
in reducing clinical risk factors in type 2 diabetes. Additionally, composite outcomes from naturopathic
practice [
] and demonstration projects [
] have led to sustained improvements in glucose control and
self-care behaviors, similar to intensive interventions tested in clinical trials [
]. If scaled eectively,
shifting therapies toward these out-of-pocket expenditures would disrupt pharmaceutical company
revenues, which account for the highest proportional cost of all diabetes services [34].
Research to date has not evaluated a “cure” as an outcome from naturopathic practice, and in fact,
very few “cures” exist in medicine at all. While curing disease (and arguably preventing or correcting
the course of a chronic disease) would be disruptive, redirecting potential revenue away from service
delivery centers, pharmacies and pharmaceutical companies generally is equivalently disruptive and
far more achievable. Naturopathic practice represents an eort to improve patient outcomes and
redirect the course of chronic diseases, and, as an extension, they could become disruptive if allowed
to scale and operate independently of the current system (see Criterion 3 below).
3. Criterion 2: A Disruptive Innovation Must Transform Elements of Clinical Practice
A second criteria an innovation in health care must meet to be considered “disruptive” is that it
must transform elements of clinical practice [
]. Naturopathy transforms clinical practice by modeling a
patient-centered approach, which manifests as longer patient visits, the delivery of pragmatic self-care
recommendations, the inclusion of non-drug/non-surgical options, and a strong consideration of patient
preferences in care [
]. The end result is consumer-oriented and includes lateral decision-making
through the creation of a functional patient–provider team (in contrast to the current top-down approach
that leaves the patient with a low locus of control over their care). Notably, improved physician–patient
communications impact adherence to evidence-based practice recommendations, improve patient
outcomes in heart disease [
], and improve the delivery of preventive services in primary care [
thus, care delivery models that encourage stronger physician–patient relationships are worthy of
attention by both insurers and health policy makers because of their potential to reduce costs.
In addition to the form of a typical naturopathic patient visit, the function of a typical visit also
varies considerably from allopathic care. Despite similarities between naturopathy and biomedicine
in the basic structure of the clinical intake and interview format (i.e., a history of present illness
including its attributes, review of systems, medical history, diagnosis and prognosis, etc.), the reach of a
typical interview also extends to contributory lifestyle factors, such as physical activity history, dietary
pattern, stress management; psychosocial stress, including social determinants of health; detailed
medication and dietary supplements reviews; a consideration of relevant environmental exposures at
work and at home; clinical prevention strategies including vaccination history, screenings and use of
personal protective equipment; and, often, an extensive sleep and digestive history. Fundamentally,
Medicina 2019,55, 603 5 of 14
the goal of many naturopathic care visits is to identify behaviors, self-care strategies, and modifiable
environmental and contextual factors that patients can change in order to improve their health and/or
function and reduce their dependency on drugs and higher-force interventions [44,48].
Existing observational practice outcomes and clinical trial data support the ecacy of naturopathy
for multiple high morbidity chronic health conditions including: cardiovascular risk, hypertension,
depression, anxiety, low back pain, and type 2 diabetes [
]. Of note, none of the clinical
studies of naturopathy cited included the use of prescription drug therapies in the tested intervention.
Changes of this type, i.e., the eective management of chronic conditions without intensified drug
therapy, are contrary to most current medical standards of care for non-communicable diseases [
Because type 2 diabetes and other chronic diseases such as cancer, chronic pulmonary diseases,
and kidney disease have a fundamental behavioral component, a model of clinical training and practice
with the potential to modify patient behavior and inflect the course of patients’ prognosis has great
potential to disrupt the status quo. In the context of type 2 diabetes, changes in clinical risk factor
control during naturopathic care are accompanied by important improvements in patient mood and
self-ecacy for change, with concurrent improvements in self-care, including glucose monitoring,
dietary change, and physical activity [
]. Depression frequently co-occurs with diabetes [
] and
is an established barrier to improved self-care and medication adherence [
]. Therefore, impacting
mood and self-ecacy, with parallel improvements in self-care strategies with established mortality
benefits [5759], holds great promise to influence the long-term disease trajectory of type 2 diabetes.
Naturopathy is both traditional and innovative in its application of evidence. Though critics often
state there is “no evidence” or too limited evidence for naturopathy, the reality is much more nuanced,
and, in many cases, this criticism is not valid. The evidence for naturopathy is not limited to trials of
individual drugs; rather, it is sourced from multiple disciplines including clinical trials of individual
nutrients, dietary interventions, botanical medicines, mind–body practices, and manual medicine
and rehabilitation interventions, with evolving practice models steeped in behavioral sciences [
In addition, naturopathy derives evidence from the traditional and historical use of practices like
botanical medicine, homeopathy, and hydrotherapy, which, similar to the implementation of many
surgical interventions, preceded the advance of evidence-based medicine paradigms. Though case
reports, case series, and expert opinions are considered “weak” or “low quality” evidence, the
accumulation of case reports and Delphi-process guided consensus statements have made important
contributions to the foundation of an evidence base, as well as clinical guidelines. One specific example
in primary care is the Eighth Joint National Committee (JNC-8) hypertension management guideline,
in which six of the nine core recommendations rely on expert opinion as their evidence base [54].
Delays in the translation of new research into practice is a barrier to improvements in clinical
care that has been recognized by the National Institutes of Health [
]. In some cases, naturopathic
doctors apply evidence that may not otherwise be translated. For example, the United States Preventive
Services Task Force (USPSTF) recommends moderate-intensity face-to-face diet and lifestyle counseling
by primary care providers to those patients at risk for cardiovascular disease with Grade B evidence [
yet national statistics are very poor for the delivery of this advice in conventional biomedicine [
Conversely, recommendations consistent with USPSTF guidance are evident in most patient visits
with naturopathic doctors [
]. Thus, the inclusion of naturopathic care may assist in the
delivery of evidence-based preventive services and can improve quality assessments by helping more
facilities meet preventive care guidelines. Furthermore, it is constructive to consider the virtues
of naturopathy as a nimble practice model for the more rapid translation of evidence into practice,
especially evidence related to dietary, nutrient, physical activity, and herbal treatments, plus evidence
of harms of prescription drugs.
Naturopathic doctors are also much less likely to use prescription medications as treatment, even
when these drugs are included in their scope of practice [
]. Because of dierences in their application
of therapies and a philosophical aversion to prescription drug therapy in practice, naturopathic doctors
are positioned to be more discerning with their use of prescription drugs, more likely to follow standard
Medicina 2019,55, 603 6 of 14
of care guidelines for the use of drugs, and thus less likely to contribute to unnecessary prescribing (e.g.,
antibiotics for viral upper respiratory tract infections [
]), therefore potentially reducing iatrogenic
causes of illness or death. Notably, most harms of medications are not discovered during Food and
Drug Administration (FDA)-regulated phase three clinical trials (often upheld as the gold standard for
evidence) but rather are discovered through post-approval epidemiologic surveillance (e.g., in 2014
there were 528,192 new case reports of a serious or fatal outcome from FDA-approved prescription
or over-the-counter drugs [
]), which is heavily dependent on provider and patient reporting, with
the costs of identified harms passed directly on to insurers and patients [
]. “De-implementation”
research is gaining importance as the harms associated with prescription drugs are identified and
centers attempt to eliminate unproven procedures and practices [
]. Given iatrogenic errors are
now considered the third largest cause of death in the United States [
], additional discretion in the
use of prescription drugs is long overdue and is exemplified by naturopathic practice.
These deviations, i.e., less reliance on prescription drugs and reduced referrals to specialists, disrupt
the business models of hospitals, large group specialty practices, surgical centers, and pharmacies,
and they shift health care expenditures to other “wellness” services, thus contributing to multiple
emerging markets.
4. Criterion 3: A Disruptive Innovation Will Disrupt or Sustain Depending on Its Integration
The third criterion to be met for a technology to be considered “disruptive” in health care is not
a criterion of the technology but rather a criterion that is determined by the reaction of the current
market/technology to the candidate disruptor (i.e., whether or not the technology disrupts depends
on whether or not it is incorporated into the status quo). Naturopathy has been at a crossroads
with “mainstream” conventional biomedicine for hundreds of years, with evidence and arguments
advocating for a relationship of opposition, integration or medical pluralism [76,77].
Present reactions to naturopathy within biomedicine suggest there is resistance to its articulation
within current care delivery models, and instead a reaction of simultaneous marginalization (by not
including naturopathy in most medical centers or insurances) and co-optation (by adopting practices)
appears more common. The invention of “integrative medicine” illustrates this point. Though the
definition of integrative medicine varies (common definitions of “integrative medicine” include:
conventional providers who adopt complementary therapies into their practices; care models that
include both conventional and complementary care disciplines oered by dierent providers in one
setting; and/or coordination between providers of dierent disciplines, including complementary
medicine), in this context, it generally includes a merging of conventional care and complementary care.
The creation of a recognized integrative medicine specialty board qualification exclusive to medical
doctors can be interpreted as a reaction to the possible threat of naturopathy redirecting patients (and
revenue) from conventional care centers. Notably, the philosophy of “integrative medicine” [
] is
nearly identical to that of naturopathy, despite its more recent creation [45,79,80].
Other evidence suggesting conventional biomedicine will resist the inclusion of naturopathy
includes positions by major medical societies and allopathic physician advocacy foundations to
prioritize opposition to naturopathy licensure and scope expansion [
]. However, this strategy is
already proving ineective. Limiting the geographic range of naturopathy licensure simply directs
consumers across state lines and already contributes to an emerging medical tourism market on the
west coast of the United States [83].
Implying a requisite separation between science and naturopathy, published editorials refuse
to label an intervention for cardiovascular risk reduction derived of naturopathic care that designed
and implemented by naturopathic doctors as “naturopathic,” instead insisting it must be labeled
“science-based lifestyle advice” [
]. Additional examples include editorials claiming the nutritional
guidance oered in naturopathic practice as being the unique role of dieticians [
] and conventional
medical news outlets haranguing naturopathy as pseudoscientific and dangerous without providing
Medicina 2019,55, 603 7 of 14
specific examples [
]. These examples suggest opponents are emphasizing scope of practice
protection rather than embracing cooperation around a shared goal to improve patient outcomes.
The insurance reimbursement of naturopathy is also a strong determinant in the “integration”
that may contribute to naturopathy’s fate. By controlling provider reimbursement and regulating the
delivery of services, insurance credentialing and reimbursement for naturopathy may actually stifle its
growth, compared to more disruptive cash-based, fee-for-service models or health insurance co-ops
leveraging long-term investments in prevention.
Ironically, a fundamental method to ensure naturopathy does not evolve as a disruptive technology
is to embrace the inclusion of naturopathic care in current models of care delivery rather than resist or
attempt to prevent its inclusion. Not unlike the current leaders in the hybrid car market (e.g., Toyota),
a delay in the adoption of hybrid and electric car technologies by other vendors (e.g., US car makers)
enabled them to establish their brand and grow their customer base, leading directly to the establishment
of a dominant market share (e.g., the Prius
) and, thus, the power to heavily influence the future of
the market. Extending this analogy back to naturopathy, a failure by health care vendors to embrace
the public’s growing interest in naturopathy and complementary medicine generally is allowing
naturopathy to gain market share by delivering a consumer-oriented model of primary care that is
mostly external to mainstream medical centers. To illustrate the potential impact of the inclusion vs.
exclusion of naturopathy from the current market, consider a hospital center that includes naturopathy
compared to one that does not. The hospital that includes naturopathy can create quality standards
around provider credentialing; can place limits the scope of practice, including orders and prescribing;
can limit indications for referrals; and can control the overall patient experience within the health
center. Maintaining clinical services in-house also increases the likelihood of internal referrals to
specialty care. However, a hospital center that does not include naturopathy faces competition from
community-based naturopathic clinics, which may provide a highly variable experience in the quality of
treatment and care, as well as re-direct potential revenue outside of the hospital. Surveys in Washington
State that compared patient satisfaction provided a specific example of naturopathic medical centers
outperforming nearly all biomedical care facilities [
]. These community-based naturopathic clinics
operate beyond hospital control and are much less likely to route customers to the hospital for specialty
care or other clinical services. This scenario also reinforces aspects of Criterion 2; by transforming
the care experience and challenging elements of the typical care delivery process, other providers’
clinical practices are disrupted with subsequent implications for inter-professional collaboration and
team-based care, as has been seen in other settings [89].
Many characteristics of naturopathy appear to mirror those characteristics sought by the public
in their health care [
]; therefore, the survival and growth of naturopathy in the healthcare market
appears highly likely. However, the degree and rate of naturopathy’s disruption will also depend on
the availability of new research that demonstrates eectiveness and patient-centeredness, increased
public awareness of their choices in prevention-based primary care and natural health specialty
services, increased access to naturopathy, and whether there is robust integration into current health
care “technology.”
5. Disruptive Innovations Leverage New Values, and Create New Markets
Leveraging new values in a marketplace is only one aspect of a truly disruptive innovation; another
aspect is the creation of (or contribution to) new markets. Naturopathy supports emerging markets in
several ways, including supporting the development of “wellness”-based economic models of health
care delivery through referrals to clinical providers not yet incorporated into mainstream health centers
(e.g., massage therapists, yoga therapists, acupuncturists, and health coaches), recommendations for
health products not widely available in mainstream pharmacies, clinics and hospitals (e.g., dietary
supplements, homeopathic remedies, herbal medicines, and natural health products), and the use
of exercise and other movement-based facilities not widely accessible via mainstream rehabilitation
centers (e.g., gyms, health spas, and yoga studios). In the United States alone, the out-of-pocket
Medicina 2019,55, 603 8 of 14
expenditures on complementary and integrative health services exceed $30.2 billion [
]. An additional
contribution to the “wellness” economy, albeit not easily quantifiable, is the contribution of naturopathy
to the food industry through guidance toward organic, natural foods. The recent purchase of Whole
Foods natural food markets by Amazon, Inc. for $13.7 billion speaks to the growing economic force
and market share held by the natural food industry [90].
While these statistics are largely derived from United States, there is reason to believe the disruption
caused by naturopathy is not limited to the United States, or North America. Public use of and
out-of-pocket expenditures for complementary and alternative health services have increased globally [
In Australia, for example, available data suggest at least 44.1% of Australians visited a complementary
medicine practitioner within the previous 12 months, with similar numbers of visits to complementary
and alternative medicine practitioners compared to conventional medical practitioners (69.3 million),
with an estimated annual expenditure of $4.13 billion Australian dollars (US $3.12 billion) [92].
Simply redirecting some proportion of the public’s available out-of-pocket health care expenditures
toward a dierent segment of health care providers and products alone does not create a viable
market—some measurable benefit or eect of this redistribution must also be created. An emerging case
exists that not only do expenditures toward naturopathic care prove cost-eective, the contributions
of naturopathy may constitute a “value added” to the workplace. For example, a clinical trial
of naturopathy for primary cardiovascular disease prevention demonstrated eectiveness and
cost-eectiveness, with a decisive contribution to cost savings being reductions in work place
presenteeism (a confusing term, “presenteeism” is working while sick or with otherwise reduced
physical and/or emotional function [
]), not the direct costs of the care provided [
]. Some authors
have extended the potential of the value added by naturopathy to posit it has greater potential to
reduce escalating costs in the developed and developing world due to its emphasis on prevention and
patient self-management in the context of an escalating prevalence of non-communicable diseases [
Some critics have argued that the additional expenditures on complementary and integrative
health services are a “double-dip” by the public (i.e., many people use complementary medicine
providers concurrent to their primary care providers), leading to excess medical spending. Though
there is limited evidence available on this topic, in states where naturopathic doctors are licensed as
primary care providers (e.g., Washington state), over utilization does not appear to occur and people
who use complementary medicine providers tend to be in better health, have fewer diagnostic tests
and attend fewer costly specialty visits [23].
Perhaps the greatest potential for disrupting the dominant market force in medicine is the
ephemeral promise of chronic disease prevention through the routine delivery of primary prevention
services and by optimizing and scaling behavior change strategies. Historically, investment in
prevention by third-party payers has been limited by the expectation of a five-year return on investment
(ROI), which simply is not possible for prevention strategies targeting chronic disease, from which the
ROI is likely 20 or 30 years away from the point(s) of intervention. Again, type 2 diabetes provides an
illustrative case example for this point. The individual level costs of type 2 diabetes are estimated at
$85,200.00 per person, translating into an approximate cost of $1.7 trillion for the 20 million adults
in the United States with type 2 diabetes (not accounting for increasing costs of treatment, disease
prevalence, or the economic losses from increased workplace absenteeism and presenteeism) [
Thus, the redirection of even 1% of the direct costs of diabetes care toward primary prevention-oriented
clinical services would create a new US$ 17 billion market.
While naturopathy has not demonstrated the ability to “cure” or “prevent” type 2 diabetes
in clinical trials, the practices recommended during naturopathic consultations for type 2 diabetes
are consistent with the recommendations in the Diabetes Prevention Program [
], as they engage
on multiple behavioral barriers to lifestyle change, translate into improved self-care, and appear to
lower blood glucose [
]. Combining those changes with reduced primary cardiovascular disease
risk [
] may create a significant inflection point in a patients’ health/risk trajectory for multiple
chronic diseases. Additionally, although evidence is still quite limited, at least two herbal medicine
Medicina 2019,55, 603 9 of 14
products have clinical trial evidence for diabetes prevention [
], and numerous nutrient or herbal
interventions used in naturopathic practice have evidence for lowering blood glucose or otherwise
impacting diabetes-related risk [
]. Thus, naturopathy oers several desirable health products
to the savvy consumer, including multiple categories of evidence-based therapeutic interventions not
routinely delivered in conventional biomedicine, with overarching goals of primary prevention and
functional health improvement—all of which hold great promise for creating inflection points in the
health trajectory for people with diabetes.
6. Conclusions and Future Directions
By meeting all three criteria outlined by the Christensen Institute, naturopathy appears to
constitute a disruptive innovation in health care. If optimized, the model of health care represented
by naturopathy has the potential to surpass allopathic care (in its current form) as a dominant model
of primary care by representing patient- and family-centered values in care delivery, a focus on
prevention, and the de-emphasis on pharmaceuticals and elective surgery in favor of pragmatic
self-care behaviors, lifestyle practices, and natural treatments. Notably, promoting healthy self-care
behaviors, de-emphasizing costly technologies that do not improve outcomes, and becoming more
judicious in the use of prescription drugs are all known opportunities to achieve the triple aim [
Thus, naturopathy may contribute to wider-ranging health service goals. Whether these changes
occur due to market pressures encouraging biomedical care providers and academic training centers
to change their model or due to naturopathic doctors playing an increasing role in care delivery
remains uncertain. Given the many barriers to rapid change in allopathic models of training and care
delivery, reductions in public trust of managed care [
], and an increasing number of deaths
attributable to medical errors, perhaps it is time to embrace the approach represented by naturopathy
and actively seek to incorporate it more widely rather than marginalize its role. As common diagnostic
and treatment algorithms become increasingly accessible through mobile applications and artificial
intelligence, the survival of biomedical primary care may require it to redefine itself and mirror the
values, if not the interventions, represented by modern naturopathy.
Conflicts of Interest: There are no conflicts of interest to declare.
Frogner, B.K.; Frech, H.E., 3rd; Parente, S.T. Comparing eciency of health systems across industrialized
countries: A panel analysis. BMC Health Serv. Res. 2015,15, 415. [CrossRef] [PubMed]
Improvement IfH. IHI Triple Aim Iniative 2017. Available online:
TripleAim/Pages/default.aspx (accessed on 5 April 2017).
Jiwa, M.; Carlsen, J.; Horner, B. Healthcare innovation and market forces. Qual. Prim. Care
,17, 1–3.
Schur, C.L.; Berk, M.L.; Yegian, J.M. Public perceptions of cost containment strategies: Mixed signals for
managed care. Health A.2004,23, 4516–4525. [CrossRef]
Luke, R.T. Health care in the United States: Current and future challenges. Manag. Care
,10, 2–6.
Christensen, C.M.; Bohmer, R.; Kenagy, J. Will Disruptive Innovations Cure Health Care? Harv. Bus. Rev.
2000,78, 102–112.
Wiedemann, L.A. A look at unintended consequences of EHRs: The industry needs to focus on building
EHRs that decrease medical errors and enhance patient care. Health Manag. Technol. 2012,33, 24–25.
8. Detsky, A.S.; Garber, A.M. Uber’s Message for Health Care. N. Engl. J. Med. 2016,374, 806–809. [CrossRef]
Christensen, C.M. The Innovator’s Dilemma: When New Technologies Cause Great Firms to Fail; Harvard Business
School Press: Boston, MA, USA, 1997.
Spencer, N. What’s Disruptive and What’s Not? Three Criteria for Identifying Disruptors in Healthcare.
Available online:
for-identifying-disruptors-in-healthcare/(accessed on 5 April 2016).
Medicina 2019,55, 603 10 of 14
11. WHO. WHO Traditional Medicine Strategy 2014–2023; WHO: Geneva, Switzerland, 2013.
Cherkin, D.C.; Deyo, R.A.; Sherman, K.J.; Hart, L.G.; Street, J.H.; Hrbek, A.; Barassi, J. Characteristics of
licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. J. Am. Board Fam.
Pract. 2002,15, 378–390.
Kennedy, D.A.; Bernhardt, B.; Snyder, T.; Bancu, V.; Cooley, K. Complementary medical health services:
A cross sectional descriptive analysis of a Canadian naturopathic teaching clinic. BMC Complement.
Altern. Med. 2015,15, 37. [CrossRef]
Bradley, R.; Kozura, E.; Buckle, H.; Kaltunas, J.; Tais, S.; Standish, L.J. Description of clinical risk factor
changes during naturopathic care for type 2 diabetes. J. Altern. Complement. Med.
,15, 633–638.
Bradley, R.; Kozura, E.; Kaltunas, J.; Oberg, E.B.; Probstfield, J.; Fitzpatrick, A.L. Observed Changes in Risk
during Naturopathic Treatment of Hypertension. Evid. Based Complement. Altern. Med.
,2011, 826751.
[CrossRef] [PubMed]
Bradley, R.; Oberg, E.B. Naturopathic medicine and type 2 diabetes: A retrospective analysis from an
academic clinic. Altern. Med. Rev. 2006,11, 30–39. [PubMed]
Bradley, R.; Sherman, K.J.; Catz, S.; Calabrese, C.; Oberg, E.B.; Jordan, L.; Cherkin, D. Adjunctive naturopathic
care for type 2 diabetes: Patient-reported and clinical outcomes after one year. BMC Complement. Altern.
Med. 2012,12, 44. [CrossRef] [PubMed]
Breed, C.; Bereznay, C. Treatment of Depression and Anxiety by Naturopathic Physicians: An Observational
Study of Naturopathic Medicine Within an Integrated Multidisciplinary Community Health Center. J. Altern.
Complement. Med. 2017,23, 348–354. [CrossRef] [PubMed]
Seely, D.; Szczurko, O.; Cooley, K.; Fritz, H.; Aberdour, S.; Herrington, C.; Gignac, T. Naturopathic medicine
for the prevention of cardiovascular disease: A randomized clinical trial. Can. Med. Assoc. J.
E409–E416. [CrossRef] [PubMed]
Jared, Z.; Stephen, P.M.; Panela, S.; Zora, D. A Hierarchy of Healing: The Therapeutic Order A Unifying
Theory of Naturopathic Medicine. In The Textbook of Natural Medicine, 4th ed.; Elsevier Chruchill Livingstone:
St. Louis, MI, USA, 2013; pp. 18–33.
Colleges AoANM. 7 Accredited Naturopathic Programs Across 8 North American Campuses. 2017. Available
online: on 5 April 2016).
22. Physicians AAoN. Professional Education. 2017. Available online:
(accessed on 5 April 2016).
Boon, H.S.; Cherkin, D.C.; Erro, J.; Sherman, K.J.; Milliman, B.; Booker, J.; Eisenberg, D.M. Practice patterns
of naturopathic physicians: Results from a random survey of licensed practitioners in two US States.
BMC Complement. Altern. Med. 2004,4, 14. [CrossRef] [PubMed]
Hough, H.J.; Dower, C.; O’Neil, E.H. Profile of a Profession: Naturopathic Practice. San Francisco, CA, Centre for
the Health Professions; San Francisco University of California: San Francisco, CA, USA, 2001.
Physicians AAoN. Regulated States & Regulatory Authorities. 2017. Available online: http://www. (accessed on 5 October 2017).
Nahin, R.L.; Barnes, P.M.; Stussman, B.J. Expenditures on Complementary Health Approaches: United States,
2012. Natl. Health Stat. Rep. 2016,95, 1–11.
Greenberg, P.E.; Fournier, A.A.; Sisitsky, T.; Pike, C.T.; Kessler, R.C. The economic burden of adults with major
depressive disorder in the United States (2005 and 2010). J. Clin. Psychiatry
,76, 155–162. [CrossRef]
Cramer, H.; Lauche, R.; Langhorst, J.; Dobos, G. Yoga for depression: A systematic review and meta-analysis.
Depress. Anxiety 2013,30, 1068–1083. [CrossRef]
Apaydin, E.A.; Maher, A.R.; Shanman, R.; Booth, M.S.; Miles, J.N.; Sorbero, M.E.; Hempel, S. A systematic
review of St. John’s wort for major depressive disorder. Syst. Rev. 2016,5, 148. [CrossRef]
Linde, K.; Berner, M.M.; Kriston, L. St John’s wort for major depression. Cochrane Database Syst. Rev.
CD000448. [CrossRef] [PubMed]
Ng, Q.X.; Venkatanarayanan, N.; Ho, C.Y. Clinical use of Hypericum perforatum (St John’s wort) in depression:
A meta-analysis. J. Aect. Disord. 2017,210, 211–221. [CrossRef] [PubMed]
Medicina 2019,55, 603 11 of 14
Maddux, R.E.; Daukantaite, D.; Tellhed, U. The eects of yoga on stress and psychological health among
employees: An 8- and 16-week intervention study. Anxiety Stress Coping
,31, 121–134. [CrossRef]
Schmid, A.A.; Van Puymbroeck, M.; Fruhauf, C.A.; Bair, M.J.; Portz, J.D. Yoga improves occupational
performance, depression, and daily activities for people with chronic pain. Work
,63, 181–189.
[CrossRef] [PubMed]
Dall, T.M.; Yang, W.; Gillespie, K.; Halder, P.; Pang, B.; Massoudi, M.; Wintfeld, N.; Hogan, P.F. The Economic
Burden of Elevated Blood Glucose Levels in 2017: Diagnosed and Undiagnosed Diabetes, Gestational
Diabetes Mellitus, and Prediabetes. Diabetes Care 2019,42, 1661–1668. [CrossRef] [PubMed]
Thind, H.; Lantini, R.; Balletto, B.L.; Donahue, M.L.; Salmoirago-Blotcher, E.; Bock, B.C.; Scott-Sheldon, L.A.
The eects of yoga among adults with type 2 diabetes: A systematic review and meta-analysis. Prev. Med.
2017,105, 116–126. [CrossRef] [PubMed]
Jayawardena, R.; Ranasinghe, P.; Chathuranga, T.; Atapattu, P.M.; Misra, A. The benefits of yoga practice
compared to physical exercise in the management of type 2 Diabetes Mellitus: A systematic review and
meta-analysis. Diabetes Metab. Syndr. 2018,12, 795–805. [CrossRef]
Skulas-Ray, A.C.; Wilson, P.W.F.; Harris, W.S.; Brinton, E.A.; Kris-Etherton, P.M.; Richter, C.K.; Blum, C.B.
Omega-3 Fatty Acids for the Management of Hypertriglyceridemia: A Science Advisory From the American
Heart Association. Circulation. 2019. [CrossRef]
Namazi, N.; Khodamoradi, K.; Khamechi, S.P.; Heshmati, J.; Ayati, M.H.; Larijani, B. The impact of cinnamon
on anthropometric indices and glycemic status in patients with type 2 diabetes: A systematic review and
meta-analysis of clinical trials. Complement. Ther. Med. 2019,43, 92–101. [CrossRef]
Allen, R.W.; Schwartzman, E.; Baker, W.L.; Coleman, C.I.; Phung, O.J. Cinnamon use in type 2 diabetes:
An updated systematic review and meta-analysis. Ann. Fam. Med. 2013,11, 452–459. [CrossRef]
Suksomboon, N.; Poolsup, N.; Yuwanakorn, A. Systematic review and meta-analysis of the ecacy and safety
of chromium supplementation in diabetes. J. Clin. Pharm. Ther. 2014,39, 292–306. [CrossRef] [PubMed]
San Mauro-Martin, I.; Ruiz-Leon, A.M.; Camina-Martin, M.A.; Garicano-Vilar, E.; Collado-Yurrita, L.;
Mateo-Silleras, B.D.; Redondo Del R
o, M.D.P. Chromium supplementation in patients with type 2 diabetes
and high risk of type 2 diabetes: A meta-analysis of randomized controlled trials. Nutr. Hosp.
,33, 27.
[CrossRef] [PubMed]
Carter, S.; Clifton, P.M.; Keogh, J.B. Eect of Intermittent Compared With Continuous Energy Restricted Diet
on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Noninferiority Trial. JAMA Netw.
Open 2018,1, e180756. [CrossRef] [PubMed]
Balducci, S.; D’Errico, V.; Haxhi, J.; Sacchetti, M.; Orlando, G.; Cardelli, P.; Lucisano, G. Eect of a Behavioral
Intervention Strategy on Sustained Change in Physical Activity and Sedentary Behavior in Patients With
Type 2 Diabetes: The IDES_2 Randomized Clinical Trial. J. Am. Med. Assoc.
,321, 880–890. [CrossRef]
Oberg, E.B.; Bradley, R.; Hsu, C.; Sherman, K.J.; Catz, S.; Calabrese, C.; Cherkin, D.C. Patient-reported
experiences with first-time naturopathic care for type 2 diabetes. PLoS ONE
,7, e48549. [CrossRef]
Fleming, S.A.; Gutknecht, N.C. Naturopathy and the primary care practice. Prim. Care
,37, 119–136.
[CrossRef] [PubMed]
Okunrintemi, V.; Spatz, E.S.; Di Capua, P.; Salami, J.A.; Valero-Elizondo, J.; Warraich, H.; Borden, W.B.
Patient-Provider Communication and Health Outcomes Among Individuals With Atherosclerotic
Cardiovascular Disease in the United States: Medical Expenditure Panel Survey 2010 to 2013. Circ. Cardiovasc.
Qual. Outcomes 2017,10, e003635. [CrossRef] [PubMed]
Flach, S.D.; McCoy, K.D.; Vaughn, T.E.; Ward, M.M.; Bootsmiller, B.J.; Doebbeling, B.N. Does patient-centered
care improve provision of preventive services? J. Gen. Intern. Med.
,19, 1019–1026. [CrossRef] [PubMed]
Oberg, E.B.; Thomas, M.S.; McCarty, M.; Berg, J.; Burlingham, B.; Bradley, R. Older Adults’ Perspectives on
Naturopathic Medicine’s Impact on Healthy Aging. Explore 2014,10, 34–43. [CrossRef] [PubMed]
Cooley, K.; Szczurko, O.; Perri, D.; Mills, E.J.; Bernhardt, B.; Zhou, Q.; Seely, D. Naturopathic care for anxiety:
A randomized controlled trial ISRCTN78958974. PLoS ONE 2009,4, e6628. [CrossRef]
Szczurko, O.; Cooley, K.; Busse, J.W.; Seely, D.; Bernhardt, B.; Guyatt, G.H.; Mills, E.J. Naturopathic care for
chronic low back pain: A randomized trial. PLoS ONE 2007,2, e919. [CrossRef] [PubMed]
Medicina 2019,55, 603 12 of 14
Thrasher, J. Pharmacologic Management of Type 2 Diabetes Mellitus: Available Therapies. Am. J. Cardiol.
2017,120, 4–16. [CrossRef] [PubMed]
Jellinger, P.S.; Handelsman, Y.; Rosenblit, P.D.; Bloomgarden, Z.T.; Fonseca, V.A.; Garber, A.J.;
Pessah-Pollack, R. American Association of Clinical Endocrinologists and American College of Endocrinology
Guidelines for Management of Dyslipidemia and Prevention of Cardiovascular Disease—Executive
Summarycomplete Appendix to Guidelines available at Pract.
23, 479–497. [PubMed]
Marathe, P.H.; Gao, H.X.; Close, K.L. American Diabetes Association Standards of Medical Care in Diabetes
2017. J. Diabetes 2017,9, 320–324. [CrossRef] [PubMed]
James, P.A.; Oparil, S.; Carter, B.L.; Cushman, W.C.; Dennison-Himmelfarb, C.; Handler, J.; Smith, S.C. 2014
evidence-based guideline for the management of high blood pressure in adults: Report from the panel
members appointed to the Eighth Joint National Committee (JNC 8). J. Am. Med. Assoc.
,311, 507–520.
[CrossRef] [PubMed]
Li, C.; Ford, E.S.; Strine, T.W.; Mokdad, A.H. Prevalence of depression among U.S. adults with diabetes:
Findings from the 2006 behavioral risk factor surveillance system. Diabetes Care
,31, 105–107. [CrossRef]
56. Gonzalez, J.S.; Safren, S.A.; Cagliero, E.; Wexler, D.J.; Delahanty, L.; Wittenberg, E.; Grant, R.W. Depression,
self-care, and medication adherence in type 2 diabetes: Relationships across the full range of symptom
severity. Diabetes Care 2007,30, 2222–2227. [CrossRef] [PubMed]
Hastert, T.A.; Ruterbusch, J.J.; Beresford, S.A.; Sheppard, L.; White, E. Contribution of health behaviors to
the association between area-level socioeconomic status and cancer mortality. Soc. Sci. Med.
,148, 52–58.
[CrossRef] [PubMed]
Mathieu, R.A.; Powell-Wiley, T.M.; Ayers, C.R.; McGuire, D.K.; Khera, A.; Das, S.R.; Lakoski, S.G. Physical
activity participation, health perceptions, and cardiovascular disease mortality in a multiethnic population:
The Dallas Heart Study. Am. Heart J. 2012,163, 1037–1040. [CrossRef]
Redmond, N.; Baer, H.J.; Hicks, L.S. Health behaviors and racial disparity in blood pressure control in the
national health and nutrition examination survey. Hypertension 2011,57, 383–389. [CrossRef]
Sciences NCfAT. Message from the NCATS Director. 2017. Available online:
aug-2017 (accessed on 6 October 2017).
Vander Schaaf, E.B.; Seashore, C.J.; Randolph, G.D. Translating Clinical Guidelines Into Practice: Challenges
and Opportunities in a Dynamic Health Care Environment. N. C. Med. J.
,76, 230–234. [CrossRef]
Force USPST. Healthful Diet and Physical Activity for Cardiovascular Disease Prevention
in Adults With Cardiovascular Risk Factors: Behavioral Counseling. 2014. Available
diet-and-physical-activity-counseling-adults- with-high-risk-of-cvd?ds=1&s=Cardiovascular. (accessed
on 6 October 2017).
Omura, J.D.; Carlson, S.A.; Paul, P.; Watson, K.B.; Loustalot, F.; Foltz, J.L.; Fulton, J.E. Adults Eligible for
Cardiovascular Disease Prevention Counseling and Participation in Aerobic Physical Activity—United
States, 2013. Morb. Mortal. Wkly. Rep. 2015,64, 1047–1051. [CrossRef] [PubMed]
Kolasa, K.M.; Rickett, K. Barriers to providing nutrition counseling cited by physicians: A survey of primary
care practitioners. Nutr. Clin. Pract. 2010,25, 502–509. [CrossRef] [PubMed]
Heaton, P.C.; Frede, S.M. Patients’ need for more counseling on diet, exercise, and smoking cessation: Results
from the National Ambulatory Medical Care Survey. J. Am. Pharm. Assoc. 2006,46, 364–369. [CrossRef]
Cherry, D.K.; Burt, C.W.; Woodwell, D.A. National Ambulatory Medical Care Survey: 2001 summary.
Adv. Data 2003,337, 1–44.
Meigs, J.B.; Staord, R.S. Cardiovascular disease prevention practices by U.S. Physicians for patients with
diabetes. J. Gen. Intern. Med. 2000,15, 220–228. [CrossRef]
Dyer, O. A third of US antibiotic prescriptions are inappropriate, finds CDC study. Br. Med. J.
,353, 2660.
Moore, T.J.; Furberg, C.D.; Mattison, D.R.; Cohen, M.R. Completeness of serious adverse drug event reports
received by the US Food and Drug Administration in 2014. Pharmacoepidemiol. Drug Saf.
,25, 713–718.
Medicina 2019,55, 603 13 of 14
Gibbons, R.D.; Amatya, A.K.; Brown, C.H.; Hur, K.; Marcus, S.M.; Bhaumik, D.K.; Mann, J.J. Post-approval
drug safety surveillance. Annu. Rev. Public Health 2010,31, 419–437. [CrossRef]
Barnes, G.D.; Misirliyan, S.; Kaatz, S.; Jackson, E.A.; Haymart, B.; Kline-Rogers, E.; Sales, A. Barriers and
facilitators to reducing frequent laboratory testing for patients who are stable on warfarin: A mixed methods
study of de-implementation in five anticoagulation clinics. Implement. Sci. 2017,12, 87. [CrossRef]
Winchester, D.E.; Schmalfuss, C.; Helfrich, C.D.; Beyth, R.J. A specialty-specific, multimodality educational
quality improvement initiative to deimplement rarely appropriate myocardial perfusion imaging. Open Heart
2017,4, e000589. [CrossRef] [PubMed]
Laan, B.J.; Spijkerman, I.J.; Godfried, M.H.; Pasmooij, B.C.; Maaskant, J.M.; Borgert, M.J.; Geerlings, S.E.
De-implementation strategy to Reduce the Inappropriate use of urinary and intravenous CATheters: Study
protocol for the RICAT-study. BMC Infect. Dis. 2017,17, 53. [CrossRef] [PubMed]
Prasad, V.; Ioannidis, J.P. Evidence-based de-implementation for contradicted, unproven, and aspiring
healthcare practices. Implement. Sci. 2014,9, 1. [CrossRef] [PubMed]
Makary, M.A.; Daniel, M. Medical error-the third leading cause of death in the US. Br. Med. J.
,353, 2139.
[CrossRef] [PubMed]
Kaptchuk, T.J.; Miller, F.G. Viewpoint: What Is the Best and Most Ethical Model for the Relationship between
Mainstream and Alternative Medicine: Opposition, Integration, or Pluralism? Acad. Med. J. Assoc. Am.
Med. Coll. 2005,80, 286–290. [CrossRef]
Wiese, M.; Oster, C.; Pincombe, J. Understanding the Emerging Relationship Between Complementary
Medicine and Mainstream Health Care: A Review of the Literature. Health 2010,14, 326–342. [CrossRef]
The Bravewell Collaborative. Philosophical Foundation for Integrative Medicine. 2015. Available online: on 7 October 2017).
Physicians AAoN. Definition of Naturopathic Medicine. 2011. Available online: http://www.naturopathic.
org/content.asp?contentid=59 (accessed on 5 April 2016).
Herman, P.M.; Sherman, K.J.; Erro, J.H.; Cherkin, D.C.; Milliman, B.; Adams, L.A. A method for describing
and evaluating naturopathic whole practice. Altern. Ther. Health Med. 2006,12, 20–28.
Isaacs, S.; Jellinek, P. Accept No Substitute: A Report on Scope of Practice. The Physicians Foundation, 2012.
Available online: of-practice/(accessed on
5 April 2016).
The American Medical Association. Scope of Practice Partnership. 2017. Available online: https://www.ama- (accessed on 3 May 2017).
83. Korn, P. Need Treatment, Will Travel (to Portland); Portland Tribune: Portland, OR, USA, 2013.
Oppel, L.B. Advising on diet and lifestyle: Naturopathy’s role? Can. Med Assoc. J.
,185, 1432. [CrossRef]
Delisle, H.; Lefebvre, S. Advising on diet and lifestyle: Naturopathy’s role? Can. Med Assoc. J.
1431. [CrossRef]
Atwood, K.C. Naturopathy: A Critical Appraisal. 2003. Available online:
viewarticle/465994 (accessed on 9 October 2017).
Atwood, K.C. Naturopathy, Pseudoscience, and Medicine: Myths and Fallacies vs Truth. 2004. Available
online: (accessed on 5 April 2016).
Alliance, W.H. Your Voice Matters: Patient Experience with Primary Care Providers in the Puget Sound
Region. 2004. Available online:
Experience-2014.pdf (accessed on 5 April 2016).
Li, J.; Westbrook, J.; Callen, J.; Georgiou, A. The role of ICT in supporting disruptive innovation: A multi-site
qualitative study of nurse practitioners in emergency departments. BMC Med. Inform. Decis. Mak.
27. [CrossRef]
Amazon and Whole Foods Market Announce Acquisition to Close This Monday, Will Work Together to Make
High-Quality, Natural and Organic Food Aordable for Everyone [Press Release]. 2017. Available online: whole-foods-market-announce-acquisition-to-
close-this-monday-will-work-together-to-make- high-quality-natural-and-organic-food-aordable-for-
everyone-2017-08-24 (accessed on 5 April 2016).
Harris, P.; Cooper, K.; Relton, C.; Thomas, K. Prevalence of complementary and alternative medicine (CAM)
use by the general population: A systematic review and update. Int. J. Clin. Pract.
,66, 924–939.
[CrossRef] [PubMed]
Medicina 2019,55, 603 14 of 14
Xue, C.; Zhang, A.; Lin, V.; Da Costa, C.; Story, D. Complementary and alternative medicine use in Australia:
A national population-based survey. J. Altern. Complement. Med. 2007,13, 643–650. [CrossRef] [PubMed]
Stromberg, C.; Aboagye, E.; Hagberg, J.; Bergstrom, G.; Lohela-Karlsson, M. Estimating the Eect and
Economic Impact of Absenteeism, Presenteeism, and Work Environment-Related Problems on Reductions in
Productivity from a Managerial Perspective. Value Health 2017,20, 1058–1064. [CrossRef] [PubMed]
Herman, P.M.; Szczurko, O.; Cooley, K.; Seely, D. A naturopathic approach to the prevention of cardiovascular
disease: Cost-eectiveness analysis of a pragmatic multi-worksite randomized clinical trial. J. Occup. Environ.
Med. 2014,56, 171–176. [CrossRef] [PubMed]
Tripathy, J.P. Can naturopathy provide answers to the escalating health care costs in India? J. Tradit.
Complement. Med. 2015,5, 63–65. [CrossRef] [PubMed]
Zhuo, X.; Zhang, P.; Hoerger, T.J. Lifetime direct medical costs of treating type 2 diabetes and diabetic
complications. Am. J. Prev. Med. 2013,45, 253–261. [CrossRef] [PubMed]
Knowler, W.C.; Barrett-Connor, E.; Fowler, S.E.; Hamman, R.F.; Lachin, J.M.; Walker, E.A.; Nathan, D.M.
Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N. Engl. J. Med.
346, 393–403. [PubMed]
Chuengsamarn, S.; Rattanamongkolgul, S.; Luechapudiporn, R.; Phisalaphong, C.; Jirawatnotai, S. Curcumin
extract for prevention of type 2 diabetes. Diabetes Care 2012,35, 2121–2127. [CrossRef] [PubMed]
Fan, G.J.; Luo, G.B.; Qin, M.L. [Eect of jiangtang bushen recipe in intervention treatment of patients with
impaired glucose tolerance]. Zhongguo Zhong Xi Yi Jie He Za Zhi 2004,24, 317–320. [PubMed]
Yeh, G. Systematic Review of Herbs and Dietary Supplements for Glycemic Control in Diabetes. Diabetes
Care 2003,36, 1277–1294. [CrossRef]
Bradley, R.; Oberg, E.B.; Calabrese, C.; Standish, L.J. Algorithm for complementary and alternative medicine
practice and research in type 2 diabetes. J. Altern. Complement. Med.
,13, 159–175. [CrossRef] [PubMed]
Ory, M.G.; Ahn, S.; Jiang, L.; Smith, M.L.; Ritter, P.L.; Whitelaw, N.; Lorig, K. Successes of a national study of
the Chronic Disease Self-Management Program: Meeting the triple aim of health care reform. Med. Care
2013,51, 992–998. [CrossRef] [PubMed]
Mechanic, D. The functions and limitations of trust in the provision of medical care. J. Health Polit. Policy
Law 1998,23, 661–686. [CrossRef] [PubMed]
Miller, B.C. Population Health Management Program Development: The Path to the Triple Aim.
2016. Available online:
development-The-path-to-the-Triple-Aim/(accessed on 9 October 2017).
2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
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... Model pendidikan untuk naturopati mirip dengan pelatihan medis allopathic dengan landasannya fisiologi dan diagnostik biomedis. Namun atribut unik naturopati dengan prioritas ulang urutan terapi yang menekankan perawatan diri berorientasi pada gaya hidup, perilaku pencegahan, nutrisi, aktivitas fisik, dan konseling manajemen stres sebelum beralih ke nutrisi klinis (menargetkan tindakan farmakologis dari nutrisi untuk penyakit tertentu terlepas dari status nutrisi), obat herbal, homeopati, terapi manual daripada menekankan terapi obat bebas dan resep atau intervensi bedah (Bradley et al., 2019). ...
... Teknik pengobatan naturopati termasuk metode tradisional dan modern, empiris dan ilmiah ((ACIH), 2017). Gambar 17.1 Hirarki tipikal terapi dalam praktek naturopati (Bradley et al., 2019). ...
... 13,14 Research suggests that NDs, as primary HCPs, may be well situated to help integrate complementary or alternative (CAM) therapies into conventional primary care, creating a more holistic model that can better address health through prevention and management of chronic disease. 13,[15][16][17][18][19] In light of the unique challenges faced by this region and in support of the integration of the naturopathic profession, there are many considerations that need to be taken into account to enact effective change in the healthcare sector. These considerations include past efforts, on going colonialism, the unique needs of northern Ontario's populations, and the ND scope of practice. ...
... Naturopathic medicine has great potential to address primary healthcare needs. 15 In addition to treating acute and chronic conditions, NDs engage in health promotion and prevention of disease. 60 Naturopathic medicine has the potential to become a "disruptive innovation" in health care due to its ability to address primary healthcare needs, particularly chronic diseases, such as depression and diabetes, without the use of expensive pharmaceutical and surgical interventions, while also providing highly qualified professionals to bolster the primary care workforce. ...
The shortage of primary healthcare practitioners, such as physicians and nurses, in northern Ontario has persisted fordecades despite multiple strategies to address it. Poor health outcomes for people living in northern Ontario must be viewed through an equity lens that takes into account the multiple proximal, intermediate, and distal social determinants of health, including, but not limited to, the impact of colonization and continued colonialism on the health of Indigenous Peoples, challenges in housing, education and employment, as well as lack of food security. The increase in chronic health conditions in northern Ontario and the need for interprofessional healthcare teams that offer patient-centred care are key issues. Whole person care that takes into consideration the integration of body, mind, and spirit is central to Indigenous concepts of health and wellness, as well as being central to the foundations of naturopathic medical philosophy. Inclusion of naturopathic doctors in publicly funded multi-disciplinary primary healthcare settings is proposed as an achievable strategy to fill gaps in health human resources and advance the movement towards holistic care for Indigenous Peoples and others living in northern Ontario.
... 19 The apparent lack of consideration of patient preference, however, seems to misalign with the patient-centered approach characteristic of naturopathic practice. 20 It is possible that this may reflect a tension between EBP and naturopathic philosophy, with a number of respondents commenting that antibiotics should be appropriately recommended or not independent of patient preference. This warrants further investigation to better understand the nuances of naturopathic clinical decisionmaking. ...
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Objective: Both the United Nations and the World Health Organization have identified antimicrobial resistance as a significant threat to global health. The Centers for Disease Control and Prevention identified five pediatric respiratory conditions as requiring particular scrutiny in terms of antibiotic stewardship. This study sought to identify strategies used by experienced naturopathic practitioners to treat acute respiratory infections in children. The authors theorize that naturopathic strategies safely fill the gap between watchful waiting and antibiotic prescription, thus reducing the use of antibiotics. Methods: Naturopathic practitioners in Canada, the United States, and Australia with a minimum of 5 years of experience in clinical naturopathic care of children were recruited for a modified Delphi study. A 14-person panel of practitioners was selected to complete a series of four iterative surveys assessing agreement to statements in five domains of knowledge/attitudes, assessment/diagnosis, management, monitoring, and education. Items were deemed to have reached consensus if they reached a predetermined threshold of 70% agreement, or failed to reach a threshold of 40% agreement. Items between these boundaries were modified and retested until either consensus was reached or the four surveys had been completed. Results: Results yielded a large degree of agreement on core naturopathic approaches to the management of acute pediatric respiratory infections, especially lifestyle strategies, including adequate rest and dietary recommendations. The use of vitamins C and D was strongly supported, as were herbs, particularly echinacea and elderberry. Some hydrotherapy and topical applications specific to the individual focus on infection also reached consensus. Results suggested that most respondents, even if they have the authority to prescribe antibiotics, rarely deem it necessary to do so. Conclusion: Findings of this study provide (1) clarity on the role of naturopathic doctors in the management of pediatric health concerns and the stewardship of antibiotics; and (2) initial guidance to less experienced naturopathic practitioners. The findings also identify key priorities for research into the safety and effectiveness of naturopathic interventions to reduce the unnecessary prescribing of antibiotics.
... Naturopathy is a medical system that aims at primary care, treatment of disease, and the well-being of people related to health (Bradley et al., 2019). Naturopathic therapy as the basis of natural healing, one of the herbal plants that can be applied is red ginger. ...
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Diabetes Mellitus (DM) is caused by unhealthy lifestyle habits and one of the treatment efforts is naturopathic therapy by utilizing the gingerol content in red ginger (Zingiber officinale). The role of nurses in complementary fields as providers of interventions can improve public health status. This narrative review aims to interpret research the potential content of red ginger as an antidiabetic. The research were carried out by identifying research questions, "what is the content of gingerol in red ginger as antidiabetic?". Literature search using EBSCO, PubMed, Springer Experiment, and Neliti. Used keywords ''Nathuropathic therapy efforts AND Gingerol OR Red ginger OR Zingiber officinale AND Antidiabetic'' obtained 140 articles. Then sorted with inclusion and exclusion criteria, so we obtained 7 articles stated that red ginger concerning intake doses per day of 1-3 and 6 grams can lower blood glucose which contains gingerol which stimulates insulin secretion and improves glucose tolerance. Red ginger as a natural ingredient is certainly easy to find, practical, has no side effects, and economical. It is necessary to conduct further research regarding the type of red ginger and the dosage that adjusted to the habits of the Indonesian people so not to cause confusion regarding the application process
... 6 Overall, communication and cooperation are both critical foundations when working towards shared goals of improving patient outcomes through prevention-oriented, patient-centered primary care. 7 During the time of COVID-19, these strategies and further innovations in collaborative care models are more important than ever. ...
... The patient-centred framework delivered by naturopaths has potential to address areas of endometriosis care that are of importance to women. These areas could be addressed through naturopathy by using a hierarchy of therapeutics [28] that aligns to reducing endometriosis-associated pain, symptom management (particularly bothersome symptoms), improving quality of life, and supporting women's satisfaction with treatment [29] through patient empowerment and self-management strategies, where appropriate. Further, this approach utilises naturopathic knowledge involving the application of traditional knowledge, scientific research, clinical intuition, and expertise delivered through evidencebased practice and adherence to the philosophical frameworks of the profession. ...
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Objectives Endometriosis is a chronic gynaecological disease with varying symptomatology and negative health outcomes. To ensure the best care for women with endometriosis, women require a multidisciplinary team approach. While some women consult with naturopaths for endometriosis, there has been little research on naturopathic knowledge and the naturopathic approach to endometriosis care. Methods This cross-sectional survey recruited naturopaths with experience in menstrual disorders from the Practitioner Research and Collaboration Initiative (PRACI) a Practice-Based Research Network (PBRN). Data collection was conducted via an online self-administrated 62-item questionnaire. Results Invitations were sent to 109 naturopaths who self-reported having experience in menstrual disorders, of whom 29 completed the survey (26.6% response rate). Naturopaths perceived endometriosis to be caused by inflammation (n=28, 96.5%) and risk factors associated with familial history (n=26, 89.6%). Many naturopaths aimed at reducing inflammation (n=27, 93.1%) and supporting gastrointestinal function (n=25, 86.2%) in their prescriptions. Naturopaths reported using various healthcare referrals to support women with endometriosis, primarily general practitioners (n=12, 41.3%), acupuncturists/Traditional Chinese Medicine practitioners (n=11, 37.9%), and gynaecologists (n=9, 31%). Naturopaths reported receiving referrals from general practitioners (n=8, 27.5%) and psychologists (n=6, 20.6%). Conclusions Naturopathic knowledge and management of endometriosis targets known problematic areas of endometriosis that can have debilitating effects on women’s quality of life. Naturopathic care has the potential to align with important health outcomes for women with endometriosis however, further attention is needed to assess the effectiveness and continue to establish a multidisciplinary approach involving naturopathic care.
Plants have been emphasized in traditional medicine since 2600 BCE. Traditional medicine has been accessible to millions of people worldwide and are prevalent in countries such as India, Pakistan, China, Korea, Africa, as well as South and Central America. Medicinal plants and awareness of traditional medicine knowledge contribute significantly in the utilization as well as discovery of plant natural resources. Potent pharmacological activities, economic viability, and low toxicity make the bioactive constituents from traditional medicinal plants as a source/s of novel compounds, chemical entities, and pharmaceutical intermediates for synthetic or semi-synthetic drugs. Since its inception, Traditional Medicine, the world’s foundation of age-old medical practice, has played a critical role in human healthcare and welfare. In the future, herbal medicines can contribute to the development of new healthcare systems by standardizing and testing plant-derived bioactive constituents. In both the developed and developing nations, ensuring the safety, purity and potential of herbal plants as well as medicines has lately emerged as a major issue. India’s materia medica contains vast knowledge of folklore traditions and traditional characteristics of therapeutically significant plants and their constituents. This present review attempts to highlight the Indian traditional medicinal system, their significance, current practices and its scope.KeywordsIndian Traditional MedicineMedicinal plantsAyurvedaSiddhaPhytoconstituents
Naturopathic medicine aims to identify factors that affect the patient's current state, with a focus on improving health thro-ugh health promotion, promotion, and disease prevention. By using different treatment modalities among complementary and alternative methods, the least harmful and most effective approaches in improving the ability to improve and maintain health are presented in line with personalized evidence-based treatments. There are six basic principles of naturopathy. These; first of all, do no harm, the healing power of nature, identifying and treating causes, teaching, treating and preventing the per-son as a whole. Observational practice results and clinical trial data report the efficacy of naturopathy in multiple chronic health conditions with high morbidity, including cardiovascular risk, hypertension, depression, anxiety, low back pain, and type 2 diabetes. In addition, it has been reported that changing patient behavior in various chronic diseases may affect the prognosis of patients. Although naturopathic approaches are both traditional and innovative approaches, there seems to be very limited evidence due to the lack of extensive experimental studies using these approaches. The aim of this article is to raise awareness about naturopathy, which is a complementary approach in the management of chronic diseases.
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El concepto de medicina alternativa fue creado por la medicina occidental para identificar prácticas médicas diferentes a la medicina convencional, tales como la medicina tradicional china y acupuntura, la homeopatía, la terapia neural, la medicina osteopática y quiropráctica, la medicina ayurveda y la medicina tradicional indígena, que también tienen fundamentos filosóficos, científicos y terapéuticos. Desafortunadamente, con el tiempo se estableció la creencia de que la medicina alternativa comprende todas las prácticas médicas que no son parte de la medicina convencional, lo que ha causado muchas inexactitudes y controversias. La medicina surgió como una necesidad de auto preservación del ser humano que considera a la salud como bienestar completo y a la enfermedad, como pérdida de esta condición. A lo largo de su evolución han emergido diversas racionalidades y algunas de ellas se han convertido en sistemas médicos. La medicina convencional se estructuró en Occidente, fundamentada en racionalidades médicas existentes para la época y enfocada en modificar la enfermedad, lo que resultó en marcadas diferencias conceptuales con sistemas de tratamiento médico ya existentes que se centraban en el individuo y en modificar los procesos de la enfermedad. Todos los sistemas médicos han tenido un impacto en diversos campos sociales. Asimismo, han surgido tendencias y estrategias de integración de la medicina convencional con otros sistemas médicos como la electroacupuntura de Voll, la homotoxicología, el balance polar electromagnético, la antroposofía, la sintergética y la biofotónica. Actualmente se considera que el objetivo de la medicina es integrar y complementar conocimientos de diferentes racionalidades médicas dentro del concepto de una sola medicina. Teniendo en cuenta lo anterior, el objetivo del presente artículo es clarificar los conceptos de las diferentes formas de medicina, plantear algunas definiciones al respecto, y proponer una definición de medicina alternativa, complementaria e integrativa.
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Introduction: The first cases of Covid-19 disease were reported in December 2019.In March 2021, the pandemic had expanded worldwide, with 114.217.365 cases and 2.533014 deaths, including 286.155 cases and 15.811 deaths in Ecuador.The goal of this study was to share the impact of COVID-19 disease on 700 chronic dialysis patients from Ecuador's highlands, representing nearly 7% of the country's dialysis population, after one year of pandemic. Materials and Methods: An observational prospective multicenter study was conducted on 700 Latin chronic dialysis patients from five distinct cities in Ecuador's highlands.Patients were tracked from February 1, 2020, through January 31, 2021. Patients with COVID-19 symptoms were found, and the disease was diagnosed only through PCR testing of nasopharyngeal swabs. Disease presentation was defined as severe if oxygen saturation was less than 90% at presentation (LOS), moderate if symptoms were present but not at LOS, and asymptomatic if no symptoms were observed. The length of stay in the hospital, the period until a negative PCR, death, and laboratory results were all recorded. Results: Two hundred and five patients (29%) had COVID-19 illness symptoms; 115 patients (16%) tested positive, and 60 percent of them were men (p=0.03). Twenty-five patients passed away (22 percent ).Mortality was linked to being over 64 years old, having a saturation of less than 90%, and having a severe illness presentation (p=0.03), as well as having previous pulmonary pathology and hospitalisation (p=0.01). Hospitalization was needed in 74 patients (64%) with hospital stay 11 days (4-15), days until death during hospitalization of 12 days (4-19) and time until negative PCR 20 days (10-25). The duration of symptomatology was 16 days (11-26). Conclusion: COVID-19 disease was more common in men, and it has resulted in an additional 22% death rate in the chronic dialysis population. Patients over the age of 64, those with prior pulmonary disease, and those with a longer LOS at presentation are at a higher risk of mortality, necessitating more frequent follow-up in this subgroup. COVID-19 causes a high level of health care burden in the dialysis community, implying that dialysis patients and professionals involved in their treatment should be included in vaccination programmes to reduce disease-related mortality, infections, and healthcare costs.
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Hypertriglyceridemia (triglycerides 200-499 mg/dL) is relatively common in the United States, whereas more severe triglyceride elevations (very high triglycerides, ≥500 mg/dL) are far less frequently observed. Both are becoming increasingly prevalent in the United States and elsewhere, likely driven in large part by growing rates of obesity and diabetes mellitus. In a 2002 American Heart Association scientific statement, the omega-3 fatty acids (n-3 FAs) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were recommended (at a dose of 2-4 g/d) for reducing triglycerides in patients with elevated triglycerides. Since 2002, prescription agents containing EPA+DHA or EPA alone have been approved by the US Food and Drug Administration for treating very high triglycerides; these agents are also widely used for hypertriglyceridemia. The purpose of this advisory is to summarize the lipid and lipoprotein effects resulting from pharmacological doses of n-3 FAs (>3 g/d total EPA+DHA) on the basis of new scientific data and availability of n-3 FA agents. In treatment of very high triglycerides with 4 g/d, EPA+DHA agents reduce triglycerides by ≥30% with concurrent increases in low-density lipoprotein cholesterol, whereas EPA-only did not raise low-density lipoprotein cholesterol in very high triglycerides. When used to treat hypertriglyceridemia, n-3 FAs with EPA+DHA or with EPA-only appear roughly comparable for triglyceride lowering and do not increase low-density lipoprotein cholesterol when used as monotherapy or in combination with a statin. In the largest trials of 4 g/d prescription n-3 FA, non-high-density lipoprotein cholesterol and apolipoprotein B were modestly decreased, indicating reductions in total atherogenic lipoproteins. The use of n-3 FA (4 g/d) for improving atherosclerotic cardiovascular disease risk in patients with hypertriglyceridemia is supported by a 25% reduction in major adverse cardiovascular events in REDUCE-IT (Reduction of Cardiovascular Events With EPA Intervention Trial), a randomized placebo-controlled trial of EPA-only in high-risk patients treated with a statin. The results of a trial of 4 g/d prescription EPA+DHA in hypertriglyceridemia are anticipated in 2020. We conclude that prescription n-3 FAs (EPA+DHA or EPA-only) at a dose of 4 g/d (>3 g/d total EPA+DHA) are an effective and safe option for reducing triglycerides as monotherapy or as an adjunct to other lipid-lowering agents.
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Importance There is no definitive evidence that changes in physical activity/sedentary behavior can be maintained long term in individuals with type 2 diabetes. Objective To investigate whether a behavioral intervention strategy can produce a sustained increase in physical activity and reduction in sedentary time among individuals with type 2 diabetes. Design, Setting, and Participants The Italian Diabetes and Exercise Study 2 was an open-label, assessor-blinded, randomized clinical superiority trial, with recruitment from October 2012 to February 2014 and follow-up until February 2017. In 3 outpatient diabetes clinics in Rome, 300 physically inactive and sedentary patients with type 2 diabetes were randomized 1:1 (stratified by center, age, and diabetes treatment) to receive a behavioral intervention or standard care for 3 years. Interventions All participants received usual care targeted to meet American Diabetes Association guideline recommendations. Participants in the behavioral intervention group (n = 150) received 1 individual theoretical counseling session and 8 individual biweekly theoretical and practical counseling sessions each year. Participants in the standard care group (n = 150) received only general physician recommendations. Main Outcomes and Measures Co-primary end points were sustained change in physical activity volume, time spent in light-intensity and moderate- to vigorous-intensity physical activity, and sedentary time, measured by an accelerometer. Results Of the 300 randomized participants (mean [SD] age, 61.6 [8.5] years; 116 women [38.7%]), 267 completed the study (133 in the behavioral intervention group and 134 in the standard care group). Median follow-up was 3.0 years. Participants in the behavioral intervention and standard care groups accumulated, respectively, 13.8 vs 10.5 metabolic equivalent-h/wk of physical activity volume (difference, 3.3 [95% CI, 2.2-4.4]; P < .001), 18.9 vs 12.5 min/dof moderate- to vigorous-intensity physical activity (difference, 6.4 [95% CI, 5.0-7.8]; P < .001), 4.6 vs 3.8 h/d of light-intensity physical activity (difference, 0.8 [95% CI, 0.5-1.1]; P < .001), and 10.9 vs 11.7 h/d of sedentary time (difference, −0.8 [95% CI, −1.0 to −0.5]; P < .001). Significant between-group differences were maintained throughout the study, but the between-group difference in moderate- to vigorous-intensity physical activity decreased during the third year from 6.5 to 3.6 min/d. There were 41 adverse events in the behavioral intervention group and 59 in the standard care group outside of the sessions; participants in the behavioral intervention group experienced 30 adverse events during the sessions (most commonly musculoskeletal injury/discomfort and mild hypoglycemia). Conclusions and Relevance Among patients with type 2 diabetes at 3 diabetes clinics in Rome who were followed up for 3 years, a behavioral intervention strategy compared with standard care resulted in a sustained increase in physical activity and decrease in sedentary time. Further research is needed to assess the generalizability of these findings.
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Importance Intermittent energy restriction is an alternative weight loss method that is becoming popular; however, to date, there are no long-term clinical trials of intermittent energy restriction in patients with type 2 diabetes. Objective To compare the effects of intermittent energy restriction (2 days per week) with those of continuous energy restriction on glycemic control and weight loss in patients with type 2 diabetes during a 12-month period. Design, Setting, and Participants Adult participants (N = 137) with type 2 diabetes were randomized 1:1 to parallel diet groups (intermittent energy restriction [n = 70] or continuous energy restriction [n = 67]) between April 7, 2015, and September 7, 2017, at the University of South Australia. Medications likely to cause hypoglycemia were reduced at baseline according to the medication management protocol. Interventions An intermittent energy restriction diet (500-600 kcal/d) followed for 2 nonconsecutive days per week (participants followed their usual diet for the other 5 days) or a continuous energy restriction diet (1200-1500 kcal/d) followed for 7 days per week for 12 months. Main Outcomes and Measures The primary outcome was change in hemoglobin A1c (HbA1c) level, with equivalence prespecified by a 90% CI margin of ±0.5%. The secondary outcome was weight loss with equivalence set at ±2.5 kg (±1.75 kg for fat mass loss and ±0.75 kg for fat-free mass loss). All other outcomes were tested for superiority. Results Of the 137 randomized participants (77 women and 60 men; mean [SD] age, 61.0 [9.1] years; mean [SD] body mass index, 36.0 [5.8] [calculated as weight in kilograms divided by height in meters squared]; and mean [SD] HbA1c level, 7.3% [1.3%]), 97 completed the trial. Intention-to-treat analysis showed similar reductions in mean (SEM) HbA1c level between the continuous and intermittent energy restriction groups (–0.5% [0.2%] vs –0.3% [0.1%]; P = .65), with a between-group difference of 0.2% (90% CI, –0.2% to 0.5%) meeting the criteria for equivalence. Mean (SEM) weight change was similar between the continuous and intermittent energy restriction groups (–5.0 [0.8] kg vs –6.8 [0.8] kg; P = .25), but the between-group difference did not meet the criteria for equivalence (–1.8 kg; 90% CI, –3.7 to 0.07 kg), nor did the between-group difference in fat mass (–1.3 kg; 90% CI, –2.8 to 0.2 kg) or fat-free mass (–0.5 kg; 90% CI, –1.4 to 0.4 kg). There were no significant differences between groups in final step count, fasting glucose levels, lipid levels, or total medication effect score at 12 months. Effects did not differ using completers analysis. Hypoglycemic or hyperglycemic events in the first 2 weeks of treatment were similar between the continuous and intermittent energy restriction groups (mean number [SEM] of events, 3.2 [0.7] vs 4.9 [1.4]; P = .28), affecting 35% of participants (16 of 46) using sulfonylureas and/or insulin. Conclusions and Relevance Intermittent energy restriction is an effective alternative diet strategy for the reduction of HbA1c and is comparable with continuous energy restriction in patients with type 2 diabetes. Trial Registration Identifier: ACTRN12615000383561
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Yoga is increasingly used as an adjunctive therapy in the management of Type-2 Diabetes Mellitus (T2DM). The present study aims to systematically evaluate the literature and perform a meta-analysis on the effects of yoga practice compared to physical exercise in the management of T2DM. Data were obtained using a stepwise search process using keywords in the following online medical databases; PubMed, Web of Science and Scopus. All controlled clinical trials involving patients with T2DM, comparing yoga as an intervention with physical exercise and evaluating glycaemic control and other outcomes between the intervention and control groups were included in the analysis. Eight studies were eligible to be included in the systematic review. In total, 842 participants were assigned to a Yoga intervention or a control group with an Exercise intervention and the age range of participants was 30–78 years. A significant reduction in FBG (15.16 mg/dl), PPBG (28.66 mg/dl), HbA1c (0.39%) and BMI (0.71 kg/m2) was noted in the intervention group (‘Yoga’) compared to the control group (‘Physical Exercise’) in the pooled analysis. We did not observe any significant difference between the two groups for lipid parameters, other body composition measures (WC and WHR) and Blood Pressure. In conclusion, our results show that Yoga has beneficial effects on glycaemic control in comparison to physical exercise in T2DM However, individual studies showed considerable heterogeneity. Hence, further well-controlled randomized trials are required prior to drawing conclusions about the benefits of yoga in comparison to physical exercise.
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Background: The stresses of modern work life necessitate effective coping strategies that are accessible and affordable to the general public. Yoga has been found to reduce stress in clinical samples, but studies are needed to examine standard gym yoga classes among functional individuals. Objectives: This study investigated the effects of 8- and 16-week gym yoga on stress and psychological health. Design and Method: Ninety individuals reporting moderate-to-high stress were randomly assigned to 16 consecutive weeks of yoga, or to a waitlist crossover group who did not practice yoga for 8 weeks then practiced yoga for 8 weeks. Stress and psychological health variables were assessed at baseline, 8 weeks, and 16 weeks. Results: Significant reductions in stress and all psychological health measures were found within the Yoga group over 16 weeks. When compared to the control group, yoga practitioners showed significant decreases in stress, anxiety, and general psychological health, and significant increases in well-being. The group who did not practice yoga showed significant decreases in stress, anxiety, depression, and insomnia after they crossed over and practiced yoga for 8 weeks. Conclusions: Gym yoga appears to be effective for stress amelioration and promotion of psychological health among workers experiencing stress.
Background: Chronic pain is a complex accumulation of physical, psychological, and social conditions, thus interventions that address pain and promote occupational performance are needed. A holistic intervention, with mind and body components, is likely necessary to best treat the complexities of chronic pain. Thus, we developed and tested a yoga intervention for people with chronic pain. Objectives: In a randomized control trial (RCT), participants with chronic pain were randomized to a yoga intervention or usual care group. Between and within group differences for pre-and post-outcome measure scores were assessed for: occupational performance, completion of activities, and depression. Methods: Pilot RCT with participant allocation to 8 weeks of yoga or usual care. Both groups received ongoing monthly self-management programming. Data were collected before and after the 8-week intervention. Participants were randomized to yoga or usual care after baseline assessments. Demographics were collected and measures included: Canadian Occupational Performance Measure (COPM) to assess occupational performance; the 15-item Frenchay Activities Index (FAI)(activities); and the 9-item Patient Health Questionnaire (PHQ-9) for depression. Independent t-tests were used to assess differences between groups. Paired t-tests were used to assess differences between pre- and post 8-week intervention for both the yoga and the usual care groups. Percent change scores and effect sizes were calculated. Results: 83 people were recruited for the study and completed baseline assessments; 44 individuals were randomized to yoga and 39 to the control group. The average age of all participants was 51.4±10.5 years, 68% were female; and 60% had at least some college education. There were no significant differences in demographics or outcome measures between groups at baseline or 8 weeks; however, the study was not powered to see such differences. Individuals randomized to the control group did not significantly improve in any outcome measure over the 8 weeks. There were significant improvements in COPM performance and COPM satisfaction scores for individuals randomized to the yoga group; both scores significantly improved. COPM performance improved by 27% with a moderate to large effect size (3.66±1.85 vs 4.66±1.93, p < 0.001, d = 0.76). COPM satisfaction significantly improved by 78% (2.14±2.31 vs. 3.80±2.50, p < 0.001) and had a large effects size (d = 1.02). FAI scores improved, indicating increased activity or engagement in daily occupation during the 8-week intervention. Scores increased by 5% (38.13±8.48 vs. 39.90±8.57, p = 0.024) with a small effect size (d = 0.37). Depression significantly decreased from 13.21±5.60 to 11.41±5.82, p = 0.041, with a small effect size. Conclusion: Data from this pilot RCT indicate yoga may be an effective therapeutic intervention with people in chronic pain to improve occupational performance, increase engagement in activities, and decrease depression. Occupational therapy practitioners may consider adding yoga as a treatment intervention to address the needs of people with pain.
OBJECTIVE This study was conducted to update national estimates of the economic burden of undiagnosed diabetes, prediabetes, and gestational diabetes mellitus (GDM) in the United States for year 2017 and provide state-level estimates. Combined with published estimates for diagnosed diabetes, these updated statistics provide a detailed picture of the economic costs associated with elevated blood glucose levels. RESEARCH DESIGN AND METHODS This study estimated medical expenditures exceeding levels occurring in the absence of diabetes or prediabetes and the indirect economic burden associated with reduced labor force participation and productivity. Data sources analyzed included Optum medical claims for ∼5.8 million commercially insured patients continuously enrolled from 2013 to 2015, Medicare Standard Analytical Files containing medical claims for ∼2.8 million Medicare patients in 2014, and the 2014 Nationwide Inpatient Sample containing ∼7.1 million discharge records. Other data sources were the U.S. Census Bureau, Centers for Disease Control and Prevention, and Centers for Medicare & Medicaid Services. RESULTS The economic burden associated with diagnosed diabetes (all ages), undiagnosed diabetes and prediabetes (adults), and GDM (mothers and newborns) reached nearly $404 billion in 2017, consisting of $327.2 billion for diagnosed diabetes, $31.7 billion for undiagnosed diabetes, $43.4 billion for prediabetes, and nearly $1.6 billion for GDM. Combined, this amounted to an economic burden of $1,240 for each American in 2017. Annual burden per case averaged $13,240 for diagnosed diabetes, $5,800 for GDM, $4,250 for undiagnosed diabetes, and $500 for prediabetes. CONCLUSIONS Updated statistics underscore the importance of reducing the burden of prediabetes and diabetes through better detection, prevention, and treatment.
Objectives The aim of this study was to propose wage multipliers that can be used to estimate the costs of productivity loss for employers in economic evaluations, using detailed information from managers. Methods Data were collected in a survey panel of 758 managers from different sectors of the labor market. Based on assumed scenarios of a period of absenteeism due to sickness, presenteeism and work environment–related problem episodes, and specified job characteristics (i.e., explanatory variables), managers assessed their impact on group productivity and cost (i.e., the dependent variable). In an ordered probit model, the extent of productivity loss resulting from job characteristics is predicted. The predicted values are used to derive wage multipliers based on the cost of productivity estimates provided by the managers. Results The results indicate that job characteristics (i.e., degree of time sensitivity of output, teamwork, or difficulty in replacing a worker) are linked to productivity loss as a result of health-related and work environment–related problems. The impact of impaired performance on productivity differs among various occupations. The mean wage multiplier is 1.97 for absenteeism, 1.70 for acute presenteeism, 1.54 for chronic presenteeism, and 1.72 for problems related to the work environment. This implies that the costs of health-related and work environment–related problems to organizations can exceed the worker’s wage. Conclusions The use of wage multipliers is recommended for calculating the cost of health-related and work environment–related productivity loss to properly account for actual costs.