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Integrative Nutrition in an Holistic Family Practice Setting: Guiding Principles & Case Studies Ranan D. Cohen, MS, RD, LDN Clinical nutritionist in private practice Holistic Family Practice, Newbury MA March 11, 2011 Holism: four dimensions “ n. the view that an organic or integrated whole has a reality independent of and greater than the sum of its parts.” (Webster’s dictionary) This definition implies synergism, potentially applying to: • the body/mind/spirit • alternative therapies •nutrients •ecological systems Nutrition Therapy as a “Recipe” ….Change several nutritional variables in combination, treating them as “ingredients” in a “recipe” designed to improve several categories of nutritional and health status together. Example: Dairy elimination diet + improving legume intake + increasing sources of ALA + an improved multi (with a better balance of B vitamins) + pro-biotics. Nutritional challenges • • • • • • • • Suboptimal intake Malabsorption Depletional factors Food sensitivities Toxic/environmental exposure Iatrogenic Genetic Emotional-spiritual /Stress PLAN Nutritional adequacy? Absorptive efficiency? Digestive efficiency? Microbiological balance? Detoxification improvement? FUNCTIONAL QUESTIONS Suboptimal intake assessment • • • • • • Water/hydration Vitamin/mineral sources EFA/EPA/DHA sources Phytochemical sources Ancillary nutrient sources Fiber intake level Fruit smoothie Spelt toast + butter Salad Bar (field greens, carrots, other vegetables, cottage cheese, kidney beans, EVOO + balsamic + rosemary + garlic) Chana masala over brown rice with mango lassi Yogurt + fruit + wholegrain graham crackers Whole-grain pancakes (include wheat germ + flaxmeal) + berries Turkey sandwich (on whole grain with grassfed turkey) + carrot sticks Yogurt + cashews + banana + kiwi Salmon + roasted red potatoes + broccoli salad+ Red Wine Malabsorption factors • • • • • Insufficient enzyme and/or HCl secretion Insufficient emulsification (lecithin) Insufficient nutrient provision (B vitamins) Food allergy/intolerance/sensitivity Impaired mucosal integrity (probiotics; SCFA; glutamine) • Iatrogenic Depletional factors • • • • • • • Pregnancy/lactation Alcoholism Smoking Surgical-metabolic/disease/other stress Medications Pollution Intensive exercise Symptom history (1) • Angular stomatitis • • • • • • • Photophobia A, B2, B6, Fe, ?EFA A, B2, B6 Eyes irritated/invaded B2 Bruise easily/gums bleed C, E, K, ?Fe Nose bleeds (frequent) K, C Poor wound healing A, C, Zn, Cu Exertional fatigue/stamina Fe, B2 Coordination/ ataxia B12, fol, B1, B6 Symptom history (2) • • • • • • • • Cold extremities/poor circulation Fe, B3, E, C Pallor Fe, Cu Poor night vision Zn, A Decreased taste/smell sensation Zn, A Muscle cramping “Burning feet” Brittle nails Dry skin/hair Mg, Ca, K+, E Panto Ca/Mg, Folate, ?Si EFA, Zn, A PAST MEDICAL HISTORY HxETOH’ism B1, Fol, B Complex, Zn, Mg Hx Smoking E/Se, Beta-Carot, C, Fol Diabetes/Hypoglycemia Cr/B3, Zn, Cu, Mn Hypertension Ca, Mg, K+/Na+ Carpal Tunnel Syndrome B6/Mg, B2 Hx Anemia (Did Fe help?) Fe, Fol/B12, Cu, E, B6 Chronic Fatigue Fe, Mg, Fol/B12, Pro, EFA Cervical Dysplasia Fol, Beta-Carot, C PAST MEDICAL HISTORY(2) Hyperemesis Gravidarum B6, B2 Fibrocystic Dx E/Se, I- Pre-menstrual Syndrome Ca, Mg, GLA “Restless Legs” Syndrome E/Se, Fol, Fe, Ca, Mg Psoriasis A, D, B6, B2, EFA Acne Vulgaris A, Zn, Se/E Hx Kidney Stones Mg, B6 Osteoporosis Ca/Mg, D, Cu, Mn, F-, B- Available (& worthwhile) labs • • • • • • • Ferritin/serum iron/TIBC Ionized calcium (& bone density) 24-hour urinary magnesium Serum B12 Serum & RBC-folate Serum pyridoxine/RBC-pyridoxine/pyridoxal PO4 Serum ascorbic acid Available (& worthwhile) labs (2) • • • • Plasma retinol 25-hydroxy vitamin D Prothrombin time/INR RBC-EFA levels Deborah - quick case history • • • • • • • 36y.o --- s/p 3 pregnancies --- fatigue, anxiety, depression Pneumonia x 2; Anemia, including in preg.; Toxemia x 2 Palpitations, dry skin, nails peeling, inability to focus No supplements; on Welbutrin TFT’s WNL; B12 - 315; ferritin, folate, MCV, H&H all WNL. Diet low in fruits, veg., legumes, EFA X2 and H2O. Therapeutic suggestions?? Deborah - quick case history • • • • • • • Suggestions: Balanced, diversified menu Multi with B complex, trace minerals, etc. (DMF) B12 -- 1mg X 2; L-tyrosine -- 500mg (after med. d/c’d) “I felt the effect of the tyrosine” Suggestions all well-implemented Energy, skin, MH (except focus), palpitations all improved Plan discontin./resumption worsening/improvement Food sensitivity: potential diagnostic connections • • • • • • • Migraine Eczema; Acne Sinus; Asthma; Bronchitis Arthritis IBS; IBD ADD/ADHD Auto-immune disease Allergy/sensitivity symptoms • • • • • • • Throat irritation/closure Nausea/vomiting Hives/rash Headache Constipation/diarrhea/stomach ache/indigestion UR congestion/stuffiness Joint pain Symptoms of Food Allergy Gastrointestinal Manifestations Abdominal pain Nausea Vomiting Diarrhea Gastrointestinal bleeding Protein-losing enteropathy Oral and pharyngeal pruritus Respiratory Manifestations Rhinitis Asthma Cough Laryngeal edema Milk-induced syndrome with respiratory disease (Heiner’s syndrome) Cutaneous Manifestations Urticaria (hives) Angiodema Eczema Erythema (skin inflammation) Itching Systemic Manifestations Anaphylaxis Hypotension Controversial or Unproven Manifestations Behavioral conditions Tension-fatigue syndrome Attention-deficit and hyperactivity disorder (ADHD) Otitis media Psychiatric disorders Neurologic disorders Musculoskeletal disorders Migraine headache Common allergenic foods • • • • • • • Cow’s milk dairy Peanuts/Soy Tree nuts Crustaceans/Mollusks Fish Eggs Wheat Taking a sensitivity history • • • • • • • Check pediatric sensitivity history Appropriate signs/Sx: GI, headache, skin,etc. Take history by symptom category “Any other food/meal that…” Review prominent allergenic foods list Foods consumed > 1X/week Chronological comparisons Shawn - quick case history • • Dry eyes, dry skin, with eruptions around flexure points • Rash around anal area, exacerbated by antibiotic Rx • • 7 y.o --- 40 lb.; 40 “ --- eczema; food sensitivities; thirst Allergy testing (RAST) + for all tree nuts, peanuts, wheat, dairy, soy, shellfish, apple, egg white & beef. All eliminated without effect! FBS -- WNL. Reports reactions to: popsicles, skittles, gummy bears & gum balls, but still in diet! • Diet low in vegetables, legumes; very low EFA X2 and H2O. • Therapeutic suggestions?? Shawn - quick case history • • • • • Dietary plan: 1) Hypo-allergenic, balanced, diversified menu with immediate reintroduction trial for wheat & beef; 2) inclusion of safflower oil and flax oil daily. Artificial additive sources excluded. Ensure adequate Ca/Mg. Pedi multi; GLA (100 mg.); Zn -7mg; Pro-biotic (5 bi. org’s) Results: Skin “about 90% resolved”, with minimal scratching of dry areas. Suggestions all well-implemented, except no pro-biotic and EFA introduced via flax only. Mother noticed regression of skin problems without this food. Therapeutic goals • • • • • • • Optimal digestive/absorptive capacity Optimal biotic balance Optimal, diversified intake without food sensitivities Optimal genetic potential Optimal detoxification Optimal exercise Optimal spiritual-emotional wellness Dysbiosis profile (1) • • • • • • • Poor fruit, vegetable and lean protein intakes Craves concentrated sugars, but ill-tolerates them Increasing pattern of food sensitivities over time IBS Hypoglycemic symptoms Chronic fatigue “Aching all over” Dysbiosis profile (2) • • • • • Poor quality of sleep PMS symptoms Antibiotics associated with yeast infection Antibiotics associated with GI symptoms Probiotic therapy/yogurt relieves GI and/or yeast challenges Dysbiosis therapy • • • • • • • • No concentrated sugars; no alcohol Garlic L. acidophilus (DDS1; NCFM; GG) Bifidobacteria (infantis; longum; bifidum) Goldenseal; Oregon grape root; Barberry root Pau D’Arco Oregano; Grapefruit seed extract; Caprylic acid Prebiotic factors Semi-volatile Organic Compounds in Adipose Tissue: Estimated Averages for the US Population and Selected Subpopulations (Am. J. Public Health 1996; 86: 1253-1259) • Objectives. The fiscal year (FY) 1986 Environmental Protection Agency National Human Adipose Tissue Survey (NHATS) was conducted to estimate average concentrations of 111 semi-volatiles in human adipose tissue within US general population and selected subpopulations. • Results. Among polychlorinated biphenyls (PCBs), average concentrations for the group aged 45 and older were 188% to 706% higher than for the 0- through 14-year-old age group. Similar increases with age were observed for pesticides. Lipotropic profile • • • • • • • Poor fruit and vegetable intakes Indeterminate food sensitivity pattern; MCS IBS Mono /hepatitis/alcoholism hx Chronic fatigue Detox. profile abnormalities Liver function tests elevated Jen - Case history (1) • 33y.o. --- Rhematoid arthritis; fatigue (intermittent) • Envir. allergies; Raynaud’s; migraines; PMS (mastalgia, mood). • • • • “Burning” sens. on top/front of feet; “restless legs”; gas/bloat. • • Relafen; Tavist-D; oc’s; 1-a-day; Cr-picol. (150mcg); Tums (2) • Multiple Sx w/ stress: memory, constip., sleep/energy ; “body ache” Family hx: mother allergic to wheat; migraine; rheum. arthritis ANA; H&H; CDSA -- + for dysbiosis, but fine for digestion. Diet needs whole grains, legumes, fruit, CS, white flour, ALA. IDEAS/SUGGESTIONS SO FAR?? Jen - Case history (2) IDEAS THUS FAR: • • • Food group improvements (fruit, whole grain, ALA, etc.) Food sensitivity (fam. hx; migraine, fatigue, GI ) B complex (multi), pantothenic acid, vitamin C, Mg (Tums) MORE FINDINGS (initial visits): • • • • Sensitivity to CS, coffee, corn, citrus shrimp, crab, soy & ?bread Elim./ challenge diet + for corn, tomatoes (joints); wheat remains. Joints reported to “feel better after a fish meal” AM joint pain decreases from 2 hours down to 20’. Jen - Case history (3) INITIAL STEPS TAKEN: • • • Elimination/challenge trials: corn, tomato, dairy, pork, beef & coffee. Nutrient-dense diet with EFA X 2 & EPA/DHA. EPA/DHA, GLA, multi w/ B complex (TF2), Ca/Mg, Flush-free B3. MORE FINDINGS: • Diet in EPA/DHA discomfort • • Change from TF2 to TheragranM decrease in energy Ran out of B3 joints felt worse; same for GLA. • Trial GF diet more improvements (joints; GI) Jen - Case history (4) RECENT UPDATE: • Pantothenic acid tried vs. “burning feet”: trial was +; d/c return of Sx, and dose related to degree of symptoms. Also has influence on how joints feel. • • “Emergen C” reported poorly tolerated (hives) • • Oatmeal “rips through me” (GI), but GF oats well-tolerated. Pro-biotic therapy used when on antibiotics, with success. Combination of med (Humera currently), nutrient-dense (elimination) diet & supplements has proven very effective. Traditional vs. optimal Rx • • • • • • Caloric balance + adjust CHO /Pro ratio Adequate protein + semi-vegetarian model 4 food groups Low-fat/SFA DRI/RDA/DV Food allergy mgt. + optimal whole grains, nuts,legumes, fish, etc. optimal EFA’s + EPA + GLA optimal vitamin/mineral intakes per individual’s history + food sensitivity mgt. IBS profile #1 • • • • • • Craving tomato /pasta dishes, corn chips, and feels they may not be well-tolerated Excellent dietary balance Adequate baseline supplementation IBS (approximately five days a week) Intermittent eczema Migraines (approximately three times a month) IBS profile #2 • • • • • • • Craves concentrated sugars, but ill-tolerates them Poor fruit, vegetable and lean protein intakes Increasing pattern of food sensitivities over time IBS Hypoglycemic symptoms Chronic fatigue “Aching all over” IBS profile #3 • • • • • • • Excellent dietary history/food group balance Adequate baseline supplementation Weight stable IBS Poor energy and sleep Recently divorced Peri-menopausal IBS profile #4 • • • • • • • Poor fruit and vegetable intakes Indeterminate food sensitivity pattern IBS Mono /hepatitis/alcoholism hx Chronic fatigue Detox profile abnormatlities Liver function tests elevated Anti-inflammatory Nutrition • • • • • • • Essential fatty acids (LA & ALA) Herbs & spices (licorice, ginger, turmeric, rosemary) Fish & fish oils (EPA/DHA) Gamma linolenic acid (GLA) Saturated fat Weight management ? Mind-body Toxic metal profile • • • • • • • • ?Metallic taste ?Headache ?Hypertension ?Bone/muscular/joint pain ?Fatigue/malaise Pediatric history Occupational history Hair, urine, blood analysis Toxic/environmental exposure • • • • • • • • Lead, cadmium, mercury Chemical/occupational exposure Air/other pollution Environmental allergens Pesticides, etc. (Ca, Zn, Se; ?chelation) (detoxification) (E/Se, C, antioxidants) (Nettle extract) (Organic foods) Food additives/food poisoning Food allergens Iron (Elimination/rotation) (Ca, whole wheat & rye)