The Functional Medicine Approach to Patient Care

The Functional Medicine Approach to Patient Care

Scott Antoine, DO, FACEPVine Healthcare, LLC

Objectives

To provide a definition of Functional MedicineTo define the need for a paradigm shift in

healthcare and the role of Functional Medicine in that shift

To show that Functional Medicine is Osteopathic Medicine

To outline the Functional Medicine approach to patient evaluation and treatment

Functional Medicine

Also known as: Functional and Integrative Medicine, Holistic

Medicine, Systems Medicine

The 4 P’s of Functional Medicine

Personalized- genetic and environmental variations drive individual treatments

Predictive- tailored health strategies based upon a personalized map of health risks with traditional and novel biomarkers

Preventive- proactive vs. reactive approaches which shift from illness to wellness, from disease treatment to functional enhancement

Participatory- empowers and engages the patient

Ultimately….

Functional Medicine is about balance:Removes what is NOT supposed to be in the

systemAdds (or maintains) what IS supposed to be in

the system

Osteopathic Medicine

DOs practice a "whole person" approach to medicine. Instead of just treating you for specific symptoms or illnesses, they regard your body as an integrated whole

Osteopathic physicians focus on preventive health care

--From the website of the American Osteopathic Association

Academic Interest in Functional Medicine

Institute of Functional Medicine (IFM) Basic and advanced courses in Functional

MedicineAttendees from 60 academic centers and

residencies including:Albert Einstein (NY), Duke, Johns Hopkins, Harvard,

UCLA, Penn, UNC, Des Moines Osteopathic, Lake Erie College of Osteopathic Medicine

Corporate and Government Interest

Medical insurers such as CIGNA are considering pilot programs using Functional Medicine

VA is exploring research in Functional Medicine

Supported by 12 Senators, Medicare has expressed interest in pilot programs for intensive lifestyle change programs

Traditional Approach to the Patient Encounter

The patient presents with symptom(s) A history of the “chief complaint” is taken “Pertinent” past medical history is obtained A physical examination is performed A differential diagnosis is made and testing is

performed A named ‘disease’ may or may not be found Medicine is given to treat the disease or lessen

symptoms

Traditional Approach to the Patient Encounter

Relies on deductive reasoning and “reductionism”

“Name it and blame it”“A drug for each bug” “A pill for each ill”Sherlock Holmes and the “Clue” analogyWorks well for acute illness or injury

You Have a Flat Tire

Call a “specialist”Look at the tireDecide if it is a nail, sidewall damage,

etcFix the problem and (hopefully) stop

the leakThis is an acute care situation

Several Problems

Tire is flatBrakes are badHole in the mufflerNeed a bunch of “specialists” If we fix these 3 problems, is the car in good

shape?This is the chronic illness model

The Burden of Chronic Illness

Data compiled in the “World Health Organization Non-Communicable Disease (NCD) Country Profile” report (2011)

Described mortality causes for 193 member states to the WHO

Data compiled for causes and risk factors

Causes of Mortality (Kenya)

Causes of Mortality (USA)

Change in BMI (USA)

Change in Blood Glucose (USA)

Risk Factors

The Burden of Chronic Disease

March 14, 2002 Study NEJM by R. Sinha et al (Vol 346 (11);802-810) showed that: 55 obese children (4-10 years old) --25% had

impaired glucose tolerance 112 obese teens (11-18 years old) -–21% had

impaired glucose tolerance. Four were diagnosed with type II DM

Recent estimates indicate that 1/3 of people born in 2000 will eventually be diabetic

How Sick is Sick?

Number of Chronic Conditions

Percentage of Medicare Spending

5+ 68%4 12%3 10%2 6%1 3%0 1%

The Problem We are treating chronic illness with the acute care model

Patients are broken into organ systems (GI, Cardiac..) There is a failure to recognize web-like interactions of

multiple comorbidities, antecedents, and triggers, in chronically-ill patients

Consequences Polypharmacy leading to non-compliance and adverse drug

reactions Coordination of care among specialists may be difficult Duplication of tests and therapies The “fire” may be out, but the embers are still

smoldering

How Could Your Car be Restored?

Comprehensive inspection (unique to your car)Examine each system from the inside, look for

problems (take it all apart), and look for connections

Add what is missing and neededGet rid of what does not belong and causes

problemsKeep up maintenance and “buy good gas” This is Functional Medicine

Basic Principles of Functional Medicine

1. The “Continuum of Wellness”Pre-DiabetesPre-HypertensionPre-DementiaAre these all separate “diseases” or

are they just pit-stops along a continuum from optimal wellness to illness?


In August 2009, after six years of planning, Johns Hopkins University School of Medicine rolled out the Genes to Society Curriculum. This novel curriculum rejects the notion that there is "normal" or "abnormal" in medicine. Rather, everyone is on a continuum. The curriculum takes a systems approach to understanding all levels of the human being - from genes, molecules, cells, and organs of the patient on one end, to the familial, community, societal, and environmental components at the other end. The GTS curriculum integrates all of these variables to help students understand why patients present the way they do. http://www.hopkinsmedicine.org/som/admissions/md/curriculum/gts.html


2. Wellness is a positive vitality and not merely the absence of disease

3. The decline of ICD-9 (and 10) and the emergence of models of systems medicine

4. Recognition of a web-like interconnectivity of bodily systems


The NIH Roadmap. Science, vol 302, Oct 2003, Elias Zerhouni“New Pathways to Discovery. This theme addresses the need to understand complex biological systems. Future progress in medicine will require quantitative knowledge about the many interconnected networks of molecules that comprise cells and tissues, along with improved insights into how these networks are regulated and interact with each other.”


5. Underlying Causes of Disease A. The “Exposome”

Toxins (drugs, chemicals, radiation, EMF) Nutrition (as a toxin) Stress Allergens Infections Trauma

**Damage is from direct mechanical effects, gene interaction, or metabolic effects**

The Exposome

What is the exposome?Success in mapping the human genome has fostered the complementary concept of the "exposome". The exposome can be defined as the measure of all the exposures of an individual in a lifetime and how those exposures relate to health. An individual’s exposure begins before birth and includes insults from environmental and occupational sources. Understanding how exposures from our environment, diet, lifestyle, etc. interact with our own unique characteristics such as genetics, physiology, and epigenetics impact our health is how the exposome will be articulated.

Source: The Centers For Disease Control (CDC) website


5. Underlying Causes of Disease (continued)

B. The Genome (genetic variation) Inherited (Familial) differences SNPs (Single Nucleotide Polymorphisms)-

must occur in at least 1% of the populationhttp://ghr.nlm.nih.gov/handbook/genomicresearch/snphttp://www.cancer.gov/cancertopics/understandingcancer/geneticvariation

Single Nucleotide Polymorphisms (SNPs)

SNPs and Cancer Risk

SNPs and Drug Interactions

Facts About SNPs

Occur about 1 time per 1000 base pairsMake up the bulk of the 3 million variations

found in the genomeOne third or more effect coenzyme-binding

sites for vitamins or nutrients and therefore have a role in disease or dysfunction*

* B Ames. Cancer Prevention and Diet: help from single nucleotide polymorphisms. Proc Natl Acad Sci USA

1999;96(22):12216-18

SNPs and Nutrients

“Our analysis of metabolic disease that affects cofactor binding, particularly as a result of polymorphic mutations, may present a novel rationale for high-dose vitamin therapy, perhaps hundreds of times the normal dietary reference intakes (DRI) in some cases..”*

*B Ames. High dose vitamin therapy stimulates variant enzymes with decreased coenzyme binding affinity (increased Km): relevance to genetic disease and polymorphisms. Am J Clin Nutr. 2002;75:616-658

MTHFR – A Case in Point

Methelenetetrahydrofolate reductaseResponsible for donating a methyl group to

B12 which then converts homocysteine to methionine

SNP results in thermolabile enzyme which is 50% less active than normal

Increased homocysteine results

The Homocysteine Cycle

Folate

THF

5,10-CH2-THF

5-CH3-THF

MTHFR

B12

B12

CH3-B12

Methionine

Homocysteine

MTHFR – A Case in Point

Homocysteine and Ischemic Heart Disease : Results of a Prospective Study With Implications Regarding Prevention Arch Intern Med. 1998;158(8):862-867

229 men without CAD who went on to die of CAD Matched to 1126 men of similar age Continuous dose-response relationship. Higher homocysteine

= more CADML Silaste, et al, Polymorphisms of key enzymes in homocysteine metabolism, affect diet responsiveness of plasma homocysteine in healthy women. J Nutr 2001;131:2643-47

Group of patients with MTHFR and Methionine Reductase SNPs Low folate vs. high folate diet (similar homocysteine at baseline) High folate group had 18% reduction in homocysteine. Low folate

group reduced 11%



C. Epigenetics (the effect the exposome has on your genome and genetic expression)

Epigenetics

Epigenetics

Epigenetics

Diabetes and Epigenetics“100% of the increase in prevalence of type II diabetes and obesity in the U.S. during the latter half of the 20th century must be attributed to a changing environment interacting with genes, since 0% of the human genome changed during this time period..”FW Booth, et al. Waging war on modern chronic diseases: primary prevention through exercise biology. J Appl Physiol. 2000; 88:774-87.



D. Loss of Functional Reserve (will affect your response to the exposome)

MC Creditor. Hazards of Hospitalization of the Elderly. Annals of Internal Medicine. 1993; 118(3):219-223


Epigenetics + Loss of Functional Reserve =



E. Deficiency States Hydration Proteins Carbohydrates Fats Vitamins Cofactors and enzymes


The “Macro/Micro” ParadoxSymptoms are experienced at the “macro”

or whole body level (nausea, diarrhea, allergies, etc.)

Causes of symptoms (and abnormal function) occur at the ‘micro’ level, often with individual chemical reactions and processes


The “Macro/Micro” Paradox These ‘micro’ changes may create whole

system malfunction, even though they may not seem related

Drugs directed at symptom relief (stop the diarrhea or heartburn) rarely fix the underlying pathology


The first component of this challenge is to recognize that inadequate intakes of specific nutrients may produce more than one disease, may produce diseases by more than one mechanism, and may require several years for the consequent morbidity to be sufficiently evident to be clinically recognizable as “disease.” Because the intakes required to prevent many of the long-latency disorders are higher than those required to prevent the respective index diseases, recommendations based solely on preventing the index diseases are no longer biologically defensible. RP Heaney, Long-latency deficiency disease: insights from calcium and vitamin D. Am J Clin Nutr 2003;78:912–9


B. Ames. The Metabolic Tune-Up: Metabolic Harmony and Disease Prevention.

J. Nutr. 133: 1544S–1548S, 2003. (University of California, Berkeley and Children’s Hospital and Research Center at Oakland)


TO RECAP:

5. Underlying Causes of DiseaseA. The ExposomeB. The Genome (Genetic Variation)C. EpigeneticsD. Loss of Functional ReserveE. Deficiency States


6. Nutrigenomics (the “epigenetics of food and nutrients”)

Advanced by Linus Pauling Nutrients modulate physiologic processes at the

molecular level This modulation gives rise to the phenotype of

health or disease

“There has been a growing recognition that both macronutrients and micronutrients can be potent dietary signals that influence metabolic programming of cells and have and important role in the control of homeostasis…”M Muller, S Kersten. Nutrigenomics: goals and strategies. Nat Rev Genet. 2003; 4:315-322

Nutrigenomics at Work


The Seven Core Clinical Imbalances1. Assimilation (Digestive, Absorptive,

Microbiological Balance)2. Defense and Repair (Inflammation and

Immune Function)3. Energy (Oxidation/Reduction and

Mitochondropathy)4. Biotransformation and Elimination

(Detoxification)


The Seven Core Clinical Imbalances (cont’d)5. Communication and Circulation (Hormonal

and Neurotransmitter Balance)6. Structural Integrity (Cellular Membrane

Function to the Musculoskeletal System)7. Mind/Body Imbalances

Notice there are 7 areas to address rather than the 12,000 diseases in ICD-9 or the 155,000 in ICD-10

Functional Medicine Approach

A timeline history is taken (including prenatal events) Medical history, diet, and lifestyle factors are

incorporated into a complete life history A physical examination is performed Laboratory testing is performed relative to the

complaints AND to assess the general state of the patient’s individual bodily functioning and toxicity

Genetic testing may be performed to look for specific disease risk or modifications of dietary intake needed

Food sensitivity testing is often performed

Functional Medicine Approach

Finally, a 2 step process to individualized treatment of the patient occurs:1. REMOVE what does not belong in the body

(bad foods, allergens, toxins, pathogens, heavy metals)

2. RESTORE (add) what the body needs to thrive (healthy foods, vitamins, minerals, botanicals, sleep, restoration, healthy relationships, spiritual health)

The GI Tract

Did You Know?The intestine is the PRIMARY immune organ in the

body---it contains almost 70% of the immune cells in the body

The intestine produces 70% of all neurotransmittersThe small intestine contains as many neurons as

the spinal cordBalance in this system is vital for overall health and

disorder here produces many total body effects

The GI Tract

A ‘microbiome’ of organisms (some good, some bad)

A “barrier” to keep toxins out and facilitate digestion

A nervous system independent of your brain which controls its function

The GI Tract

It is affected by What comes into the intestine

Toxins (GMOs, Pesticides, HFCS, additives and preservatives)

Inflammatory foods / allergens High glycemic load foods

The health of the intestinal barrier What lives in the intestine

Normal bacteria Yeast / pathologic bacteria / viruses / parasites

“Symptoms” of Disordered GI Function

Gastrointestinal Nausea, vomiting, diarrhea, constipation, weight loss. Abdominal pain, bloating, “IBS”, Crohn’s, Ulcerative

Colitis, colon cancer Immune

Frequent infections, bacterial overgrowth, yeast overgrowth, lupus, rheumatoid arthritis

Hematologic (blood cells) Anemia Decreased white blood cell count

“Symptoms” of Disordered GI Function

Cardiovascular High cholesterol and triglycerides, high blood pressure,

coronary vessel blockages Dermatologic (skin)

Rashes, hives, psoriasis Endocrine

Diabetes, metabolic syndrome, decreased libido, abnormal periods, PMS

Neurologic / Psychiatric Migraines, depression, anxiety, insomnia, fatigue,

dementia, ADHD, schizophrenia, “brain fog”

The Normal Intestine

“Leaky Gut”

Leaky Gut Consequences

Impaired absorption of vitamins, amino acids, minerals

Increased chance of abnormal bacteria and yeast overgrowth

Abnormal or insufficient GI production of vital hormones and neurotransmitters

Triggering of the Immune system

Triggering of The Immune System by GI Barrier Disruption

Controlling GI Damage

StressEnvironmental toxins (Pesticides, drugs, ETOH)Heavy metalsAnd--- a “Wonder Drug”

Question: The “Ideal” Drug

Name the drug which is inexpensive, readily available, easy to use, and can treat a wide variety of disorders with virtually no side effects. It has been shown to have the ability to “turn off” cancer causing genes and “turn on” cancer fighting genes…

Healthy Food!

Healthy Foods

Organic and grass-fed (or free-range) lean meats

Small/wild fishFresh organic vegetables with high fiberFresh organic fruitsNon-GMO foodsMinimally processed

Unhealthy Foods

Meats and produce produced with pesticides, hormones, antibiotics, and GMOs

High Fructose Corn Syrup. (It may be corn-sugar, but it will still kill you)

Refined (especially white) sugar and grainsAny processed food Beware if more than 5 ingredients!

Food Allergies

The difference between food ‘sensitivities’ and ‘allergies’

Testing methods Increased gut permeability may show an

“allergic” response to many foods due to sensitization by particles exposed to the immune system

Most Common Pro-inflammatory/Allergenic

FoodsGlutenDairyCornSoyEggPeanuts/other nutsAll are held as part of an elimination diet

Gluten

The protein “gliaden” is found in wheat and other grains

30% of Northern Europeans carry the HLA DQ8 gene or DQ2 gene for celiac disease

1% of the population (1 in 100) have celiac disease. Many are undiagnosed

Even in the absence of the genetic predisposition or celiac antibodies, many people are gluten ‘sensitive’

Gluten Sensitivity-Why Now?

Gluten has been in wheat for thousands of years

Are we just better at diagnosing it? Is the incidence rising? If there is more gluten sensitivity, why now?

Gluten Sensitivity

In an article by Dr. Joseph Murray published in 2009 in the Journal “Gastroenterology”on Celiac Disease: (Gastroenterology Volume 137, Issue 1, July 2009)

9133 “healthy” young adults between 1948 and 1954 had antibody tests done

12768 “health young adults” compared in 2009 The undiagnosed patients in the early study

had a 4x greater risk of death The amount of undiagnosed patients in the

recent 2009 study was 4.5 times higher than the earlier study (400%>)

Gluten Sensitivity Scope

Likely 1.8 million people actually have Celiac

1.4 million of these patients do not know it

Some estimate it may be 6% of the population

Why The Change?

Our gut has a much higher toxin load (pesticides, processed foods, additives)

Wheat has been genetically engineered to be more hearty. This has saved many from starvation, but some believe that it has made the gluten more irritating or has raised the gluten content

What Does Gluten Do?

What Does Gluten Do?

Up-regulates the inflammation response Increased free radicals (make you age) Thyroid dysfunction Hormonal disorders and infertility Forms neuroactive peptides “gluten exorphins”

which affect cognitive function and increase symptoms in autistic children

Activates the Immune System

Should Your Patient Be Gluten Free?

It is a personal decision. Should have family ‘buy-in’ Definitely a smart first step if they have digestive

issues Not everyone may respond poorly to gluten exposure.

Some may detoxify well. Impossible to tell who will Some studies have shown when patients were placed

on a gluten free diet versus standard diet in a blinded fashion, the gluten free cohort had less digestive complaints after 6 weeks

Cutting down vs. stopping—The “tack” example

What About Dairy?

Our Track Record

Our Track Record

Our Track Record

Keeping Your GI Tract Healthy/Repairing Damage

Specific DietsStandard American Diet (sad it is)Elimination Diet (“oligo-antigenic diet”)Mediterranean diet- Abundant Plants foods,

fresh fruit as dessert, olive oil as principle fat, cheese and yogurt for dairy, low meat, moderate wine consumption

Paleolithic Diet

Standard Supplements

MultivitaminVitamin DCalciumCo-Q10Vitamin AB12 and FolateFish Oil (DHA and

EPA)Vitamin EVitamin CMagnesiumCurcuminProbiotics

Based Upon Clinical Situation

Pharmacologic agentsSpecialty referralDetoxification and Methylation supportCounselingThe Exercise PrescriptionStress reduction and spiritual health

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The Functional Medicine Approach to Patient Care

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