Corporate Wellness Programs Open Doors to Integrative Therapies

The National Center for Complementary and Alternative Medicine (NCCAM) website lists over 600 specific alternative therapies. According to Ken Pelletier, PhD, MD (Professor of Public Health, University of Arizona School of Medicine), "When I hear someone in a workplace wellness program say alternative therapies don't work, I ask: 'Which therapies, for what conditions, in what populations, and in what situations?' It really depends on what you are talking about. Then there are people who say, 'If it's natural, it must be OK.' But look at that list of over 600 therapies. A significant number carry a very real potential to do harm."

Ken has extensively reviewed complementary and alternative medicine (CAM) studies from around the world. "Because of where I work, my research must conform to a standard of best possible evidence as seen in randomized clinical trials. But there are a number of potentially important therapies and interventions that simply don't lend themselves to that type of analysis."

Often such studies lack the necessary documentation but still see excellent outcomes. Ken cautions corporate wellness practitioners against discounting such studies and recommends analyzing them using a 3-pronged triage-type approach:

Is there clear evidence from clinicians that the therapy works well in the patient's situation?
What's available in the literature and online showing what does not work?
What studies are underway that require us to simply wait and see?

As increasing numbers of CAM therapies gain acceptance in employee health programs, it becomes necessary to develop a common vocabulary. The term Integrative Medicine (IM) describes an evidence-based fusion of conventional and CAM practices. IM is not a physician-centric system -- practitioners function in truly integrated or virtual systems with providers of diverse competencies. Together they form a clinical network where outcomes are enhanced from working together, rather than at odds with each other. These networks typically fall into 4 categories:

Freestanding IM clinics that house multiple disciplines
Family practice group with a virtual network of respected CAM practitioners for patient referrals
IM services affiliated within a hospital setting
Therapeutic disciplines offered through nonmedical settings like worksite health promotion programs, schools, extension programs, and even churches.

According to the 2007 National (US) Health Interview Survey of 23,393 adults and 9417 children ages 17 and under, 38% of adults and 12% of children use some form of CAM. This is reflected by the increasing numbers of health insurance plans that cover such CAM therapies as acupuncture, chiropractic care, naturopathy (in certain states), nutrition counseling, stress management, and behavioral medicine. Even vitamins/minerals, herbals, exercise equipment, books, videos, and fitness club memberships can be found as health plan benefits. Ken points out the reason: it's what their corporate health and wellness customers want. "Although health plans increasingly counsel corporate clients on CAM coverage trends, the insurance industry is not the point of innovation here; it's the purchaser. Larger companies form a purchasing coalition based on demands from employees and unions. If there is solid evidence behind the request, they balance the interest with legal issues, costs, and other practical considerations to determine what becomes part of a benefit package."

High-tech industries took the lead in offering IM to corporate wellness audiences. Computer, telecommunication, banking/financial, airline/aerospace, petrochemical, and automotive employers know IM appeals to their highly educated, competitive employees... who tend to stay with their company for the long term. "These corporations look at their employees' welfare as an investment. They want to preserve these assets and enhance their productivity on the job in every way possible. Because these industries are so competitive, IM therapies often become a recruitment and retention benefit."

Even when a health plan can't (or won't) cover CAM, other workplace wellness programs have opened their doors to practitioners who provide onsite services. Ken is all for this. "Certain CAM providers are almost universally accepted now, but this is too new an area to know definitively what works. If a wellness program wants to offer aromatherapy in conjunction with a relaxation room, why not? I've seen Ayurvedic medicine in larger employee wellness programs along with traditional benefits, especially when there's a significant Asian demographic. Fitness programs go beyond aerobics to include yoga and martial arts. If these services meet employee expectations and are done responsibly with employee cost-sharing, it's a win-win proposition."

Finding the Right Practitioners

The trend is toward outsourcing IM therapies, and corporate wellness purchasers must do their homework when selecting practitioners. Whittling down the field can be challenging; find out if the practitioner:

Carries appropriate licenses/credentialing
Is a member of any well respected professional associations and serves on any boards in their field
Graduated from a recognized school in their field
Has a successful record in providing the services required -- demand measurements and outcomes that show evidence within a given period
Provides excellent references
Has a history of any lawsuits or complaints
Maintains a good reputation... ask around.

Planning the Program

Wellness program planners need to involve employees, unions, labor, and management in defining what is wanted. If they help develop specifications, it won't be viewed as a union or management program... it will be their program. This minimizes problems with acceptance or disillusionment.

Next build a clear picture of the desired services and define specifications to practitioners. What will the chiropractor do for us? What will an acupuncture session look like? If pain is a cost center, what is the evidence that this therapy will reduce those claims and disability leaves?

A Bright Future Ahead

As Director of the Corporate Health Improvement Program (CHIP), a collaborative research program involving 15 Fortune 500 corporations, Ken has a unique perspective for IM's future. "CHIP is 25 years old. Over that time, some of the first true IM models have been tested within member corporate wellness worksites. We meet twice a year with our corporate members to review the research. The data is extremely positive and the impact will permeate throughout the industries involved."

"One of our members is Ford. Back pain was the single largest contributing cost to producing their cars. They had 24/7 clinic staff onsite to deal with back pain alone. We demonstrated that combining traditional medicine with acupuncture and mind/body therapies was more effective than traditional medicine alone."

"When you can demonstrate a more cost-effective way to manage a condition, a company will be interested. They have no inherent bias; they just want evidence -- and a vast amount of literature shows it. The return on investment runs from 3:1 to 5:1, taking about 3.25 years to see that ROI."

Corporate wellness professionals can read Ken's summary, "A Review and Analysis of the Clinical and Cost-Effectiveness Studies of Comprehensive Health Promotion and Disease Management Programs at the Worksite: Update VII. 2004-2008," in the Journal of Occupational and Environmental Medicine, Volume 51, Number 7, July 2009.

Ken concludes, "Read the evidence. The literature is there to allow you to make informed choices. But be a Doubting Thomas. As researchers say, 'In God we trust; all others must present data.' Wellness program managers will find IM to be a sound business strategy... a tremendous investment in your population. They are worthy of that investment and they'll reciprocate when they see you care."

Dean Witherspoon, CEO and founder of employee wellness firm, Health Enhancement Systems, has 25 years in health promotion. He has served on the board of the Association for Worksite Health Promotion and held several regional as well as state offices. Dean is a nationally known speaker and author, having presented at more than 70 conferences and written hundreds of employee wellness articles for national publications.

For more information on employee wellness topics, check out the free white papers at http://whitepapers.hesonline.com/.

Contact: Dean Witherspoon, Health Enhancement Systems, http://HealthEnhancementSystems.com, 800.326.2317

New Research Methods May Lead to Integrative Treatments In Texas

Steve Mister, President and CEO of the Council for Responsible Nutrition, called upon scientific colleagues during this May's symposium to consider alternative methods for studying nutrition and the effects of dietary supplements.

This year's symposium, The Workshop, drew scientists and medical practitioners from across the country to discuss new research in the field of nutrition. While the current model for testing the health effects of particular nutrients and nutritional supplements utilizes randomized clinical trials (RCTs) and evidence-based medicine (EBM), the same methods employed to test the efficacy of pharmaceutical drugs, Mr. Mister urged scientists to consider approaches that may be more reflective of the complex nature of nutrients.

"(I) recognize (the) scientific rigor or RCTs...but we can't ignore all other research -- case-control and cohort studies, and other epidemiological data...(that) may be just as rigorous for proving hypotheses as well as developing them."

The repercussions of these seemingly simple statements may be huge for the natural health, healthcare, and health insurance industries. The entire country, from Texas, to California, to New York would be dramatically impacted by national organizations', such as the American Medical Association's, acceptance of data from studies other than the standard RCTs and EBM. Evidence integrated from observational studies focusing on nutritional supplements may eventually allow for the prescription of nutrients and supplements to, at least in part, officially treat certain conditions.

Texas, with its high levels of chronic diseases such as diabetes, and its fight against the growing epidemic of obesity, may particularly stand to benefit. Imagine a diabetic patient walking into a medical clinic in Dallas, Houston, Austin, or any other part of the state, and receiving supplements, along with other drugs, to treat the condition.

Some of the main differences between pharmaceutical drugs and nutritional supplements lies in the complex nature of nutrients, which interact with multiple tissues and body systems on multiple levels, and are often interdependent. For instance, research suggests that calcium supplements may have a greater effect when taken with vitamin D. RCTs isolate one or two compounds, at a single dose, for a few years at a time at best, and collect the data independently from other substances (such as nutrients) the subject may be ingesting.

Chronic diseases take years to develop, and perhaps years in order for nutrients or other natural supplements to have an effect. It is not possible to isolate single compounds within nutrients, test and analyze them over only a few months or years, and exclusively use data that has a clear, direct connection with those compounds. To isolate and test every active compound in even the most simple of natural remedies, such as garlic, would literally take decades, and would still probably miss very important pieces of evidence.

To discount observational studies simply because they are not confirmed by a clinical trial may also be dangerous. Too many variables affect the outcome of nutritional studies, many of which cannot be controlled, and perhaps should not be controlled, to collect the most accurate data. Such evidence may take longer to sift through in order to find cause and effect, particularly considering nutrients' symbiotic relationship with other compounds and hormones, but finding accurate answers would be worth it.

Many others at The Workshop agreed that a single research approach, like RCTs, may not be suitable for such a complex task. In contrast to pharmaceutical drugs, "nutrients have beneficial effects on multiple body tissues, and interact in a dynamic fashion with other nutrients," said Jeffrey Blumberg, Ph.D., of the Friedman School of Nutrition Science and Policy at Tufts University.

Robert C. Hearney, M.D., of Creighton University's Osteoporosis Research Center: "(Scientists) ...have eagerly embraced an evidence-based medicine approach without checking to see if it fits nutrition context." He went on to say that RCTs impose constraints ill-suited to testing nutrients and vitamins.

According to these scientists, observational studies may, in fact, be a better method for collecting data on dietary and nutritional supplements, supported by RCTs and EBM. Observational studies can better represent typical populations, typical behaviors, and how food and supplements are, in reality, used. Observational studies also bypass an important ethical dilemma: it's simply not conscience to deprive a subject of a vital nutrient, just to see which tissues are affected and how.

Many nationally-recognized organizations already use observational and experimental studies for data collection. The Institute of Medicine's (IOM) Dietary Reference Intakes, or DRIs, are based on data collected from observational and experimental studies. The Dietary Guidelines for Americans, developed by the U.S. Department of Agriculture (USDA), uses primarily clinical trials and observational studies, including cross-sectional, case-controlled, and cohort studies.

This new attitude is welcomed by the natural health community, which has been arguing the same point for years. Specific nutrients, foods, and herbs do, in fact, have a marked effect on many diseases and conditions, but precisely how most of them work is still a mystery. It's the observational, and other methods of study, that confirm this.

For instance, herbal formulas created by practitioners of Traditional Chinese Medicine are often extremely complex, and, in order to work to their best advantage, are tailored to each individual. Few specific compounds can, as of yet, be isolated and linked with one particular effect with any accuracy, but practitioners have recorded volumes upon volumes of "anecdotal" data over thousands of years stating that they work. Viral counts have been known to go down, the efficacy of immune systems have increased, and discomfort and disease all but eliminated in certain cases.

Similarly, acupuncture -- a process Chinese medical practitioners articulate as a method for clearing energy paths, called meridians, and a treatment articulated by Western medical practitioners as a method used to release certain natural compounds and reduce inflammation -- is an approved therapy for Carpal Tunnel Syndrome. We don't know precisely how it works, but somehow it just does. To discount such evidence simply because the data cannot be properly collected and analyzed through RCTs would not only be foolish, but would also deprive patients of receiving a possibly effective treatment.

So, if such research approaches are already accepted by national institutes, why are they not used more often? Part of it, simply and unfortunately, is money. Makers of dietary supplements are not allowed to claim their products treat or cure any disease. This provides less incentive for those with greater financial resources to fund such projects. Even if they were to find strong evidence that certain supplements do, in fact, treat and/or cure disease, they would not be allowed to advertise it.

The American public is growing more accepting of data collected through methods other than the traditional RCTs and EBM, however, as evidenced by the growing herbal, organic foods, and natural health care industries. Several universities across the country, in fact, now offer accredited, post-graduate, four-year degrees in Chinese and naturopathic medicine, much like graduate degrees in allopathic medicine (which produce M.D.s). With policies of open communication and integration, these two schools of thought, with their different research methods, may accomplish more medically in this era than ever before.

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