Integrative Nutrition in an Holistic

Family Practice Setting: Guiding Principles & Case

Studies

Ranan D. Cohen, MS, RD, LDN

Clinical nutritionist in private practiceHolistic Family Practice, Newbury MA

March 11, 2011

Holism: four dimensions

“ n. the view that an organic or integrated whole has a reality independent of and greater than the sum of its parts.”

(Webster’s dictionary)

This definition implies synergism, potentially applying to:

• the body/mind/spirit

• alternative therapies

•nutrients

•ecological systems

Nutrition Therapy as a “Recipe”

….Change several nutritional variables in combination, treating them as “ingredients” in a “recipe” designed to improve several categories of nutritional and health status together.

Example: Dairy elimination diet + improving legume intake + increasing sources of ALA + an improved multi (with a better balance of B vitamins) + pro-biotics.

Nutritional challenges• Suboptimal intake

• Malabsorption

• Depletional factors

• Food sensitivities

• Toxic/environmental exposure

• Iatrogenic

• Genetic

• Emotional-spiritual /Stress

FUNCTIONAL QUESTIONS

PLAN

Nutritional adequacy? Digestive efficiency?

Absorptive efficiency?Microbiological

balance?Detoxificationimprovement?

Suboptimal intake assessment

• Water/hydration

• Vitamin/mineral sources

• EFA/EPA/DHA sources

• Phytochemical sources

• Ancillary nutrient sources

• Fiber intake level

Fruit smoothieSpelt toast + butter

Salad Bar (field greens, carrots, other vegetables, cottage cheese, kidney beans, EVOO + balsamic + rosemary + garlic)

Chana masala over brown rice with mango lassi

Yogurt + fruit + whole-grain graham crackers

Whole-grain pancakes (include wheat germ + flaxmeal) + berries

Turkey sandwich (on whole grain with grass-fed turkey) + carrot sticks

Yogurt + cashews + banana + kiwi

Salmon + roasted red potatoes + broccoli salad+ Red Wine

Malabsorption factors• Insufficient enzyme and/or HCl secretion

• Insufficient emulsification (lecithin)

• Insufficient nutrient provision (B vitamins)

• Food allergy/intolerance/sensitivity

• Impaired mucosal integrity (probiotics; SCFA;

glutamine)

• Iatrogenic

Depletional factors

• Pregnancy/lactation

• Alcoholism

• Smoking

• Surgical-metabolic/disease/other stress

• Medications

• Pollution

• Intensive exercise

Symptom history (1)

• Angular stomatitis A, B2, B6, Fe, ?EFA

• Photophobia A, B2, B6

• Eyes irritated/invaded B2

• Bruise easily/gums bleed C, E, K, ?Fe

• Nose bleeds (frequent) K, C

• Poor wound healing A, C, Zn, Cu

• Exertional fatigue/stamina Fe, B2

• Coordination/ ataxia B12, fol, B1, B6

Symptom history (2)

• Cold extremities/poor circulation Fe, B3, E, C

• Pallor Fe, Cu

• Poor night vision Zn, A

• Decreased taste/smell sensation Zn, A

• Muscle cramping Mg, Ca, K+, E

• “Burning feet” Panto

• Brittle nails Ca/Mg, Folate, ?Si

• Dry skin/hair EFA, Zn, A

PAST MEDICAL HISTORY

HxETOH’ism

Hx Smoking

Diabetes/Hypoglycemia

Hypertension

Carpal Tunnel Syndrome

Hx Anemia (Did Fe help?)

Chronic Fatigue

Cervical Dysplasia

B1, Fol, B Complex, Zn, Mg

E/Se, Beta-Carot, C, Fol

Cr/B3, Zn, Cu, Mn

Ca, Mg, K+/Na+

B6/Mg, B2

Fe, Fol/B12, Cu, E, B6

Fe, Mg, Fol/B12, Pro, EFA

Fol, Beta-Carot, C

PAST MEDICAL HISTORY(2)

Hyperemesis Gravidarum

Fibrocystic Dx

Pre-menstrual Syndrome

“Restless Legs” Syndrome

Psoriasis

Acne Vulgaris

Hx Kidney Stones

Osteoporosis

B6, B2

E/Se, I-

Ca, Mg, GLA

E/Se, Fol, Fe, Ca, Mg

A, D, B6, B2, EFA

A, Zn, Se/E

Mg, B6

Ca/Mg, D, Cu, Mn, F-, B-

Available (& worthwhile) labs

• Ferritin/serum iron/TIBC

• Ionized calcium (& bone density)

• 24-hour urinary magnesium

• Serum B12

• Serum & RBC-folate

• Serum pyridoxine/RBC-pyridoxine/pyridoxal PO4

• Serum ascorbic acid

Available (& worthwhile) labs (2)

• Plasma retinol

• 25-hydroxy vitamin D

• Prothrombin time/INR

• RBC-EFA levels

Deborah - quick case history

• 36y.o --- s/p 3 pregnancies --- fatigue, anxiety, depression

• Pneumonia x 2; Anemia, including in preg.; Toxemia x 2

• Palpitations, dry skin, nails peeling, inability to focus

• No supplements; on Welbutrin

• TFT’s WNL; B12 - 315; ferritin, folate, MCV, H&H all WNL.

• Diet low in fruits, veg., legumes, EFA X2 and H2O.

• Therapeutic suggestions??

Deborah - quick case history

• Suggestions: Balanced, diversified menu

• Multi with B complex, trace minerals, etc. (DMF)

• B12 -- 1mg X 2; L-tyrosine -- 500mg (after med. d/c’d)

• “I felt the effect of the tyrosine”

• Suggestions all well-implemented

• Energy, skin, MH (except focus), palpitations all improved

• Plan discontin./resumption worsening/improvement

Food sensitivity: potential diagnostic connections

• Migraine • Eczema; Acne

• Sinus; Asthma; Bronchitis

• Arthritis

• IBS; IBD

• ADD/ADHD

• Auto-immune disease

Allergy/sensitivity symptoms

• Throat irritation/closure • Nausea/vomiting

• Hives/rash

• Headache

• Constipation/diarrhea/stomach ache/indigestion

• UR congestion/stuffiness

• Joint pain

Symptoms of Food AllergyGastrointestinal

ManifestationsAbdominal painNauseaVomitingDiarrheaGastrointestinal bleedingProtein-losing enteropathyOral and pharyngeal pruritus

Cutaneous ManifestationsUrticaria (hives)AngiodemaEczemaErythema (skin inflammation)Itching

Respiratory Manifestations

RhinitisAsthmaCoughLaryngeal edemaMilk-induced syndrome

with respiratory disease (Heiner’s syndrome)

Systemic ManifestationsAnaphylaxisHypotension

Controversial or Unproven Manifestations

Behavioral conditionsTension-fatigue syndromeAttention-deficit and

hyperactivity disorder (ADHD)

Otitis mediaPsychiatric disordersNeurologic disordersMusculoskeletal disordersMigraine headache

Common allergenic foods

• Cow’s milk dairy • Peanuts/Soy

• Tree nuts

• Crustaceans/Mollusks

• Fish

• Eggs

• Wheat

Taking a sensitivity history

• Check pediatric sensitivity history • Appropriate signs/Sx: GI, headache,

skin,etc.

• Take history by symptom category

• “Any other food/meal that…”

• Review prominent allergenic foods list

• Foods consumed > 1X/week

• Chronological comparisons

Shawn - quick case history

• 7 y.o --- 40 lb.; 40 “ --- eczema; food sensitivities; thirst

• Dry eyes, dry skin, with eruptions around flexure points

• Rash around anal area, exacerbated by antibiotic Rx

• Allergy testing (RAST) + for all tree nuts, peanuts, wheat, dairy, soy, shellfish, apple, egg white & beef. All eliminated without effect! FBS -- WNL.

• Reports reactions to: popsicles, skittles, gummy bears & gum balls, but still in diet!

• Diet low in vegetables, legumes; very low EFA X2 and

H2O.

• Therapeutic suggestions??

Shawn - quick case history

• Dietary plan: 1) Hypo-allergenic, balanced, diversified menu with immediate reintroduction trial for

wheat & beef; 2) inclusion of safflower oil and flax oil daily.

• Artificial additive sources excluded. Ensure adequate Ca/Mg.

• Pedi multi; GLA (100 mg.); Zn -7mg; Pro-biotic (5 bi. org’s)

• Results: Skin “about 90% resolved”, with minimalscratching of dry areas.

• Suggestions all well-implemented, except no pro-biotic and EFA introduced via flax only. Mother noticed regression

of skin problems without this food.

Therapeutic goals • Optimal digestive/absorptive capacity • Optimal biotic balance

• Optimal, diversified intake without food sensitivities

• Optimal genetic potential

• Optimal detoxification

• Optimal exercise

• Optimal spiritual-emotional wellness

Dysbiosis profile (1)• Poor fruit, vegetable and lean protein intakes

• Craves concentrated sugars, but ill-tolerates them

• Increasing pattern of food sensitivities over time

• IBS

• Hypoglycemic symptoms

• Chronic fatigue

• “Aching all over”

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Dysbiosis profile (2)

• Poor quality of sleep

• PMS symptoms • Antibiotics associated with yeast infection

• Antibiotics associated with GI symptoms

• Probiotic therapy/yogurt relieves GI and/or yeast challenges

Dysbiosis therapy • No concentrated sugars; no alcohol

• Garlic

• L. acidophilus (DDS1; NCFM; GG) • Bifidobacteria (infantis; longum; bifidum)

• Goldenseal; Oregon grape root; Barberry root

• Pau D’Arco

• Oregano; Grapefruit seed extract; Caprylic acid

• Prebiotic factors

Semi-volatile Organic Compounds in Adipose Tissue: Estimated Averages for the US

Population and Selected Subpopulations (Am. J. Public Health 1996; 86: 1253-1259)

• Objectives. The fiscal year (FY) 1986 Environmental Protection Agency National Human Adipose Tissue Survey (NHATS) was conducted to estimate average concentrations of 111 semi-volatiles in human adipose tissue within US general population and selected subpopulations.

• Results. Among polychlorinated biphenyls (PCBs), average concentrations for the group aged 45 and older were 188% to 706% higher than for the 0- through 14-year-old age group. Similar increases with age were observed for pesticides.

Lipotropic profile

• Poor fruit and vegetable intakes

• Indeterminate food sensitivity pattern; MCS

• IBS

• Mono /hepatitis/alcoholism hx

• Chronic fatigue

• Detox. profile abnormalities

• Liver function tests elevated

Jen - Case history (1)

• 33y.o. --- Rhematoid arthritis; fatigue (intermittent)

• Envir. allergies; Raynaud’s; migraines; PMS (mastalgia, mood).

• “Burning” sens. on top/front of feet; “restless legs”; gas/bloat.

• Multiple Sx w/ stress: memory, constip., sleep/energy ; “body ache”

• Family hx: mother allergic to wheat; migraine; rheum. arthritis

• ANA; H&H; CDSA -- + for dysbiosis, but fine for digestion.

• Relafen; Tavist-D; oc’s; 1-a-day; Cr-picol. (150mcg); Tums (2)

• Diet needs whole grains, legumes, fruit, CS, white flour, ALA.

• IDEAS/SUGGESTIONS SO FAR??

Jen - Case history (2)

IDEAS THUS FAR:

• Food group improvements (fruit, whole grain, ALA, etc.)

• Food sensitivity (fam. hx; migraine, fatigue, GI )

• B complex (multi), pantothenic acid, vitamin C, Mg (Tums) MORE FINDINGS (initial visits):

• Sensitivity to CS, coffee, corn, citrus shrimp, crab, soy & ?bread

• Elim./ challenge diet + for corn, tomatoes (joints); wheat remains.

• Joints reported to “feel better after a fish meal”

• AM joint pain decreases from 2 hours down to 20’.

Jen - Case history (3)

INITIAL STEPS TAKEN:

• Elimination/challenge trials: corn, tomato, dairy, pork, beef & coffee.

• Nutrient-dense diet with EFA X 2 & EPA/DHA.

• EPA/DHA, GLA, multi w/ B complex (TF2), Ca/Mg, Flush-free B3. MORE FINDINGS:

• Diet in EPA/DHA discomfort

• Change from TF2 to TheragranM decrease in energy

• Ran out of B3 joints felt worse; same for GLA.

• Trial GF diet more improvements (joints; GI)

Jen - Case history (4)

RECENT UPDATE:

• Pantothenic acid tried vs. “burning feet”: trial was +; d/c

return of Sx, and dose related to degree of symptoms. Also has influence on how joints feel.

• “Emergen C” reported poorly tolerated (hives)

• Oatmeal “rips through me” (GI), but GF oats well-

tolerated. • Pro-biotic therapy used when on antibiotics, with success.

• Combination of med (Humera currently), nutrient-dense (elimination) diet & supplements has proven very effective.

Traditional vs. optimal Rx

• Caloric balance + adjust CHO /Pro ratio

• Adequate protein + semi-vegetarian model

• 4 food groups + optimal whole grains, nuts,legumes,

fish, etc.

• Low-fat/SFA optimal EFA’s + EPA + GLA

• DRI/RDA/DV optimal vitamin/mineral intakes per

individual’s history

• Food allergy mgt. + food sensitivity mgt.

IBS profile #1

• Craving tomato /pasta dishes, corn chips, and feels they may not be well-tolerated

• Excellent dietary balance

• Adequate baseline supplementation

• IBS (approximately five days a week)

• Intermittent eczema

• Migraines (approximately three times a month)

IBS profile #2

• Craves concentrated sugars, but ill-tolerates them

• Poor fruit, vegetable and lean protein intakes • Increasing pattern of food sensitivities over time

• IBS

• Hypoglycemic symptoms

• Chronic fatigue

• “Aching all over”

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IBS profile #3

• Excellent dietary history/food group balance

• Adequate baseline supplementation

• Weight stable

• IBS

• Poor energy and sleep

• Recently divorced

• Peri-menopausal

IBS profile #4

• Poor fruit and vegetable intakes

• Indeterminate food sensitivity pattern

• IBS

• Mono /hepatitis/alcoholism hx

• Chronic fatigue

• Detox profile abnormatlities

• Liver function tests elevated

Anti-inflammatory Nutrition

• Essential fatty acids (LA & ALA) • Herbs & spices (licorice, ginger, turmeric, rosemary)

• Fish & fish oils (EPA/DHA)

• Gamma linolenic acid (GLA)

• Saturated fat

• Weight management

• ? Mind-body

Toxic metal profile• ?Metallic taste

• ?Headache

• ?Hypertension

• ?Bone/muscular/joint pain

• ?Fatigue/malaise

• Pediatric history

• Occupational history

• Hair, urine, blood analysis

Toxic/environmental exposure

• Lead, cadmium, mercury (Ca, Zn, Se; ?chelation)

• Chemical/occupational exposure (detoxification)

• Air/other pollution (E/Se, C, antioxidants)

• Environmental allergens (Nettle extract)

• Pesticides, etc. (Organic foods)

• Food additives/food poisoning

• Food allergens (Elimination/rotation)

• Iron (Ca, whole wheat & rye)