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TRANSCRIPT
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Functional Medicine 101Aarti Batavia MS, RDN, CLT, CFSP, IFMCP.
September 7th , 2017
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Objectives
Understand the concept of Functional Medicine.
Identify elements of Functional Medicine Understand the seven biological systems in
which clinical imbalances are found and its relevance to nutrition.
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21st Century Medicine: An Era of Chronic Disease.
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The Landscape is Changing…
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Chronic Disease in America Today
Prevalence: 1 in 2 has > one chronic disease
Deaths: 7 out of 10 deaths each year
ADLs : ¼ have 1 or more limitations in ADLs
Arthritis: is common cause of disability
Disabilities: Leading cause of kidney disease, blindness, non-trauma related amputation
Obesity: 1 in 3 adults is obese, 1 in 5 youth
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Global Burden of Disease Surprises - 2020
The Global Burden of Disease Study (GBD) is a comprehensive regional and global research program of disease burden that assesses mortality and disability from major diseases, injuries, and risk factors.
GBD is a collaboration of over 1,800 researchers from 127 countries
1. Rapid rise in chronic disease - 73% of GBD by 2020 2. High level of mental illness- 3.7 % of GBD- depression3. Significant increase in cancer- Number 1 killer in many countries.
http://www.healthdata.org/acting-data/following-money-us-health-care-leads-surprises-and-insights-us-policies
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http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf?ua=1 Accessed June 30, 2016
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BOI: Burden of Illness
Obesity, CVD, Diabetes Depression, ADHD, Autism Allergies, Asthma, and Respiratory Diseases Digestive Disorders: IBS and GERD Back Pain Migraines Autoimmune Diseases (24 million) Functional Somatic Syndromes (CFIDS, FMS,
MCS, interstitial cystitis)
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Roadmap for Changing Paradigm
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What is Functional Medicine?Functional medicine is a science-based personalized healthcare approach that assesses and treats underlying causes of illness through individually tailored therapies to restore health and improve function.
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Functional Medicine- HistoryDeveloped by Jeffery Bland, PhD Synthesized the concept of
biomolecular nutrition as a foundation based on works by
Linus Pauling –molecular medicine and nutrition
Roger Williams-biochemical individuality
Abram Hofer-biomolecularpsychiatry
Hans Selye-mind/body link Bruce Ames-nutrition and
genetic polymorphisms Archibald Garrod-diseases of
genetic metabolism
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With Jeffrey Bland.
With Jeffrey Bland.
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Six Core Principles of Functional Medicine
1. An understanding of the biochemical individuality of each human being, based on the concepts of genetic and environmental uniqueness;
2. Awareness of the evidence that supports a patient-centered rather than a disease-centered approach to treatment;
3. Search for a dynamic balance among the internal and external factors in a patient’s body, mind, and spirit;
4. Familiarity with the web-like interconnections of internal physiological factors;
5. Identification of health as a positive vitality-not merely the absence of disease-emphasizing those factors that encourage a vigorous physiology;
6. Promotion of organ reserve as the means to enhance the health span, not just the life span, of each patient.
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Inflammation Hormones Genetics and Epigenetics Diet and Exercise Mood Disorders
One Condition: Many Imbalances
ObesityObesity
One Imbalance: Many Conditions
InflammationInflammation
Heart Disease Depression Arthritis Cancer Diabetes
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3945755/http://circ.ahajournals.org/content/105/22/2611
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Old Paradigm
A “team” of doctors Psychiatrist, lung specialist, allergist,
neurologist and gastroenterologist No one asked - How is everything
connected? Their job: match the pill to the ill! Did the individual just have bad luck to have
so many different problems? We are asking the wrong questions
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Key differences between Conventional and Functional Medicine
The Conventional Model Differential diagnosis:Reductionism Eliminating
confounding variables Naming and blaming Confirmatory
laboratory and imaging tests
Symptom suppression
The Functional Model Etiologic and causative
evaluation: patterns and connections
Including all variables New lenses and
cognitiveorganization
Testing: causes andmechanisms
Removing causes andrestoring normal function
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Differential Diagnosis
ICD-10
7 Biological Systems
PhenomenologySymptoms
Medication/Surgery
Pathology
Causes/Etiology
Promote BalanceRid-Get
Imbalances in Function
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What is Evidence-basedClinical Practice?
Evidence-based clinical practice is an approach to decision-making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits that patient best.
Gray JAM. 1997. Evidence-based healthcare: how to make health policy and management decisions. London: Churchill Livingstone
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The Biological Systems:
FORM Follows
FUNCTION
Assorted forks. From left to right: dessert fork, relish fork, salad fork, dinner fork, cold cuts fork, serving fork, carving fork.http://en.wikipedia.org/
Artist: Claudia Makeyev
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Loss of Function Proceeds Onset of Disease
“Loss of function proceeds onset of disease. Disease does not come as a bump in the night; It comes as a consequence of declining function over time.”
“Conversations with Jeffery Bland, PhD.”; Alternative Therapies2004
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“Pre” Disease?
• Pre-Diabetes• Pre-Hypertension• Pre-Dementia (MCI)• Pre-autoimmune diseaseOr• The Continuum of Dysfunction?
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Courtesy: Dean Ornish
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Elements of Functional Medicine
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GOTOIT Steps: Practicing Functional Medicine
Gather Organize Tell Order Initiate Track
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With David Jones and Sid Baker
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Elements of Functional Medicine
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Antecedents, Triggers, and Mediators
Antecedents are factors, genetic or acquired, that predispose individual to an illness or pattern
Triggers are factors that provoke the symptoms and signs of illness
Mediators/mediation are factors, biochemical or psychosocial, that contribute to pathological changes and dysfunctional responses
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Epi·ge·net·ics - “above genetics”Epigenetics research refers to the studyof heritable changes in gene functionthat occur without a change in thesequence of the DNA. (i.e. DNAmethylation & chromatin structure)
Genome (DNA) comparable to hardware of computer
Epigenetics comparable to software – could be running a complety different program.
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The 7 Systems:Core Clinical Imbalances
1. Assimilation (Digestive, absorptive, and microbiological imbalances)
2. Defense & Repair (Immune and inflammatory imbalances)
3. Energy (Oxidation-reduction imbalances and mitochondropathy)
4. Biotransformation and Elimination (Detoxification)5. Communication (Hormonal and neurotransmitter6. imbalances)7. Transport (Circulatory)8. Structural Integrity (imbalances from cellular
membrane function to the musculoskeletal system)
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AssimilationGastrointestinal
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AssimilationBreath
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Assimilation-Skin
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Defend and
Repair
Immune System
Inflammation DNA Repair
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Cellular Energy and Mitochondrial Function
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Cellular Energy and Mitochondrial Function
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Total Toxic Load
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Detoxification and Elimination
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Transport and Circulation
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Structural Integrity
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Meet Steve Steve, 51 YOM, Caucasian, Ht- 5 feet
10 inches tall, Wt- 193 lbs, Fat % 24.4, BMI -27.9.
Currently works as massage therapist, previous occupation –mechanic, exposure to exhaust fumes, CO, solvents.
Lives with his wife, Kim and step daughter, Emily.
Family hx: Father- prostate cancer, dementia, smoking, dyslipidemia, food allergy-egg whiteMother- breast cancer, and smokingGrandparents ( 1 of 4)- glaucoma, smoking and cardiovascular dx.
Chief complaints: Dyspahgia- food caught more than 10 times in 2014.Seasonal allergiesRestless leg syndromeGastritisEoE confirmed via biopsySkin tag melanomaDyslipidemia
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Meet Steve Personal Lifestyle Factors: Exercise: Cardio – 60 mins twice/wk and then
weight training 60 mins 2xwk. Nutrition- Mixed diet, leaning towards Paleo. Low
starch. Meat and nut butters for breakfast50% meals
away from home. Loves to eat Fast eater Erratic eating habits Late night eating Stress- Father passed away in May 2013.
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Is the advanced practice of personalized nutrition assessment, diagnosis, intervention, and monitoring with the goal of promoting optimal health and preventing diet-and-lifestyle related disease.
Functional Nutrition…
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RADIAL DIAGRAM
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Meet Steve- Pathophysiology of EoE
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Meet Steve- Pathophysiology of EoE
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Eosinophilic esophagitis (EoE) is an atopic inflammatory disease of the esophagus .The disorder is sometimes referred to as “asthma of the esophagus” given that it shares many clinical and pathophysiologic characteristics with asthma
Eosinophils are typically present throughout the gastrointestinal tract since it is continuously exposed to foods, environmental allergens, toxins, and pathogens.
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In EoE,, eosinophils infiltrate the esophagus, contributing to tissue damage and chronic inflammation. EoE is defined as a clinicopathologic disorder characterized by >15 eosinophils per high power field [HPF] in one or more esophageal biopsy specimens and, the absence of pathologic gastrointestinal reflux disease (GERD)
Evidence suggests that the disease is associated with T helper cell (Th)-2 type immune responses, which are typical of other atopic conditions. In particular, elevated levels of the Th2 cytokines interleukin (IL)-4, IL-5, and IL-13, as well as mast cells, have been found in the esophagus of EoE patients.
There is evidence suggesting a genetic predisposition for the disease since the gene for eotaxin-3 – a chemokine involved in promoting eosinophil accumulation and adhesion – has been found to be overexpressed in patients with EoE.
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EoE is also believed to be a mixed immunoglobulin (Ig)E- and non-IgE–mediated allergic response to food and environmental allergens. IgE-mediated reactions are immediate hypersensitivity responses that usually occur within minutes after exposure to an allergen.
Non-IgE mediated allergic disorders are characterized by a delayed onset (hours or days after exposure to the antigen) and potentially more chronic symptoms.
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LABS: Rule out – Ig E and non
Ig E food allergies/ sensitivities
Blood biochemistry
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Meet Steve Blood Biochemistry April 9th 2014
Creatinine Kinase IU/ L(50-280) 454 (H)
Cholesterol mg/dL(40) 53
LDL mg/dL (
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Meet Steve Nutrition Dx:
Food and nutrition related knowledge deficit r/t altered GI function and dyslipidemia AEB elevated lipid labs, recent diagnosis of food allergies and food sensitivities, dysphagia, confirmation of EoE through biopsy , patient’s diet history and verbalization to make dietary changes.
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Dietary Choices
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Image Courtesy: www.ibsfree.net, http://www.breakingtheviciouscycle.info/, http://www.choosemyplate.gov/ http://www.phoenixhelix.com/
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The Dynamics of the Eating Experience
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Nutritional Plan: Elimination/
Anti-inflammatory Food Plan
Addition of prebiotic/ probiotic foods.
Supplements
Meet Steve
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Visit 3 Visit 4 Visit 5 Visit 6
Probiotics antimicrobials Berberine Vit C
L- Glutamine Turmeric + visit 3 Phosphotidyl Choline MVI
Magnesium EPO
Vit C+ D Vit C
B complex B12
Co Q10
Omega 3
Meet Steve
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Symptom Survey:27 to 16Weight : May to Nov :193 to 173 in = -21 lbsNov to March: 172 lbs to 179 = + 4 lbs.
Meet Steve
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Meet Steve Blood Biochemistry April 9th Oct 10th March 9th
Creatinine Kinase IU/ L(50-280) 454 220
Cholesterol mg/dL(40) 53 45
LDL mg/dL (4.2
Vit D ( fxnal med- 50-70 ng/ml) 57 103 >150
CBC (eosinophils) (0-6.0) 8.5 6.2
Blood glucose 102
Mag ( 4.0-6.4 mg/dL) 5.3 5.7
Vit B12 pg/ml ( fxnally above 700) 502
Hcy (0-14umols/L) fxnal- less than 9 11 9
Creatinine (0,5-1.30 mg/dL) 1.00 1.10
Zinc (9-14 mg/L) 10.7
TSH (fxnal- 1-2.00 IU/ml) 2.66
Ferritin (fxnal 50-70 ng/ml) 48
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The Power of FoodWe are More than Our Genes
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Food Speaks To Our GenesHow? Transcriptomics
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Ways in Which Phytochemicals Can Influence Genetic Expression & Cellular Function Nuclear Transcription Factor Regulation Epigenetic Regulation Intercellular Signal Transduction
Modulation Response Element Effectors Redox Regulation Enzyme Inhibitors Precursors to Cellular Mediators Post translational Protein Modification
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Nutrigenomics studies how nutrients affect your body’s expression of your genes.
Nutrigenetics examines how your body responds to nutrients based on your genetics.
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Randy Jirtle, Ph.D.“The Father of Nutritional
Epigenetics”
Visiting Professor, McArdle Laboratory, University of Wisconsin
Pioneered the use of Agouti mouse to look at the effect of diet, nutrients and environmental agents including BPA on the mammalian epigenome and disease susceptiblity
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Randy Jirtle and Nutritional Epigenomics—
The Agouti Mouse Story
Cooney CA et al. Maternal methyl supplements in mice affect epigenetic variation and DNA methylation of offspring.J Nutr. 2002 Aug;132(8 Suppl):2393S-2400S.
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With Randy Jirtle.
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Methyl metabolism showing some major metabolic intermediates, cofactors and dietary sources of methyl
groups.
Craig A. Cooney et al. J. Nutr. 2002;132:2393S-2400S
©2002 by American Society for Nutrition
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Functions of MethylationSeveral functions of Methylation: 1. Turn on and off genes (gene regulation)2. Process chemicals, endogenous and xenobiotic
compounds (biotransformation)3. Build neurotransmitters ( epi, melatonin)4. Metabolize neurotransmitters (dopamine, norepi, epi)5. Process hormones (estrogens)6. Build immune cells ( T cells, NK cells)7. DNA synthesis and Repair ( Thymine aka 5-methyl uracil)8. Produce energy (CoQ10, carnitine, creatine ATP)9. Produce protective coating on nerves ( myelination)10. Build and maintain cell membranes (phosphotidyl
choline)
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Nutrients which influence the metabolic network interactions with the methylation cycle.• Protein: methionine, arginine, cysteine, choline,• tryptophan, tyrosine, serine, betaine• Fat: DHA• Carbohydrate: high simple carbohydrate
increases• requirements for niacin• Minerals: Magnesium (Met>SamE)• Zinc (Homocysteine to Methionine),• Phosphorus (Phosphorus in ATP)• Vitamins: Thiamin, Riboflavin, Pyridoxine, Niacin,• Folate, B-12
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http://mthfrsupport.com/
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Assessing Your Knowledge
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Resources
Institute for Functional Medicine www.functionalmedicine.org
Dietitians in Integrative and Functional Medicine www.integrativerd.org
Center for Body Mind Medicine- Food As Medicine http://cmbm.org/professional-trainings/food-as-medicine/
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Integrative & Functional Nutrition Graduate Degree Programs
Bastyr University: MS Nutrition (*Leads to RDN credential, on campus only)
Bridgeport University: MS Human Nutrition
Maryland University of Integrative Health: MS Nutrition and Integrative Health
University of Western Sciences: MS Human Nutrition and Functional Medicine
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Integrative and Functional Medicine Certificate Programs
Rutgers School of Related Healthcare Professions –certificate in Integrative Health and Wellness
Kansas University –Dietetics and Integrative Medicine Certificate Program
Arizona Center for Integrative Medicine –Integrative Lifestyle and Health Certificate
Integrative and Functional Nutrition Academy-Multi-Track IFN modules and Culinary Track
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Take Aways
A Functional Medicine Dietitian…. Takes the time to listen to a patient’s story. Draws
connections between core areas of imbalance and looks for the root cause(s) of disease
Collaborates with other Functional Medicine healthcare providers
Assesses knowledge and seeks additional training as needed