Download What is a Toxicant?

Lowering the Toxic Body Burden
Using Diet, Lifestyle, and Other
Strategies
Dan Lukaczer, ND
Applying Functional Medicine in Clinical Practice
London, England
October 2015
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
etelling the Patient’s Story
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Antecedents
Assimilation
Defense & Repair
(Predisposing FactorsGenetic/Environmental)
(e.g., Digestion, Absorption,
Microbiota/GI, Respiration)
(e.g., Immune, Inflammation,
Infection/Microbiota)
Triggering Events
(Activators)
Structural Integrity
Energy
(e.g., from Subcellular
Membranes to Musculoskeletal
Structure)
(e.g., Energy Regulation,
Mitochondrial Function)
Classes of Toxicants
emotional
cognitive
regulation, grief,
function,
sadness, anger,
perceptual patterns
• Metals
etc.
meaning
& purpose,
• Persistent Organic
Pollutants
relationship with something
e.g.,
e.g.,
e.g.,
greater
Mediators/Perpetuators
(Contributors)
Spiritual
Communication
Biotransformation & Elimination
•
Biological
Toxins
(e.g., Endocrine, Neurotransmitters,
(e.g., Toxicity, Detoxification)
Transport
Immune messengers)
Biotransformation
(e.g., Cardiovascular, Lymphatic
• Electromagnetic
System)
& Elimination
• Psych/Spiritual
Personalizing Lifestyle Factors
Sleep & Relaxation
Nutrition & Hydration
(e.g., Toxicity,
Detoxification)
Stress & Resilience
Relationships &
Networks
©2015 The2011
Institute
for Functional
Medicine
Name:____________________________ Date:___________ CC:_____________________________________
© Copyright
Institute
for Functional
Learning Objectives
• Define what a toxicant is, outline our increasing
exposure to toxins, and evaluate the health
consequences of a chronic, low level toxic load
• Understand the process of biotransformation or
detoxification and how it may be modified
• Develop competency in assessing for chronic
toxicity
• Develop strategies to minimise toxic exposure,
increase mobilisation, biotransformation, and
excretion of toxins.
• Be able to implement a foundational detoxification
programme
©2015 The Institute for Functional Medicine
Functional Medicine & Toxicology:
Fundamental Principles
1. Exposure to environmental toxins is widespread,
increasing and lifelong.
2. The total body burden of these toxins can act
synergistically to cause physiologic dysfunction.
3. This dysfunction can lead to chronic illnesses in
susceptible individuals.
4. Susceptibility is largely defined by an individual’s
ability to biotransform, detoxify and eliminate
exogenous and endogenous toxins.
5. Lifestyle, diet and nutraceuticals can enhance
detoxification, prevent disease and restore health.
©2015 The Institute for Functional Medicine
Which patients might benefit from a
focus on toxins and biotransformation?
• Feels vaguely unwell & persistently fatigued
• Has experienced sudden onset of autoimmune
disease or chronic neurologic disorder
• Is sensitive to all sorts of fumes, solvents
cosmetics, and detergents
• Has a personal or strong family history of cancer
• Has a long history of constipation
• Has a past medical history of an acute toxic
exposure
©2015 The Institute for Functional Medicine
What is a Toxicant?
• Any substance that causes structural
damage or functional disturbances.
• Exposure can occur through ingestion,
inhalation, absorption, injection, etc., or
through internal metabolic processes.
– Exogenous
– Endogenous
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
Types of Exogenous Toxicants
• Pesticides
– Insecticides, herbicides
• Industrial compounds and chemical byproducts
• Volatile organics, solvents and detergents, toxic
metals, plasticisers, insulators (asbestos)
•
•
•
•
•
•
Combustion/incineration pollutants
Synthetic medications or natural phytochemicals
Food additives and preparation by-products
Cosmetic additives
Electromagnetic radiation
Psycho-spiritual
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
Types of Endogenous Toxicants
• Reactive oxygen and nitrogen species (hydroxyl,
superoxide, peroxyl, peroxynitrite)
– By-product of respiration (mitochondria)
– By-product of hepatic and gastrointestinal
detoxication
– Response to microbial attack (oxidative burst)
– Consequence of tissue ischaemia (upregulation of
xanthine oxidase)
• Lipid peroxides (rancid fats)
• Oxidised glucose and advanced glycosylated
end products (AGEs)
©2015 The Institute for Functional Medicine
Types of Endogenous Toxicants
Imbalanced metabolism
– Major inborn errors of metabolism (enzymatic)
• Homocysteinemia
• Phenylketonuria
– “Minor” enzymatic dysfunctions
(polymorphisms)
– Urea cycle abnormalities: hyperammonaemia
from inability to metabolise nitrogen
©2015 The Institute for Functional Medicine
Types of Endogenous Toxicants
Products of dysbiosis
– Bacteria: putrescine, cadaverine, ammonia,
etc.
– Yeasts: arabinose, tartrate, citramalate, etc.
– Secondary bile acids (deconjugated)
– Beta glucuronidase (elaborated by bacteria
and causing enterohepatic recirculation of
hormones and other toxins)
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
Increasing Exposure
• Since WWII, over 85,000 synthetic chemicals
have been registered with the US EPA
• >140,000 chemicals are on the European
market (UNEP.org)
• Each year, an estimated 2,000 new chemicals
are introduced for use in everyday items
including foods, personal care products,
prescription drugs, household cleaners,
pesticides, and lawn care products
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
Body Burden: The Pollution in People
Mount Sinai School of Medicine, New York
http://www.ewg.org/sites/bodyburden1/es.php
Laboratory tests uncovered 167 chemical
pollutants in blood & urine from nine
volunteers, including an average of 53
carcinogens in each person. The people
tested do not work with chemicals and do
not live near an industrial facility.
©2015 The Institute for Functional Medicine
Bisphenol-A
• Commercial plasticiser: over 8 billion pounds
produced every year (lining canned food &
drinks; water bottles; cash register receipts);
over 100 tons released into the atmosphere
every year
• Readily absorbed through skin and gut mucosa
• More than 90% of people in US have
measurable BPA in their bodies
Endocr Rev. 2009; 30(1): 75–95.
©2015 The Institute for Functional Medicine
The “Exposome”
Combined Exposures from All
Sources That Reach the Body’s
Internal Chemical Environment
Science, 2010, Vol 330: 460-461
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
Are “low” levels of
toxicants
(nanograms or
picograms per mL)
significant?
©2015 The Institute for Functional Medicine
“The demonstration of biological effects at very
low levels of exposure suggests that two
toxicological axioms—(1) all chemicals have
thresholds below which they cause no adverse
effects, and (2) that ‘the dose makes the poison’—
should be reevaluated.”
Public Health Reports, 2002, Vol 117: 315-323
©2015 The Institute for Functional Medicine
Chronic Low-Level Toxicity
• Biologic effects of many toxicants are
not linear – very low doses can have
profound physiologic effects
• Chemical sensitivity varies
considerably, depending on species,
life stages, biochemical individuality
and synergistic effects from multiple
toxicants
©2015 The Institute for Functional Medicine
How Low is Low Enough?
Lead poisoning was diagnosed historically if
whole-blood lead levels were found to be:
60 mcg/dl - 1960s
30 mcg/dl - 1975
25 mcg/dl - 1985
10 mcg/dl - 1991
Each 10 mcg rise in lead = fall in children’s IQ
by 4.6 pts. From 1 to 10 mcg = fall in IQ by 7.4
pts.
N Engl J Med 2003 Apr 17;348(16):1517-26.
©2015 The Institute for Functional Medicine
Lead
The understanding of lead toxicity has advanced
substantially in the past 3 decades and focus has
shifted from high-dose effects in clinically
symptomatic individuals to the consequences of
exposure at lower doses that cause no overt or
apparent symptoms. More refined epidemiological
techniques and better outcome measures has
lowered the least observable effect level for lead
until it approaches zero.
Needleman H, Lead poisoning Annu Rev Med. 2004;55:209-22.
©2015 The Institute for Functional Medicine
Arsenic
“Long-term exposure to arsenic has been
found to be associated with an increased
risk of diabetes mellitus, hypertension,
ischemic heart disease, and cerebral
infarction in a dose-response relationship …
after adjustment for other cardiovascular risk
factors”
Wang CH, et al., Biological gradient between long-term arsenic exposure and
carotid atherosclerosis. Circulation 2002 Vol 105: 1804-1809.
©2015 The Institute for Functional Medicine
Organochlorines
Organochlorine insecticides produce a direct toxic
action on the dopaminergic tracts of the substantia
nigra and may contribute to the development of
Parkinson’s Disease in those rendered susceptible
by virtue of cytochrome P-450 polymorphism,
excessive exposure, or other factors.”
Corrigan FM, et al., Organochlorine insecticides in substantia nigra in
Parkinson's disease. J Toxicol Environ Health A. 2000 Feb 25;59(4):229-34.
©2015 The Institute for Functional Medicine
Bisphenol-A
• Endocrine disruptor: can mimic effects of
oestrogen (and other hormones) and
interfere with cellular signaling
• Higher levels of urinary excretion linked to
diabetes, obesity, heart disease, liver
inflammation
• Also linked to cancer, thyroid disorders,
infertility
Endocr Rev. 2009; 30(1): 75–95.
©2015 The Institute for Functional Medicine
PLOS One, 2014, Volume 9(10): e110509
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
State of the Science:
Endocrine Disrupting Chemicals
• Many endocrine-related disorders are on the rise
• The speed which the increases in disease incidence
have occurred in recent decades rules out genetic
factors as the sole plausible explanation
• Numerous laboratory studies support the idea that
chemical exposures contribute to endocrine disorders in
humans and wildlife.
• The most sensitive window of exposure to EDCs is
during critical periods of development, such as foetal
development & puberty
World Health Organization, 2012
©2015 The Institute for Functional Medicine
State of the Science:
Endocrine Disrupting Chemicals
• Environmental chemicals can exert endocrine
disrupting effects on more than just estrogen,
androgen, and thyroid hormone action. Some
are known to interact with multiple hormone
receptors simultaneously.
• Disease risk due to EDCs may be significantly
underestimated.
• An important focus should be on reducing
exposures by a variety of mechanisms.
World Health Organisation, 2012
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
Synergistic Effects of Toxic Metals:
The Sum Is Greater then the Parts
• The administration of an essentially no response
level (LD1) of a mercury salt together with 1/20th
of the LD1 of a lead salt killed all the animals.
• “Generally, a combination was synergistic when
the most toxic member was present at or near its
LD1 dose in the presence of a much less toxic
member.”
Schubert et al., Combined effects in toxicology – a rapid systematic testing
procedure: cadmium, mercury and lead. J Toxicology & Environ Health 1978
4:763.
©2015 The Institute for Functional Medicine
www.childenvironment.org
Mount Sinai
School of Medicine
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
Dave’s Chief Complaints
• Weight Gain (30 lbs in last decade)
– Mostly over the last 5-7 years, round the waist
•
•
•
•
Elevated cholesterol and triglycerides levels
Increased Blood Pressure
Fatigues more easily than in past
Less stamina in exercise and physical
activity
• Some muscle and joint stiffness
©2015 The Institute for Functional Medicine
Exposures from Construction Sites and Electrical Supplies
Loves to cook “foodie”
Electrician; working on construction sites since mid 20s
50 52
25
54
57
Increased Triglycerides
Hypertension, Incr Chol & LDL
Incr glucose
Weight Gain & Fatigue
Avid exerciser and runner
Reduced exercise
Weight Gain/Inc Waist Circ
Hypertension
Dyslipidemia
Fatigue/Reduce
Stamina
©2015 The Institute for Functional Medicine
Obesity Overweight
VAT (Incr WHR)
Hypertension
Endothelial Dysfunction
Erectile Dysfunction
Joint Stiffness
Mild Testosterone Def
Insulin Resistance
Metabolic Syndrome
Adequate and
Restful
Inconsistent
walking
Inflammation
VAT (Incr WHR)
Low D
InflamVascular Risks
Fatigue
Muscle Soreness
Oxidative Stress
Occupational Exposure
Lead exposure
Heavy Metal concern
Low Glutathione
Insulin Resistance
Blood Sugar Elevation
HTN and Met Syn
Low Anti-oxidants
Moving, job satisfaction, excited about
Reduced Magnesium
change to position for retirement ,
Methylation concerns
happy in marriage
Low B2, B6, B12, Folic Acid
©2015 The Institute for Functional Medicine
Lead and CVD
Circulation 2009;120:1056-1064
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
POPs and Diabetes
• Investigation of the association between diabetes
prevalence and persistent organic pollutants (POPs) in
2,016 adult participants in the NHANES 1999-2002.
• After adjustment for age, sex, race, ethnicity, poverty
income ratio, BMI, and waist circumference, diabetes
prevalence was strongly associated with lipid-adjusted
serum concentrations of all six POPs tested.
• Participants were classified according to the sum of the
six POPs. The adjusted odds ratios for risk of diabetes
and sum POPs was 1.0, 14.0, 14.7, 38.3, and 37.7
Lee et. al., A strong dose-response relation between serum concentrations of persistent organic
pollutants and diabetes: results from the National Health and Examination Survey 1999-2002.
Diabetes Care. 2006 Jul;29(7):1638-44.
©2015 The Institute for Functional Medicine
POPs and Diabetes
• 749 nondiabetics were assessed for 19 POPs
• POPs detectable in > or = 60% of participants.
• Among subclasses, organochlorine (OC) pesticides were
most strongly associated with HOMA-IR (a measure of
insulin resistance.
• POPs may be associated with type 2 diabetes risk by
increasing insulin resistance, and POPs may interact
with obesity to increase the risk of type 2 diabetes.
Lee et. al., Association between serum concentrations of persistent organic pollutants and insulin
resistance among nondiabetic adults: results from the National Health and Nutrition Examination
Survey 1999-2002. Diabetes Care. 2007 Mar;30(3):622-8.
©2015 The Institute for Functional Medicine
Conclusions:
There is Plausible Evidence to Link Toxic
Exposure with Risk of:
• Selected cancers
• Autoimmune disease
• Neurological diseases: ALS, Parkinson’s disease,
Alzheimer’s disease
• Neuropsychiatric illnesses: depression, anxiety,
inattention, hyperactivity
• Chronic fatigue syndrome, fibromyalgia, multiple
chemical sensitivity
• Allergies, asthma
• Cardiovascular disease
©2015 The Institute for Functional Medicine
Conclusions:
Chronic Toxicant Exposure may:
• Amplify other pathological processes
• Create or contribute to a wide variety of
chronic diseases
• Lead to toxicant-induced loss of tolerance
©2015 The Institute for Functional Medicine
“We are what we…..
Eat
Drink
Breathe
Touch
…and can’t Eliminate
©2015 The Institute for Functional Medicine
TOTAL TOXIC LOAD
results from
Total Toxic Exposure
minus
Ability to Biotransform
and
Excrete Toxins
©2015 The Institute for Functional Medicine
From. Larry Needham, PhD: CDC NCEH Presentation (2004)
©2015 The Institute for Functional Medicine
Learning Objectives
• Define what a toxicant is, outline our increasing
exposure to toxins, and evaluate the health
consequences of a chronic, low level toxic load.
• Understand the process of biotransformation or
detoxification and how it may be modified.
• Develop competency in assessing for chronic
toxicity.
• Develop strategies to minimise toxic exposure,
increase mobilisation, biotransformation, and
excretion of toxins.
• Be able to implement a foundational detoxification
programme.
©2015 The Institute for Functional Medicine
Detoxification
Chemical changes of a xenobiotic,
phytochemical or endogenous
compound that render it less toxic
and/or more readily excreted.
©2015 The Institute for Functional Medicine
“Detoxification is central to understanding
functional assessment in medicine, not so much
because we live in a toxic environment but
because detoxification is the biggest item in each
individual’s biochemical budget.
“It handles waste not only from our environment,
but from every process in all the organs and
systems of the body.”
Sidney Baker, MD
Detoxification and Healing
©2015 The Institute for Functional Medicine
How are toxicants transformed and
eliminated from the body?
Biotransformation
The process of chemically modifying a
substance to render it less toxic and more
readily excreted in the urine or stool.
Biotransformation occurs with both exogenous
and endogenous compounds.
©2015 The Institute for Functional Medicine
Biotransformation is…
•
A constantly active process
•
ATP (energy) dependent
•
Highly nutrient dependent
•
Polymorphic: marked inter-individual
variability
©2015 The Institute for Functional Medicine
Biotransformation is…
• Inducible by toxicants, drugs,
phytochemicals
• Additive (e.g. affected by total load)
• Redundant (multiple substrates processed
through same pathways)
©2015 The Institute for Functional Medicine
Cellular Biotransformation:
Xenobiotics, Phytochemicals &
Endogenous Compounds
• Hydrophilic compounds:
readily excreted in urine and/or bile.
• Lipophilic compounds:
must be chemically altered into hydrophilic
compounds to facilitate elimination.
©2015 The Institute for Functional Medicine
Cellular Biotransformation of
Lipophilic Compounds
Process of detoxication typically
involves two steps:
– Phase I bioactivation
(“functionalisation”)
– Phase II conjugation
©2015 The Institute for Functional Medicine
Types of Reactions
Parent
Compound
Activated
Intermediate
WaterSoluble
Compound
Phase I
Phase II
Cytochrome P450 enzymes:
Oxidation
Reduction
Hydrolysis
Glucuronosyl Transferase (UGT)
Sulfo-transferases (SULT)
Amino Acid Conjugation
Glutathione Conjugation
Acetylation
Methylation
©2015 The Institute for Functional Medicine
Enzymatic Biotransformation
• Phase I & II enzymes are highly polymorphic:
considerable individual variation in activity
based on genotype
• Phase I & II enzymes can be induced or
inhibited by diet, chemical compounds and
hormones
• Upregulation of phase I relative to phase II
can increase production of highly toxic
compounds
• Upregulation of phase II leads to elimination
of toxins
©2015 The Institute for Functional Medicine
Cellular Biotransformation of
Lipophilic Compounds
• All tissues have some activity
• Majority of reactions occur in liver
• Relatively high activity in GI tract,
lungs, kidneys, skin, and blood
brain barrier
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
Intestinal bacteria play a major role
in biotransformation and
detoxification and may explain some
of the differences in xenobiotic
metabolism between individuals
Mol Nutr Food Res. 2013 Jan;57(1):84-99
©2015 The Institute for Functional Medicine
Phase I Reactions
• Introduce or expose a functional group
on the parent compound;
• Making it more polar.
• May activate inert compounds
(e.g. pro-drugs & pro-carcinogens)
©2015 The Institute for Functional Medicine
Cytochrome P450 Mono-oxygenases
The Primary Phase I Enzyme System
Activity in humans includes over 200,000
substrates:
– Pharmaceuticals
– Xenobiotics
– Phytochemicals
– Cholesterol, steroids, eicosanoids, retinoids,
vitamin D
©2015 The Institute for Functional Medicine
Relative contribution of CYP450 enzymes
to known drug metabolism
©2015 The Institute for Functional Medicine
CYP450 Phenotypic Variability
• Activity can range from 5 fold in
constitutive expression to 400
fold as result of drug interactions
• Genetic polymorphisms can
result in increased, decreased or
null activity
©2015 The Institute for Functional Medicine
CYP450: Inhibition
• Phase I inhibition can increase blood
levels of a drug or hormone
• A major cause of drug-drug and drugphytochemical interactions
©2015 The Institute for Functional Medicine
CYP450 Inhibitors
•
•
•
•
•
•
•
•
Cimetidine: multiple enzymes
Antifungal medications
SSRIs (fluoxetine, paroxetine, fluvoxamine)
Grapefruit juice (furanocoumarins): CYP3A4
Berberine: CYP2D6, CYP3A4, CYP2C9
Green tea catechins: CYP1A1, 1A2, 1B1
Garlic: CYP2E1
Star fruit juice: CYP2A6, CYP1A2, CYP3A4
©2015 The Institute for Functional Medicine
CYP450 Induction
• Phase I induction can decrease blood levels of a
drug or hormone
• Commonly induced enzymes: CYP 1A; CYP1B1;
CYP2E1
• Occurs by upregulation of transcription
• Imbalanced induction (phase 1 > phase 2), may
result in pathological detoxification
• Result is increased risk of cancer and
inflammatory disease
©2015 The Institute for Functional Medicine
Phase II Reactions
• Covalent linkage between
parent compound functional
group and water-soluble moiety
• Product generally inactive and
excreted via bile or urine
©2015 The Institute for Functional Medicine
Phase II Enzymes
• Resulting conjugates are highly polar,
usually inactive & rapidly excreted in urine
and/or feces (through biliary route)
• High molecular weight conjugates
excreted in bile are subject to enzymatic
cleavage by intestinal microflora, allowing
enterohepatic recirculation (e.g.
oestrogen, organochlorines)
©2015 The Institute for Functional Medicine
Phase II Enzymes:
Conjugating Reagents
• Glucuronic acid (uridine-diphosphateglucuronosyltransferases: UGT)
• Sulfate (sulfonyltransferases: SULT)
• Glutathione (gluthathione-S-transferases:
GST)
• Acetate (N-acetyltransferases: NAT)
• Amino acids (taurine, glycine, glutamine)
• Methyl group (methyltransferases; e.g.
COMT)
©2015 The Institute for Functional Medicine
Phase II Enzymes
• Under basal conditions, Phase II enzymes do not operate
at maximum capacity
• Phase II activity (UGT, GST, NQO1) can be substantially
increased by genetic induction, primarily via Nrf2/ARE
pathway
• SNPs in Phase II (UGT, SULT) affect individual
susceptibility to toxicants and drugs
• Supporting Phase II conjugation is an effective strategy
for protection against chronic disease
• Objective is to induce Phase II enzymes with minimal
effects on Phase I
©2015 The Institute for Functional Medicine
Imbalanced Detoxification
Non-Polar
Xenobiotic
Phase I
Phase II
CYP P450
Conjugation
Reactive Intermediate
Inert
Water-Soluble
Metabolite
Damage to DNA,
RNA, Proteins
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
Why some people retain toxins, or
are more sensitive to toxins
1.
2.
3.
4.
5.
6.
7.
8.
9.
Overwhelming toxic load
Poor biotransformation/elimination
Polymorphisms in phase I & II enzymes
Intestinal dysbiosis
Nutrient deficiencies
High sugar, low protein diets
Oxidative stress
Chronic inflammation
Stress, emotional trauma
©2015 The Institute for Functional Medicine
Learning Objectives
• Define what a toxicant is, outline our increasing
exposure to toxins, and evaluate the health
consequences of a chronic, low level toxic load
• Understand the process of biotransformation or
detoxification and how it may be modified
• Develop competency in assessing for chronic
toxicity
• Develop strategies to minimise toxic exposure,
increase mobilisation, biotransformation, and
excretion of toxins.
• Be able to implement a foundational detoxification
programme.
©2015 The Institute for Functional Medicine
Assessing Chronic Toxicity:
History
• Exposome history
• Home & work environment
• Diet & Lifestyle
• Medical Symptoms questionnaire (MSQ)
• Toxicity Exposure Questionnaires (TEQ)
• History of reactions to drugs, chemicals, odours,
etc.
©2015 The Institute for Functional Medicine
How Many People Are We
Talking About?
Chemical intolerance occurs in 1 of 5
primary care patients yet is rarely diagnosed
by busy practitioners.
Chemical Intolerance in Primary Care Settings: Prevalence, Comorbidity, and
Outcomes Ann Fam Med, 2012, Vol 10: 357-365
©2015 The Institute for Functional Medicine
Medical Symptoms Questionnaire (MSQ)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
HEAD
EYES
EARS
NOSE
MOUTH/THROAT
SKIN
HEART
LUNGS
DIGESTIVE TRACT
JOINTS/MUSCLE
WEIGHT
ENERGY/ACTIVITY
MIND
EMOTIONS
OTHER
71 questions
Scored: 0 – 4
Total: 0 – 284
©2015 The Institute for Functional Medicine
Toxin Exposure Questionnaire (TEQ)
Exposure Sources:
•
•
•
•
•
•
Community
Home
Occupational
Hobbies
Diet & Lifestyle
Medical/Dental
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
How Toxic are You?
• Take out the
TEQ-20 that is in
your folder and
complete it for
yourself
• Then discuss
with your group
members
©2015 The Institute for Functional Medicine
Intake &
Medical History
Key
Questionnaires
TEQ
MSQ
Environmental Exposures
Known Toxic Exposures:
Occupational, Lifestyle,
Residential, Medical?
FUNCTIONAL
LAB TESTS
Nutritional &
Assimilation
Physical Exam &
Conventional
Labs
Patient Sensitivity Level
Toxicity Signs/Symptoms?
Nutritional Deficiencies?
Detox & Elim. Capacity?
Toxic
Damage
Genetic
Body
Burden Susceptibility
Review of Findings &
Intervention Programme
©2015 The Institute for Functional Medicine
Assessing Chronic
Low-level Toxicity
• Physical findings
• Markers of increased susceptibility (SNPs)
• Markers of toxic damage
• Oxidative stress
• GGT
• Direct measurement of toxins
©2015 The Institute for Functional Medicine
Assessing Toxicity
• Identify triggers
– Toxic metals: hair, blood, urine analysis pre and
post DMSA challenge
– Organic toxicants (fat biopsy; blood, urine)
– Stool analysis
– Hepatic detoxification and oxidative stress profiles
– Intestinal permeability testing
• Identify mediators
– Extra and intracellular antioxidant level
– Oxidative stress markers
– Essential fatty acid profile
©2015 The Institute for Functional Medicine
Learning Objectives
• Define what a toxicant is, outline our increasing
exposure to toxins, and evaluate the health
consequences of a chronic, low level toxic load
• Understand the process of biotransformation or
detoxification and how it may be modified
• Develop competency in assessing for chronic
toxicity
• Develop strategies to minimise toxic exposure,
increase mobilisation, biotransformation, and
excretion of toxins.
• Be able to implement a foundational detoxification
programme.
©2015 The Institute for Functional Medicine
Functional Medicine Strategies
for Living in a Toxic World
1. Minimise exogenous toxic exposure
2. Optimise bowel health, mobilisation and
excretion of toxins
3. Optimise balanced Phase I and II
biotransformation of toxins
©2015 The Institute for Functional Medicine
Strategy 1
Minimise Toxic Exposure
©2015 The Institute for Functional Medicine
Top Ten Lifestyle Choices to
Decrease Toxin Exposure
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Avoid using pesticides/herbicides in home and garden
Filter water with R/O and carbon filter
Use non-toxic cleaning agents
Use nontoxic building materials & carpets whenever
possible in any project or remodel
Use “natural” cosmetics, nail polish and fragrances
Consider ‘organic whenever possible’ in food, but prioritise
organic meat and dairy.
Be careful with consumption of large predator fish.
Do not get amalgam fillings and/or consider removal
Avoiding living near high tension power lines
Clean furnace filters regularly; consider HEPA filter
©2015 The Institute for Functional Medicine
Reducing
Exposures
to Harmful Chemicals
Daily Activity
Questionnaire
Patient Nameto
_______________________________________________________________
Date___________________
Exposure
potentially harmful chemicals on a daily basis is virtually unavoidable.
The majority
of the 85,000 chemicals registered for production under the U.S. Toxic Substances Control Act
Please check the one best response for each activity described below:
1
(TSCA) were grandfathered in with little or no health and safety testing. Medical conditions
linked to toxic chemicals include obesity, metabolic syndrome, diabetes, cardiovascular disease,
SEDENTARY BE
HAVIOR
Alzheimer’s
and
Parkinson’s, cancers,
and
complaints such as fibromyalgia and
t ofmultisystem
the day
o 1 Mos
2
multiple
chemical
sensitivities.
Sitting while
watching TV,
at
o 2 Half of the day
a computer, driving, talking
on the phone, or reading
o
3
Some of the day
4 Rarely
Tota l _________
o are
Ten categories of toxic chemicals
known to be especially prevalent, persistent, and
detrimental
to human
and environmental
health:
ACTIVITIES OF
DAILY LIVING
o 1 Need some assistance
1. heavy metals: lead (Pb), o
mercury
arsenic (As), cadmium (Cd), aluminum (Al)
2 Slight(Hg),
dif culty
Bathing, dressing,
feeding
2. polycyclic
self, toilet
aromatic hydrocarbons
(PAHs)
dif culty
o 3 Minimal
3. plastics (phthalates)
Tota l _________
o 4 No problem
4. phenols,
particularly bisphenol A (BPA)
LAUNDR
Y
o 1 Unable
5. organochloride pesticides (OCs)
o 2 Occasionally
6. organophosphate pesticides
(OPs)
o 3 Regularly in small steps or with help
7. polychlorinated dibenzo-dioxin
& furanwithout
(dioxins)
help
Tota l _________
o 4 Regularly
8. polychlorinated biphenyls (PCBs)
COOKING
1 Unable
9. polybrominated diphenyl o
ethers
(PBDEs)
Take-out, breakfast, or simple lunch only
o 2(PFCs)
10. polyfluorinated compounds
o
o
3
4
Simple microwave or crockpot meal
Regular meals
o
2
0-1 per day
Tota l _________
Reducing Dietary Exposures
HOUS
KEEPING organic and low-fat
1. EChoose
no-fat animal products such as dairy, eggs, meats (PAHs,
o 1orUnable
2 Light dusting, straighten up
o PBDEs).
OCs, OPs, dioxins, PCBs,
3 Regular
housekeeping
small
steps or
with help
2. Choose cooking methodsothat
are low-char
and in
that
allow
animal
fats to drip away, such
4 Fully
capable PCBs, PBDEs)
Tota l _________
o OPs,
as steaming. (PAHs, OCs,
dioxins,
3.
Consult
local wildlife agencies
before
eating
freshwater
fish
(PCBs,
dioxins,
PBDEs).
GR
OCE
RY SHOPPING
o 1 Unable
4. Never eat farmed salmono(PCBs),
avoid
eating
larger
carnivorous fish (Hg, PBDEs,
2 Occasional
(once
or twice
per month)
PCBs) and use the Environmental
Working
(EWG) Good Seafood Guide.3
but withGroup
assistance
o 3 Frequent,
problem
Tota l _________
o 4 Nosteel
5. Use glass, ceramic, or stainless
containers for heating and storing hot food.
(phthalates).
SOCIAL
ACTIVITIES
o 1 Unable
6. Avoid plastic water bottles,
travel mugs and bladder-style hydration reservoirs and do
Church, temple,
o 2 Infrequently
not
wash plastic food or beverage
containers
under
high
heat (phthalates).
family and
friends
(once or
twice per
month)
o 3 Occasionally
7. Avoid using vinyl cling wrap
do only
buy canned
foods that are BPA-free.
(BPA).
Frequently
(weekly
or more often)
Tota
l _________
o 4and
8. Avoid high-fructose corn syrup and rice syrup (As) and processed foods containing BHT,
DRIVING
1
Unable
o artificial colorings and sweeteners.
BHA, benzoate, sulfites, and
Very limited
o 2 organic
9. Choose local, seasonal, and
produce whenever possible. Wash all fruits and
o 3 Cautious, local trips
vegetables using mild additive-free
soap and clean water (OCs, OPs).
Tota l _________
o 4 Distant trips or traf c
10. Choose organic versions of the EWG “Dirty Dozen” list of high-pesticide produce. (OCs,
ERRANDS
OR4LIGHT CHORES
OPs).
o 1 None
Post of ce,
drop of a child
o 3 2-3 per day
Reducing
Home & Office Exposures
4 No or few restrictions
l _________
o Water
1. Consult the EWG Drinking
Database5 and consider testing your waterTota
supply.
Use
a NSF-certified water filter if indicated (Pb, As, Cd, trihalomethane, atrazine,
benzene,
Grand Tota
l _________
etc.).
2. Clear standing water out of plumbing lines in your home or office by flushing the toilet or
Version 4
© 2015 The Institute for Functional Medicine
letting the tap run for several minutes before pouring out tap water for consumption (Pb,
other metals).
3. Filter shower water (chlorine, OCs), and don't buy new vinyl shower curtains
(phthalates).
4. Filter air in your bedroom and office using filters, ionizers or plants.6 (airborne toxins).
©2015 The Institute for Functional Medicine
Strategy 2
Optimise bowel health,
mobilisation and excretion
of toxins
©2015 The Institute for Functional Medicine
Optimising Bowel Health
• For allergic or vulnerable individuals:
• Oligoantigenic diets
• Nutrient dense functional foods
• Bowel rehabilitation programme (5R)
©2015 The Institute for Functional Medicine
Utilising the 5R Bowel
Programme for Detoxification
•
•
•
•
Remove pathogens
Replace enzymes & hydrochloric acid
Repair damaged intestinal mucosa
Re-inoculate with
– Prebiotics (arabinogalactan, inulin)
– Probiotics
• Rebalance
©2015 The Institute for Functional Medicine
Agents That Repair
Intestinal Mucosa
• Probiotics
• Plant fibres
• L-glutamine
– 5-15 grammes daily
• Arabinogalactan (Western Larch bark)
– 2-10 grammes daily
©2015 The Institute for Functional Medicine
Agents That Repair
Intestinal Mucosa
• Aloe vera mucopolysaccharides
– 100-500 mg daily
• Licorice root (deglycyrrhizinated)
– 500-2000 mg daily
• Bovine colostrum
– 5-15 grammes daily
©2015 The Institute for Functional Medicine
Enhancing Mobilization and
Excretion of Toxins
• Exercise and Saunas = sweat
• Polysaccharides from algae &
seaweeds
– Chlorella pyrenoidosa
– Fucus (bladderwrack)
– Laminaria (kelp)
• D-glucaric acid
• Cholegogues and cholerectics
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
Physiologic Effects of Sauna
• Increases peripheral circulation.
• Decreases circulation to muscles, kidney
and viscera.
• Increases metabolic rate.
• Increases O2 consumption.
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
“These results suggest that the
administration of nori prevented dioxin
from being efficiently absorbed and
reabsorbed from the gastrointestinal
tract, and might be useful for protecting
humans exposed to dioxin from ill
effects.”
Biosci Biotechnol Biochem, 2002, 66(11): 2306-2313
©2015 The Institute for Functional Medicine
Cracked-Cell Chlorella
• Studied extensively in Japan, where it is widely used
as nutritional supplement (1000 tons produced per
year).
• Increases excretion of:
–
–
–
–
Lead
Cadmium
Uranium
Mercury
• Accelerates elimination of chlorinated hydrocarbons:
– PCBs
– Chlordecone (Kepone)
©2015 The Institute for Functional Medicine
Beta-glucuronidase and
Elimination of Toxins
Toxins
Conjugation
(Glucuronosyl Transferase)
Carcinogens
Made Harmless
Tumour Promoters
Deconjugation
Excretion
from Body
Steroid Hormones
Sterols
Deconjugation by
(β-Glucuronidase)
D-Glucarate
©2015 The Institute for Functional Medicine
Beta Glucuronidase
• Salvage enzyme that recycles conjugated
compounds
• Found in tissues throughout the body,
concentration varies with each individual
• High levels associated with increased
cancer risk (esp. breast)
• Elevated levels found with
– dysbiosis (GI)
– exposure to xenobiotics (cigarette smoke,
PAHs, nitrosamines)
©2015 The Institute for Functional Medicine
D-glucaric acid
(Calcium or Potassium D-glucarate)
• Found in cruciferous vegetables, citrus,
apples, apricots, bean sprouts & cherries
• Inhibits beta-glucuronidase
• Regulates blood levels of bile acids &
steroid hormones
• Protects against cancer of breast,
prostate, lung, colon, bladder, & skin
(animal studies)
• Dosage: 500-1000 mg tid
©2015 The Institute for Functional Medicine
Oregon Grape
Root
©2015 The Institute for Functional Medicine
Cholagogues & Cholerectics:
Enhancing Secretion of Toxins by
Increasing Bile Flow
•
•
•
•
•
•
•
•
Berberine (Coptis chinensis)
Coffee
Turmeric (Curcumin)
Milk thistle
Globe Artichoke
Greater Celandine
Dandelion
Taurine
©2015 The Institute for Functional Medicine
Strategy 3
Optimise balanced Phase I and II
biotransformation of toxins
©2015 The Institute for Functional Medicine
Overload Phase I?
©2015 The Institute for Functional Medicine
Nutritional & Phytochemical Support
for Assisted Biotransformation
• Adequate protein source for enzyme
production
• Conjugant precursors for phase II
reactions
• Enzymatic cofactors for phase I & II
• Transcription inducers of phase II
enzymes
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
Phase 2 Response from Fruits/Vegetables
Apples
Oranges
Lemons
Grapefruit
Pears
Rhubarb
Mango
Avocado
Peach
Nectarine
Grapes
Dates
Figs
Apricot
Spinach
Beets
Lettuce
Chicory
Mizuna
Corn
Peas
Carrots
Potato
Tomato
Blueberries
Raspberries
Plum
Pumpkin
Squash
Green Beans
Watermelon
Canteloupe
Honeydew
Strawberries
Oregano
Basil
Cardamon
Cinnamon
Cloves
Pepper
Noni Juice
Collards
Turnips
Leeks
Garlic
Chives
Onion
Broccoli
Watercress
Cauliflower
Cabbage
Brussels
Sprouts
Arugula
Kale
Kohlrabi
Daikon
Red Radish
Horseradish
Chinese
Cabbage
Bok Choy
©2015 The Institute for Functional Medicine
Phase II Enzyme Inducers
• Glucosinolates
– Sulforaphane
– Phenylethylisothiocyanate (watercress)
– Di-indolylmethane (active form of I3C)
• Flavonoids
– Ellagic acid
– Green tea catechins
©2015 The Institute for Functional Medicine
Phase II Enzyme Inducers
• Organosulphur compounds
– Garlic
– NAC, glutathione
•
•
•
•
•
Curcuminoids (turmeric)
Milk Thistle (silymarin)
Artichoke (cynarin)
Rosemary (carnosol)
Monoterpenes (citrus peel, cherries)
©2015 The Institute for Functional Medicine
Sulforaphane
• Discovered in 1992 at Johns Hopkins
• Over 560 scientific papers now published
• Glucoraphanin precursor found in broccoli
(sprouts & seeds), Brussels sprouts & kale
• Potent transcription inducer of phase II
detoxification & antioxidant enzymes:
– GST transferases
– Epoxide hydrolases
– Quinone reductases
– Glucuronosyl transferases
©2015 The Institute for Functional Medicine
Glucosinolates
• Precursors to bioactive isothiocyanates (ITC)
– Often hydrolysed to ITC by enzyme myrosinase
– or converted by gut flora (Phenylethyl ITC )
– Include indole-3-carbinol, Diindolylmethane and sulphorphane
• Rich sources include broccoli & watercress,
but all crucifers contain glucosinolates
• Bifunctional modulators
– Inhibition of specific phase I enzymes
– Induction of phase II enyzmes
• Glucuronosyltransferases
• Glutathione-S-transferases
©2015 The Institute for Functional Medicine
Cooked or Raw?
isothiocyanate production is more
extensive after consumption of raw
vegetables but that isothiocyanates
still arise, albeit to a lesser degree,
when cooked vegetables are
consumed.
©2015 The Institute for Functional Medicine
Turmeric
(Curcuma Longa)
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
Cofactors That Support Phase II
Conjugation
•
•
•
•
•
•
Glycine
Taurine
Glutamine
Sodium sulfate
Pantothenic acid
Magnesium
Methylators:
– Methylfolate
– Methylcobalamin
– Trimethylglycine
– SAMe
– Phosphatidylcholine
©2015 The Institute for Functional Medicine
Nutrition and Cellular Protection
• Increasing evidence indicates that anti- inflammatory
nutrients, in particular dietary long-chain omega-3
polyunsaturated fatty acids and plant-derived flavonoids, can
be used as a therapeutic approach to deter toxicological
insults and pathologies associated with exposure to
environmental pollutants
• It appears that fish-derived omega-3 fatty acids are extremely
protective against pollutant-induced inflammation, and
membrane domains such as caveolae or other types of lipid
rafts may provide a regulatory platform for cellular protection
by omega-3 fatty acids
Hennig, et al, Nutrition Can Modulate The Toxicity of Environmental Pollutants EHP, 2012, Vol
120(6): 771-774
©2015 The Institute for Functional Medicine
Enhance Antioxidant Reserves
Imbalanced Detoxification is a Major Source
of Free Radicals
Phase II
Phase I
Conjugation
CYP P450
Reactive Intermediate
Non-Polar
Xenobiotic
Inert
Water-Soluble
Metabolite
Damage to DNA,
RNA, Proteins
©2015 The Institute for Functional Medicine
Nutrition and Cellular Protection
• Study data suggest that antioxidant nutrients, such as
vitamin E and dietary flavonoids, as well as a high ratio
of omega-3 to omega-6 fatty acids, can protect against
endothelial cell damage mediated by persistent organic
pollutants.
• Diets rich in antioxidants and anti-inflammatory nutrients
can improve health and decrease vulnerability to
additional chemical stressors.
Hennig, et al, Nutrition Can Modulate The Toxicity of Environmental Pollutants
EHP, 2012, Vol 120(6): 771-774
©2015 The Institute for Functional Medicine
Antioxidants for Detox:
Useful Sources
• Rosemary
• Curcumin (turmeric)
• Flavonoids
–
–
–
–
–
Anthocyanidins (berries, grapes, beets)
Ellagic acid (pomegranate, strawberries)
Quercitin (fruit and vegetable skin)
Green tea catechins (polyphenols)
Trans-resveratrol (Cabernet; Merlot)
©2015 The Institute for Functional Medicine
Antioxidants for Detox:
Useful Sources
•
•
•
•
Carotenoids (Lycopene)
Tocopherols (esp. gamma & alpha)
NAC/ Glutathione
Alpha lipoic acid
• Coenzyme Q10
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
©2015 The Institute for Functional Medicine
Glutathione
• The primary intracellular non-enzymatic
antioxidant: present in all living cells
• High concentrations in brain parenchyma
& liver
• Neutralises exogenous & endogenous
peroxides
• Phase II conjugating agent for heavy
metals, external toxicants, carcinogens,
pharmaceuticals
©2015 The Institute for Functional Medicine
Dietary Supplements to Optimize
Reduced Glutathione Levels
•
•
•
•
•
•
Vitamin C: 500-3000 mg
N-acetyl cysteine, 600-3000 mg/day
Lipoic acid, 200-1800 mg/day
Curcumin: 500-3000 mg/day
Milk thistle: 1000-2000 mg/ day
Whey protein concentrates, 2-3 servings/day (2040 grams)
©2015 The Institute for Functional Medicine
Detoxification Basics
Liver detoxification pathways and supportive nutrients
© 2007 The Institute for Functional Medicine
Selected Phytonutrients with roles in Detoxification
Phytonutrient
Sources
Detox Effects
Dosage
Curcumin
(diferulomethane)
Turmeric
• Upregulation of Phase II
• Cholagogue & Cholerectic
• Antioxidant & Antiinflammatory
500-3000 mg/day
and dietary sources
Glucosinolates:
• Induces Phase II detox
enzymes
• Induces Antioxidant enzymes
>100 mg/day
• Sulforaphane
• Phenylethylisothiocyanate
• Di-indolemethane
Cruciferous Vegetables
• Cabbage
• Broccoli
• Brussels sprouts
• Watercress
Ellagic Acid
Walnuts, pomegranate,
raspberries, strawberries
•
•
•
•
250 mg/day
Catechins
Green Tea
Cocoa
• Bi-functional Modulator of
Phase I and II enzymes
• Antioxidant
• Binds toxins
>500 mg/day
Organosulfates
• Γ-glutamylcysteines
• Cysteine sulfoxides
Alliums
• Garlic
• Onion
• Increases Glutathione
• Induce phase II
1000mg/day (as
Garlic)
Silymarin
Milk Thistle
• Hepatoprotectant
• Antioxidant
• Increases glutathione
400-1200mg/day
Hepatoprotectant
Binds some toxins
Inhibits CYP1A1 of carcinogens
Induces Phase II
©2015 The Institute for Functional Medicine
Learning Objectives
• Define what a toxicant is, outline our increasing
exposure to toxins, and evaluate the health
consequences of a chronic, low level toxic load
• Understand the process of biotransformation or
detoxification and how it may be modified
• Develop competency in assessing for chronic
toxicity
• Develop strategies to minimise toxic exposure,
increase mobilisation, biotransformation, and
excretion of toxins.
• Be able to implement a foundational detoxification
programme.
©2015 The Institute for Functional Medicine
First, start with food
©2015 The Institute for Functional Medicine
Dietary Protocols should be:
• Flexible and adaptable
• Relatively easy and straightforward to use
• Designed to allow for consistent evaluation
©2015 The Institute for Functional Medicine
Core Food Plan
Modifications
Elimination
Diet
Comprehensive Elimination Diet
Core Food
Plan
Low
Glycaemic
Impact
Cardiometabolic Food Plan
Detox
Foods
Detoxification
Food
Plan
©2015
The Institute
for Functional Medicine
©2015 The Institute for Functional Medicine
Comprehensive
Guide
©2015 The Institute for Functional Medicine
Complementing Dietary Protocols with
Oligoantigenic Food Products
• Generally easily digested
• Enhanced compliance from use of single
formula
• Versatility of administration (powder versus pills)
• Nutrient dense formulations can supply
antioxidants and other nutrients specific for
application
©2015 The Institute for Functional Medicine
Foundation Detox Protocol
• Hypoallergenic dietary programme:
– Detox diet programme
– Increased dietary fibre content (or supplement)
– Clean source of low allergy protein
• Nutritional support for Phase 1/Phase 2
• Antioxidant and Phase 2 induction support
• Sauna, hot/cold hydrotherapy
©2015 The Institute for Functional Medicine
Foundation 4-6 Week Programme:
Moderate Intensity
• Programme A:
• Begin detox diet
• After 1 week, work in one day in which diet consists of steamed
vegetables, rice and 3 servings of detox functional food
• Maintain programme for 4-6 weeks
• Programme B:
•
•
•
•
•
Begin detox diet
Begin to ramp up with clean supplemental detox functional food
Work up to 2-3 servings with detox diet
Maintain programme for 4-6 weeks
Gradually ramp down while maintaining detox diet
©2015 The Institute for Functional Medicine
Foundation 21 Day Programme:
Aggressive
• Day 1:
•
•
Begin detox diet
Begin ramp up of supplemental nutritional support
• Day 7-11:
– Gradually eliminate dietary protein sources, grains, fruits and
vegetables
– Begin to ramp up with clean detox functional food
• Day 11-13:
– ‘fasting’ for 3 days on detox functional food and nutritional support
only
• Day 14-21:
– Gradually ramp down on detox functional food while ramping back
up on full diet protocol
©2015 The Institute for Functional Medicine
Alternative Foundation 17 Day Programme
Aggressive
• Day 1-7:
• Begin detox diet
• Day 8-11:
– Gradually eliminate dietary protein sources, grains, fruits and
vegetables
– Begin to ramp up with detox functional food
• Day 12-14:
– Cruciferous vegetables and detox functional food for 3 days
• Day 15-17:
– Gradually ramp down on detox functional food while ramping
back up on full detox diet protocol
©2015 The Institute for Functional Medicine
What are the main variables to
clinical response?
• Genetic limitations on detoxification (Phenotypic
status)
• Genetic predisposition to toxicant-related illness
such as autoimmunity and cancer
• General health, current/past illnesses, medications
• Quantity, intensity, duration, and diversity of
exposure
• Diet and antioxidant status
• Age and Gender
• Gastrointestinal flora and bowel frequency
©2015 The Institute for Functional Medicine
Functional Medicine & Toxicology:
Fundamental Principles
1. Exposure to environmental toxins is widespread,
increasing and lifelong.
2. The total body burden of these toxins can act
synergistically to cause physiologic dysfunction.
3. This dysfunction can lead to chronic illnesses in
susceptible individuals.
4. Susceptibility is largely defined by an individual’s
ability to biotransform, detoxify and eliminate
exogenous and endogenous toxins.
5. Lifestyle, diet and nutraceuticals can enhance
detoxification, prevent disease and restore health.
©2015 The Institute for Functional Medicine
Precautionary Principle:
“We (as physicians) must act on facts…and on
the most accurate interpretation of them,
using the best scientific information. That
does not mean that we must sit back until we
have 100% evidence about everything.
When the state of the health of the people is
at stake…we should be prepared to take
action to diminish those risks even when the
scientific knowledge is not conclusive.”
Horton. Lancet. 1998;352(9124):251
©2015 The Institute for Functional Medicine
“In every case of every
malady there are two sets of
factors at work in the
formation of the morbid
picture, namely, internal or
constitutional factors
inherent in the sufferer and
usually inherited from his
forebears, and external ones
which fire the train.”
Archibald Garrod Inborn Factors in
Disease (1908)
©2015 The Institute for Functional Medicine