Erica Oberg

The Intersecting Paradigms of Naturopathic Medicine and Public Health: Opportunities for Naturopathic Medicine

Complementary medicine research, including naturopathic medicine research, is plagued with many methodological challenges. Many of these challenges have also been experienced in public health research. Public health research has met these challenges with a long history of multidisciplinary, multimethod, and whole systems approaches to research that may better resonate with the ?real world? clinical settings of naturopathic medicine. Additionally, many of the underlying principles of naturopathic medicine are analogous to the underlying principles and activities of public health, specifically in such areas as health promotion, prevention, patient education, and proactive rather than reactive approaches to disease management and treatment. Future research in the field of naturopathic medicine may benefit from adopting public health research models rather than focusing exclusively on biomedical models. A complementary and collaborative relationship between these fields may provide an opportunity to deliver research that more accurately reflects naturopathic medicine practice, as well as providing the opportunity to improve health outcomes more generally.

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

BackgroundSeveral small, uncontrolled studies have found improvements in self-care behaviors and reductions in clinical risk in persons with type 2 diabetes who received care from licensed naturopathic physicians. To extend these findings and determine the feasibility and promise of a randomized clinical trial, we conducted a prospective study to measure the effects of adjunctive naturopathic care (ANC) in primary care patients with inadequately controlled type 2 diabetes.MethodsForty patients with type 2 diabetes were invited from a large integrated health care system to receive up to eight ANC visits for up to one year. Participants were required to have hemoglobin A1c (HbA1c) values between 7.5-9.5 % and at least one additional cardiovascular risk factor (i.e., hypertension, hyperlipidemia or overweight). Standardized instruments were administered by telephone to collect outcome data on self-care, self-efficacy, diabetes problem areas, perceived stress, motivation, and mood. Changes from baseline scores were calculated at 6- and 12-months after entry into the study. Six and 12-month changes in clinical risk factors (i.e., HbA1c, lipid and blood pressure) were calculated for the ANC cohort, and compared to changes in a cohort of 329 eligible, non-participating patients constructed using electronic medical records data. Between-cohort comparisons were adjusted for age, gender, baseline HbA1c, and diabetes medications. Six months was pre-specified as the primary endpoint for outcome assessment.ResultsParticipants made 3.9 ANC visits on average during the year, 78 % of which occurred within six months of entry into the study. At 6-months, significant improvements were found in most patient-reported measures, including glucose testing (P = 0.001), diet (P = 0.001), physical activity (P = 0.02), mood (P = 0.001), self-efficacy (P = 0.0001) and motivation to change lifestyle (P = 0.003). Improvements in glucose testing, mood, self-efficacy and motivation to change lifestyle persisted at 12-months (all P < 0.005). For clinical outcomes, mean HbA1c decreased by −0.90 % (P = 0.02) in the ANC cohort at 6-months, a −0.51 % mean difference compared to usual care (P = 0.07). Reductions at 12-months were not statistically significant (−0.34 % in the ANC cohort, P = 0.14; -0.37 % difference compared to the usual care cohort, P = 0.12).ConclusionsImprovements were noted in self-monitoring of glucose, diet, self-efficacy, motivation and mood following initiation of ANC for patients with inadequately controlled type 2 diabetes. Study participants also experienced reductions in blood glucose that exceeded those for similar patients who did not receive ANC. Randomized clinical trials will be necessary to determine if ANC was responsible for these benefits.

Patient-Reported Experiences with First-Time Naturopathic Care for Type 2 Diabetes

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

Observed Changes in Risk during Naturopathic Treatment of Hypertension

Few outcome assessments are published from complementary and alternative medicine (CAM) practices. We aimed to describe patient and practice characteristics of ND care for hypertension (HTN), quantify changes in blood pressure (BP), and evaluate the proportion achieving control of HTN during care. A retrospective, observational study of ND practice in HTN was performed in an outpatient clinic in WA State. Eighty-five charts were abstracted for the final analysis. At initiation of care, the mean patient age was 61 years, with 51% having stage 2 HTN, despite common use of anti-hypertensive medications (47%). Patients with both stage 1 and stage 2 HTN appeared to improve during care, with stage 2 patients achieving mean reductions of −26 mmHg (P < .0001) and −11 mmHg (P < .0001) in systolic BP (SBP) and diastolic BP (DBP), respectively. The proportion of patients achieving control (<140/90 mmHg) in both SBP and DBP was increased significantly from 14 to 44% (P < .033), although the statistical significance was not maintained upon correction for multiple comparisons. BP appears to improve during ND care for HTN, in a high-risk population. Randomized trials are warranted.

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

Background: Interest in case studies has undergone a resurgence concurrent with increasing prioritization of illustrations of patient-centered care. However, substantial inclusion of the patient in these reports remains limited. Here, a doctor and patient collaborate to present her case report of self-directed mindfulness training and the subsequent changes in blood pressure, migraine frequency, and quality of life. Methods: After receiving encouragement from her naturopathic doctor, the patient initiated an 8-week program in mindfulness training following the Kabat-Zinn protocol and logged her daily blood pressure and symptoms before and after meditation sessions over an 11-week period. Results: Patient-reported outcomes included decreased perceived stress, increased focus, and a newfound sense of centeredness and calm. Changes in objective outcomes were clinically and statistically significant, including reductions in mean systolic and diastolic blood pressure between week 1 and week 11 (P = .0001 and P = .0004 for systolic and diastolic, respectively, by paired, 2-sided t-tests). Self-reported frequency of chronic migraine was also reduced. Critical to the patients success was that mindfulness training was first approached in a simple, accessible manner prior to embarking on a deeper, extended experience. Discussion and Conclusion: Self-directed mindfulness training can have a meaningful impact on both subjective and objective health outcomes. It may take years of encouragement from a healthcare provider before a patient is ready to adopt a mind-body practice; it is important to recognize and counsel patients with messages appropriate to their stage of change and self-efficacy. Additionally, case studies that combine the voice of the clinician and the patient can provide useful illustrations of truly patient-centered care.

Naturopathic Practice at North American Academic Institutions: Description of 300,483 Visits and Comparison to Conventional Primary Care

This study collected patient visit data to explore similarities and differences between conventional and naturopathic primary care (PC). Administrative data from practice management software systems from the main teaching clinics of four of the eight accredited North American naturopathic academic institutions were abstracted into an integrated database containing five years (2006–2010) of visit, patient, laboratory, and prescribing data. Descriptive analyses of healthcare services were compared to the National Ambulatory Medical Care Survey (NAMCS). Over the five-year period, 300,483 patient visits to naturopathic doctors occurred at clinics, excluding visits at clinics operated by the schools in community settings. Patients were 69% female; mean age was 39 (SE 0.09). Older adults (>65) comprised 9% of the population and children (<16) comprised 8%. Comparing academic naturopathic clinics to national conventional PC (NAMCS), we found more patients paid out of pocket at naturopathic clinics (50 vs. 4%) and naturopathic clinics more frequently offered discounted care (26 vs. 0.3%). There was a 44% overlap in the most frequent 25 diagnoses for PC at conventional community clinics. Overall, these data suggest substantial similarities in care offered by academic naturopathic clinics, at which most Naturopathic Doctor (ND) students are trained, and by conventional PC practices.

Utilization of Acupuncture Therapy among Pediatric Oncology Patients at a Tertiary Care Pediatric Hospital

Background: Acupuncture is infrequently studied in the pediatric oncology population. However its potential as a complementary cancer care modality in the reduction of treatment-related side effects and improvements in quality of life has been demonstrated in adults. Our study aims to characterize the patients and utilization of acupuncture therapy among the pediatric population. Methods: A retrospective analysis of medical records for patients between the ages of 0-18 years, undergoing treatment for an oncological diagnosis and had received acupuncture therapy between January 2004 and September 2012 was conducted. Results: A total of 133 patients, comprising 3.2% of our pediatric oncology population, utilized acupuncture therapy. A cumulative of 523 acupuncture treatments was provided. Treatments were tolerated well by patients, perceived as beneficial, and without any serious adverse events. Acupuncture treatments addressed a wide variety of patients’ complaints and cancer treatment-related side effects. Conclusions: Acupuncture use among the pediatric oncology population is relatively low; however, our findings demonstrate its potential as a complementary cancer care modality in clinical practice for this unique population in the future.

Impact of Vitamin D3 Dietary Supplement Matrix on Clinical Response

CONTEXT As a result of research suggesting increased health risk with low serum 25-hydroxycholecalciferol (25(OH)D), health care providers are measuring it frequently. Providers and patients are faced with treatment choices when low status is identified. OBJECTIVE To compare the safety and efficacy of three vitamin D3 dietary supplements with different delivery matrices. SETTING AND DESIGN A 12-week, parallel group, single-masked, clinical trial was conducted in Seattle, Washington and Kailua Kona, Hawaii. Sixty-six healthy adults with (25(OH)D) <33 ng/mL were randomly assigned to take one of three D3 supplements, ie, a chewable tablet (TAB), an oil-emulsified drop (DROP), or an encapsulated powder (CAP) at a label-claimed dose of 10,000 IU/day. Actual D3 content was assessed by a third party and the results adjusted based on the actual D3 content administered. Mean change in 25(OH)D/mcg D3 administered; difference in the proportion of D3 insufficient participants (ie, 25(OH)D ≤30 ng/mL) reaching sufficiency (ie, 25(OH)D ≥30 ng/mL); and mean change in serum 1, 25-dihydroxycholecalciferol were measured. RESULTS In two of the three products tested, the measured vitamin D3 content varied considerably from the label-claimed dose. Differences in 25(OH)D/mcg D3 administered were significantly different between groups (P = .04; n = 55). Pairwise comparisons demonstrated DROP resulted in a greater increase than TAB (P < .05) but not than CAP. TAB was not different from CAP. The proportions reaching sufficiency were: 100% (TAB and CAP) and 80% (DROP) (P = .03 between groups; n = 55). 1, 25-Dihydroxycholecalciferol did not change significantly in any group. CONCLUSIONS Oil-emulsified vitamin D3 supplements resulted in a greater mean change in serum 25(OH)D concentration, but fewer patients reaching vitamin D sufficiency, than chewable or encapsulated supplements.

Epigenetics in Clinical Practice: Characterizing Patient and Provider Experiences with MTHFR Polymorphisms and Methylfolate

Background: Observational research associating methylenetetrahydrofolate reductase (MTHFR) polymorphisms with risk of autism, depression, cancer and cardiovascular disease has led to increased diagnoses of MTHFR, however, doctors lack knowledge about safety, effectiveness, and clinical implications of MTHFR treatment. Treatment strategies are hypothetical and mechanistically-based, including methylfolate with or without other B vitamins. Aims: This study was designed to formally describe patient and healthcare provider experiences with the diagnosis and clinical management of MTHFR. Methods: Guided by a structured interview guide, a qualitative study queried patients’ and providers’ observations regarding: testing indications, reaction to results, treatment protocols, and clinical response including adverse effects. Results: Thirty patients and eight doctors participated. Patient themes included emotionality associated with diagnosis, classification of signs and symptoms, and challenges with treatment. They expressed confusion over their diagnosis, and frustration with the state of knowledge their providers had regarding MTHFR. Testing indications included: fatigue (21%), hormone imbalances (13%), and neurological symptoms (13%) including brain fog (8%). Patients reported improvements in physical (60%) and mental/behavioral symptoms (36%) following treatment. A minority of participants reported side effects but they occurred in almost every body system and ranged in severity. Doctors relied on trial and error to determine treatment doses, frequency and components. Conclusions: MTHFR testing results in variable clinical processes in domains related to delivery of diagnosis and prognosis, and therapeutic options. However, patients report largely positive experiences. Clinicians and patients would benefit from therapeutic algorithms based on rigorous research.

OA07.04. Self-care, use of CAM and satisfaction with health care in people with inadequately controlled Type 2 diabetes

Methods Patients with inadequately controlled T2D from Group Health Cooperative were invited to participate in a telephone survey. The survey queried interest in ANC, current CAM use, and current self-care. Self-care behavior, perceptions about blood sugar, and motivation for behavior change were assessed using the Summary of Diabetes Self-care Activities, Perceptions of Blood Sugar Control and the Readiness Index instruments, respectively. Survey responses were then compared between people who expressed great interest in using ANC services and those who expressed less interest.