Functional Medicine Functional The Systemized Approach ...

2008© 2010

Functional Medicine The Systemized Approach to Fibromyalgia

Functional Medicine The Systemized Approach

Using a Case study of Fibromyalgia

© 20102

Be open minded, but not so open minded that your brains fall out.

Groucho Marx

© 201016 © 20106

Functional Medicine Key Components

➢ A Continuum of Health & Wellness ➢ Balance ➢ Biochemical Individuality

➢ Personalized Treatment

➢ InterConnection

Dean Ornish, MD 2010

FIBROMYALGIA

© 20106




➢ InterConnection

Balance

Balance© 201010




➢ InterConnection

© 201013

“You”

“Phenotype”

© 201015




➢ InterConnection

© 201017

Personalized Medicine

• Integrating the cutting edge, science-based tools of diagnostic medicine • Looking ‘upstream’ to assess and treat the underlying causes of illness • Individually tailored therapies to restore health and improve function.

© 201018

Personalized Diagnostics

To create an understanding of balance in the human body we look @: • Hormones, chemicals, minerals, metabolites • Body fluids (blood, urine, stool, saliva, DNA) • Inter-relationship of these compounds in optimally healthy people

We compare an individual with the optimized norm and give recommendations to bring the person to balance.

© 201019

Personalized Treatment• Risk assessment, not disease detection

• Early changes in biochemical balance are evaluated and treated (vitamins, minerals, nutrition, lifestyle changes, drugs, etc.) before the onset of disease

• Identify and correct imbalance in an individual – “powerful medicine” at the heart of personalized medicine

Hea

lth

Stat

us

© 201022

Time

EVENTS

The Prevention Process

HEALTH

SYMPTOMS

DIS–EASE

© 201023




➢ InterConnection

© 201025

The Web of InterConnections . . . Defense & Repair

Energy Regulation

Biotransformation

Transportation

Assimilation

Structural Imbalance

Communication

Biotransformation & Elimination (e.g., Toxicity, Detoxification)

Energy(e.g., Energy Regulation, Mitochondrial Function)

Communication (e.g., Endocrine, Neurotransmitters, Immune messengers)

Defense & Repair (e.g., Immune, Inflammation, Infection/Microbiota)

Structural Integrity (e.g., from Subcellular Membranes to Musculoskeletal Structure)

Assimilation (e.g., Digestion, Absorption, Microbiota/GI, Respiration)

Antecedents (Predisposing Factors- Genetic/Environmental)

Triggering Events (Activators)

The Patient’s Story Retold

Exercise &Movement

Nutrition & Hydration

Physiology and Function: Organizing the Patient’s Clinical Imbalances

Mediators/Perpetuators (Contributors)

e.g., cognitive function, perceptual patterns

e.g., emotional regulation, grief, sadness, anger,

etc.

e.g., meaning & purpose, relationship with something greater

Sleep & Relaxation Stress & Resilience Relationships &Networks

Spiritual

Transport (e.g., Cardiovascular, Lymphatic System)

Personalized Lifestyle Factors

Endo-toxicity Defense & Repair

Energy Regulatione.g., emotional

ToxicityBiotransformation & Elimination (e.g., Toxicity, Detoxification)

Energy (e.g., Energy Regulation, Mitochondrial Function)

Exercise & Movement

Fundamental Lifestyle FactorsNutrition & Hydration

Physiology and Function: organisingthe Patient’s Clinical Imbalances Assimilation (e.g., Digestion, Absorption, Microbiota/GI, Respiration)


regulation, grief, sadness, anger, etc.

Sleep & Relaxation

Name:____________________________Date:___________CC:_____________________________________

Stress & Resilience Relationships & Networks

Structural Integrity

Communication


Antecedents

Family History of CVD, T2DM, Depr, Dementia, Cancer


•Stress •Sugar

Modifiable Lifestyle Factors for Clinicians Using the Functional Medicine Model


Spiritual

Transport

•High GI/GL Foods •Sedentary Behavior

Mediators/Perpetuators •Visceral Adipose •Inflammation •Insulin•Cortisol •Toxins

3

Functional Medicine Systemized Approach

GO TO IT

O T TG

Gather Oneself & Information Organize on Timeline & Matrix Tell the Patient’s Story Order of your Priorities Initiate Assessment and Care Track Progress

O I

Definitions:

• Timeline: a form used to plot all information from prebirth to

current status

• Matrix: a form used to gain a quick perspective of all imbalances

• 7 Biological Systems: are systems that make up the physiological

functioning of the body

• Antecedents: are factors, genetic, orn acquired that predispose an

individual to an illness or pattern

• Triggers: are factors that provoke the symptoms and signs of illness

• Mediators: are factors, biochemical or psychosocial that contribute

to pathological changes and dysfunctional responses

Case Study: Joan (Fibromyalgia)

SUMMARY • Age 45 female caucasian

• Long history of fatigue, anxiety, lethargy, multiple tender points, depression, achy

stiff joints and muscles.

• Dx: 10 yrs ago with fibromyalgia

• Medications: Cymbalta, Lyrica (feels drowsy most of the time)

• 3 Teenage Kids

• High stress

• Enjoyed exercise in early adulthood then slowly less until none by age 34

• Multiple antibiotics in teens and 30’s

• Increased weight, initially around hips then waist too, now 185 lbs

• Insomnia worse last few years, difficulty falling asleep

• Family hx: Mother Ra in 40’s, diabetes age 35; Father colon cancer age 58

• Mercury Amalgams

Prec

once

ptio

n

Pren

atal

CurrentConcerns

Antecedents

Triggers or TriggeringEvents

Signs, Symptoms or Diseases Reported

Birth

7-10

Multiple antibiotics

13-15

Severe Acne

3545

Asthma; Increased depression and Fatigue Resistant Weight LossHeadaches

40

Achy muscles joint, Dx FibromyalgiaIncreased stress Severe Fatigue Developed

Chronic Antibiotic use for years; 2wks of every month and a half

3 Children born; at ages of 25, 27, 29

22-30

Dx: Dysbiosis & Hypothyroidism

LMP

43

Mother: dx diabetes RAFather: Colon cancer

Biotransformation & Elimination

Communication

Defense & Repair


AssimilationAntecedents

Triggering Events


Relationships & Networks Exercise & Movement

Personalized Lifestyle FactorsNutrition & Hydration


Mediators/Perpetuators

Mental

Spiritual

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________

Emotional

Transport

Stress & Resilience

Energy

MATRIX


ENERGY

Communication

Defense & Repair



Triggering Events






Mental

Spiritual

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________

Emotional

Transport

Stress & Resilience

Fatigue, lethargy, Chronic Muscle pain Organic acidsMATRIX

Gather Case Study: Joan - MSQ & Organic acids


ENERGY

Communication

Defense & Repair



Triggering Events






Mental

Spiritual

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________

Emotional

Transport

Stress & Resilience

Increased BMI Waist / hip circumference Incr fat % Incr BMI Cell membrane

Fatigue, lethargy, Chronic Muscle pain Organic acids

Nutrition PE & Lab RequestAnthropometrics

Biomarkers and Functional Labs (POMFAB)

Clinical Indicators from Nutrition Physical Exam

Diet and Lifestyle Assessment

Defining Body Composition: Pattern Recognition

OVER Weight

Gynoid Obesity

overfat OVER SAT Subcutaneous

Adipose Tissue

overfat OVER VAT

Visceral Adipose Tissue

Android Obesity

Using Waist CircumferenceCountry/Ethnic Group GenderEthnic South/Central America South Asians‐Chinese, Malay, Asian‐ Indian.

Male

Waist Circumference‐Increased Health risk>90 cm >35.5 inches

Chinese, Japanese

Europids, Sub‐Saharan African, Eastern Mediteranean, Middle East(Arab) populations

Female Male Female Male

>80 cm>90 cm>80 cm>94 cm

>31.5 inches>35.5 inches>31.5 inches>37 inches

USA

Female Male Female

>80 cm>102 cm>88 cm

>31.5 inches>40 inches>35 inches

Alberti KGMM, P. Zimmet P, Shaw J : Metabolic syndrome—a new world‐wide definition. A Consensus Statement from the International Diabetes Federation Diabet. Med. 23, 469–480 (2006)

Body Composition Assessment

Fat Mass % Male FemaleAge 20‐39 8‐13 17‐21Age 40‐59 11‐16 19‐23Age 60‐79 13‐18 24‐31

Male FemaleBMI‐ Overweight

>25 >25

Obese >30 >30

US‐non ethnic Male FemaleWaist Circumference >40 in

102 cm>35 inches 88 cm

Waist/Hip >0.9 >0.8

JOAN: 185 lbs BMI: 35 Waist: 40inches Hip: 45 Inches WHR: 0.9 Fat %: 38

Gather Case Study: Joan - ANTHROPOMETRICS


ENERGY

Communication

Defense & Repair



Triggering Events






Mental

Spiritual

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________

Emotional

Transport

Stress & Resilience



Fatty acid profile MSQ 114 Low Omega 3 index High ox stress ( lipid peroxidase)

Genes Polymorphisms which render individuals with different susceptibilities

Function Shifts physiologic state into “alarm” reaction characterized by inflammatory process

Symptoms of Inflammation

-osis becomes -itis with increasing severity

©2017 The Institute for Functional Medicine

NF‐κB binds to DNA, leading to activation

of…..

Leukotrienes Prostaglandins

NF‐κB Activated

Inflammatory Trigger

CyclooxygenaseLipoxygenase

TNF, IL1, IL6

Biologics Rituximab

Etanercept, Etc.

Less inflammatory eicosanoids


Flax, walnut, canola, soy, chia, hemp

Sunflower, safflower, peanut, most vegetable oils

Borage, black currant seed, evening primrose

Animal fat, dairy, shellfish

Linoleic acid (LA) 18:2n‐6

Alpha‐linolenic acid (ALA) 18:3n‐3

Delta‐6‐desaturase (Inhibited by age.

alcohol)

Delta‐6‐elongase

Delta‐5‐desaturase (up‐

regulated by insulin)

Beta Oxidation

Eicosatetraenoic acid 20:4n‐3

Eicosapentaenoic acid (EPA) 20:5n‐3

Docosapentaenoic acid 22:5n‐3

Docosahexaenoic acid (DHA)

22:6n‐3

Docosapentaenoic acid 22:5n‐6

Adrenic acid 22:4n‐6

Arachidonic acid (AA)

20:4n‐6

Gamma‐linolenic acid (GLA)

18:3n‐6

Dihomo‐gamma‐ linolenic acid 20:3n‐

6

Stearidonic acid 18:4n‐3

Delta‐5‐elongase

Cold water fish, wild game, enriched eggs

Omega 6 Familyvegetable oils, grains

Omega 3 FamilyCold water fish, flax oil

Inhibition


Lipoxins (anti‐inflammatory)

More inflammatory eicosanoids

Cold water fish, wild game, enriched eggs, algae

Retro conversion

Retro conversion

Gather Case Study: Joan - Genetics & Organic acids Gather Case Study: Joan - Genetics & Organic acids


ENERGY

Communication

Defense & Repair



Triggering Events






Mental

Spiritual

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________

Emotional

Transport

Stress & Resilience




High MSQ 114 Genetic deletions Low glutathione

Types of Reactions

PHASE ICytochrome P450 enzymes:

Oxidation Reduction Hydrolysis

Water‐ Soluble

Compound

PHASE IIGlucuronosyl Transferase (UGT) Sulfo‐transferases (SULT) Amino Acid Conjugation Glutathione Conjugation Acetylation Methylation

Parent Compound

Activated Intermediate

Imbalanced Detoxification

Phase I CYP P450 Phase II

Conjugation

Damage to DNA, RNA, Proteins

Reactive IntermediateNon‐Polar Xenobiotic Inert Water‐

Soluble Metabolite

Gather Case Study: Joan - Genetics & Organic acids

Gather Case Study: Joan - Genetics & Organic acids


ENERGY

Communication

Defense & Repair



Triggering Events






Mental

Spiritual

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________

Emotional

Transport

Stress & Resilience





Dysbiosis Constipation GERD Organic acids High Elastase

Mother: RA, diabetes

Father: Cancer

3rd child birth

Loss of father

Stress Insomnia Sedentary High simple sugar diet

Insomnia 10 hrs sleep Not refreshed

None Skips breakfast Low protein / high carb 3 cups coffee

Takes B vitamin

High

NO relaxation tech

Marriage rated fair Has good friends Good relation with Mother

Energy

Transport

Defense and Repair


Communication

Detoxification & Biotransformation

Assimilation

Properly Functioning

Gastrointestinal Ecosystem

DIG

IN

Digestion / Absorption

Intestinal PermeabilityGut microbiota / DysbiosisImmune Modulation/Inflammation

Nervous System

Key Functional Roles & Aspects of the Gut

Impairments in Digestion and Absorption

• Inadequate mastication • Hypochlorhydria • Pancreatic insufficiency • Bile insufficiency • Brush Border Injury

Brush Border injury

Gather Case Study: Joan - MSQ & Organic acids


ENERGY

Communication

Defense & Repair



Triggering Events






Mental

Spiritual

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________

Emotional

Transport

Stress & Resilience







Father: Cancer

3rd child birth

Loss of father


Insomnia 10 hrs sleep Not refreshed

None Skips breakfast Low protein / high carb 3 cups coffee Takes B vitamin

High

NO relaxation tech


Suppressed 24 hr cortisol Light sleeper Irritability Depression

Gather Case Study: Joan - Stress Q & Salivary 24 hr Cortisol


ENERGY

Communication

Defense & Repair



Triggering Events






Mental

Spiritual

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________

Emotional

Transport

Stress & Resilience







Father: Cancer

3rd child birth

Loss of father


Insomnia 10 hrs sleep

Not refreshed


Takes B vitamin

High

NO relaxation tech



Apo E4 Poor lipid profile

Total Toxic Load

Gather Case Study: Joan - Genetics & Mercury Amalgams


ENERGY

Communication

Defense & Repair



Triggering Events






Mental

Spiritual

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________

Emotional

Transport

Stress & Resilience







Father: Cancer

3rd child birth

Loss of father



Not refreshed


High

NO relaxation tech




Gather Case Study: Joan - Self Care questionnaire

Gather Case Study: Joan - Sleep questionnaire

Tips for getting a goodnight’s sleep! 1. Maintain a regular sleep schedule. 2. Establish a regular, relaxing bedtime routine. 3. Create a sleep-conducive environment. 4. Sleep on a comfortable mattress and pillows. 5. Finish eating at least 2-3 hours before bedtime. 6. Exercise regularly. 7. Avoid caffeine, nicotine and alcohol close to bedtime. 8. Keep a sleep diary!

National Sleep Foundation

(www.sleepfoundation.org)


ENERGY

Communication

Defense & Repair



Triggering Events






Mental

Spiritual

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________

Emotional

Transport

Stress & Resilience







Father: Cancer

3rd child birth

Loss of father



Not refreshed


High

NO relaxation tech




Exercise and Staying in Motion…

Walking / Jog for 30 min 3 times per week. Specific Autonomic Stretching routine 20 min before bed 3 per week 15 min Body weight program working large muscle groups


ENERGY

Communication

Defense & Repair



Triggering Events






Mental

Spiritual

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________

Emotional

Transport

Stress & Resilience







Father: Cancer

3rd child birth

Loss of father



Not refreshed


Takes B vitamin

High

NO relaxation tech





Energy (e.g., Energy Regulation, Mitochondrial Function)








Exercise & Movement Nutrition &Hydration




e.g., cognitive function,perceptual patterns

e.g., emotional regulation, grief,

sadness, anger, etc.

Sleep & Relaxation

Name:____________________________Date:___________CC:_____________________________________

Spiritual

Circulation (e.g., Cardiovascular, Lymphatic

System Fluid Balance)

Personalized Lifestyle FactorsStress & Resilience Relationships & Networks

Elimination diet To Maintainance Detox Food Plan


ENERGY

Communication

Defense & Repair



Triggering Events






Mental

Spiritual

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________

Emotional

Transport

Stress & Resilience







Father: Cancer

3rd child birth

Loss of father



Not refreshed


High stress with teenagers

NO relaxation tech

Highly strung personality




Balance

Balance

JOAN:

FREE MEDITATION APPS: OMVANA

USE IN BED INSTEAD OF TV / FACEBOOK

Initiate Case Study: Joan - Restoration Prescription


ENERGY

Communication

Defense & Repair



Triggering Events






Mental

Spiritual

Sleep & Relaxation

Name:____________________________ Date:___________ CC:_____________________________________

Emotional

Transport

Stress & Resilience







Father: Cancer

3rd child birth

Loss of father



Not refreshed


High stress with teenagers

NO relaxation tech

Highly strung personality




Healthy Relationships

(e.g., Energy Regulation,









Exercise & Movement Nutrition & Hydration





regulation, grief, sadness, anger, etc.

Sleep & Relaxation

Name:____________________________Date:___________CC:_____________________________________© Copyright 2011Institute for Functional Medicine

Stress & Resilience Relationships & Networks

Spiritual

Transport (e.g., Cardiovascular, Lymphatic System)

Personalized Lifestyle Factors

e.g., emotional EnergyMitochondrial Function)

Case Study: Joan (Fibromyalgia)

SUMMARY PLAN OF CARE • Focus to restore mitochondrial health ( reassess using organic acids at 6 months)

• Reduce MSQ to below 30 ( from 114), reassessed every 30 days

• Elimination diet Plus 5R Program

• Sleep hygiene optimization

• Exercise routine customized to Functional Metabolic Threshold

• Relaxation techniques: ANS stretch routine and meditation app prior to bed

• Mercury amalgams removed

• Supplements to support gut health, inflammation, oxidative stress, mitochondrial

health, detox and methylation

• Gratitude journal

• Manual therapy, ANS techniques, acupuncture, myofascial release techniques

• Low dose DMSA (250mg) to remove mercury and lead initiated after MSQ under 50 and

gut health optimal (monitored by FM physician)

• No more meds

Cellular Energy andMitochondrial Function

Cellular Energy andMitochondrial Function

Lipoic Acid

SUPPORTING THE MITOCHONDRIAL ETC

Organic acids: Real time mitochondrial function

Gather Case Study: Joan - 6 months later


NO

Increased WC?

Increased BIA Fat%?

YES

Abnormal High BMI?

YES

Dx:OverFatYESYES

Gut/Detox/HPATGG dysfunctions?

Assessing Body Composition

YES

NO YES

NO

Increased WHR?

TLC Nx/ Rx

NO

Increased WC or WHR?

YES

NO

Increased BIA Fat%?

NO

NO

Increased WHR?

Increased BIA Fat%?

Metabolically Obese (OverVAT)

YESNO

Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle MassObesity/ Obese or Athlete overSAT

Gynoid Possible HighObesity/ Muscle Mass overSAT or Large

Skeletal Frame

Increased BIA Fat%?

Dx:Overweight/Obese

MetSyn?

Dx:OverVAT

YES

Android Obesity (OverVAT)

YES

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