AODA Functional Medicine 101 - Copy · 0hhw 6whyh 6whyh

Functional Medicine 101Aarti Batavia MS, RDN, CLT, CFSP, IFMCP.

[email protected]

September 7th , 2017

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.

21st Century Medicine: An Era of Chronic Disease.

The Landscape is Changing…

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

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

http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf?ua=1 Accessed June 30, 2016

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)

Roadmap for Changing Paradigm

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.

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

With Jeffrey Bland.

With Jeffrey Bland.

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.

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

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3945755/http://circ.ahajournals.org/content/105/22/2611

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

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

Differential Diagnosis

ICD-10

7 Biological Systems

PhenomenologySymptoms

Medication/Surgery

Pathology

Causes/Etiology

Promote BalanceRid-Get

Imbalances in Function

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

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

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

“Pre” Disease?

• Pre-Diabetes• Pre-Hypertension• Pre-Dementia (MCI)• Pre-autoimmune diseaseOr• The Continuum of Dysfunction?

Courtesy: Dean Ornish

Elements of Functional Medicine

GOTOIT Steps: Practicing Functional Medicine

Gather Organize Tell Order Initiate Track

With David Jones and Sid Baker

Elements of Functional Medicine

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

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.

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)

AssimilationGastrointestinal

AssimilationBreath

Assimilation-Skin

Defend and

Repair

Immune System

Inflammation DNA Repair

Cellular Energy and Mitochondrial Function

Cellular Energy and Mitochondrial Function

Total Toxic Load

Detoxification and Elimination

Transport and Circulation

Structural Integrity

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

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.

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…

RADIAL DIAGRAM

Meet Steve- Pathophysiology of EoE

Meet Steve- Pathophysiology of EoE

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.

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.

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.

LABS: Rule out – Ig E and non

Ig E food allergies/ sensitivities

Blood biochemistry

Meet Steve Blood Biochemistry April 9th 2014

Creatinine Kinase IU/ L(50-280) 454 (H)

Cholesterol mg/dL(40) 53

LDL mg/dL (

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.

Dietary Choices

Image Courtesy: www.ibsfree.net, http://www.breakingtheviciouscycle.info/, http://www.choosemyplate.gov/ http://www.phoenixhelix.com/

The Dynamics of the Eating Experience

Nutritional Plan: Elimination/

Anti-inflammatory Food Plan

Addition of prebiotic/ probiotic foods.

Supplements

Meet Steve

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

Symptom Survey:27 to 16Weight : May to Nov :193 to 173 in = -21 lbsNov to March: 172 lbs to 179 = + 4 lbs.

Meet Steve

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

The Power of FoodWe are More than Our Genes

Food Speaks To Our GenesHow? Transcriptomics

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

Nutrigenomics studies how nutrients affect your body’s expression of your genes.

Nutrigenetics examines how your body responds to nutrients based on your genetics.

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

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.

With Randy Jirtle.

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

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)

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

http://mthfrsupport.com/

Assessing Your Knowledge

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/

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

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

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