a paradigm shift in diagnosing and treating asd patients: autism is a treatable medical and...

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A Paradigm Shift in Diagnosing and Treating ASD patients: Autism is a treatable medical and metabolic disease with behavioral components Prepared Statement: Congressional Autism Hearing

Original: November 29, 2012, Last Updated: Jan 31, 2013

Cassandra L. Smith, PhD¹ ² Professor, Biomedical Engineer, Biology and Experimental Therapeutics and Pharmacology, Boston University¹ Director of Research, Athena Biomedical Institute²

Kazuko Grace² Consumer Advocate, Athena Biomedical Institute²

A Paradigm Shift in Diagnosing and Treating ASD patients:

Autism is a Treatable Medical and Metabolic Disease with Behavioral Components

A Paradigm Shift in Diagnosing and Treating ASD patients: Autism is a Treatable Medical and Metabolic Disease with Behavioral Components Prepared Statement: Congressional Autism Hearing November 29, 2012 Last updated in January 31, 2013

Dr. Cassandra L. Smith Professor, Biomedical Engineer, Biology and Experimental Therapeutics and Pharmacology, Boston University Director of Research, Athena Biomedical Institute

Kazuko Grace Athena Biomedical Institute www.athenabiomedicalinstitute.org

Abstract: Research on autism and autism spectrum disorders

(hereafter referred to as ASD), and other serious neurobehavioral

disorders, has minimally influenced patient outcome or disease

prevention. Although research links many genetic and

environmental factors to these diseases, no single or small number

of factors is responsible for disease in the majority of patients. An

increasing number of seemingly disparate factors (genetic,

environmental, and epigenetic) linked to ASD are converging on

specific medical anomalies. Additionally, research tells us that

each patient is unique. The medical abnormalities found in ASD

are serious and debilitating and, in some cases, have been known

for a long time. However, diagnosis and treatment of ASD remains

focused on behavioral abnormalities. The translation of research to

the clinic means that a new diagnostic and treatment paradigm

must be developed that acknowledges the unique spectrum of

medical and behavioral symptoms present in each patient.

Diagnosis and treatment of medical abnormalities will improve

patient quality of life and behavior. Today, this new paradigm is

only benefiting a small number of individuals that can either

personally pay for treatment, or are patients in free non-insurance

reimbursed clinics.

ABI©2012, 2013

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Prepared Statement of Dr. Cassandra L. Smith

Professor, Biomedical Engineer, Biology and

Experimental Therapeutics and Pharmacology, Boston University

Director of Research, Athena Biomedical Institute

and

Kazuko Grace, Consumer Advocate

Athena Biomedical Institute

Contact Information:

Email: [email protected]

Tel: 617 571 3068


Autism is a treatable medical and metabolic disease with

behavioral components.

Abstract: Research on autism and autism spectrum disorders (hereafter referred to

as ASD), and other serious neurobehavioral disorders, has minimally influenced

patient outcome or disease prevention. Although research links many genetic and

environmental factors to these diseases, no single or small number of factors is

responsible for disease in the majority of patients. An increasing number of

seemingly disparate factors (genetic, environmental, and epigenetic) linked to ASD

are converging on specific medical anomalies. Additionally, research tells us that

each patient is unique. The medical abnormalities found in ASD are serious and

debilitating and, in some cases, have been known for a long time. However,

diagnosis and treatment of ASD remains focused on behavioral abnormalities. The

translation of research to the clinic means that a new diagnostic and treatment

paradigm must be developed that acknowledges the unique spectrum of medical and

behavioral symptoms present in each patient. Diagnosis and treatment of medical

abnormalities will improve patient quality of life and behavior. Today, this new

paradigm is only benefiting a small number of individuals that can either personally

pay for treatment, or are patients in free non-insurance reimbursed clinics.

Introduction: Research has linked many genetic, epigenetic and environmental factors to

ASD and other serious neurobehavioral diseases like schizophrenia. Many factors should

be linked to these diseases because the brain is the most complex and evolved organ, and

will be sensitive to the greatest number of factors. Although research findings do not

provide the simple sought after answer, useful new information on how to diagnose and

treat serious symptoms in ASD should not be ignored.

Increasingly, seemingly disparate genetic, environmental, epigenetic and

medical factors linked to ASD are converging on deficits in specific metabolic processes.

The medical and metabolic abnormalities of ASD patients need to be diagnosed because

available treatments can improve the quality of life and behavior of these patients, and in

some cases prevent disease. Diagnostic regimes must be broad because research tells us

that each patient is unique. "Biomedical" diagnosis and treatment is increasingly, albeit

slowly, becoming recognized as important to these patients. Here, we will provide an

overview of genetic, environmental and epigenetic factors linked to the medical and

metabolic abnormalities present in ASD patients. A synopsis of the content of this paper is

presented in Table 1.

The issues raised are important discussion points for not only ASD but also

other serious neurobehavioral disorders like schizophrenia. Clearly, these suggestions

entail a major change in the manner in which neurobehavioral diseases are viewed within

the medical field, and by the public.

Appendix 1 has a glossary of scientific terms, abbreviations, and acronyms used

in this document. The Addendum has a list of suggested testing for comprehensive

assessment of each ASD patient. The Addendum is meant as a starting point for

discussion.

Diagnosis and treatment is based on behavioral criteria: ASD is diagnosed by the

presence of behavioral abnormalities that include impaired verbal and nonverbal

communication and social interactions, and stereotypic behavior and interest. In most

cases testing for genetic (e.g. genotyping, gene expression and epigenetic assessment) or

medical (e. g. metabolite, screening for toxic chemical, infections, inflammation, digestions

issues, and nutritional status) problems is not done, although these issues commonly

occur in ASD. Likewise, treatment regimes focus on insurance covered behavioral

interventions.

Genetic Liability Highly Variable: There are over 100 genetic loci linked to ASD. These

genes code for proteins involved in a variety of processes including: brain development

and function; metabolic pathways important in DNA and RNA replication; energy

production; cellular responses to inflammation and infection, xenobiotic exposures,

oxidative stress; and epigenomic programming.

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Table 1. Synopsis: ASD is a group of complex medical and metabolic diseases with behavioral abnormalities. 1. Diagnosis and treatment of ASD patients are focused on behavioral abnormalities and not the cause of disease, or presenting medical and metabolic problems. 2. Many varied (genes, environmental, medical and metabolic) factors are linked to ASD. 2.1 The brain is the most highly evolved organ should have the greatest number of factors linked to its development and function. 2.2 Early life is uniquely and especially sensitive to disruption. 2.3 Heritability measurements in ASD are mis-interpreted as saying disease is mainly due to genetic causes. 3. Over 100 genes are linked to AS 3.1 Genes linked to ASD are involved in neurodevelopment and brain function, metabolic pathways, and known medical conditions. 3.2 Some genes linked to ASD are also linked to rare genetic diseases caused by known single gene mutations. 3.21 Some rare genetic diseases are preventable through early diagnosis and intervention. 3.3 ASD displays genetic anticipation with successive generations have more severe and early onsets of disease. 4. ASD is linked to elevated rates of mutation making each patient unique. 4.1 Genetic and environmental factors linked to ASD can increase mutation rates and contribute to genetic anticipation and the spectrum of symptoms. 5. Xenobiotic exposures that increase the presence of reactive oxygen species (ROS) are linked to ASD but are difficult to assess. 5.1 Both major and minor xenobiotic exposures can be important. 5.2 A subset of individuals may be sensitive to xenobiotics like the heavy metals mercury. 5.3 Sensitivity to exposure can have a genetic origin, or be confounded by other, even non- assessed environmental factors. 5.4 Sensitivity can be due to deficits in the detoxification process, or the production and cellular response to the accompanying oxidative stress. 6. Infection and inflammation, commonly seen in ASD, impede biological processes and hinder the bodies response to stress. 6.1 Infection and inflammation impede DNA and RNA synthesis. 6.2 Gastrointenstinal disorders can lead to malabsorption and malnutrition. 6.2 Malnutrition before 2 years of age leads to behavioral abnormalities that resists nutritional interventions. 7. Nutrition is under-appreciated in pharmaceutical industry and in medicine. 7.1 Typically, medical professionals are not well-versed in nutrition, and insurance does not pay for such consultations unless symptoms are overt and classical. 7.2 Early nutritional interventions can prevent some ASD. 7.3 Essential nutrients must be obtained from the diet or the billions of bacterial that inhabit our bodies.

8. Folate, methionine, transulfuration and dopamine metabolic pathways are closely linked to each other and to ASD in multiple ways.

8.1 These pathways are involved in DNA and RNA synthesis, epigenomic programming, energy production, the cellular response to oxidative stress, and dopamine metabolism. 8.2 Multiple essential nutrients are required by these pathways. 8.3 Usually, most ROS are produced in the mitochondria during ATP (energy) production 8.31 Mitochondrial defects are found in a subset of ASD patients.

8.32 ATP is required for all bodily responses, e.g. infection, inflammation, response to ROS etc. 8.4 Complex and system biology approaches are needed to understand the dynamics of metabolic pathways in ASD. 9. Epigenomic regulation of development and function is disrupted in ASD. 9.1 Epigenomics represents the interaction between the genome and the environment. 9.2 The greatest amount of epigenomic programming occurs early in live.

9.3 Many and varied epigenomic changes are linked to ASD that include DNA methylation, histone modification. 10. Treatment of medical and metabolic abnormalities will improve the quality of life and behavior of patients.

About 20% of ASD patients, have "secondary autism", because a rare genetic

disorders with a single gene cause is present. Fragile X syndrome is the most common

genetic disorder linked to (1-2%) ASD patients, and is the most common cause of

hereditary mental retardation. Other single gene disorders linked to ADS are

developmental diseases that impact brain function and development.

The new ASD diagnostic criteria proposed in the Diagnostic and Statistical

Manual for Mental Illnesses (DSM-)-V, published by the American Psychiatric Association,

increases the number of disorders placed under the ASD umbrella without regard to

disease cause or treatment. For instance, Rett syndrome, a rare single gene disease linked

to a global deficite in epigenetic programming is now classified as part of the ASD

spectrum. Another group of genetic diseases linked to ASD involve “inborn-errors-of -

metabolism” (Karnebeek and Stockler, 2011). In some of these diseases, early dietary

interventions can prevent or reduce illness. An example of a severe brain disease

prevented by early detection and treatment is phenylketonuria. In the United States, all

newborns are tested for this disease because early and a simple dietary intervention

(elimination of phenylalanine) can prevents brain damage and disease.

Diagnosis of ASD based on behavioral abnormalities discourages genetic testing

for rare, treatable genetic diseases. Such a focus ignores research progress that defines

subsets of patients where prevention is possible, and adds un-necessary complexity to

basic and applied research and treatment.

Families segregating ASD with multiple family members affected by disease are

identified (Piven et al., 1997). In some families, ASD does not appear to be multi-

generational. Instead, less severe behavior abnormalities are seen in earlier generations

reminiscent of "genetic anticipation". Genetic anticipation refers to diseases that become

more severe, or have an earlier age of onset in successive generations. Genetic

anticipation in ASD may not be surprising given the recent rapid increase in disease

occurrence.

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A contributor to genetic anticipation in ASD can be the elevated rate of mutations found

in patients. Mutations that occur in egg and sperm will be passed to the next generation,

and can contribute to increasing disease liability, severity, the myriad of symptoms, and

genetic anticipation. Elevated mutation rates are found in other neurobehavioral diseases

(e. g. Nguyen et al., 2003 and many more recent genetic studies)

Mutations in sperm accumulate with paternal age, and elder fathers have an

increased number of children with ASD (For review see Smith et al., 2010, 2012). Further,

many environmental factors (discussed below) linked to ASD have the potential to

increase mutation rates and affect genetic anticipation. Thus, several lines of evidence

link ASD to increased mutation rate. Importantly, each patient has a unique set of

mutations and each patient must be tested for a broad range of mutational liabilities.

Similar results are found for other serious neuropsychiatric diseases like schizophrenia.

In the past, some research funding agencies focused almost exclusively on

genetic studies because ASD is said to have ~80% heritability. This was unfortunate

because of the widespread misunderstanding of heritability measurements especially in

neurobehavioral disorders. An ~80% heritability refers to the amount of disease

phenotypic variation that is due to genetic variation and NOT the percent of disease due to

genetic mutations. In addition, heritability does NOT measure the affect of environment on

disease variability. For instance, ~80% of a disease phenotypic variability may be linked

to both genetic and environmental factors. Today, more research funds are being spent

on environmental factors linked to ASD, although the general perception remains that ASD

is a genetic disease.

Environment Exposure History and Response Highly Variable: The industrial age

included the introduction of more than 100,000 commercially important chemicals into

the environment. Research on these chemicals is ongoing in a variety of arenas because of

their potential to influence many biological and organ systems, and diseases. One

outcome of environmental research has been the reduction or elimination of some

dangerous compounds from the environment.

However, the ability to define the effect of an environmental factor on humans

remains difficult because of the great genetic variability and environmental-history

differences between individuals. Further, the affect of multiple, varied low dose

exposures to different compounds may be important but is even more difficult to study.

Other complexities include exposure length, dose, time of life, and the presence of

confounding but un-assessed exposures and factors. For example, research has

demonstrated that ambient temperature, a simple environmental factor, can affect

outcome of an exposure.

Although controversial, xenobiotic, heavy metal like mercury are linked to ASD.

Some theorized that mercury in vaccines was responsible for the increase in ASD.

Although, the Federal Vaccine Court ruled in 2010 that there was insufficient evidence to

link vaccination to ASD, the controversy has not been put to rest. In 2011, Holland et al.

reported an increased incidence of ASD in vaccinated children. The picture became more

complicated because trans-generation mercury exposure was linked to ASD (Shandley and

Austin, 2011). In this study, grandchildren of pink disease (infantile acrodynia) patients

had an astounding 1 in 22 probability of becoming ill with ASD. Pink disease occurs in a

subset of individuals with elevated mercury levels.

Many studies support the idea that a subset of individuals is sensitive to

xenobiotics. Sensitivity may be due to defects in xenobiotic metabolism responsible for

detoxification of these compounds. Other sensitivity is due to the production or removal

of reactive oxygen species (ROS) and oxidative stress that is generated during the

detoxification process.

Genetic testing has identified deficits in these metabolic processes in some ASD

patients. Although direct and indirect affects may be difficult to sort out in individual

patients, detection of faulty pathways, and interventions that improve these pathways are

possible. For instance, the use of dietary anti-oxidants can improve the response to

oxidative stress and treatment regimes that remove detectable xenobiotics and reduced

ASD symptoms have been reported.

Nutrition and exercise is an under considered but un-refuted environmental

factor important for good health. Generally, the medical profession is not well versed in

nutrition and many clinicians fail to appreciate or treat nutrients as pharmaceuticals.

Similarly, medical insurance reimbursement for nutritional assessments and treatments

are limited to those patients with classical and severe symptoms of malnutrition.

Nutritional interventions in ASD have not been evaluated yet in many conventional

evidence based studies such as those used for pharmaceutical drug testing. Meanwhile,

parents of ASD patients continue to use nutritional interventions and, in some cases,

report good outcomes. The generally lack of interest in nutra-pharmaceuticals research in

both the pharmaceutical industry and the medical community is not surprising. Likewise,

exercise is an under utilized but beneficial ASD treatment (Sowa and Meulenbroek, 2012)

as it is for many common illnesses.

Under-nutrition and malnutrition before two years of age will lead to behavioral

abnormalities that resist nutritional interventions later in life (Galler et al., 1996).

Gastrointestinal problems and malnutrition are often present in ASD patients.

Gastrointestinal problems, including infection and inflammation, can lead to

malabsorption and malnutrition. Recently, the American Pediatric Association advocated

for the inclusion of gastrointestinal disorder assessment and treatment in ASD (Buie et al.,

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2012). Although a start, it is not clear that this testing will occur early enough to prevent

disease occurrence or to reduce severity (see phenylketonuria above).

Nutritional, genetic, environmental, medical and metabolic factors linked to ASD

converge on the abnormalities in the Folate-Methionine-Transulfuration-Dopamine

(FMTD) hub. Details are provided in Figure 1. In brief, the FMTD metabolic hub includes

pathways involved in oxidative stress response, DNA and RNA synthesis, energy

production, dopamine metabolism, and epigenomic programming.

Epigenetics Programming and ASD: Genetic and environmental factors linked to ASD

interfere with epigenomic programming directly and indirectly. Epigenetics

programming is a fuzzy term that refers to gene-environment interactions, and

developmental programs that enable a single inherited genome to code for multiple cell

type such as neurons, muscle and blood (for reviews see Abdolmaleky et al., 2008, Smith

et al., 2010, Smith and Huang, 2012). The greatest amount of epigenomic programming

occurs early in life. However, epigenomic programming is dynamic, and changes occur

throughout life.

Interference in epigenomic programming in early in life has the greatest

consequences because the largest number of cells and the earliest developmental

programs are affected. Some affects may not be apparent until much later in life or even

in another generation. The brain has the greatest amount of epigenetic programming, and

the greatest sensitivity to factors that interfere with this process.

Figure 1. The folate-methionine-transulfuration-dopamine (FMTD) metabolic hub. Nutrition, DNA and RNA synthesis, intracellular oxidative stress, epigenomic programming, and dopamine metabolism are closely linked in the FMTD metabolic hub. Abnormalities in these processes are linked to ASD. Details of the FMTD hub are provided here. Essential nutrients (dotted lines) that must be provided by the diet or from our microbiome are vitamins B9 (folate), B6, and B12; the amino acid methionine (met); and betaine/choline. Folate is converted to dihydrofolate (DHF), then tetrahydrofolate (THF) derivatives. The folate cycle (blue) directly participates in the synthesis of dTMP from dUMP and IMP (red *). dTMP is converted to dTTP and used for DNA synthesis. IMP is a precursor for the synthesis of all purine. Purines are required for DNA and RNA synthesis, and the energy currency of the cell, ATP and GTP. The major product of the met cycle (red) is S-adenosyl methionine (SAM). In epigenetic programming, methyl transferases (MT) enzymes use SAM as a methyl group donor. In the met cycle, SAM is made from met and ATP. Met is obtained exogenously, and can regenerated from homocysteine (HCY) by the addition of a methyl groups from THF or betaine (obtained from choline in the diet) by the enzymes methionine synthetase (MS), or betaine homocysteine methyl transferase (BHMT), respectively. The transulfuration pathway (green) synthesizes the major intracellular antioxidant, glutathione (GSH), and the amino acid cysteine (cys) from HCY. The enzyme MS has a second substrate, the demethylated dopamine D4 receptor (HCY-DRD4), that is converted to methylated DRD4 (met-DRD4) by the additional of a methyl group from THF (purple). The methylated DRD4 receptor (met-DRD4) covalently transfers the methyl group to lipopolysaccharides, changing cellular membrane characteristics.

Today a large research effort is focused on cataloguing the many epigenomic

changes that occur in ASD. Ultimately, the number of epigenetic changes will be at least an

order of magnitude greater than the observed genomic changes linked to ASD. Many

epigenetic changes will affect the same pathways that have been identified in earlier

genetic and environmental studies and are discussed above. Here, the discussion will

focus on global epigenetic changes that are linked to ASD and likely contribute to the

systemic and complex nature of disease.

The FMTD metabolic hub depicted in Figure 1 is the key global metabolic regulator of

epigenetic programming. In the FMTD hub, S-adenosyl methionine (SAM), a sulfur

containing metabolite, is the major methyl donor required for epigenomic programming.

DNA methylation is the best-studied epigenetic process, and generally DNA methylation of

gene promoter regions is associated with a loss of expression. Methyl groups from SAM

are donated to a wide variety of large (e.g. DNA, RNA, proteins, lipids and polysaccharides)

and small molecules (e. g. dopamine). Some xenobiotic detoxification reactions utilize

SAM. The FMTD hub is sensitive to nutrition, infection, inflammation, oxidative stress, and

toxic exposures.

Dopamine metabolism, a major process in the brain, is linked directly to the

FMTD metabolic hub and ASD (for review Smith et al., 2010, 2012). Direct links include

epigenetic programming of genes involved in dopamine metabolism, degradation of

dopamine by a methyl transferase (COMT), and methylation of the dopamine receptor D4

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(DRD4 receptor). Methyl transferase (MT) enzymes that use SAM or folate as a methyl

donor occur in all these reactions.

The FMTD hub is connected to the greatest number of intracellular reactions

because two metabolites, ATP and SAM, are the most used cofactors in the cell. During

evolution, the extensive metabolic wiring optimized the FMTD and imparted unique

characteristics: robustness to familiar conditions, and sensitivity to unfamiliar conditions.

The industrial age introduced new types and higher levels of xenobiotics. Some

xenobiotics that affect the FMTD hub were not encountered previously during evolution.

Xenobiotic exposures will increase the level of reactive oxygen species (ROS) and

oxidative stress. These exposures affect the FMTD hub because glutathione (GSH), a

sulfur-containing metabolite product of the FMTD hub, is the primary intracellular

antioxidant. Heavy metal exposures increase the level of reactive oxygen species (ROS),

and bind sulfur containing endogenous anti-oxidants.

Most ROS within a cell are produced as a side product of energy production

(ATP) in the mitochondria. Increases in processes that require ATP, like xenobiotic

metabolism and an oxidative stress response, will increase the level of ROS in the cells.

Infection and inflammation will increase the level of intracellular ROS and oxidative stress

directly, and indirectly because the biological response to these events includes an

increase in DNA and RNA synthesis, and energy production. Deficits in mitochondrial

function are detected in a subset of ASD patients (Anitha et al., 2012, Villafuerte, 2011)

Multiple essential nutrients (e.g. B vitamins, amino acids, and betaine/choline)

required within the FMTD hub must be acquired exogenously. Nutritional deficiencies

including both folate and betaine/choline are linked to behavioral and brain

abnormalities, ASD and schizophrenia (Smith et al., 2010, 2012, Blusztajn and Mellott,

2012)

Exogenous sources for essential nutrients include the diet and the microbiome.

The microbiome refers to the billions of microorganism that share our bodies.

Treatments with antibiotics to fight infection can change the microbiome detrimentally.

Although, this is a new area of research, abnormal microbiomes are detected in ASD (e. g.

Parracho et al., 2005), and other neuropsychiatric patients (Severance et al., 2012).

Severe gastrointestinal disorders in both adults and children, including ASD, are

linked to changes in the microbiome (e. g. Parracho et al., 2005; Benache et a., 2012), for

instance, infection by the pathogenic microorganism Clostridium difficile. Recently, fecal

transplants were used to successfully treat adult patients with C. difficile infections

(Stollman and Surawicz, 2012; Gought et al., 2011). Fecal transplants in ASD have yet to

be done, and are likely to be able to treat less severe microbiome imbalances. At this time,

the contribution of diet and the microbiome to human nutrition (or other internal

processes) is largely unknown, although dietary deficiencies alone are known to cause

disease.

Abnormal homocysteine (HCY) levels in blood are detected in many ASD

patients. HCY is a key FMTD metabolite with changes found many common diseases (e. g.

neuropsychiatric, cancer, and cardiovascular). In most cases, normalization of HCY levels

through simple (single) nutritional interventions has not been accompanied by a

reduction in disease symptoms. Hence, HCY levels are no longer monitored clinically.

The affect of nutritional intervention in neurobehavioral disease is not clear.

Folate and methionine supplementation alter psychotic symptoms (up and down,

respectively) in adult schizophrenia patients. Further, some pharmaceuticals useful in

treated schizophrenia affect the FMTD hub directly. An example is the increased

incidence of ASD like symptoms in children from mothers treated with valporate (to

control seizures) during pregnancy (Bromely et a., 2009). As a consequence of this

observation, valporate treatment of pregnant rodents is used to create rodent model of

ASD (Bambini-Junior et al., 2011). Valporate affects the production of SAM and epigenetic

programming.

Some clinical tests, including the measurement of single metabolites, are used

routinely to monitor health overall, while others are only used when warranted by

presenting symptoms. Research argues for monitoring ASD patient health using both old

(e.g. HCY), and newly identified important metabolites.

Global monitoring approaches used in systems biology can help understanding

disease in individual ASD patients. SNP testing and DNA sequencing which provide direct

information about genetic make-up is now in the clinical arena. Gene expression, a state-

of-the art research method, monitors cell function and has been useful for diagnosing and

treating cancer patients. Epigenomic changes and treatments based on this knowledge

are revolutionizing the treatment of cancer, especially blood displasias. In contrast to

other diseases, in cancer, the affected tumor tissue is available for analysis, and more

recent work has detected the DNA footprint of solid tumor cancer cells in blood.

As brain tissue is not readily available, metabolic monitoring of ASD patients

will need to be done with blood, or another readily available tissue. Changes in blood are

monitored for many diseases, and are linked already to ASD. Clinical tests of blood for

folate, HCY and other metabolites are done on blood, already. Whether changes are a

direct or indirect consequence of disease, blood has, and can serve as a sentinel of mental

health.

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The new paradigm: ASD is a group of complex medical and metabolic diseases with

behavioral abnormalities. Increasingly, the medical profession is recognizing that the

standard-of-care for ASD should include detection and treatment of non-behavioral

abnormalities. ASD patients have multiple and varying medical and metabolic problems

that need to be detected and treated. Today, ASD clinics that try to treat medical and

metabolic aspects of disease fall outside current insurance reimbursement schemes, and

in some cases mainstream medicine.

ASD is an illness that costs the government about $60 billion per year in the US

and is likely to increase. Schizophrenia, a similar common neurobehavioral disorder costs

about $160 billion per year. Both ASD and schizophrenia are common, severe and

lifelong. Research progress has increased our understanding of what processes are

abnormal for these diseases. However, the funds spent on research do not reflect the

relative cost of these diseases, and research results, for the most part, have yet to be

translated to the clinic. An estimated 20% of schizophrenia and ASD patients have

underlying but undetected medical disorders. It is a disgrace that patients are not tested

and treated for underlying medical and metabolic problems.

The U. S. National Institute of Health is moving towards a paradigm of

prevention rather than treatment of disease. Genetic make-up, infections, inflammation,

toxic exposures, malnutrition, diet and exercise influence the health of all individuals.

Research increasingly and repeatedly links environmental factors to many common

disorders. Appropriate diet and exercise will improve health for all individuals, and

reduce disease. For instance, a ~40% decrease in breast cancer can be realized through

diet and exercise. The translation of recent research observations to the clinic, whether

for breast cancer, ASD or schizophrenia can reduce disease.

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Appendix 1. Glossary of Scientific Terms and Acronyms

Anti-oxidant - molecules that protect cells from chemical damage caused by free radicals

ASD - autism spectrum disorder

Betaine - a small neutral metabolite that donates methyl groups to HCY

BHMT - betaine homocysteine methyl transferase enzyme

CH3-lipopolysaccharide - methylated lipopolysaccharide found in the cell membrane

Cys - cysteine, a sulfur containing amino acid

DSM - Diagnostic and Statistical Manuel for Mental Diseases published by the American Psychiatric

Association

DHF - dihydrofolate

Dopamine - neurotransmitter

DRD4 - dopamine receptor D4

dTMP - deoxythymidine mononucleoside, a precursor in dTTP synthesis

dTTP - deoxythymidine triphosphate, a precursor used in DNA synthesis

dUMP - deoxyuridine monophosphate, a precursor for dTMP synthesis

Epigenetics - a fuzzy scientific term that involves gene-environment interactions, and processes that

allow a single genome to develop into multiple cell types

Fragile X disease - most common cause of hereditary mental retardation

Federal Vaccination Court - refers to the Office of Special Masters of the U. S. Federal Claims Court

that administers a no-fault system for litigations involving vaccine injury

FMTD metabolic hub - folate-methionine-transulfuration-dopamine

Folate - vitamin B9

Gene expression - measurement of mRNA or protein levels

Genetic anticipation - phenomenon observed in some genetic diseases where severity increases,

and/or age of onset decreases in successive generations.

GSH - glutathione, a tripeptide composed of glycine-cysteine-glutamine with a gamma peptide bond

between the gamma carboxyl group of glutamine and the amino group of cysteine

HCY - homocysteine

HCY-DRD4 - demethylated DRD4 receptor

MET-DRD4 - methylated DRD4 receptor

IMP - inosine monophosphate, a precursor to the synthesis of all purines

Inborn-errors-of-metabolism - a large number of single gene diseases linked to metabolism

Met - methionine; a sulfur containing amino acids

MS - methionine synthase enzyme

MT - methyl transferase enzyme

Oxidative stress - refers to an imbalance in the level of reactive oxygen specie (ROS)s and the

biological detoxification pathways

ROS - reactive oxygen species

Phenylalanine - amino acid

Phenylketonuria - inborn error of metabolism disease

Pink disease - a disease found in a subset of individuals with elevated levels of mercury

characterized by pink hands or feet

Rett Syndrome - single gene disorder with a mutation in MeCP (methylated cytosine binding

protein) gene

17

SAM - S-adenosyl methionine, the major methyl donor in the cell

THF - tetrahydrofolate

Transulfuration pathway - metabolic pathway that converts homocysteine (HCY) to glutathione

(GSH) and cysteine an amino acid

Vitamin - small molecular compound essential to cells that must be obtained exogenously

Xenobiotic - small molecular weight molecule not ordinarily present in a biological system

Xenobiotic metabolism - pathway that detoxifies a xenobiotic

Addendum I

Suggested Medical and Metabolic Assessments Useful for ASD

A Paradigm Shift in Diagnosing and Treating ASD patients: Autism is a Treatable Medical and Metabolic Disease with Behavioral Components Addendum I Suggested Medical and Metabolic Assessments Useful for ASD Prepared Statement: Congressional Autism Hearing Original: November 29, 2012 Last updated: January 31, 2013







and

Kazuko Grace, Consumer Advocate

Athena Biomedical Institute

Contact Information:

Email: [email protected]

Tel: 617 571 3068


Autism is a treatable medical and metabolic disease with behavioral

components.

Addendum I


Addendum I - Suggested Medical and Metabolic Assessments Useful for ASD


Cassandra L. Smith, and Kazuko Grace

Boston University and Athena Biomedical Institute

_____________________________

Introduction: Most governmental funds are directed towards studies on the causes

of ASD while translation of research results to patients is minimal. Research has

revealed some important ways to improve patient treatment today. However, the

answer is not simple.1 Each patient is unique and can have a unique variety of

medical, metabolic, epigenomic and behavioral symptoms.2 Hence, complex

diagnosis and treatment regimes need to be applied to patient care. Each patient

must be viewed from a holistic rather than the traditional reductionist perspective,

requiring input from multidisciplinary fields characteristics of “systems biology”.

Systems biology is a field of biology that focuses on understanding the many varied

complex interactions that occur in the body. Today’s clinician is not well versed in

all aspects of disease and research outcomes, and needs direct input from

researchers to insure maximal benefit to the patient.3

There is a revolution in research on disease prompted by the human genome

project. Arguably, patients likely to benefit the most from the new finding and

technologies are those with neurobehavioral illnesses like ASD. It is especially

egregious not to identify patients with inborn-errors-of-metabolism in time for

treatment interventions that may prevent a severe, lifelong, and untreatable illness.4

In most cases, insurance does not cover diagnostic procedures and treatments

for the medical, metabolic and epigenomic abnormalities linked to ASD. Patients

who can self-fund benefit from the accumulated knowledge of research. However,

testing alone is prohibitively expensive.5

21

The American Academy of Pediatrics believes that children's medical care

should be accessible, family-centered, continuous, comprehensive, coordinated,

compassionate, and culturally effective.6 7 Comprehensive health care insurance

coverage of ASD will reduce the financial burdens on families with ill children.8

Admittedly, this will be expensive. However, early diagnosis and treatment can limit,

and some cases, prevent disease, reduce the estimated ~60 billion dollar per year

expense for ASD. 9 10 11 12

This Addendum includes testing for a plethora of abnormalities found in ASD

patients with variable presentations. Because each patient is unique, a wide range of

testing is necessary to optimized individual treatments; however, we recognize the

financial burden imposed by all this testing. We present this list as a starting point

for discussion to develop an optimized testing hierarchy and treatment regime that

must include patient and advocate participation.

Behavior is influenced by medical and metabolic abnormalities: Today, autism

behavioral analysis includes hearing, speech and language, motor social skills. Other

testing that may uncover underlying medical or metabolic abnormalities that affect

behavioral is not done.13

A symptom of ASD is communication deficits, and some patients are non-

verbal. Putting aside the general issue that children have difficulty describing

symptoms, ASD imposes an additional handicap. Children with ASD may not reveal

health problems ranging from pain from the stomach, bladder, ear, infections etc.

Instead, these problems may be expressed as behavioral issues such as

aggressiveness, screaming etc. Many parents experience emergency room trip for

their children with ASD but disturbing behavioral problems may prevent medical

personnel from searching for and treating medical issues that can disrupt behavior.

Most physicians do not know that up to 20% of ASD patients have underlying

undiagnosed and untreated medical illness. 14


Research Funds: ASD is at epidemic proportions. Schizophrenia, an orphan

neurobehavioral disease similar to ASD also occurs in epidemic proportions.

Comprehensive medical testing of schizophrenia patients are predicted to reveal

underlying disease in 20% of patients, including inborn errors of metabolism that in

some cases are treatable. Today, comprehensive medical testing is not done on

schizophrenia patients. Research funds spent by the US government are minimal,

and not in line with the estimated ~160 million dollars per expense of schizophrenia.

Further, the scarce research resources tend to be concentrated in specific centers.

Unfortunately, the field of mental health has been rift with soothsayers that are

subsequently proven wrong, but who controlled the direction of research and

treatment. Concentrating research funds in the hands of a few investigators

prevents innovation. The historic low funding rates for research and treatment of

neurobehavioral disease limits innovation and improvements in clinical treatments.

Pharmaceutical companies have moved away from developing new drugs for

neurobehavioral diseases because of unusually high expense. If comprehensive

testing is not done on ASD, the situation continues to evolve towards the same

unsatisfying and frustrated outcome seen in schizophrenia where patients are

abandoned and viewed generally as being hopelessly ill.15

A new standard of care for ASD: Today, the question is what should the standard of

care be for ASD? Certainly, the underlying genetic liabilities associated with disease

need to be determined, and testing is easy and relatively inexpensive. Medical

abnormalities in ASD should be assessed by conventional testing, and by targeted

analysis of metabolites linked to diseases. For instance, immune and inflammatory

responses can be monitored with well-established laboratory tests. Some metabolite

levels are measured clinically already, but others metabolite abnormalities linked to

ASD need to be added to the testing repertoire.

23

Gene expression, epigenomic and metabolomics testing is important because

these measurements represent functional test that reflect the combined affects of

genetic, epigenetic and environmental factors. Gene expression and epigenomic

testing is well established and quite helpful in distinguishing between different types

of cancer. In ASD gene expression testing might be done using a sentinel, readily

available tissue like blood, or saliva. Recent findings show that solid tumors leave

detectable DNA residues in the blood.

The molecular functional studies can reveal past and present toxic exposures.

Some toxic chemical can be detected directly and removed. Individuals with

sensitivities can be identified and monitored. Comprehensive diagnostic testing

using the new genomic approaches can reveal a wide range of metabolic conditions

that warrant treatment.

Prospective: Below we provide a suggested list of assessment that should be

considered in the treatment of ASD patients. This list is long and comprehensive,

and is meant to serve as a starting point of discussion for a new treatment

paradigm.16


Addendum I


Table of Contents

Introduction .............................................................................................................................................. 19

1. EVALUATION PROCESS .................................................................................................................................................... 25

a. Physical Exam and History ................................................................................................................. 25

i. When full metabolic evaluation should be performed .......................................... 25

2. DIAGNOSTIC TESTING ...................................................................................................................................................... 26

a. Metabolic Evaluation ............................................................................................................................. 26

i. Genetic Genotype/Phenotype Testing .......................................................................... 27

ii. Genetic Disease Testing (secondary autism) ............................................................. 27

iii. IEM (Inborn Errors of Metabolism) ............................................................................... 28

b. Metabolic Biomedical Phenotype Testing .................................................................................... 29

i. Amino Acids ............................................................................................................................. 29

ii. Cholesterol & bile acids ....................................................................................................... 30

iii. Creatine ...................................................................................................................................... 32

iv. Fatty Acid Metabolism Disorders .................................................................................... 31

v. Glucose transport & regulation ........................................................................................ 31

vi. Hyperhomocysteinemia ...................................................................................................... 31

vii. Lysosomes ................................................................................................................................. 32

viii.. Metals ......................................................................................................................................... 32

ix. Mitochondrial Dysfunction ............................................................................................... 34

x. Neurotransmission ................................................................................................................ 35

xi. Organic acids ........................................................................................................................... 36

xii. Pyrimidines ............................................................................................................................... 37

xiii. Hormone Metabolism ........................................................................................................... 37

xiv. Epsilon-trimethyllysine hydroxylase deficiency ..................................................... 37

xv. Urea cycle ................................................................................................................................. 38

xvi. Vitamins/co-factors .............................................................................................................. 38

c. Drug Metabolism .................................................................................................................................... 40

i. Risperidone ............................................................................................................................... 40

25

ii. Risperdal .................................................................................................................................... 40

iii. Ibuprofen ................................................................................................................................... 40

iv. Acetaminophen ...................................................................................................................... 40

v. Aspirin ......................................................................................................................................... 40

d. Functional Testing ................................................................................................................................. 40

i. Chemistries .............................................................................................................................. 40

ii. Mitochondrial Function ...................................................................................................... 41

iii. Organic Acids .......................................................................................................................... 41

iv. Amino Acids .............................................................................................................................. 44

v. Lipid Metabolism .................................................................................................................... 47

vi. Elemental Analysis ............................................................................................................... 47

vii. Vitamins and Metabolic Function .................................................................................. 48

viii. Metabolic and Essential Fatty Acids .............................................................................. 48

ix. Hormone Metabolism .......................................................................................................... 50

x. Gastrointestinal Function .................................................................................................. 50

xi. Detoxification Function ...................................................................................................... 51

xii. Immune function ................................................................................................................... 51

e. Mast Cell ...................................................................................................................................................... 56

f. Peptides....................................................................................................................................................... 56

g. Neurotoxins .............................................................................................................................................. 57

i. Heavy Metals ........................................................................................................................... 57

ii. Biotoxins ................................................................................................................................... 57

iii. Xenobiotics (man-made environmental toxins) and Food Preservatives .... 57

3. FAMILY TESTING ................................................................................................................................................................. 58

a. Mother ......................................................................................................................................................... 58

b. Father ........................................................................................................................................................... 58

c. Siblings ........................................................................................................................................................ 58

4. LIST OF ABBREVIATIONS ................................................................................................................................................ 60

5. REFERENCES ......................................................................................................................................................................... 63



1. Evaluation Process

a. Physical Exam and History

i. When full metabolic evaluation should be performed:

1. Sleep: sleep disturbance, abnormal snoring, pauses in

breathing or instances of abnormally low breathing 17 18 19

2. Body weights: obesity (overweight) or underweight

3. Height, weight and head circumference 20

4. Eating/Feeding disorders: food aversion, narrow food

preferences, poor appetite, vomiting, appetite loss 21

5. Repetitive infections 22

6. MIA (maternal immune activation) risk factor to ASD like

behavior 23

7. Repetitive asthma event 24

8. Repetitive behaviors 25 26

9. "Allergic-like" symptoms 27

10. Gastrointestinal: Diarrhea and/or constipation, abdominal

discomfort, abnormal odor of stool 28

11. Hearing: Healing loss, sound sensitivity

12. Eyes: Light sensitivity, Blurred vision, yellowing of the eyes

13. Joint and Muscle: poor muscle tone, poor eye-hand

coordination, chewing/swallowing problems, pain

14. physical and motor problems 29 30

15. Abnormal body Sensitivities: Pain, tempters, touch

16. Autonomic disturbances: excessive sweating, poor circulation

17. Seizures 31 32

18. Skin: rashes, itches, bumps, color 33

19. Neonatal jaundice 34

20. Head Circumference: too large or too small 35

21. Hand and feet: cold hand and feet, soft and/or waved nail

27

22. Vitals: elevated heart rate, low/high blood presser, continuous

low-grade fever, low or high oxygen level

23. Increase incidence of allergies: Foods, inhalant, chemical, mold

24. Urine: Abnormal odors, dark color

25. Hair: Steely, spots of gray hair

26. Rapid breathing or shortness of breath

27. Family History: Metabolic Disease in maternal, paternal, and

siblings

28. Others as pediatricians feel necessary

With any developmental delay is occurring.

2. Diagnostic Testing

a. Metabolic Evaluation

i. Genetic Genotype/Phenotype Testing 36 37:

AANAT, ABCD1, ACAT1, ACE, ACP*1A, ACP1, ACSL4, ACTA, ADA,

ADCY5, ADNP, ADRB2, AGT, AGT1, AGTR1, AGTR2, AHCY, ALA, ALT,

ANoA, AP3B2, APO E2, APO E3, APO E4, APOC3, ARID1B, ASMT,

ASMT1, ASMTL, ATD, ATXN1, BCKDK, BCOR, BDNF 38, BHMT, BHMT2,

BMPR2, BRSK2, BRWD1, C2Oortf7, C4B 39, CACNA1D, CACNA1E,

CADPS2, CALCR, CBS, CCP1, CD19, CD36, CD44, CD8, CDC42BPB,

CDH10, CDH5, CDKL5, CETP, CHD3, CHD7, CHD8, CHDH, CNOT4,

CNTFR, CNTNAP1, CNTNAP2, COL1A1, COMT 40, CPT2, CTA1, CTH,

CTNNB1, CTT1, CUL3, CUL5DAT1, CYBA*8, CYBA, CYBB, CYP 1B1,

CYP1A1*2A, CYP1A1*2C, CYP1A1, CYP1A2, CYP1B1, CYP21A2,

CYP27B1, CYP2A6, CYP2C19*2, CYP2C19*3, CYP2C19, CYP2C9*2,

CYP2C9*3, CYP2D6 41 , CYP2D6*3, CYP2E1*5A, CYP3A4*17,

CYP3A4*1B, CYP3A4*3, CYP3A4, DHPR, DISC1, DLX1, DLX2, DNMT3B,

DR13, DRD2, DRD342 43, DSCR1, DVR, DYRK1A, Dyrk1a, EAAT3,

EHD2, eNOS, Factor I, Factor II, Factor V, FBXO10, FOXL2, FOXP1,

FOXP2, FTSJ1, G6PD, G6PDH, GABAᴀ 44, GABRA1 45, GABRA2,

GABRA4, GABRA5, GABRA6, GABRA6, GABRB1 46, GABRB1, GABRB3,

GABRB3, GABRD, GABRD, GABRG, GABRG, GABRG1, GABRG1,GABRG2,


GABRP, GABRR1, GABRR2, GAD 1, GAD 2, GAD, GATA3, GCH1, GCLC,

GCLM, GCPII, GDI1, GNB3, GNMT, GP3a, GP3APL(A), GPX1, GPX2,

GRIP1 47, GRIP2, GRM5 48, GSS, GSTM149, GSTO1, GSTP1, GPS1,

GRINL1A, HADH2, HCCS, HCE2 (CES2), HLA 50, HLA-A2, HLA-DR4,

HLA-DQ8, HMX1, HOXA1, HTR1D, HDGFRP2, HDLBP, HYR1, IFN-γ,

IFN-γ/α/β, IL-1 β 51, IL-2, IL-4, IL-5, IL-6 52, IL-8, IL-10, IL-12, IL-13,

IL-12p40, IL-12p70, IL-13, IL-17, IL-23, ITGA4, ITGB3, KATNAL2, LPL,

MAOA, MARK1, MAT, MCP-1, MDMA, MECP2, MERRF, MET 53, Mic B,

MIF, mMT-I, MnSOD, MS(MTR), MS-MTRR, MSR(MS_MTRR), MT,

MT1 (L/E), MT-2, MT3, MTF1, MTHFR 54 55, MTHFS, MT-ND1, MT-

ND2, MT-ND3, MT-ND4, MT-ND5, MT-ND6, MTR, MTRR, MT-T52,

MBD5, MDM2, MLL3, NLGN1, NOTCH3, NR4A2, NTNG1, NTNG1,

NADH2, NAPQI, NAT 1, NAT 2, NDUFA1, NDUFA11, NDUFAF2,

NDUFS1, NDUFS2, NDUFS4, NDUFS6, NNMT, NOS, NPY1, NPY5,

NRCAM, NTRK2, OTC, OXTR, OPRL1, PCDHB4, PDCD1, PSEN1, PTEN,

PTPRK PAI-1, PCV2a, PCV2b,56 PCBD1, PEMT, PITX1, PON1, PON2,

PPAR-g2, PTEN, PTS, QDPR, RELN, RFC1, RGMA, RORA 57, RPS6KA3,

RUVBL1, SESN2, SETBP1, SAHH (AHCY), SAM, SCN1A, SCN1B, SELE,

SELS (SEPS1), SHMT1, SLC19A3, SLC25A12, SLC40A1, SLC6A4,

SNRPN, SOD2, SOD2, SOD3, STK39, SUOX, SVF1, TCN2, TCOF1, TDF,

TGFBR1, TGFBR2, TGF-β 58, TGF-β1, TGIF, TH, TH-1, TH-2, TIMM8A,

TM4SF2 (TSPAN7), TMEM1, TMLHE, TNF – alpha, TPH1, TPH2 59 60,

UMPS, UPP1, VCX3A, VDR, ZnT1, α7nAChR 61, others.

ii. Genetic Disease Testing (secondary autism):

1. Genetic Disease with ASD like features including:

a. Celiac Disease 62

b. G6PD (Glucose-6-Phosphate Dehydrogenase)

Deficiencies

c. Mitochondria Disease

d. Pink Disease 63

e. Rett syndrome 64

f. Sickle Cell Anemia

29

g. Tourette syndrome 65

h. Wilson’s Disease

i. others

2. Genetic Disease with secondly ASD

a. Down’s Syndrome

b. Fragile X Syndrome

c. others

iii. IEM (Inborn Errors of Metabolism): 66

1. Abnormal intestinal permeability 67

2. BH4 deficiency 68

3. Biotin responsive basal ganglia disease

4. C4B deficiency 69

5. Carnitine palmitoyltransferase II deficiency (CPT-II)

6. Cerebral folate receptor deficiency

7. Co enzyme Q10 deficiency

8. Congenital intrinsic factor deficiency

9. Dysfunction of mitochondrial β-oxidation 70

10. Fatty aldehydes Sjögren–Larsson syndrome

11. Glucose transport & regulation (GLUT1) deficiency syndrome

12. Glucose-6-Phosphate Dehydrogenase deficiency

13. Hyperinsulinism hyperammonemia syndrome

14. Hyperphenylalaninemia 71

15. Imerslund Gräsbeck syndrome

16. Immune / Autoimmune Dysfunction 72 73 74

17. Lysosomal Gaucher disease

18. Menkes disease-occipital horn syndrome

19. Mitochondria dysfunction 75 76 77

20. Mitochondrial Oxidative Phosphorylation (OXPHOS)

Dysfunction

21. Neurotransmitters DHPR (Dihydropteridine reductase)

deficiency


22. peripheral blood (PB) monocytes and specific polysaccharide

antibody deficiency (SPAD) 78

23. Phenylketonuria 79

24. PHGDH deficiency: D-3-phosphoglycerate dehydrogenase

(serine deficiency)

25. PSAT deficiency: phosphoserine aminotransferase deficiency

(serine deficiency)

26. PSPH (phosphoserine phosphatase) deficiency (serine

deficiency)

27. PTPS (6 Pyruvoyl Tetrahydropterin Synthase) deficiency

(biopterin deficiency)

28. Pyridoxine dependent epilepsy

29. Smith–Lemli–Opitz Syndrome

30. SPR (Sepiapterin Reductase) deficiency

31. Thiamine-responsive encephalopathy

32. Tyrosine hydroxylase deficiency

33. Vitamins/co-factors Biotinidase deficiency

b. Metabolic Biomedical Phenotype Testing: 80 (a) OMIM#81, (b)

Biochemical deficiency, (c) Gene(s). Remark: l.o.: late-onset form, AD:

autosomal dominant, AR: autosomal recessive, Mt: mitochondrial

i. Amino Acids:

1. Branched-chain ketoacid dehydrogenase kinase deficiency

a. 614901

b. Branched-chain ketoacid dehydrogenase kinase

deficiency 82

c. BCKDK (16p11.2)

2. HHH syndrome (hyperornithinemia, hyperammonemia,

homocitrullinemia)

a. 238970

b. Ornithine translocase

c. SLC25A15 (AR)

3. l.o. Non-ketotic hyperglycinemia

31

a. 605899

b. Aminomethyltransferase/glycine

decarboxylase/glycine cleavage system H protein

c. AMT/GLDC/GCSH (AR)

4. Phenylketonuria

a. 261600

b. Phenylalanine hydroxylase

c. PAH (AR)

5. PHGDH deficiency (Serine deficiency)

a. 601815

b. Phosphoglycerate dehydrogenase

c. PHGDH (AR)

6. PSAT deficiency (Serine deficiency)

a. 610992

b. Phosphoserine aminotransferase

c. PSAT1 (AR)

7. PSPH deficiency (Serine deficiency)

a. 614023

b. Phosphoserine phosphatase

c. PSPH (AR)

8. Tyrosinemia type II

a. 276600

b. Cytosolic tyrosine aminotransferase

c. TAT (AR)

ii. Cholesterol & bile acids

1. Cerebrotendinous xanthomatosis

a. 213700

b. Sterol-27-hydroxylase

c. CYP27A1 (AR)

2. Smith–Lemli–Opitz Syndrome

a. 270400

b. 7-Dehydroxycholesterol reductase

c. DHCR7 (AR)


iii. Creatine

1. AGAT deficiency

a. 612718

b. Arginine: glycine amidinotransferase

c. GATM (AR)

2. Creatine transporter Defect

a. 300352

b. Creatine transporter

c. SLC6A8 (X-linked)

3. GAMT deficiency

a. 612736

b. Guanidino-acetate-N-methyltransferase

c. GAMT (AR)

iv. Fatty Acid Metabolism Disorders

1. Sjögren–Larsson syndrome

a. 270200

b. Fatty aldehyde dehydrogenase

c. ALDH3A2 (AR)

v. Glucose transport & regulation

1. GLUT1 deficiency syndrome

a. 606777

b. Glucose transporter blood–brain barrier

c. SLC2A1 (AR)

2. Hyperinsulinism hyperammonemia syndrome

a. 606762

b. Glutamate dehydrogenase superactivity

c. GLUD1 (AR)

vi. Hyperhomocysteinemia

1. Cobalamin C deficiency

a. 277400

b. Methylmalonyl-CoA mutase and

homocysteine :methyltetrahydrofolate

methyltransferase

33

c. MMACHC (AR)

2. Cobalamin D deficiency

a. 277410

b. C2ORF25 protein

c. MMADHC (AR)

3. Cobalamin E deficiency

a. 236270

b. Methionine synthase reductase

c. MTRR (AR)

4. Cobalamin F deficiency

a. 277380

b. Lysosomal cobalamin exporter

c. LMBRD1 (AR)

5. Cobalamin G deficiency

a. 250940

b. 5-Methyltetrahydrofolate-homocysteine, S-

methyltransferase

c. MTR (AR)

6. Homocystinuria

a. 236200

b. Cystathatione β-synthase

c. CBS (AR)

7. l.o. MTHFR deficiency

a. 236250

b. Methylenetetrahydrofolate reductase deficiency

c. MTHFR (AR)

vii. Lysosomes

1. α-Mannosidosis

a. 248500

b. α-Mannosidase

c. MAN2B1 (AR)

2. Aspartylglucosaminuria

a. 208400


b. Aspartylglucosaminidase

c. AGA (AR)

3. Aspartylglucosaminuria

a. 208400

b. Aspartylglucosaminidase

c. AGA (AR)

4. Gaucher disease type III

a. 231000

b. ß-Glucosidase

c. GBA (AR)

5. Hunter syndrome (MPS II)

a. 309900

b. Iduronate-2-sulfatase

c. IDS (X-linked)

6. Sanfilippo syndrome B (MPS IIIb)

a. 252920

b. N-acetyl-glucosaminidase

c. NAGLU (AR)

7. Sanfilippo syndrome C (MPS IIIc)

a. 252930

b. Acetyl-CoA glucosamine-N-acetyl transferase

c. HGSNAT (AR)

8. Sanfilippo syndrome D (MPS IIId)

a. 252940

b. N-acetyl-glucosamine-6-Sulfatase

c. GNS (AR)

9. Sly syndrome (MPS VII)

a. 253220

b. β-glucuronidase

c. GUSB (AR)

10. Niemann–Pick disease type C

a. 257220

b. Intracellular transport cholesterol & sphingosines

35

c. NPC1 NPC2 (AR)

viii. Metals

1. Aceruloplasminemia

a. 604290

b. Ceruloplasmin (iron homeostasis)

c. CP (AR)

2. Menkes disease/Occipital horn syndrome

a. 304150

b. Copper transport protein (efflux from cell)

c. ATP7A (AR)

3. Wilson disease

a. 277900

b. Copper transport protein (liver to bile)

c. ATP7B (AR)

ix. Mitochondrial Dysfunction 83

1. Co enzyme Q10 deficiency

a. 607426

b. Coenzyme Q2 or mitochondrial

parahydroxybenzoatepolyprenyltransferase;

aprataxin; prenyl diphosphate, synthase subunit 1;

prenyl diphosphate synthase subunit 2; coenzyme

Q8; coenzyme Q9

c. COQ2, APTX, PDSS1,PDSS2, CABC1, COQ9 (most AR)

2. MELAS

a. 540000

b. Mitochondrial energy deficiency

c. MTTL1, MTTQ, MTTH, MTTK, MTTC, MTTS1, MTND1,

MTND5,MTND6, MTTS2 (Mt)

3. PDH complex deficiency

a. OMIM# according to each enzyme subunit

deficiency:312170; 245348; 245349

b. Pyruvate dehydrogenase complex (E1α, E2, E3)

c. PDHA1 (X-linked),DLAT (AR), PDHX (AR)


4. Mitochondrial Elongation Factor G1

a. 609060

b. Combined oxidative phosphorylation deficiency 1

c. GFM1 (3q25.32)

5. Carnitine palmitoyltransferase II

a. 600649

b. palmitoyltransferase II Dificiency Infantile

c. CPT2 (1p32.3)

x. Neurotransmission

1. DHPR deficiency (biopterin deficiency)

a. 261630

b. Dihydropteridine reductase

c. QDPR (AR)

2. GTPCH1 deficiency (biopterin deficiency)

a. 233910

b. GTP cyclohydrolase

c. GCH1 (AR)

3. PCD deficiency (biopterin deficiency)

a. 264070

b. Pterin-4α-carbinolamine dehydratase

c. PCBD1 (AR)

4. PTPS deficiency (biopterin deficiency)

a. 261640

b. 6-Pyruvoyltetrahydropterin synthase

c. PTS (AR)

5. SPR deficiency (biopterin deficiency)

a. 612716

b. Sepiapterin reductase

c. SPR (AR)

6. SSADH deficiency

a. 271980

b. Succinic semialdehyde dehydrogenase

c. ALDH5A1 (AR)

37

7. Tyrosine Hydroxylase Deficiency

a. 605407

b. Tyrosine Hydroxylase

c. TH (AR)

xi. Organic acids:

1. 3-Methylcrotonyl glycinuria

a. GENE OMIM # 210200; 210210

b. 3-Methylcrotonyl CoA carboxylase (3-MCC)

c. MCC1/MCC2 (AR)

2. 3-Methylglutaconic aciduria type I

a. 250950

b. 3-Methylglutaconyl-CoA hydratase

c. AUH (AR)

3. β-Ketothiolase deficiency

a. 203750

b. Mitochondrial acetoacetyl-CoA thiolase

c. ACAT1 (AR)

4. Cobalamin A deficiency

a. 251100

b. MMAA protein

c. MMAA (AR)

5. Cobalamin B deficiency

a. 251110

b. Cob(I)alamin adenosyltransferase

c. MMAB (AR)

6. Ethylmalonic encephalopathy

a. 602473

b. Mitochondrial sulfur dioxygenase

c. ETHE1 (AR)

7. l.o. Glutaric acidemia I

a. 231670

b. Glutaryl-CoA dehydrogenase

c. GCDH (AR)


8. Glutaric acidemia II

a. 231680

b. Multiple acyl-CoA dehydrogenase

c. ETFA, ETFB, ETFDH (AR)

9. HMG-CoA lyase deficiency

a. 246450

b. 3-Hydroxy-3-methylglutaryl-CoA lyase

c. HMGCL (AR)

10. mHMG-CoA synthase deficiency

a. 605911

b. Mitochondrial 3-hydroxy-3-Methylglutaryl-CoA

synthase

c. HMGCS2 (AR)

11. l.o. Propionic acidemia

a. 606054

b. Propionyl-CoA carboxylase

c. PCCA/PCCB (AR)

12. SCOT deficiency

a. 245050

b. Succinyl-CoA 3-oxoacid CoA transferase

c. OXCT1 (AR)

xii. Pyrimidines

1. Pyrimidine 5-nucleotidase superactivity

a. 606224

b. Pyrimidine-5-nucleotidase Superactivity

c. NT5C3 (AR)

xiii. Hormone Metabolism

1. Smith-Lemli-Opitz syndrome (SLOS) 84

a. 270400

b. Smith-Lemli-Opitz syndrome

c. DHCR7

xiv. Epsilon-trimethyllysine hydroxylase deficiency 85

a. 300872, 209850 (Autism susceptibility 1)

39

b. Epsilon-trimethyllysine hydroxylase deficiency

c. TMLHE (Xq28)

xv. Urea cycle 86

1. l.o. Argininemia

a. 207800

b. Arginase 87

c. ARG1 (AR)

2. l.o. Argininosuccinic aciduria

a. 207900

b. Argininosuccinate lyase

c. ASL (AR)

3. l.o. CPS deficiency

a. 237300

b. Carbamoyl phosphate synthetase

c. CPS1 (AR)

4. Citrullinemia type II

a. 605814

b. Citrin (aspartate–glutamate carrier)

c. SLC25A13

5. l.o. NAGS deficiency

a. 237310

b. N-acetylglutamate synthetase

c. NAGS (AR)

6. l.o. OTC Deficiency

a. 311250

b. Ornithine transcarbamoylase

c. OTC (X-linked)

7. L.o. Citrullinemia

a. 215700

b. Argininosuccinate Synthetase

c. ASS1 (AR)

xvi. Vitamins/co-factors

1. Biotin responsive basal ganglia disease


a. 607483

b. Biotin transport

c. SLC19A3(AR)

2. Cerebral folate receptor-α deficiency

a. 613068

b. a.o. Cerebral folate transporter

c. FOLR1 (AR)

3. Congenital intrinsic factor deficiency

a. 261000

b. Intrinsic factor deficiency

c. GIF (AR)

4. Holocarboxylase synthetase deficiency

a. 253270

b. Holocarboxylase synthetase

c. HLCS (AR)

5. Imerslund Gräsbeck syndrome

a. 261100

b. IF-Cbl receptor defects (cubulin/amnionless)

c. CUBN & AMN (AR)

6. Molybdenum co-factor deficiency type A

a. 252150

b. Sulfite oxidase & xanthine dehydrogenase &

aldehyde oxidase

c. MOCS1, MOCS2, (AR)

7. Pyridoxine dependent epilepsy

a. 266100

b. Pyridoxine phosphate oxidase

c. ALDH7A1 (AR)

8. Thiamine responsive encephalopathy

a. 606152

b. Thiamine transport

c. SLC19A3 (AR)

9. Biotinidase deficiency

41

a. 253260

b. Biotinidase

c. BTD (AR)

c. Drug Metabolism:88

i. Risperidone

1. rs1176713 is a SNP, also known as g.14396A>G, in the 5-

hydroxytryptamine (serotonin) receptor 3A HTR3A gene

ii. Risperdal

1. rs8179183 is a SNP in the leptin receptor LEPR gene.

iii. Ibuprofen

1. SNP rs1057910(A), located in the cytochrome p450 CYP2C9,

CYP2C9*1. rs1057910(C), CYP2C9*3, Ile359Leu or A1075C,

iv. Acetaminophen

1. rs1467558(A;G)

v. Aspirin

1. rs5918(C), rs3798220

d. Functional Testing: 89 90

i. Chemistries:

1. Complete Blood Count (CBC) is a standard, broad screening

test used to check for disorders such as anemia, abnormal

clotting, and infection. CBC is performed on the blood: WBC,

RBC, Hemoglobin, Hematocrit, MCV, MCH, MCHC, RDW,

Platelet Count, MPV and Differential (Absolute and Percent -

Neutrophils, Lymphocytes, Monocytes, Eosinophils, and

Basophils), Ferritin

2. Basic Comprehensive Metabolic Panel (CMP) is a standard

panel of tests that provides important information about the

current status of the kidneys, liver, blood sugar, blood proteins,

and electrolyte and acid/base balance. CMP is performed on


the blood. Basic Metabolic Panel: Albumin, Albumin/Globulin

Ratio (calculated), Alkaline Phosphatase, ALT, AST,

BUN/Creatinine Ratio (calculated), Calcium, Carbon Dioxide,

Chloride, Creatinine with GFR Estimated, Globulin (calculated),

Glucose, Potassium, Sodium, Total Bilirubin, Total Protein,

Urea Nitrogen

ii. Mitochondrial Function

1. Acylcarnitines, blood plasma and whole blood 91

a. Carnetine

b. Acryl free carnitine ratio

2. Amino Acids, plasma

a. Alanine

b. Alanine/Lysine ratio

c. Glycine

d. Proline

e. Tyrosine

f. Sorcosine

3. OAT, urine

a. TCA intermediates

b. Ethylmalonate

c. 3- dimethyl glutaconate

d. Dicarboxylic acid

iii. Organic Acids: 92 93

1. General Indicators of Gastrointestinal Dysbiosis:

a. Citramalic Acid

b. 5-Hydroxy-methyl-furoic Acid

c. 3-Oxoglutaric Acid

d. Furan-2,5-dicarboxylic Acid

e. Furancarbonylglycine

f. Tartaric Acid

g. Arabinose

43

h. Carboxycitric Acid

i. Tricarballylic Acid

j. 2-Hydroxyphenylacetic Acid

k. 4-Hydroxyphenylacetic Acid

l. 4-Hydroxybenzoic Acid

m. Hippuric Acid

n. 4-Hydroxyhippuric Acid

o. 3-Indoleacetic Acid

p. HPHPA 94 (3-(3-hydroxyphenyl)-3-hydroxypropionic

acid)

q. 4-Cresol

r. DHPPA(dihydroxyphenylpropionic acid)

2. Oxalate Metabolism:

a. Glyceric Acid

b. Glycolic Acid

c. Oxalic Acid

3. Glycolytic Cycle Metabolites:

a. Lactic Acid

b. Pyruvic Acid

c. 2-Hydroxybutyric Acid

4. Krebs Cycle Metabolites:

a. Succinic Acid

b. Fumaric Acid

c. Malic Acid

d. 2-Oxoglutaric Acid

e. Aconitic Acid

f. Citric Acid

5. Neurotransmitter Metabolism:

a. HVA and VMA


b. 5-Hydroxyindoleacetic Acid

c. Quinolinic Acid

d. Kynurenic Acid (KYNA)

e. Quinolinic Acid / Kynurenic Acid Ratio

f. Quinolinic acid / 5-HIAA Ratio

6. Pyrimidine Metabolism:

a. Uracil

b. Thymine

7. Ketone and Fatty Acid Oxidation:

a. 3-Hydroxybutyric Acid

b. Acetoacetic Acid

c. 4-Hydroxybutyric Acid

d. Adipic Acid

e. Suberic Acid

f. Sebacic Acid

g. Ethylmalonic Acid

h. Methylsuccinic Acid

i. Nutritional Markers:

j. Methylmalonic Acid

k. Pyridoxic Acid

l. Pantothenic Acid

m. Glutaric Acid

n. valproic acid (Depakene), or celiac disease

o. Ascorbic Acid

p. 3-Hydroxy-3-methylglutaric Acid

q. N-Acetylcysteine Acid

r. Methylcitric Acid

8. Indicators of Detoxification:

a. Pyroglutamic Acid

b. Orotic Acid

45

c. 2-Hydroxyhippuric Acid

9. Amino Acid Metabolites:

a. 2-Hydroxyisovaleric Acid

b. 2-Oxoisovaleric Acid

c. 3-Methyl-2-oxovaleric Acid

d. 2-Hydroxyisocaproic Acid

e. 2-Oxoisocaproic Acid

f. Mandelic Acid

g. Phenyllactic Acid

h. Phenylpyruvic Acid

i. Homogentisic Acid

j. 4-Hydroxyphenyllactic Acid

k. N-Acetylaspartic Acid

l. Malonic Acid

m. Methylglutaric Acid

n. 3-Methylglutaconic

o. 3-Hydroxyglutaric

10. Bone Metabolism:

a. Phosphoric Acid

iv. Amino Acids:

1. Plasma Amino Acids:95

a. 1-Methylhistidine

b. 3-Methylhistidine

c. Alanine

d. Alpha-amino-N-butyric acid

e. Alpha-aminoadipic acid

f. Ammonia

g. Anserine (dipeptide)

h. Arginine

i. Argininosuccinic acid


j. Asparagine

k. Aspartic acid

l. Beta-alanine

m. Beta-aminoisobutyric acid

n. Carnosine (dipeptide)

o. Citrulline

p. Cyst(e)ine

q. Cystathionine

r. Ethanolamine

s. Gamma-aminobutyric acid

t. Glutamic acid

u. Glutamine

v. Glycine

w. Histidine

x. Homocystine

y. Hydroxyproline

z. Isoleucine

aa. Leucine

bb. Lysine

cc. Methionine

dd. Ornithine

ee. Phenylalanine

ff. Phosphoethanolamine

gg. Phosphoserine

hh. Proline

ii. Sarcosine

jj. Serine

kk. Taurine

ll. Threonine

mm. Tryptophan

nn. Tyrosine

oo. Urea

pp. Valine

47

2. Urine Amino Acids:

a. 1-Methylhistidine

b. 3-Methylhistidine

c. Alanine

d. Alpha-amino-N-butyric acid

e. Alpha-aminoadipic acid

f. Ammonia

g. Anserine (dipeptide)

h. Arginine

i. Argininosuccinic acid

j. Asparagine

k. Aspartic acid

l. Beta-alanine

m. Beta-aminoisobutyric acid

n. Carnosine (dipeptide)

o. Citrulline

p. Cyst(e)ine

q. Cystathionine

r. Ethanolamine

s. Gamma-aminobutyric acid

t. Glutamic acid

u. Glutamine

v. Glycine

w. Histidine

x. Homocystine

y. Hydroxyproline

z. Isoleucine

aa. Leucine

bb. Lysine

cc. Methionine

dd. Ornithine

ee. Phenylalanine


ff. Phosphoethanolamine

gg. Phosphoserine

hh. Proline

ii. Sarcosine

jj. Serine

kk. Taurine

ll. Threonine

mm. Tryptophan

nn. Tyrosine

oo. Urea

pp. Valine

v. Lipid Metabolism: 96

1. Total cholesterol:

a. LDL

b. HDL

2. Apolipoprotein A-I (Apo A-1)

3. Apolipoprotein B (Apo B)

4. Lipoprotein (a) (Lp (a))

5. Homocysteine

6. Triglycerides

vi. Elemental Analysis: 97

1. RBC 98: Boron, Chromium, Calcium, Copper, Iron, Magnesium,

Manganese, Molybdenum, Phosphorus, Potassium, Selenium,

Vanadium, Zinc

2. WBC: Calcium (Ca), Magnesium (Mg), Copper (Cu), Zinc (Zn),

Manganese (Mn), Lithium (Li), Selenium (Se), Strontium (Sr),

Molybdenum (Mo)

3. Serum Elements: Calcium, Magnesium, Sodium, Potassium,

Phosphorus, Iron

4. Urine: Barium, Boron, Calcium, Chromium, Cobalt, Copper,

Iron, Lithium, Magnesium, Manganese, Molybdenum,

49

Phosphorus, Potassium, Selenium, Sodium, Strontium, Sulfur,

Vanadium, Zinc, Zirconia

5. Hair 99: Calcium, Magnesium, Sodium, Potassium, Copper, Zinc,

Manganese, Chromium, Vanadium, Molybdenum, Boron,

Iodine, Lithium, Phosphorus, Selenium, Strontium, Sulfur,

Barium, Cobalt, Iron, Germanium, Rubidium, Zirconium; Ratios:

Calcium/Magnesium, Sodium/Potassium, Zinc/Copper,

Zinc/Cadmium, Calcium/Phosphorus

vii. Vitamins and Metabolic Function : 100 101

1. CoQ10

2. Folic Acids 102

3. Vitamin A

4. Vitamin B:

a. Vitamin B1 (Thiamine)

b. Vitamin B3 (Niacin)

c. Vitamin B6 (Pyridoxine)

d. Vitamin MeB12 (Methylcobalamin)

5. Vitamin C

6. Vitamin D: 103

a. Vitamin D, 25-OH, Total

b. Vitamin D, 25-OH, D3

c. Vitamin D, 25-OH, D2

7. Vitamin E

8. Vitamin H (Biotin)

9. Vitamin K

viii. Metabolic and Essential Fatty Acids: 104 105

1. Total Saturated

2. Total Monounsaturated

3. Total Polyunsaturated

4. Total Omega 3

5. Total Omega 6


6. Total Fatty Acids

7. Omega 3 Series:

a. Alpha-Linolenic

b. Eicosapentaenoic

c. Docosapentaenoic

d. Docosahexaenoic

8. Omega 6 Series:

a. Linoleic

b. Gamma-Linolenic

c. Dihomo-Gamma-Linolenic

d. Arachidonic

e. Docosapentaenoic

f. Docosatetraenoic

9. Omega 9 Series

a. Eicosatrienoic

10. Monosaturated Series

a. Lauroleic

b. Myristoleic

c. Palmitoleic

d. Hexadecenoic

e. Vaccenic

f. Oleic

g. Nervonic

11. Saturated: Caprylic, Lauric, Myristic, Palmitic, Stearic,

Arachidic, Docosanoic, Tetracosanoic, Hexacosanoic

12. Branched-chain: Pristanic, Phytanic

13. Ratios: Triene-to-Tetraene

14. Behenic

15. Elaidic

16. Margaric

17. Nervonic

18. Pentadecanoic

51

ix. Hormone Metabolism:

1. Thyroid 106 107 108

a. Free T3

b. Free T4

c. Reverse T3

d. TSH

2. Plasma Leptin 109

3. Melatonin (N-acetyl-5-methoxytryptamine) 110

4. Growth Hormone 111

a. IGF-1

b. IGF-2

c. IGFBP-3

d. Growth hormone binding protein (GHBP)

e. dehydroepiandrosterone (DHEA)

f. DHEA sulphate (DHEAS)

x. Gastrointestinal Function: 112

1. Intestinal Permeability 113

2. Comprehensive Digestive Stool Analysis: 114

a. Bacteriology Culture, aerobic

b. Bacteriology Culture, aerobic x 3

c. Bacteriology Culture, anaerobic

d. Beneficial SCFAs

e. Beta-Glucuronidase

f. Bile Acids

g. Calprotectin

h. Cryptosporidium EIA

i. Deoxycholic Acid

j. Entamoeba histolytica

k. Eosinophil Protein X (EPX)

l. Giardia lamblia EIA

m. LithoCholic Acid

n. Pancreatic Elastase


o. Parasite Identification, Concentrate Prep

p. Parasite Identification, Trichrome Stain

q. Putrefactive SCFAs

r. Yeast Culture

s. n-Butyrate %

t. pH

u. Clostridium difficile Toxin A and B

v. H. pylori Stool Antigen

w. Shiga Toxin E. coli

xi. Detoxification Function: 115

1. Total Oxidant Level

2. Uric Acid:

a. Uric Acid Urine

b. Uric Acid Blood

3. Glutathione 116 117 118:

a. Total Glutathione

b. Reduced Glutathione

c. Peroxidase Glutathione (GPX)

4. Superoxide Dismutase (SOD)

5. Cysteine/Sulfate Ratio

6. Cysteine/Cystine Ratio

7. Melatonin

8. Glucose-6-Phosphate Dehydrogenase (G6PD) 119

9. Metallothionein antibodies (anti-MT)

a. antinuclear antibodies against nucleolar antigens

(ANoA)

b. antilaminin antibodies (ALA)

c. antibodies to metallothionein protein (anti-MT)

xii. Immune function 120

1. Immune Deficiencies: 121

a. Immunoglobulins IgA, IgM, IgE, IgG

53

b. IgG Subclasses 1, 2, 3 and 4

c. Monoclonal antibodies 122

d. B Lymphocyte Antigen D8/17 123

2. AutoImmune 124

a. plasma progranulin 125

b. Serum Neurokinin A / Anti-ribosomal P protein

antibodies 126

3. Allergies 127

a. Food Allergies 128

i. IgE Antibodies: Almond, Adzuki Bean, Almond,

Apple, Apricot, Asparagus, Avocado, Banana,

Barley, Beef, Beet, Blueberry, Broccoli,

Buckwheat, Cabbage, Cane Sugar, Carrot,

Casein, Cashews, Celery, Cheese, Chicken,

Coconut, Cod Fish, Cocoa, Coffee, Corn, Crab,

Cranberry, Eggplant, Egg White, Egg Yolk, Flax,

Garbanzo Bean, Garlic, Gluten, Goat’s Milk

Cheese, Grape, Grapefruit, Green Bean, Green

Pepper, Halibut, Hazelnut, Honey, Kidney Bean,

Lamb, Lemon, Lentil, Lettuce, Lima Bean,

Lobster, Mango, Milk, Millet, Mushroom, Oat,

Onion, Orange, Papaya, Pea, Peach, Peanut,

Pear, Pecan, Pineapple, Pinto Bean, Pistachio,

Plum, Pork, Potato, Pumpkin, Radish, Raisin,

Rice, Rye, Salmon, Sardine, Sesame, Shrimp,

Soybean, Spinach, Strawberry, Sunflower,

Sweet Potato, Tomato, Turkey, Tuna, Walnut,

Watermelon, Wheat, Whey, Yogurt, Yeast

(Bakers), Yeast (Brewers), Zucchini

ii. IgG Food Antibodies: Abalone, Almond, Apple,

Apricot, Asparagus, Avocado, Baker’s Yeast

(Saccharomyces cerevisiae), Bamboo Shoot,

Banana, Barley, Beef, Black Pepper, Bonito,


Buckwheat, Burdock (Gobo), Beet, Blueberry,

Brewer’s Yeast (Saccharomyces cerevisiae),

Broccoli, Buckwheat, Cherry, Chestnut, Chicken,

Clam, Cocoa, Coconut, Coffee, Corn, Crab,

Cucumber, Curry Powder, Cabbage, Candida

albicans, Cane Sugar, Carrot, Cashews, Casein,

Celery, Cheese, Chicken, Cod fish, Cranberry,

Duck, Eggplant, Egg White, Egg Yolk, Flax,

Garbanzo Beans, Garlic, Ginger, Gliadin, Goat’s

Milk Cheese, Grape, Grapefruit, Green Bean,

Green Pepper, Green Tea, Halibut, Hazelnut,

Honey, Jack Mackerel, Kiwi, Kombu (Kelp),

Kidney Bean, Lamb, Lemon, Lentil, Lettuce,

Laver (Nori), Lotus Root, Lima bean, Lobster,

Mackerel, Mango, Melon, Miso, Milk, Millet,

Mozzarella Cheese, Mushroom, Mushroom-

Enoki, Mushroom-Shiitake, Mustard, Oat, Olive,

Onion, Oolong Tea, Orange, Oyster, Pacific

Saury, Papaya, Pea, Peach, Peanut, Pear, Pecan,

Pineapple, Pinto Bean, Pistachio, Plum (Prune),

Pork, Potato, Pumpkin, Radish, Radish-Daikon,

Red Pepper, Rice, Rye, Salmon, Sardine,

Seaweed (Wakame), Sesame, Shrimp, Sorghum,

Soybean, Spinach, Squid, Strawberry,

Sunflower, Sweet Potato, Tomato, Tuna, Vanilla

Bean, Turkey, Wheat Gluten, Walnut,

Watermelon, Wheat, Whey, Yogurt

iii. Spices IgG: Allspice – IgG, Basil – IgG, Bay leaf

– IgG, Black Pepper – IgG, Cayenne Pepper –

IgG, Cinnamon – IgG, Cloves – IgG, Cumin – IgG,

Curry – IgG, Dill – IgG, Fennel seed – IgG,

Ginger – IgG, Horseradish – IgG, Marjoram –

55

IgG, Mustard – IgG, Nutmeg – IgG, Oregano –

IgG, Paprika – IgG, Parsley – IgG, Peppermint –

IgG, Rosemary – IgG, Sage – IgG, Thyme – IgG,

Total IgG, Vanilla – IgG

iv. IgE Inhalant Allergies: Alder Tree- IgE,

Australian Pine Tree- IgE, Bahia Grass- IgE,

Bermuda Grass- IgE, Birch Tree- IgE, Brome

Grass- IgE, Canary Grass- IgE, Cat dander- IgE,

Cocklebur- IgE, Cockroach- IgE, Common

Ragweed- IgE, Cottonwood Tree- IgE,

Cultivated Oat Grass- IgE, Dandelion- IgE, Dog

dander- IgE, Elm Tree- IgE, English Plantain-

IgE, Eucalyptus Tree- IgE, Giant Ragweed- IgE,

Johnson Grass- IgE, June Grass (Kentucky

Blue)- IgE, Lamb's quarters- IgE, Maple Tree-

IgE, Mesquite Tree- IgE, Mite Generic- IgE,

Mold Generic- IgE, Mountain Cedar Tree- IgE,

Nettle- IgE, Oak Tree- IgE, Olive Tree- IgE,

Orchard Grass- IgE, Pecan Tree- IgE, Perennial

Rye Grass- IgE, Red Top- IgE, Rough Marsh

Elder- IgE, Rough Pigweed- IgE, Russian

Thistle- IgE, Scale- IgE, Sweet Vernal Grass- IgE,

Timothy Grass- IgE, Total IgE, Walnut Tree- IgE,

Western Ragweed- IgE, White Mulberry Tree-

IgE

4. Inflammation

a. Acute-phase reaction (APR) markers

i. C-Reactive Protein (CRP)

ii. S100 protein


5. Opiate Receptors: Gluten / Casein Peptides 129

a. Gliadorphin (peptide from wheat)

b. Casomorphin (peptide from dairy)

6. Infection (blood test): 130

a. Virus:131

i. Polyomaviruses

1. BK virus (BKV) 132

2. Cytomegalovirus (CMV)

3. Epstein Barr virus (EBV)

4. Human Herpes Virus-6 (HHV-6)

5. Human Herpes Virus-7 (HHV-7)

6. JC virus (JCV)

7. Simian virus 40 (SV40) 133

8. Varicella-Zoster virus (ZVZ)

9. PCV2b

10. Herpes simplex virus type 1 (HSV-1)

11. Herpes simplex virus type 2 (HSV-2)

ii. Retroviruses

iii. Rubeola/Measles Edmonston Strain

Inactivated Cell Extract

b. Bacteria:

i. Mycoplasma pneumonia

ii. Chlamydia pneumonia 134

iii. Toxoplasma gondii

iv. Group A β-hemolytic Streptococci (GABHS) 135

1. DNase antibodies in serum (ADB)

2. Antistreptolysin O titer (ASO)

c. Vector-Born:136

i. Borrelia burgdorferi c6 peptide antibodies by

ELISA

ii. Lyme disease Western blot

57

d. Mycology:

i. Aspergillus fumigatus

7. Plasma Chemokines 137

e. Mast Cell 138

i. Corticotropin-releasing hormone (CRH)

ii. mitochondrial DNA, IgE/anti-IgE

iii. 24 hours to measure vascular endothelial growth factor (VEGF)

release by ELISA or for 6 hours or quantitative PCR

f. Peptides

i. Neuropeptides / Brain Inflammation (13 amino acid

neuropeptide)

1. Neurotensin (NT) 139

ii. Beta-amyloid peptide

iii. Beta-Amyloid Precursor Protein 140

1. Tau,

2. Tubulin

3. Synuclein

4. Amyloid Precursor Protein (APP) 141

5. Apo E

6. AD/PD related Proteins

7. Calmodulin

8. (sAPP-α ELISA)142

iv. Monoclonal Antibodies

1. Beta Amyloid

2. Tubulin

3. Tau and Related proteins

g. Neurotoxins 143


i. Heavy Metals: 144 145 146

1. Porphyrins: 147

a. Coproporphyrin I and III (CP)

b. Heptacarboxy (7-CP)

c. Hexacarboxy (6-CP)

d. Pentacarboxy (5-CP)

e. Precoproporphyrin (PreCP)

f. Uroporphyrins (UP)

2. Hair 148 149: Aluminum 150, Antimony, Arsenic, Beryllium,

Bismuth, Cadmium, Lead, Mercury, Platinum, Thallium,

Thorium, Uranium, Nickel, Silver, Tin, Titanium

3. RBC: Arsenic, Cadmium, Lead, Mercury, Thallium

4. WBC: Arsenic (As), Barium (Ba), Cadmium (Cd), Cobalt (Co),

Lead (Pb), Mercury (Hg), Nickel (Ni), Platinum (Pt), Silver (Ag),

Thallium (Tl), Uranium (U)

5. Urine 151: Aluminum, Antimony, Arsenic, Beryllium, Bismuth,

Cadmium, Lead, Mercury, Nickel, Platinum, Thallium, Thorium,

Tin, Tungsten, Uranium

6. Spot Urine: Urine protein to creatinine ratio (PrCP) 152

7. Fecal: Antimony, Arsenic, Beryllium, Bismuth, Cadmium,

Copper, Lead, Mercury, Nickel, Platinum, Thallium, Tungsten,

Uranium

ii. Biotoxins: Biotoxins are poisons that come from plants or animals.

mold, black mold, tetanus toxin, botulinum toxin,

ascaridin (from intestinal parasites), unspecified toxins

from streptococci, staphylococci, lyme disease 153,

clamydia, tuberculosis, fungal toxins and toxins

produced by viruses

iii. Xenobiotics (man-made environmental toxins) and Food

Preservatives: 154

59

Thimerosal155, Bisphenol A (BPA), Oxybenzone, Parabens,

Phthalates, Butylated Hydroxyanisole (BHA),

Perfluorooctanoic Acid (PFOA), Perchlorate,

Decabromodiphenyl Ether (DECA), Asbestos, The Hazards

Lurking at Home, Oxybenzone, Fluoride, Parabens,

Phthalate, Butylated Hydroxyanisole (BHA),

Perfluorooctanoic Acid (PFOA), Perchlorate,

Decabromodiphenyl Ether (DECA), Asbestos, The Hazards

Lurking at Home, dioxin, phthalates, formaldehyde,

insecticides, wood preservatives, Polychlorinated biphenyl

(PCB)156, Polybrominated diphenyl ethers (PBDEs) 157,

Pesticide 158, aspartame, caramel colorings, fluoride,

methyl-and propyl-paraben, etc.

3. Family Testing

a. Mother 159

i. Metabolism Genes: MTHFR, COMT, MTRR, BHMT, FOLR2, CBS, TCN2,

etc. 160

ii. Genotype and Phenotype Genetic Tests: 161

iii. Neuroinflammation 162

iv. Drug Metabolism (Pregnancy) 163

v. Comprehensive Metabolic Analysis 164

1. Organic Acids 165

vi. Heavy Metals:

1. Mercury 166

2. Lead 167

vii. Essential Minerals 168

viii. Vitamins

1. Folic Acids 169

2. Vitamin D 170 171

ix. Vitamins and Minerals (Prenatal Vitamins) 172

x. Xenobiotics173 174


xi. Infection 175 176

xii. Antioxidants

1. Glutathione 177

b. Father

i. Genotype and Phenotype genetic testing 178 179

ii. Infection 180

c. Sibling(s) 181

i. Genotype and Phenotype genetic testing 182

61

4. List of abbreviations

4-AA: 4-aminoantipyrine

5-CP:. Pentacarboxy

5-HT: serotonin

5'-IMP: 5'-inosine monophosphate

5'-NT: 5'-nucleotidase

6-CP: Hexacarboxy

7-CP: Heptacarboxy

AD Alzheimer’s disease

ADA: adenosine deaminase

Ag: Silver

APO A-1 Apolipoprotein A-I

APO B Apolipoprotein B

As: Arsenic

ASD Autism spectrum disorders

Ba: Barium

BBB Blood brain barrier

BHA: Butylated Hydroxyanisole Perfluorooctanoic Acid

BKV: BK virus

BPA: Thimerosal , Bisphenol A

Ca: Calcium

Cd: Cadmium

CMV: Cytomegalovirus

CNS Central nervous system

Co: Cobalt

CP: Coproporphyrin

CPS-1: carbamoyl phosphate synthetase-1

Cr: creatine

CRP: C-reactive protein

Cu: Copper

DECA: Decabromodiphenyl Ether

EBV: Epstein Barr virus

EHSPT: N-ethyl N-(2-hydroxy-3-sulfopropyl)-3-methylaniline


FAP functional abdominal pain

GABA: gamma-aminobutyric acid

GDH: glutamate dehydrogenase

GERD gastroesophageal reflux disease

GFCF gluten-free, casein-free

Gln: glutamine

Glu: glutamate

GRADE Grading of Recommendations Assessment, Development, and

Evaluation

GS: glutamate synthase

GSH: Glutathione

H2O2: hydrogen peroxide

Hg: Mercury

HHV-6: Human Herpes Virus-6

HHV-7: Human Herpes Virus-7

HPLC: high-performance liquid chromatography

HSV-1: Herpes simplex virus type 1

HSV-2: Herpes simplex virus type 2

IBS irritable bowel syndrome

IDO Indoleamine 2,3-dioxygenase

Ig immunoglobulin

IL Interleukin

JCV: John Cunningham Virus

Li: Lithium

Lp (a) Lipoprotein (a)

MeB12: Methylcobalamin

Mg: Magnesium

Mn: Manganese

Mo: Molybdenum

MPTP: mitochondrial permeability transition pore

mtCK: mitochondrial creatine kinase

Ni: Nickel

NLH nodular lymphoid hyperplasia

63

NMDA N-Methyl-D-aspartic acid

NO: nitric oxide

NOS not otherwise specified

OTC: Ornithine Transcarbamylase

PANDAS Pediatric autoimmune diseases associated with strep

Pb: Lead

PBDEs: Polybrominated Diphenyl Ethers

PCB: Polychlorinated Biphenyl

PCr; phosphorylcreatine

PCV2a: Porcine circovirus genotype 2a

PCV2b: Porcine circovirus genotype 2b

PDD pervasive developmental disorder

PFOA: Perfluorooctanoic Acid

PLS LYME patients with prior treatment and persistent symptoms

PNP: Purine Nucleoside Phosphorylase

POD: peroxidase

PreCP: Precoproporphyrin

Pt: Platinum

Redox Reduction-Oxidation

Se: Selenium

SIV: Simian Immunodeficiency Virus

Sr: Strontium

SV40: Simian Virus 40

Tl: Thallium

TNF Tumor necrosis factor

U: Uranium

UP: Uroporphyrins

XOD: xanthine oxidase

Zn: Zinc

ZVZ: Varicella-Zoster virus

α-KG: α-ketoglutaric acid


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Addendum II

Epigenetics and Clinical Origen of Behaviors to

Optimizing Health of ASD Patients

Research and Clinical Research Direction


Kazuko Grace Athena Biomedical Institute [email protected] 617-500-5980 www.athenabiomedicalinstitute.org

A Paradigm Shift in Diagnosing and Treating ASD patients: Autism is a Treatable Medical and Metabolic Disease with Behavioral Components Prepared Statement: Congressional Autism Hearing November 29, 2012 Last updated January 31, 2013

Dr. Cassandra L. Smith Professor, Biomedical Engineer, Biology and Experimental Therapeutics and Pharmacology, Boston University Director of Research, Athena Biomedical Institute [email protected]


(Addendum II) Epigenetics and Clinical Origen of Behaviors to Optimizing Health of ASD Patients Research and Clinical Research Direction

Epigenetics and Clinical Origen of Behaviors to

Optimizing Health of ASD Patients:

Research and Clinical Research Direction

Addendum II

Cassandra L. Smith, and Kazuko Grace

Boston University and Athena Biomedical Institute

Abstract: Autism remains a complex disorder that resists the best efforts of

dedicated clinicians, researchers, educators and families seeking cause(s),

robust diagnostic criteria and most importantly effective treatments and

preventive measures. Clinical research is directed towards understanding cause

and effect relationship and the established scientifically proven therapeutic

treatments.i Our goal is to develop state-of -the-art diagnostic assessment

protocols and individualized treatment regimes for patients with autism and

related disorders that are consistent with available but admittedly complex data.

The best effort must include input from a variety of individuals including

patients and caregivers who are excluded generally from medical and scientific

discussion to improve diagnosing, treating and managing patients. This aspect is

especially problematic in neurobehavioral diseases. The expert group needs to

include computer scientist and system biologists who are expert at handling and

analyzing complex datasets.

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Introduction: This document is being provided as a starting point for discussion

for how to improve the lives of autism patients and their families. We hope the

discussion will include the collective experiences of clinicians, staff, patients and

families. Towards this end, we encourage the Oversight Committee to support:

1. The formation of a group of working committees composed not only of

researchers and clinicians but also parents, staff, and patients to tackle

the demanding task of formulating new approaches (diagnosis, treatment

and management) to autism based on what might seem to be a

bewildering array of research results. This community effort requires the

participation of computer scientists, and system biologist used to

handling large datasets. The results of each of groups should be made

publically available.

2. The development of a publically available database with various

research and clinical results from individual studies from anonymized

patients.

3. The development of a reference set of anonymized patient samples

that will be publically available, and where individuals wanting to analyze

the samples agree to testing the entire reference set and to put results

into the public domain.

Today, autism is defined primarily by behaviors symptoms. Current diagnostic

strategies are observational in focus, but include: extensive medical history and

physical exam, non-specific evaluations such as intelligence, language and

achievement testing. Specific autism inventories and questionnaires that are age

specific, such as the Autism Diagnostic Observation Scales (ADOS), Autism

Diagnostic Inventory (ADI) and others. Diagnosis depends on the observational

and clinical skills of the examiner.

Medical testing such as MRI or CT scans, EEG’s, blood and urine tests, and

genetic tests are done primarily to rule in, or out, any contributing medical

disorders. Diagnosis is based on pooling all of the acquired information resulting

in a diagnostic impression. Similar diagnostic strategies are used for virtually all

mental health and developmental disorders.

1) What causes autism and the increase incidence of disease?

Autism has many underlying etiologies difficulties. Autism is not a single

disorder like Down's syndrome that is due to a single cause, chromosome 21

trisomy. Instead, autism is the pathological outcome of variety of assaults on the


developing brain. Many different etiologies have been linked to an increase in

autism including genetic predispositions, rare genetic diseases, infectious agents,

nutrition and exposures to toxins.

Although research worldwide is identifying factors that contribute to autism,

we need better integration of results in order to improve understanding of

disease presentation in individuals. Likewise a better understanding and

integration of factors linked to autism can reduce the increasing incidence of

autism. Autism is linked to many genetic and environmental factors, as are other

common diseases.

Much progress has been made in understanding the genetic liabilities with

over one hundred genes linked to autism. However, these findings have had

little affect on patient treatment or outcome. Further, changes in diagnostic

criteria proposed in DMS-V are putting rare genetic diseases with precise causes

under the umbrella of autism subtracting rather than increasing our knowledge

of disease.

Research into toxicity mechanisms is ongoing although not to the same level

of organization and intensity as genetics. Immune system abnormalities,

infectious diseases, dietary problems, and adverse environmental exposures are

all areas that are being studied as well. Many of these issues overlap factors

linked to other common diseases that do not appear to be increasing.

2) How to improve diagnosis of autism?

Without knowing the causes, we are left with a diagnosis based on behavior,

and this is fraught with inconsistencies, and is at best an inexact science. At

present there is no useful set of markers to aid diagnosis, or screen families for

risk factors for developing autism. Instead a robust diagnostic and predictive

tool that combines testing of factors linked to autism needs to be established.

3) What treatments make a significant difference to autism patients?

Our current treatment strategies are focused on behavioral outcomes. The

many and varied medical and metabolic aspects of disease need to be carefully

and scientifically assessed for each patient and where necessary treated.

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Parents have instituted treatment regimes that are not scientific proven, but

have been reported to improve the health and behavior of autism patients. All

treatments should be monitored scientifically whether nutritional or otherwise

non-conventional so that the best information is available for what treatments

are most effective for which subsets of patients. This type of understanding only

comes about through cooperation between clinicians, researchers, caregivers,

families and patients.

Theranostics approach to autism: Here, we advocating for what some have

called a theranostic medicine approach. This approach includes a portmanteau

of diagnostic testing and the development of individualized treatment regimes.

Research is tell us that making inroads into autism and other serious

neurobehavioral disorders will require theranostic approaches, although clearly

all patients will benefit from a change in attitude. ii

Ten million DNA differences between any two individual representing only 1%

of the genome. However, we are all aware that there are significant differences

in humans. These genetic differences lead to variations in obvious phenotypes

such as height, skin color, and ethnic/racial characteristics and how we respond

to medications and even foods. Two major areas of personalized medicine are

pharmacogenomics and nutritional genomics.iii

Pharmacogenomics: One form of personalized medicine involves

pharmacogenomics. This is a branch of pharmacology which deals with how

inherited genetic variations influence the body’s response to medications by

correlating single-nucleotide polymorphisms to a drug’s efficacy or toxicity. Just

as genetic variation can determine hair color, there are genetic variants that

determine how an individual metabolizes specific medicines. For example,

mutations may cause certain drugs may stay in one person's body longer than

usual lead to serious side effects. Alternatively, another mutation will make the

same medication less potent in other individuals.

An additional concern is the affect of xenobiotic metabolism on metabolic

process indirectly through the production of oxidative stress. Xenobiotic

metabolism will produce reactive oxygen species and induce oxidative stress

directly. Further, xenobiotic metabolism will produce oxidative stress indirectly

because this process itself requires energy, and may impair mitochondrial

function. The primary source for energy metabolism in the cell is the

mitochondria. Energy production will increase the level of reactive oxygen

species. Excess activity of an enzyme like a P450 enzyme located within the

mitochondrial membrane will interfere with energy production.

The treatment of patients is slowly changing. Today, before diagnosis and

even a single dose of medication, a simple DNA test could reveal the medication


and dose to be used in a particular patient. Personalized medicine will also help

in adjusting pharmaceutical dose. Genetic testing can aid the design and

application of better drugs in the pharmaceutical arena and decrease medical

costs.

Most important, medicine will move into a new era where patients are no longer

guinea pigs that are subjected to trial and error with toxic drugs.iv v This is

especially important for patients with neurobehavioral disorders like

schizophrenia that are subjected to one severe treatment regime after another.

The outcome is eventual improvements in a minority, and increased resistance

to drug treatment in a majority of patients.

“As the field advances, we expect to see more efficient clinical trials based on a

more thorough understanding of the genetic basis of disease. We also anticipate

that some previously failed medications will be recognized as safe and effective and

will be approved for subgroups of patients with specific genetic markers.”

-Margaret Hamburg, M.D.

Commissioner, U.S. Food and Drug Administration

-Francis Collins, M.D., Ph.D.

Director, National Institutes of Health

(The Case for Personalized Medicine, 3rd Edition 2011)

Nutritional Genomics: Nutritional imbalances are observed in many disease

including: aging, alcoholism/substance abuse, behavioral disorders, cancer,

cardiovascular diseases, chronic fatigue, deafness, diabetes, immune disorders,

macular degeneration, multiple sclerosis, neurological disorders, osteoporosis,

Parkinson's, and stroke. The basic premise of nutritional genomics is that

dietary recommendations based on our understanding of nutrient-gene

interactions will be important for the management of complex chronic diseases.

For example, 5,10 Methylenetetrahydrofolate reductase (MTHFR) is a key

enzyme that directs folate (vitamin B12) obtained from food towards DNA and

RNA synthesis, the synthesis of key metabolites: S-adenosyl methionine,

homocysteine, cysteine, glutathione, and methylation of the dopamine receptor

D4. S-adenosyl methionine is the second most used metabolite in the cell after

ATP the major energy transducer produced in the mitochondria. Glutathione is

the major intracellular antioxidant and increasing evidence links oxidative stress

to autism. Homocysteine is the major metabolite shared by these pathways. In

some cells, dietary choline can substitute for folate at least for the production of

S-adenosyl methionine, homocysteine, and glutathione. These pathways

100

required other nutrients that must be obtained from the diet such as vitamin B6,

B9, and methionine.

Genetic variations in the MTFHR (C677T and A677T) code for enzymes with

lower levels of activity. Lower activity of the MTHFR enzyme as well as low

levels of vitamins B12 and B6 leads to increased levels homocysteine linked to

many diseases, including autism, schizophrenia, neural tube defect,

cardiovascular disease, and cancer. Folate deficiencies during pregnancy are

linked to increased incidence of schizophrenia and autism in offspring. Further,

in some cases treatment of schizophrenia patients with folate improves

psychotic symptoms. The idea that nutrition is important in neurobehavioral

diseases was advocated by 50 years ago by Linus Pauling the only individual to

receive two undivided Nobel prizes.

Summary: Research examining a reference set of individuals with a large

variety of biochemical, and medical, and molecular tests should enable

improvements in patient's health. This is a combination of research and clinical

research approach, and requires the input of system biology approaches to

integrate large and complex data sets.

Clinicians have many years of training and experience in medicine and

sometimes research. Researchers have vast knowledge in basic and in some

cases applied science but generally do not treat patients. As important as these

experts are, caregivers, patients and families have personal experiences with

autism, and can make important observations from their own experiences that

often provide direction for treatment and research strategies.

The treatment of neurobehavioral disorders is difficult and involves

knowledge across many fields including psychology, behavior, education,

nutrition, research, medicine, genetics, physical/occupational therapy, and

computer science. There is no one individual who is or can be an in all these

areas. Instead, respective expertise must be shared in an environment that is

conducive to trust and mutual respect. Then, we can make inroads into the

development of best practices for the evaluation and treatment of individuals

struggling with consequences of autism.


References:

i B. M. Lester, C. J. Marsit, E. Conradt, C. Bromer and J. F. Padbury (2012)

Behavioral epigenetics and the developmental origins of child mental health

disorders: Journal of Developmental Origins of Health and Disease (DOHaD) pp

1-14

ii Davide Brambilla(2012) Polymeric nanoparticles as original theranostic

approach for alzheimer‟s disease: Lundi 18 Juin 2012, 12:47:13

iii W. Gregory Feero, M.D., Ph.D., Editor, Alan E. Guttmacher, M.D., Editor (2012)

Genomic Medicine — An Updated Primer: N Engl J Med 2010; 362:2001-2011

iv President's Council of Advisors on Science and Technology (2008) Priorities

for Personalized Medicine : PRESIDENT’S COUNCIL OF ADVISORS ON SCIENCE

AND TECHNOLOGY

v The Care for Personalized Medicine, Third Edition (2009) Personalized

Medicine Coalition





Kazuko Grace Athena Biomedical Institute

www.athenabiomedicalinstitute.org Original: November 29th, 2012, Last updated January 31, 2013

Developing a New Diagnostic and Treatment Paradigm for Autism

Autism is a Treatable Medical and Metabolic Disease with Behavioral Components

a paradigm shift in diagnosing and treating asd patients: autism is a treatable medical and...

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