A Case Study Discussion of the New Era of Applying the...
Transcript of A Case Study Discussion of the New Era of Applying the...
A Case Study Discussion of the New Era of Applying the Functional Medicine
Model to Patient Care When Managing Detox-Related Health Concerns
Kristi Hughes, ND 2014 South Africa
©2014 The Institute for Functional Medicine
Disclosure
• KRISTI HUGHES, ND is the Associate Director for Functional Medicine at the Institute for Functional Medicine.
• She is the Director of Medical Education for Functional Medicine South Africa.
• She is also an Independent Contractor for Metagenics, Nutrition Dynamics, Health World, and Amipro South Africa.
©2014 The Institute for Functional Medicine
FUNCTIONAL MEDICINE addresses the underlying causes of disease, using a systems-oriented approach and engaging both patient and practitioner in a therapeutic partnership.
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Functional Medicine Operating System
for Identifying Toxicity Concerns
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O T T G
Gather Oneself & Information
Organize on Timeline & Matrix
Tell the Patient’s Story
Order of your Priorities
Initiate Assessment and Care
Track Progress
O I
©2014 The Institute for Functional Medicine
©2014 The Institute for Functional Medicine
ather
information through intake forms, questionnaires, the initial consultation, physical exam, and objective data. A detailed functional medicine history taken appropriate to age, gender, and nature of presenting problems
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Gathering Key Detox Information
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Advanced Detox Assessment
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The Functional Medicine
Timeline
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Age Birth
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Signs, Symptoms or Diseases Reported
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Total Toxic Load (Body Burden)
Over extended periods of time, small daily doses of multiple
contaminants have cumulative detrimental effects on physiologic
pathways that can eventually impair health and cause disease.
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Functional Toxicology Triggers
Genomic Predisposition
Mediators
Chronic Disease
Toxins
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ADHD Allergies Alzheimer’s Anemia/ Immune
Suppression
Autism AI Diseases BP and Kidney Disease
Cancer
BPA Lead Mercury Phthalates PCBs
Antimony BPA Cadmium Formaldehyde Mold Nickel Phthalates
Aluminum Lead Mercury
Benzene Cadmium Lead PAHs
Mercury Arsenic Lead Mercury Mold
Arsenic Lead Mercury
Aluminum (breast?) Arsenic Benzene BPA Cadmium EMFs Formaldehyde HAs Lead Nickel Perchloroethylene Phthalates Solvents Vinyl chloride PVC Dioxin
Source: IFM Toolkit
Potential Associations between Toxins & Diseases
©2014 The Institute for Functional Medicine
CFS, FA Diabetes/IR Fertility Issues & Menstrual Disorders
Multiple Chemical
Sensitivities
Neuro-behavioral
issues
Neuro-development
issues
Osteoporosis Parkinson’s Peripheral Neuropathy
Arsenic Benzene Cd EMR FA Pb Hg Mold Ni PCE POPs PCBs Solvents PVC Dioxin
Arsenic BPA EMFs Pesticides PCBs PVC Dioxin Vinyl chloride
Arsenic BPA Cd EMF FA Pb Hg Phthalates PCBs PAHs Solvents PVC Dioxin
Benzene FA Mold Pesticides PCBs Solvents Vinyl chloride PVC Dioxin
Al As EMFs Pb Hg Mold Phthalates PCBs Solvents
As Pb Hg PCBs Solvents
Cd Pb
Mn Pesticides
As Pb Hg PCBs
Source: IFM Toolkit
Potential Associations between Toxins & Diseases
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ATMs Antecedents, Triggers, and
Mediators in Case Evaluation
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Definitions: 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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Antecedents
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Triggers or Triggering Events
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Mediators/Perpetuators
The ABCDs of Functional Nutrition Evaluation
(Identifying Detox Related Nutrition Concerns)
Dr. Michael Stone
A B
C D
Anthropometrics Biomarkers & Labs Clinical Indicators Diet and Lifestyle Assessment
The ABCDs of Functional Nutritional
Evaluation
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Context Company
Quality
Quantity
ABCD of Nutrition Evaluation
-Anthropometrics -Biochemical Markers -Clinical Findings -Diet Evaluation
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Anthropometrics
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NO
NO
Possible High Muscle Mass
or Athlete
NO
Increased BIA Fat%?
YES
Abnormal High BMI?
YES YES YES
NO
Gut/Detox/HPATGG dysfunctions?
Assessing Body Composition
YES
NO YES
Ideal Skinny Fat or Metabolically
Obese
NO
Increased WHR?
TLC Nx/ Rx
YES
Increased BIA Fat%?
NO
Increased WHR?
Increased BIA Fat%?
Metabolically Obese
(OverVAT)
YES NO
Gynoid Obesity/ overSAT
Gynoid Obesity/ overSAT
Possible High Muscle Mass
or Large Skeletal Frame
Increased BIA Fat%?
Android Obesity (OverVAT)
MetSyn?
YES
YES
>25 Overwt >30 Obese
Dx: OverFAT Dx:OverVAT or OverSAT Dx: Overweight
Increased WC?
Increased WC or WHR?
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Environmental Toxins Affect Obesity
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Atrazine, Insulin Resistance and Obesity
“These results suggest that long-term exposure to the herbicide ATZ (atrazine) might contribute to the development of insulin resistance and obesity, particularly where a high-fat diet is prevalent.
ATZ has been extensively used in the USA since the early 1960s, a time frame that corresponds to the beginning of the present obesity epidemic.
ATZ-usage and obesity maps show striking overlaps, suggesting that heavy usage of ATZ may be associated with the risk of obesity.”
Lim S et al. Chronic Exposure to the Herbicide, Atrazine, Causes Mitochondrial Dysfunction and Insulin Resistance. PLoS ONE, April 2009;4(4):e5186.
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Abdominal Obesity>Inflammation >Cardiometabolic Syndrome>CVD
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Anthropometrics
Biomarkers and Functional Labs (PFC-MVP)
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BioMarkers and Functional Labs
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P F
R
O T
I
E
N
A
T &
C A R
B O H Y
M
I
E
R A
L
N
S
V
I
A
M I
S
T
N
P H
T O
N U
S
Y
T D O I L R
A T E
R I
N T E
S
©2014 The Institute for Functional Medicine
Putative Serological Biomarkers to Consider for Toxicity
• Gamma-glutamyltransferase (GGT) – >40 units/L
• Uric acid – >8mg/dl
• Homocysteine – >11 micromol/L
• hsC-reactive protein – >0.7 mg/L
• Magnesium – <2meq/dL
• Antinuclear antibody titer – >1:125
• Apo B/Apo A1 – >0.6
• Hemoglobin A1c – >5.5%
• 25-Hydroxyvitamin D3 – <30 ng/ml
• Body Mass Index – >27
• Body Composition – Normal WHR – >30% body fat
• Urinary microalbumin – >30 mg in 24 hr
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GGT: A Novel CV Risk Marker “In the upper reference range, GGT was found to be an independent biomarker of the metabolic syndrome, with a 20% per GGT quartile trend rise. Additionally, GGT was positively correlated with an 18% per quartile risk of cardiovascular events and a 26% per quartile increased risk of all-cause mortality.”
Mason JE et al. Prev Cardiol 2010;13(1):36-41.
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Glucose Tolerance Test SI - International Units
75 gm dextrose Optimal Levels • Fasting insulin 28-35 pmol/L • 1/2 hour insulin <215 pmol/L • 1 and 2 hour insulin <215 • Fasting glucose-4.4-5.0mmol/L
• 2 hour glucose- 4.4-6.6mmol/L
• HgA1C < 0.055
Diagnostic IR • >85 pmol/L • > 395 insulin • > 350 insulin • > 5.5 = hypergly • >7.0 = DM2 • > 11 mmol/L - 2
hour glucose • > 0.06 – HgA1C
JAMA 2007;297:2092-102. McAuley, K. Diabetes Care. 2001;24:460-464.
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Higher V.A.T. = Higher Glucose and Insulin
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Clinical Indicators from Nutrition Physical Exam
Anthropometrics
Biomarkers and Functional Labs (PFC-MVP)
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©2014 The Institute for Functional Medicine
Diet and Lifestyle Assessment
Clinical Indicators from Nutrition Physical Exam
Anthropometrics
Biomarkers and Functional Labs (PFC-MVP)
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Diet, Nutrition, and Lifestyle
Journal
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rganize the subjective and objective details from the patient’s story within the functional medicine paradigm Positioning the patient’s presenting signs and symptoms, along with the details of the case history on the timeline and functional medicine matrix
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The Functional Medicine
Matrix
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Biotransformation & Elimination
(e.g., Toxicity, Detoxification)
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Defense & Repair (e.g., Immune, Inflammation, Infection/Microbiota)
Assimilation (e.g., Digestion, Absorption, Microbiota/GI, Respiration)
Spiritual
e.g., meaning & purpose, relationship with something greater
e.g., cognitive function, perceptual patterns
e.g., emotional regulation, grief, sadness, anger, etc.
Transport (e.g., Cardiovascular, Lymphatic System)
Biotransformation & Elimination (e.g., Toxicity, Detoxification)
Energy (e.g., Energy Regulation, Mitochondrial Function)
Communication (e.g., Endocrine, Neurotransmitters,
Immune messengers)
Structural Integrity (e.g., from Subcellular Membranes
to Musculoskeletal Structure)
Toxicity Influences
Biotransformation & Elimination
(e.g., Toxicity, Detoxification)
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Nutrition Evaluation
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Functional Nutrition
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Case Based Learning
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O T T G
Gather Oneself & Information
Organize on Timeline & Matrix
Tell the Patient’s Story
O I
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Dave’s Chief Complaints
• Weight Gain (30 lbs in last decade) – Mostly over the last 5-7 years, round the waist
• Elevated cholesterol and triglycerides levels • Increased Blood Pressure • Fatigues more easily than in past • Less stamina in exercise and physical
activity • Some muscle and joint stiffness
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©2014 The Institute for Functional Medicine
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25 57
Weight Gain/Inc Waist Circ Hypertension Dyslipidemia
Fatigue/Reduce Stamina
50
Electrician; working on construction sites since mid 20s
Weight Gain & Fatigue
Hypertension Incr Chol & LDL
Avid exerciser and runner Reduced exercise
Loves to cook “foodie”
Increased Triglycerides
Incr glucose
Carol’s plan
52 54
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NO
NO
Possible High Muscle Mass
or Athlete
NO
Increased BIA Fat%?
YES
Abnormal High BMI?
YES YES YES
NO
Gut/Detox/HPATGG dysfunctions?
Assessing Body Composition
YES
NO YES
Ideal Skinny Fat or Metabolically
Obese
NO
Increased WHR?
TLC Nx/ Rx
YES
Increased BIA Fat%?
NO
Increased WHR?
Increased BIA Fat%?
Metabolically Obese
(OverVAT)
YES NO
Gynoid Obesity/ overSAT
Gynoid Obesity/ overSAT
Possible High Muscle Mass
or Large Skeletal Frame
Increased BIA Fat%?
Android Obesity (OverVAT)
MetSyn?
YES
YES
Dx: OverFAT Dx:OverVAT or OverSAT Dx: Overweight
Increased WC?
Increased WC or WHR?
©2014 The Institute for Functional Medicine
O T T G
Gather Oneself & Information
Organize on Timeline & Matrix
Tell the Patient’s Story
Order of your Priorities
O I
©2014 The Institute for Functional Medicine
Nutrition Assessments
PFC-MVP Biomarkers
Gather Organize Re-Tell
Order/Prioritize The ABCDs of
Nutrition Evaluation
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Where’s the Ink?
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Pattern Recognition
Undernourished
Reduce Exposures
Ensure a Safe Detox
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Pattern Recognition
Undernourished
Reduce Exposures
Ensure a Safe Detox
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TOTAL TOXIC LOAD equals
Total Toxic Exposure minus
Ability to Detoxify and
Eliminate Toxins
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Where’s the Ink?
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Obesity, VAT (Incr WHR) Hypertension Endothelial Dysfunction??? Joint stiffness morning
Mild Testosterone Deficiency??? Insulin Resistance??? Insulin Resistance???
Blood Sugar Elevation HTN and Met Syn???
Occupational Exposure
Fatigue Muscle Soreness
Obesity, VAT (Incr WHR) Endothelial Dysfunction??? Joint stiffness morning
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Pattern Recognition
Undernourished
Reduce Exposures
Ensure a Safe Detox
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Functional Nutrition
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Macronutrients
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Micronutrients & Phytonutrients
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Pattern Recognition
Undernourished
Reduce Exposures
Ensure a Safe Detox
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Minimizing Toxic Exposure • Avoid cigarette smoke & charred meat • Test home for radon • Eat organic foods; buy organic flowers • Drink purified or spring water • Eat generous amounts of sea vegetables,
green algae, &/or Spirulina • Minimize consumption of certain fish & shellfish
– Mercury in large tuna, swordfish, shark, king mackerel, tilefish – PCBs in farmed salmon & sport fish (Great Lakes; Hudson R) – Oysters “downstream” from wastewater
• Drink alcohol in moderation • Don’t take acetaminophen for a hangover • Avoid polypharmacy
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• Avoid synthetic pesticides/ herbicides • Use non toxic cleaning agents; patronize chemical
free dry-cleaners • Use nontoxic building materials & carpets • Use “natural” cosmetics, shampoos, nail polish &
fragrances • Clean indoor air with plants and ionizers • Use polyethylene (“clear”) food wrap (if any) • Don’t microwave plastics! • Use BPA-free water bottles & canned food • Don’t overheat empty Teflon® cookware • Don’t lick picnic tables or wooden rails!
Minimizing Toxic Exposure
©2014 The Institute for Functional Medicine
Remove Toxic Foods
Food toxins include:
– Petrochemical residues from some farming practices
– Mercury from industrial waste in fish
– Lead in the water – Advanced glycation
endproducts (AGEs) from food preparation (overcooking)
– Polyaromatic hydrocarbons from charbroiled meat
– Trans fats – Naturally-occurring plant toxins
(e.g., aflatoxin)
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Include Clean, Nourishing Foods Eat foods which:
– Nourish the organs of detoxification (e.g., liver)
– Provide substrates and cofactors for optimal detoxification through cellular, hepatic, gastrointestinal, and renal mechanisms
– Modify genetic expression
– Provide phytochemicals that impact cellular signaling
©2014 The Institute for Functional Medicine
©2014 The Institute for Functional Medicine
Pattern Recognition
Undernourished
Reduce Exposures
Ensure a Safe Detox
©2014 The Institute for Functional Medicine
O T T G
Gather Oneself & Information
Organize on Timeline & Matrix
Tell the Patient’s Story
Order of your Priorities
Initiate Assessment and Care
O I
©2014 The Institute for Functional Medicine
Nutrition Assessments
PFC-MVP Biomarkers
Gather Organize Re-Tell
Order/Prioritize The ABCDs of
Nutrition Evaluation
Nutrition Therapeutic Interventions
©2014 The Institute for Functional Medicine
Nutrition Assessments
PFC-MVP Biomarkers
Gather Organize Re-Tell
Order/Prioritize The ABCDs of
Nutrition Evaluation
Nutrition Therapeutic Interventions
©2014 The Institute for Functional Medicine
Why is Food Important to
Your Patient’s
Detoxification Process?
Food Plays a Role in All Phases of Detoxification
Toxins In
Phase I Support
Phase I Protection
Phase II Support
Toxins Out
FOOD
O T T G
Gather Oneself & Information
Organize on Timeline & Matrix
Tell the Patient’s Story
Order of your Priorities
Initiate Assessment and Care
Track Progress
O I
CHANGING THE WAY WE DO MEDICINE, AND THE MEDICINE WE DO
www.functionalmedicine.org
©2014 The Institute for Functional Medicine
Attributions and Recognized Contributors to IFM Content Development
• IFM Medical Education Team
– Patrick Hanaway, MD, Dan Lukaczer ND • Functional Nutrition Development Team
– Elizabeth Boham, MD, Ruth Debusk PhD, RD, MS, Deanna Minich, PhD, Michael Stone, MS, MD, Barb Schiltz, MS, Mary Willis RD
• Staff at Institute for Functional Medicine • Faculty Contributors
– John Cline, MD, Kara Fitzgerald, N.D., David Jones, MD, Rick Mayfield, DC, CCN, Robert Rountree MD, Shilpa Saxena, MD
• Previous Contributors – Diana Noland, RD,MPH,CCN, Kathy Mahan, RD,
Linda Massey, RD, PhD, Alex Vasquez, DO, ND,DC