Download Optimal Gastrointestinal Health

The Functional Medicine
Approach to Patient Care
Scott Antoine, DO, FACEP
Vine Healthcare, LLC
Objectives
 To provide a definition of Functional Medicine
 To define the need for a paradigm shift in
healthcare and the role of Functional Medicine in
that shift
 To show that Functional Medicine is Osteopathic
Medicine
 To outline the Functional Medicine approach to
patient evaluation and treatment
Functional Medicine
Also known as:
Functional and Integrative Medicine, Holistic
Medicine, Systems Medicine
The 4 P’s of Functional
Medicine
 Personalized- genetic and environmental variations
drive individual treatments
 Predictive- tailored health strategies based upon a
personalized map of health risks with traditional
and novel biomarkers
 Preventive- proactive vs. reactive approaches which
shift from illness to wellness, from disease
treatment to functional enhancement
 Participatory- empowers and engages the patient
Ultimately….
Functional Medicine is about balance:
 Removes what is NOT supposed to be in the system
 Adds (or maintains) what IS supposed to be in the
system
Osteopathic Medicine
 DOs practice a "whole person" approach to
medicine. Instead of just treating you for specific
symptoms or illnesses, they regard your body as an
integrated whole
 Osteopathic physicians focus on preventive health
care
--From the website of the American Osteopathic
Association
Academic Interest in
Functional Medicine
Institute of Functional Medicine (IFM)
 Basic and advanced courses in Functional Medicine
 Attendees from 60 academic centers and residencies
including:
Albert Einstein (NY), Duke, Johns Hopkins, Harvard, UCLA,
Penn, UNC, Des Moines Osteopathic, Lake Erie College of
Osteopathic Medicine
Corporate and
Government Interest
 Medical insurers such as CIGNA are considering
pilot programs using Functional Medicine
 VA is exploring research in Functional Medicine
 Supported by 12 Senators, Medicare has expressed
interest in pilot programs for intensive lifestyle
change programs
Traditional Approach to
the Patient Encounter
 The patient presents with symptom(s)
 A history of the “chief complaint” is taken
 “Pertinent” past medical history is obtained
 A physical examination is performed
 A differential diagnosis is made and testing is performed
 A named ‘disease’ may or may not be found
 Medicine is given to treat the disease or lessen symptoms
Traditional Approach to
the Patient Encounter
 Relies on deductive reasoning and “reductionism”
 “Name it and blame it”
 “A drug for each bug”
 “A pill for each ill”
 Sherlock Holmes and the “Clue” analogy
 Works well for acute illness or injury
You Have a Flat Tire
 Call a “specialist”
 Look at the tire
 Decide if it is a nail, sidewall damage, etc
 Fix the problem and (hopefully) stop the
leak
 This is an acute care situation
Several Problems
 Tire is flat
 Brakes are bad
 Hole in the muffler
 Need a bunch of “specialists”
 If we fix these 3 problems, is the car in good shape?
 This is the chronic illness model
The Burden of Chronic
Illness
 Data compiled in the “World Health Organization
Non-Communicable Disease (NCD) Country
Profile” report (2011)
 Described mortality causes for 193 member states to
the WHO
 Data compiled for causes and risk factors
Causes of Mortality
(Kenya)
Causes of Mortality (USA)
Change in BMI (USA)
Change in Blood Glucose
(USA)
Risk Factors
The Burden of Chronic
Disease
 March 14, 2002 Study NEJM by R. Sinha et al (Vol
346 (11);802-810) showed that:
 55 obese children (4-10 years old) --25% had impaired
glucose tolerance
 112 obese teens (11-18 years old) -–21% had impaired
glucose tolerance. Four were diagnosed with type II
DM
 Recent estimates indicate that 1/3 of people born in
2000 will eventually be diabetic
How Sick is Sick?
Number of Chronic Conditions
Percentage of Medicare Spending
5+
68%
4
12%
3
10%
2
6%
1
3%
0
1%
The Problem
 We are treating chronic illness with the acute care model
 Patients are broken into organ systems (GI, Cardiac..)
 There is a failure to recognize web-like interactions of
multiple comorbidities, antecedents, and triggers, in
chronically-ill patients
 Consequences
 Polypharmacy leading to non-compliance and adverse
drug reactions
 Coordination of care among specialists may be difficult
 Duplication of tests and therapies
 The “fire” may be out, but the embers are still smoldering
How Could Your Car be
Restored?
 Comprehensive inspection (unique to your car)
 Examine each system from the inside, look for
problems (take it all apart), and look for connections
 Add what is missing and needed
 Get rid of what does not belong and causes
problems
 Keep up maintenance and “buy good gas”
 This is Functional Medicine
Basic Principles of
Functional Medicine
1. The “Continuum of Wellness”
 Pre-Diabetes
 Pre-Hypertension
 Pre-Dementia
 Are these all separate “diseases” or are
they just pit-stops along a continuum from
optimal wellness to illness?
Basic Principles of
Functional Medicine
In August 2009, after six years of planning, Johns Hopkins
University School of Medicine rolled out the Genes to Society
Curriculum. This novel curriculum rejects the notion that there is
"normal" or "abnormal" in medicine. Rather, everyone is on a
continuum.
The curriculum takes a systems approach to
understanding all levels of the human being - from genes,
molecules, cells, and organs of the patient on one end, to the
familial, community, societal, and environmental components at
the other end. The GTS curriculum integrates all of these
variables to help students understand why patients present the
way they do.
http://www.hopkinsmedicine.org/som/admissions/md/curriculum/g
ts.html
Basic Principles of
Functional Medicine
2. Wellness is a positive vitality and not
merely the absence of disease
3. The decline of ICD-9 (and 10) and the
emergence of models of systems medicine
4. Recognition of a web-like interconnectivity
of bodily systems
Basic Principles of
Functional Medicine
The NIH Roadmap. Science, vol 302, Oct 2003, Elias
Zerhouni
“New Pathways to Discovery. This theme addresses the need
to understand complex biological systems. Future progress
in medicine will require quantitative knowledge about the
many interconnected networks of molecules that comprise
cells and tissues, along with improved insights into how
these networks are regulated and interact with each other.”
Basic Principles of
Functional Medicine
5. Underlying Causes of Disease
A. The “Exposome”






Toxins (drugs, chemicals, radiation, EMF)
Nutrition (as a toxin)
Stress
Allergens
Infections
Trauma
**Damage is from direct mechanical effects, gene interaction,
or metabolic effects**
The Exposome
What is the exposome?
Success in mapping the human genome has fostered the
complementary concept of the "exposome". The exposome can
be defined as the measure of all the exposures of an individual
in a lifetime and how those exposures relate to health. An
individual’s exposure begins before birth and includes insults
from environmental and occupational sources. Understanding
how exposures from our environment, diet, lifestyle, etc.
interact with our own unique characteristics such as genetics,
physiology, and epigenetics impact our health is how the
exposome will be articulated.
Source: The Centers For Disease Control (CDC) website
Basic Principles of
Functional Medicine
5. Underlying Causes of Disease (continued)
B. The Genome (genetic variation)


Inherited (Familial) differences
SNPs (Single Nucleotide Polymorphisms)- must
occur in at least 1% of the population
http://ghr.nlm.nih.gov/handbook/genomicresearch/snp
http://www.cancer.gov/cancertopics/understandingcanc
er/geneticvariation
Single Nucleotide
Polymorphisms (SNPs)
SNPs and Cancer Risk
SNPs and Drug
Interactions
Facts About SNPs
 Occur about 1 time per 1000 base pairs
 Make up the bulk of the 3 million variations found
in the genome
 One third or more effect coenzyme-binding sites for
vitamins or nutrients and therefore have a role in
disease or dysfunction*
* B Ames. Cancer Prevention and Diet: help from single nucleotide
polymorphisms. Proc Natl Acad Sci USA 1999;96(22):12216-18
SNPs and Nutrients
 “Our analysis of metabolic disease that affects cofactor
binding, particularly as a result of polymorphic mutations,
may present a novel rationale for high-dose vitamin therapy,
perhaps hundreds of times the normal dietary reference intakes
(DRI) in some cases..”*
*B Ames. High dose vitamin therapy stimulates variant enzymes with
decreased coenzyme binding affinity (increased Km): relevance to genetic disease
and polymorphisms. Am J Clin Nutr. 2002;75:616-658
MTHFR – A Case in Point
 Methelenetetrahydrofolate reductase
 Responsible for donating a methyl group to B12
which then converts homocysteine to methionine
 SNP results in thermolabile enzyme which is 50%
less active than normal
 Increased homocysteine results
The Homocysteine Cycle
Folat
e
THF
Methionine
B12
5,10-CH2-THF
CH3-B12
MTHFR
Homocysteine
B12
5-CH3-THF
MTHFR – A Case in Point
Homocysteine and Ischemic Heart Disease : Results of a
Prospective Study With Implications Regarding Prevention Arch
Intern Med. 1998;158(8):862-867
 229 men without CAD who went on to die of CAD
 Matched to 1126 men of similar age
 Continuous dose-response relationship. Higher homocysteine
= more CAD
ML Silaste, et al, Polymorphisms of key enzymes in homocysteine
metabolism, affect diet responsiveness of plasma homocysteine in
healthy women. J Nutr 2001;131:2643-47



Group of patients with MTHFR and Methionine Reductase SNPs
Low folate vs. high folate diet (similar homocysteine at baseline)
High folate group had 18% reduction in homocysteine. Low folate
group reduced 11%
Basic Principles of
Functional Medicine
5. Underlying Causes of Disease (continued)
C. Epigenetics (the effect the exposome has on your
genome and genetic expression)
Epigenetics
Epigenetics
Epigenetics
Diabetes and Epigenetics
“100% of the increase in prevalence of type II diabetes and
obesity in the U.S. during the latter half of the 20th century
must be attributed to a changing environment interacting
with genes, since 0% of the human genome changed during
this time period..”
FW Booth, et al. Waging war on modern chronic diseases: primary prevention
through exercise biology. J Appl Physiol. 2000; 88:774-87.
Basic Principles of
Functional Medicine
5. Underlying Causes of Disease (continued)
D. Loss of Functional Reserve (will affect your
response to the exposome)
MC Creditor. Hazards of Hospitalization of the Elderly. Annals of
Internal Medicine. 1993; 118(3):219-223
Basic Principles of
Functional Medicine
Epigenetics + Loss of Functional Reserve =
Basic Principles of
Functional Medicine
5. Underlying Causes of Disease (continued)
E. Deficiency States






Hydration
Proteins
Carbohydrates
Fats
Vitamins
Cofactors and enzymes
Basic Principles of
Functional Medicine
The “Macro/Micro” Paradox
 Symptoms are experienced at the “macro” or
whole body level (nausea, diarrhea, allergies, etc.)
 Causes of symptoms (and abnormal function)
occur at the ‘micro’ level, often with individual
chemical reactions and processes
Basic Principles of
Functional Medicine
The “Macro/Micro” Paradox
 These ‘micro’ changes may create whole system
malfunction, even though they may not seem
related
 Drugs directed at symptom relief (stop the
diarrhea or heartburn) rarely fix the underlying
pathology
Basic Principles of
Functional Medicine
The first component of this challenge is to recognize that
inadequate intakes of specific nutrients may produce more
than one disease, may produce diseases by more than one
mechanism, and may require several years for the
consequent morbidity to be sufficiently evident to be
clinically recognizable as “disease.” Because the intakes
required to prevent many of the long-latency disorders are
higher than those required to prevent the respective index
diseases, recommendations based solely on preventing the
index diseases are no longer biologically defensible.
RP Heaney, Long-latency deficiency disease: insights from calcium and vitamin
D. Am J Clin Nutr 2003;78:912–9
Basic Principles of
Functional Medicine
B. Ames. The Metabolic Tune-Up: Metabolic Harmony and Disease
Prevention.
J. Nutr. 133: 1544S–1548S, 2003. (University of California, Berkeley
and Children’s Hospital and Research Center at Oakland)
Basic Principles of
Functional Medicine
TO RECAP:
5. Underlying Causes of Disease
A.
B.
C.
D.
E.
The Exposome
The Genome (Genetic Variation)
Epigenetics
Loss of Functional Reserve
Deficiency States
Basic Principles of
Functional Medicine
6. Nutrigenomics (the “epigenetics of food and nutrients”)
 Advanced by Linus Pauling
 Nutrients modulate physiologic processes at the
molecular level
 This modulation gives rise to the phenotype of health or
disease
“There has been a growing recognition that both macronutrients and
micronutrients can be potent dietary signals that influence metabolic
programming of cells and have and important role in the control of
homeostasis…”
M Muller, S Kersten. Nutrigenomics: goals and strategies. Nat Rev Genet. 2003;
4:315-322
Nutrigenomics at Work
Basic Principles of
Functional Medicine
The Seven Core Clinical Imbalances
1. Assimilation (Digestive, Absorptive,
Microbiological Balance)
2. Defense and Repair (Inflammation and
Immune Function)
3. Energy (Oxidation/Reduction and
Mitochondropathy)
4. Biotransformation and Elimination
(Detoxification)
Basic Principles of
Functional Medicine
The Seven Core Clinical Imbalances (cont’d)
5. Communication and Circulation (Hormonal
and Neurotransmitter Balance)
6. Structural Integrity (Cellular Membrane
Function to the Musculoskeletal System)
7. Mind/Body Imbalances
Notice there are 7 areas to address rather than the
12,000 diseases in ICD-9 or the 155,000 in ICD-10
Functional Medicine
Approach
 A timeline history is taken (including prenatal events)
 Medical history, diet, and lifestyle factors are
incorporated into a complete life history
 A physical examination is performed
 Laboratory testing is performed relative to the
complaints AND to assess the general state of the
patient’s individual bodily functioning and toxicity
 Genetic testing may be performed to look for specific
disease risk or modifications of dietary intake needed
 Food sensitivity testing is often performed
Functional Medicine
Approach
Finally, a 2 step process to individualized
treatment of the patient occurs:
1. REMOVE what does not belong in the body (bad
foods, allergens, toxins, pathogens, heavy metals)
2. RESTORE (add) what the body needs to thrive
(healthy foods, vitamins, minerals, botanicals,
sleep, restoration, healthy relationships, spiritual
health)
The GI Tract
Did You Know?
 The intestine is the PRIMARY immune organ in the
body---it contains almost 70% of the immune cells in
the body
 The intestine produces 70% of all neurotransmitters
 The small intestine contains as many neurons as the
spinal cord
 Balance in this system is vital for overall health and
disorder here produces many total body effects
The GI Tract
 A ‘microbiome’ of organisms (some good, some
bad)
 A “barrier” to keep toxins out and facilitate
digestion
 A nervous system independent of your brain which
controls its function
The GI Tract
It is affected by
 What comes into the intestine
 Toxins (GMOs, Pesticides, HFCS, additives and
preservatives)
 Inflammatory foods / allergens
 High glycemic load foods
 The health of the intestinal barrier
 What lives in the intestine
 Normal bacteria
 Yeast / pathologic bacteria / viruses / parasites
“Symptoms” of Disordered
GI Function
 Gastrointestinal
 Nausea, vomiting, diarrhea, constipation, weight loss.
 Abdominal pain, bloating, “IBS”, Crohn’s, Ulcerative
Colitis, colon cancer
 Immune
 Frequent infections, bacterial overgrowth, yeast
overgrowth, lupus, rheumatoid arthritis
 Hematologic (blood cells)
 Anemia
 Decreased white blood cell count
“Symptoms” of Disordered
GI Function
 Cardiovascular
 High cholesterol and triglycerides, high blood pressure,
coronary vessel blockages
 Dermatologic (skin)
 Rashes, hives, psoriasis
 Endocrine
 Diabetes, metabolic syndrome, decreased libido, abnormal
periods, PMS
 Neurologic / Psychiatric
 Migraines, depression, anxiety, insomnia, fatigue,
dementia, ADHD, schizophrenia, “brain fog”
The Normal Intestine
“Leaky Gut”
Leaky Gut Consequences
 Impaired absorption of vitamins, amino acids,
minerals
 Increased chance of abnormal bacteria and yeast
overgrowth
 Abnormal or insufficient GI production of vital
hormones and neurotransmitters
 Triggering of the Immune system
Triggering of The Immune System
by GI Barrier Disruption
Controlling GI Damage
 Stress
 Environmental toxins (Pesticides, drugs, ETOH)
 Heavy metals
 And--- a “Wonder Drug”
Question: The “Ideal” Drug
Name the drug which is inexpensive,
readily available, easy to use, and can
treat a wide variety of disorders with
virtually no side effects. It has been
shown to have the ability to “turn off”
cancer causing genes and “turn on”
cancer fighting genes…
Healthy Food!
Healthy Foods
 Organic and grass-fed (or free-range) lean meats
 Small/wild fish
 Fresh organic vegetables with high fiber
 Fresh organic fruits
 Non-GMO foods
 Minimally processed
Unhealthy Foods
 Meats and produce produced with pesticides,
hormones, antibiotics, and GMOs
 High Fructose Corn Syrup. (It may be corn-sugar,
but it will still kill you)
 Refined (especially white) sugar and grains
 Any processed food
 Beware if more than 5 ingredients!
Food Allergies
 The difference between food ‘sensitivities’ and
‘allergies’
 Testing methods
 Increased gut permeability may show an “allergic”
response to many foods due to sensitization by
particles exposed to the immune system
Most Common
Pro-inflammatory/Allergenic Foods
 Gluten
 Dairy
 Corn
 Soy
 Egg
 Peanuts/other nuts
 All are held as part of an elimination diet
Gluten
 The protein “gliaden” is found in wheat and other
grains
 30% of Northern Europeans carry the HLA DQ8
gene or DQ2 gene for celiac disease
 1% of the population (1 in 100) have celiac disease.
Many are undiagnosed
 Even in the absence of the genetic predisposition or
celiac antibodies, many people are gluten ‘sensitive’
Gluten Sensitivity-Why Now?
 Gluten has been in wheat for thousands of years
 Are we just better at diagnosing it?
 Is the incidence rising?
 If there is more gluten sensitivity, why now?
Gluten Sensitivity
In an article by Dr. Joseph Murray published in 2009 in
the Journal “Gastroenterology”on Celiac Disease:
(Gastroenterology Volume 137, Issue 1, July 2009)
 9133 “healthy” young adults between 1948 and 1954
had antibody tests done
 12768 “health young adults” compared in 2009
 The undiagnosed patients in the early study had a 4x
greater risk of death
 The amount of undiagnosed patients in the recent
2009 study was 4.5 times higher than the earlier study
(400%>)
Gluten Sensitivity Scope
 Likely 1.8 million people actually have
Celiac
 1.4 million of these patients do not know it
 Some estimate it may be 6% of the
population
Why The Change?
 Our gut has a much higher toxin load (pesticides,
processed foods, additives)
 Wheat has been genetically engineered to be more
hearty. This has saved many from starvation, but
some believe that it has made the gluten more
irritating or has raised the gluten content
What Does Gluten Do?
What Does Gluten Do?
 Up-regulates the inflammation response




Increased free radicals (make you age)
Thyroid dysfunction
Hormonal disorders and infertility
Forms neuroactive peptides “gluten exorphins” which
affect cognitive function and increase symptoms in
autistic children
 Activates the Immune System
Should Your Patient Be
Gluten Free?
 It is a personal decision. Should have family ‘buy-in’
 Definitely a smart first step if they have digestive issues
 Not everyone may respond poorly to gluten exposure.
Some may detoxify well. Impossible to tell who will
 Some studies have shown when patients were placed on
a gluten free diet versus standard diet in a blinded
fashion, the gluten free cohort had less digestive
complaints after 6 weeks
 Cutting down vs. stopping—The “tack” example
What About Dairy?
Our Track Record
Our Track Record
Our Track Record
Keeping Your GI Tract
Healthy/Repairing Damage
Specific Diets
 Standard American Diet (sad it is)
 Elimination Diet (“oligo-antigenic diet”)
 Mediterranean diet- Abundant Plants foods, fresh
fruit as dessert, olive oil as principle fat, cheese and
yogurt for dairy, low meat, moderate wine
consumption
 Paleolithic Diet
Standard Supplements
 Multivitamin
 Vitamin E
 Vitamin D
 Vitamin C
 Calcium
 Magnesium
 Co-Q10
 Curcumin
 Vitamin A
 Probiotics
 B12 and Folate
 Fish Oil (DHA and EPA)
Based Upon Clinical
Situation
 Pharmacologic agents
 Specialty referral
 Detoxification and Methylation support
 Counseling
 The Exercise Prescription
 Stress reduction and spiritual health
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