article on disease prevention
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During 2012, the USDHHS’s Health Resources and Services Administration funded 12 accredited preventive medicine residencies to incorporate an evidence-based integrative medicine curriculum into their training programs. It also funded a national coordinating center at the American College of Preventive Medicine, known as the Integrative Medicine in Preventive Medicine Education (IMPriME) Center, to provide technical assistance to the 12 grantees. To help with this task, the IMPriME Center established a multidisciplinary steering committee, versed in integrative medicine, whose primary aim was to develop integrative medicine core competencies for incorporation into preventive medicine graduate medical education training. The competency development process was informed by central integrative medicine definitions and principles, preventive medicine’s dual role in clinical and population-based prevention, and the burgeoning evidence base of integrative medicine. The steering committee considered an interdisciplinary integrative medicine contextual framework guided by several themes related to workforce development and population health. A list of nine competencies, mapped to the six general domains of competence approved by the Accreditation Council of Graduate Medical Education, was operationalized through an iterative exercise with the 12 grantees in a process that included mapping each site’s competency and curriculum products to the core competencies. The competencies, along with central curricular components informed by grantees’ work presented elsewhere in this supplement, are outlined as a roadmap for residency programs aiming to incorporate integrative medicine content into their curricula. This set of competencies adds to the larger efforts of the IMPriME initiative to facilitate and enhance further curriculum development and implementation by not only the current grantees but other stakeholders in graduate medical education around integrative medicine training.
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One of the major goals in the field of health promotion and disease prevention is to identify risk factors for disease so that information about these risk factors can then be shared with people. Our hope is that people will use this information to change their behavior to lower their disease risk. There are three major problems with this model that require our serious attention.
The first problem is that after decades of epidemiologic research, it has proven very difficult to identify disease risk factors. Consider, for example, the case of coronary heart disease. For over 50 years, extensive research has been done all over the world to identify risk factors for this disease. As a result, we now have knowledge about many of them including serum cholesterol, high blood pressure, cigarette smoking, physical inactivity, obesity, diabetes and so on. In spite of this success, however, most of the coronary heart disease that occurs is not explained by these risk factors. It is estimated that all of the risk factors we know about, combined, explain less than half of the CHD that occurs.1 This does not, of course, diminish the importance of the risk factors we have identified, but it does suggest that things are more complicated than we had thought. The problem we have with CHD is very much the same for many other diseases as well.
The second problem is that even when we do identify disease risk factors, we have a very difficult time in getting people to change their behavior. Many research studies have shown that even when people know about risk factors for disease, this often does not result in their changing behavior to lower risk. Most behavior changes occur, in fact, in response to a variety of environmental and community forces that constrain and modify behavior. Cigarette smoking offers a clear example on this phenomenon.
This is a major issue for us in public health. If one of our goals is to prevent disease and promote health, I do not think we can accomplish this mission by an exclusive focus on individual diseases and risk factors. There is a lesson to be learned here by looking at the success we have had in preventing many infectious diseases. Some of that success has been attributable, of course, to vaccines. But most of this success has been due to an improvement in the environment. This improvement came about because of the way in which diseases were classified. These disease classifications were in terms of water-borne diseases, food-borne diseases, air-borne diseases and vector-borne diseases. These disease classifications are not of much value clinically—in the treatment of individual cases—but they are of great importance in telling where diseases are coming from and where we should direct our prevention efforts.
Do we have a similar classification system for the noninfectious diseases of concern today? Do we have a way of understanding the environmental and community forces that influence disease risk and that shape behaviour in the first place? An understanding of the fundamental determinants of health and disease would seem to be a first priority for developing a truly effective program to prevent disease and promote health and, in my view, we do not currently have a model of this kind.
This problem constitutes a major challenge to our current public health model and, to address it, we will need a different approach. The new approach will require a new way of classifying disease, one that does not depend on the currently-used clinical model of disease. It will also require that we focus (i) more on life problems that are of concern to people in the community and (ii) less on problems of concern to us; experts in Public Health.
To develop effective intervention programs, we will need to get people to change high-risk behavior. We will need for people to stop doing things they have done for years and they will need to begin doing things they perhaps have never done before. And we in the field of health promotion will need to develop much more effective ways of communicating with people in the community. To do that, we will have to re-think the way we classify diseases, we will need to understand better what people care about, and we will need to do more relevant research. This will require a new way of funding such research and of training a new generation of people working in the field of health promotion and disease prevention. To accomplish this transformation, we will require governmental policies very different from those now in place. That may be the biggest, and most difficult, challenge of all.
These are very challenging issues. But so is the problem we face. We will need to do our best. And we will need to begin soon.
The first problem is that after decades of epidemiologic research, it has proven very difficult to identify disease risk factors. Consider, for example, the case of coronary heart disease. For over 50 years, extensive research has been done all over the world to identify risk factors for this disease. As a result, we now have knowledge about many of them including serum cholesterol, high blood pressure, cigarette smoking, physical inactivity, obesity, diabetes and so on. In spite of this success, however, most of the coronary heart disease that occurs is not explained by these risk factors. It is estimated that all of the risk factors we know about, combined, explain less than half of the CHD that occurs.1 This does not, of course, diminish the importance of the risk factors we have identified, but it does suggest that things are more complicated than we had thought. The problem we have with CHD is very much the same for many other diseases as well.
The second problem is that even when we do identify disease risk factors, we have a very difficult time in getting people to change their behavior. Many research studies have shown that even when people know about risk factors for disease, this often does not result in their changing behavior to lower risk. Most behavior changes occur, in fact, in response to a variety of environmental and community forces that constrain and modify behavior. Cigarette smoking offers a clear example on this phenomenon.
This is a major issue for us in public health. If one of our goals is to prevent disease and promote health, I do not think we can accomplish this mission by an exclusive focus on individual diseases and risk factors. There is a lesson to be learned here by looking at the success we have had in preventing many infectious diseases. Some of that success has been attributable, of course, to vaccines. But most of this success has been due to an improvement in the environment. This improvement came about because of the way in which diseases were classified. These disease classifications were in terms of water-borne diseases, food-borne diseases, air-borne diseases and vector-borne diseases. These disease classifications are not of much value clinically—in the treatment of individual cases—but they are of great importance in telling where diseases are coming from and where we should direct our prevention efforts.
Do we have a similar classification system for the noninfectious diseases of concern today? Do we have a way of understanding the environmental and community forces that influence disease risk and that shape behaviour in the first place? An understanding of the fundamental determinants of health and disease would seem to be a first priority for developing a truly effective program to prevent disease and promote health and, in my view, we do not currently have a model of this kind.
This problem constitutes a major challenge to our current public health model and, to address it, we will need a different approach. The new approach will require a new way of classifying disease, one that does not depend on the currently-used clinical model of disease. It will also require that we focus (i) more on life problems that are of concern to people in the community and (ii) less on problems of concern to us; experts in Public Health.
To develop effective intervention programs, we will need to get people to change high-risk behavior. We will need for people to stop doing things they have done for years and they will need to begin doing things they perhaps have never done before. And we in the field of health promotion will need to develop much more effective ways of communicating with people in the community. To do that, we will have to re-think the way we classify diseases, we will need to understand better what people care about, and we will need to do more relevant research. This will require a new way of funding such research and of training a new generation of people working in the field of health promotion and disease prevention. To accomplish this transformation, we will require governmental policies very different from those now in place. That may be the biggest, and most difficult, challenge of all.
These are very challenging issues. But so is the problem we face. We will need to do our best. And we will need to begin soon.
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