We have noticed much confusion among our broad digital health/virtual-first care network about the definitions of conventional, lifestyle, functional and alternative medicine. To add to the confusion, each picks and chooses techniques from the others to incorporate into their approach. For more than a decade, our team has focused on illuminating the invisible epidemic of AutoImmune and Inflammatory Diseases (AIIDs), and applying digital health technology to improve care for AIID patients. We have used the tagline: “Applying the best of digital, conventional & functional medicine,” since 2015 at Stanford MedX.

We now think “lifestyle medicine” better captures our view on integrating effective, evidence-based, non-pharmaceutical interventions into digitally enabled AIID care. Lifestyle Medicine interventions utilize everyday patient behavior change as primary modalities for chronic disease treatment. In recent years, this approach has been converging into conventional practice. We believe that this is essential, as lifestyle interventions are a necessary adjunct to pharmaceuticals and procedures for patients with chronic diseases, especially AIIDs.

Medical (or healthcare) philosophies (or paradigms)

Conventional Western Scientific Medicine

The Good

Also called allopathic, biomedicine or evidence-based medicine, this is the predominant philosophy in the Anglosphere, South America, Europe, and increasingly across East & West Asia. Over the late 19th – 20th Centuries, the scientific paradigm delivered unprecedented technical progress (germ theory, anesthesia, radiation, antibiotics, pharmacology, diagnostic tests, biotech). These technical advances produced unequaled effects on personal and public health.

Two examples:

• The germ theory of disease (late 1800s) revolutionized prevention (clean water, avoiding contagion, laboratory vaccines) and treatment (sterile surgery, antibiotics) of infectious diseases, with profound impact on life expectancy, world population growth, and human genomics.
• The invention of diagnostic tests to detect abnormal biological processes before they progress to symptomatic disease. This includes mechanical tests like blood pressure, imaging tests like X-rays & MRIs, blood & urine tests for pathogens & diagnostic biomarkers such as antibodies, glucose, lipids, hormones & kidney function markers. 

The Bad

Less than a century after the historical conquest of infectious diseases, chronic conditions have become the leading causes of death in many populations. Despite 20thC miracles like insulin, organ transplants and biopharmaceuticals, when it comes to chronic diseases, conventional medicine is producing diminishing returns. Moreover, many patients perceive conventional care as too payer-driven, impersonal, narrowly focused on test results, insensitive to drug side-effects, and treating diagnoses rather than people. For autoimmune patients, the conventional system often misdiagnoses, or presumes symptoms are psychological. Even after diagnosis, it offers them slow, hit-or-miss and expensive drug-focused care.

The Ugly

Marc Braman (past President of the American College of Lifestyle Medicine) and many others criticize conventional medicine for a narrow focus on “pills & procedures.” This is entrenched through government-funded scientific research, medical education & clinical guidelines, third-party payers (3PP), fee for services (FFS), the pharmaceutical and medical device industries. The paradigm is: Interpret symptoms (test) – make a diagnosis – prescribe medications and/or procedures. This feedback loop means medical research and education focus almost exclusively on tests, pharmaceuticals and procedures. Since the turn of the century, this paradigm has increased costs without improving health. 

Examples:

• Pharmaceuticals: Research to find drug targets, develop diagnostics and drugs for target diseases, conduct costly randomized clinical trials (RCTs) to gain regulatory approval, then aggressively market medicines to doctors and patients. While it produced miracles in the 20thC for infectious diseases, type 1 diabetes and previously fatal rare diseases, by the turn of the century, this paradigm was producing fewer miracles for cancer and chronic conditions.
• Medical devices: Identify conditions to treat via procedures with instruments, implements, implants, etc., then use advanced engineering to develop better hardware. This includes medical artifacts from bandages and blood pressure meters to pacemakers and surgical robots.

Another critique points to a focus on “sick care”: Do nothing until patients present with symptoms; then treat symptoms until gone. This is an overstatement, since screening tests are used to predict bone, cancer, heart & kidney disease. However, screening procedures like bone density, colonoscopy and mammography are FFS cash cows with many false positives and poor ROI. For example, lab tests for diabetes markers and lipid disorders may lead to over-prescribing antihyperglycemic agents for “prediabetics” or statins for patients whose only risk factor is high total cholesterol. 

Although this is now changing, lifestyle has been a peripheral concern, not usually reimbursed and often unguided, e.g., advice to patients to “stop smoking, lose weight, be more active.” Physicians may prescribe a limited course of hands-on PT or OT, but most payers do not reimburse support for long-term exercise & hands-on therapies. Likewise, dieticians or nutritionists are often not covered by third party payers. 

Lifestyle Medicine

Lifestyle medicine today rests on a growing consensus and scientific evidence base.

The paradigm: Chronic diseases are caused by a counterproductive interaction between our ancient evolutionary adaptations to infections, food scarcity, high activity and natural circadian rhythms (millions of years of natural selection encoded in our DNA) and our modern low-infection, high-calorie, sedentary, socially stressful & circadian-disrupted lifestyles. Thus, lifestyle interventions aim to prevent or manage chronic disease through changing everyday patient behaviors.

Today, lifestyle interventions are increasingly adopted by conventional medicine. Although in most cases patients still pay directly for lifestyle support, payers are beginning to realize the power of lifestyle interventions in chronic disease. Emerging digital health & V1C companies that integrate lifestyle & conventional interventions focus on diabetes, kidney failure, obesity and musculoskeletal (MSK) conditions. Some examples include Omada & Virta (diabetes), Sword, Hinge Health, and Kaia (MSK). More recently, a handful of startups focused on AIIDs either lead with lifestyle (Mymee) or integrate it with conventional specialty care (Aila, AndHealth)

The Good

Lifestyle medicine is more holistic than conventional medicine, with a focus on what patients do every day. Unlike Functional, the Lifestyle movement has worked since the ‘80s to develop an evidence base and pursue reimbursement. In 2011, the Ornish Diet to control heart disease was the first lifestyle intervention to receive Medicare reimbursement approval. The American College of Lifestyle Medicine (ACLM) lists 6 pillars of lifestyle medicine:

1. Healthful diet
2. Adequate physical activity
3. Restorative sleep
4. Stress management
5. Avoiding risky substances 
6. Positive social connections

As lifestyle is increasingly incorporated into diabetes, obesity, heart & MSK programs, AIIDs are obvious next targets. Practitioners choose components based on patients’ individual circumstances. Wellness programs also focus on lifestyle interventions; however, their target users are not (yet) ill, but rather hoping to improve fitness & prevent disease.

Typical interventions:

• Diet & nutrition: Deficiencies, weight management, triggers, allergies, sensitivities.
  • “Plant-based, nutrient-dense” (Mediterranean) diet and special diets (elimination, keto, AIP, rare diseases, etc.).
  • Less use of supplements than functional, athletic or anti-aging enthusiasts.
• Exercise: Daily activity, aerobic exercise, strength and flexibility training, physical and occupational therapy (hands-on and guided exercises). 
• Circadian management: Sleep, timing of food, exercise, medications.
• Psychological care, aka behavioral/mental health: Mood disorders, fatigue, relationships, mind/body, breathing practices, CBT, etc.
• Reducing risky habits: Smoking, alcohol, recreational drug use.

The Bad

Lifestyle doesn’t replace conventional medicine; it has limited impact on preventing infections, cancer or cardiac conditions. A poor genetic hand may trump decades of careful behaviors. Unlike Functional, Lifestyle positions itself as adjunctive, not a replacement for conventional care. Most AIID patients will do better with well-matched medications plus better lifestyles. 

The Ugly

Most importantly, most lifestyle interventions are not reimbursed by payers. The current evidence base supporting lifestyle medicine is limited, which gives conventional clinicians further reason to ignore it. Most of the current evidence is observational, as it is difficult to perform robust RCTs on diet, exercise, sleep or stress management. For example, digging into most published peer-reviewed research on diets (e.g., plant-based) reveals positive bias, sloppy methodology and significant confounders, like body mass index (BMI) and social class. Nevertheless, the evidence base is growing and digital health companies like Omada have done persuasive studies on the impact of diet and exercise on type 2 diabetes.

Integrative Medicine

As the name suggests, integrative medicine draws from multiple modalities and integrates them into practice. This philosophy shares a holistic patient view with functional and lifestyle medicine, and combines modalities from alternative medicine with conventional approaches. There are many different, sometimes conflicting, definitions of integrative medicine and Integrative Medicine (Dr Andrew Weill is the most famous of the long-term proponents). The mix of conventional, alternative & functional medicine modalities varies between each practice, provider, and patient, since each pulls different pieces from the other philosophies. 

Functional Medicine

Functional Medicine focuses on “root causes” of disease. The paradigm presumes these are negative interactions between patients’ endocrine (hormonal), gastrointestinal & immune systems and their environments. Environmental triggers of disease are called “toxins,” including food reactions and chemical exposures. Lingering infections or dysfunctional immunological reactions are also possible root causes. Most Functional practices are paid directly by patients and generate substantial revenues from high-mark-up testing & supplements (often self-branded). However, some healthcare plans and employers now pay for some functional programs and some functional models have been funded by VCs. for example: Parsley, WellTheory, AndHealth, and Gritwell.

The Good

The philosophy is holistic, viewing patients as more than a collection of symptoms & diagnoses. Practices often focus on chronic conditions, including AIIDs, as well as prevention and wellness. Practitioners seek to avoid pharmaceuticals & procedures, and are more sensitive to side-effect trade offs. They offer more “advanced” tests than conventional–e.g., thyroid beyond TSH, adrenal, sex hormones–and interpret the results differently. 

• People with ME/CFS/SEID, Fibromyalgia, long covid and AIIDs may switch to Functional practices (despite having to pay out of pocket) because they feel they get more sympathetic care than from conventional practices. 
• Many menopausal women find conventional medicine offers little support, given widespread reluctance to prescribe female hormone replacement therapy (HRT). They move to Functional practices to get natural hormones (e.g., compounded), supplements and sympathy.

The Bad

Functional medicine claims to seek “root causes,” generally negative interactions between the environment and patients’ gastrointestinal, endocrine and immune systems. However,  many of these hypotheses are not (yet?) supported by scientific evidence:

• “Leaky gut,” which triggers an immune response to GI bacteria.
• Adrenal or mitochondrial fatigue/exhaustion.
• Environmental toxins: Mold exposure, chemical sensitivities, residual pesticides & other chemicals in food, which “detoxification” regimens are supposed to address.

Functional practices also have a heavy focus on diet & nutrition, especially “natural” supplements.

• Specific diets: Elimination, Paleo, AIP, low-FODMAP, etc., biased toward organic and plant-based. 
• Supplements, hormones and vitamins (sometimes injectables).
• A preference for “natural” (plant-derived) supplements over synthetics or pharmaceuticals.

The Ugly

Functional Medicine is viewed with suspicion by many conventional clinicians, professional organizations, and third-party payers (although some plans now offer some coverage). Some of their concerns with Functional Medicine are:

• Avoiding seeking an evidence base to avoid the regulatory constraints of conventional medicine and obscure how effective or ineffective functional interventions are. 
• Aggressive online and social media marketing to attract patients frustrated with conventional care. However, it’s not clear that it delivers on its implied promise to do better than conventional, although many feel they get more sympathetic care.
• Business models: Most practices generate revenue from high-markup tests & supplements. Many use self-promotion and funnel marketing tactics to sell webinars, workshops, books, and food programs of dubious value.

Alternative (Natural, Traditional) Medicine

This group includes survivors of older traditions that have been largely superseded by scientific medicine. These modalities have been often dismissed as pseudoscience, quackery or, at best, fringe. Nevertheless, some modalities are now reimbursable adjuncts to conventional care. These include acupuncture, therapeutic massage, Tai Chi, and meditation. Moreover, they continue to attract a loyal and self-paying following, especially patients unhappy with conventional medicine. 

Asian (Eastern) traditional medical practices: 

• Traditional Chinese medicine (TCM): Acupuncture, herbs, Tai Chi.
• Ayurvedic (Indian) medicine: Meditation, breathing practices, yogas, etc. 
• Therapeutic massage: Many methods branching from ancient roots.

Western traditional and alternative practices:

• Chiropractic, naturopathy, osteopathy, homeopathy, hypnotism, herbalism and mineral baths grew from 19th C roots, in opposition to the pre-chemistry practices of Galenic medicine (humor theory, bloodletting, purges, metallic salts, surgery) , before the germ theory established the scientific medical paradigm.
• Likewise, massage and movement therapies (Pilates, Feldenkrais, Gyrotonic), are thriving survivors of decades-old practices.
• Supplements: The supplements industry has grown into a multi-billion dollar behemoth with considerable anti-regulatory clout. They have become increasingly trendy, with figureheads such as Gwyneth Paltrow and Alex Jones selling the same supplements to very different target markets.
• Psychedelic medicine, now attracting scientific pharmacological research after decades in the shadows. Includes synthetic chemicals (LSD, MDMA, ketamine) and ethnobotanicals (psilocybin mushrooms, ibogaine, ayahuasca).

Conclusion

We believe that the scientific paradigm is an essential foundation for medical care and that most AIID patients would benefit from a combination of conventional and lifestyle interventions. Furthermore, we believe that lifestyle modifications are absolutely necessary components of preventing and managing AIIDs, as well as many other chronic illnesses. Ideally, lifestyle would be addressed through affordable, guided care for everybody, especially people at risk, even before symptoms emerge. Several VC-funded digital health programs addressing lifestyle factors have launched for managing diabetes and chronic MSK conditions.

Recent updates to professional guidelines, e.g., the American College of Rheumatology (ACR), and the American College of Gastroenterology (ACG), suggest some lifestyle interventions, with caveats that the evidence base is still weak. Likewise, the use of exercise in managing MSK AIIDs like rheumatoid arthritis (RA) & lupus has recently reached professional guidelines, although exercise has long been a central component of care plans for spondyloarthritis (SpA).

Given these trends, we expect lifestyle will continue to converge with conventional medicine. The biggest systemic barriers to widespread use of lifestyle interventions are lack of reimbursement, clinical ignorance, skepticism and inertia. Breaking those barriers will require enough scientific data to prove the benefits of lifestyle. That takes us to the biggest challenge of all: Getting people to change their behaviors. That applies not only to patients in lifestyle programs, but also all people at risk for chronic conditions in hopes of preventing disease, or needing less conventional treatment.

The biggest challenge of all: Getting people to change their behaviors–not only patients in lifestyle programs, but also all people at risk for chronic conditions in hopes of preventing disease or needing less conventional treatment.

Authors: DrBonnie360, Ellen M Martin & Ellie Duvall

We approach these thought leadership posts from our multi-lens perspectives. 

• DrBonnie360: Digital/virtual health consultant, clinical dentist, Wall Street analyst, patient & advocate.  
• Ellen M Martin: Consultant, editor, life science finance/IR/marcomm, autoimmune caretaker.
• Ellie Duvall: Digital health equity research intern, Physiological Sciences undergraduate student at UCLA.

Strategic Consulting & Professional Services

We provide professional consulting services to investment, emerging and established companies. Our work bridges silos and fills gaps to help our clients improve care for AIID patients and reduce costs. Informed by patient and caretaker perspectives, we urge investors & clients to integrate the best of digital, conventional and functional medicine into AIID care delivery.

• We help our clients leverage digital innovations into V1C for AIID patients. 
• Our subject matter expertise includes: oral health, microbiome, autoimmune patient journeys, competitive landscape analysis, strategic positioning & messaging, digital health, and self-hacking.
• We have decades of experience in finance, marketing and communications for dozens of healthcare and life sciences organizations, emerging and established.
• Our backgrounds include clinical dentistry, osteology, biotech IR/PR, marcomm, content creation, strategic consulting, and autoimmune advocacy.

Contact us to help you map your market landscape and understand patients unmet needs. Also, we can help you clarify and articulate your company’s market position and differentiators. Long before COVID-19, we were facilitating virtual sessions. We also create compelling content: articles, blog posts, collateral, e-books, web copy and white papers. Our Autoimmune Connect/DrBonnie360 website showcases our own content.