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

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.

FUNCTIONAL MEDICINE addresses the underlying causes of disease, using a systems-oriented approach and engaging both patient and practitioner in a therapeutic partnership.

Functional Medicine Operating System

for Identifying Toxicity Concerns

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

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

Gathering Key Detox Information

Advanced Detox Assessment

The Functional Medicine

Timeline

Age Birth

Signs, Symptoms or Diseases Reported

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.

Functional Toxicology Triggers

Genomic Predisposition

Mediators

Chronic Disease

Toxins

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

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

Mn Pesticides

As Pb Hg PCBs

Source: IFM Toolkit

Potential Associations between Toxins & Diseases

ATMs Antecedents, Triggers, and

Mediators in Case Evaluation

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

Antecedents

Triggers or Triggering Events

Mediators/Perpetuators

The ABCDs of Functional Nutrition Evaluation

(Identifying Detox Related Nutrition Concerns)

Dr. Michael Stone

Anthropometrics Biomarkers & Labs Clinical Indicators Diet and Lifestyle Assessment

The ABCDs of Functional Nutritional

Evaluation

Context Company

Quality

Quantity

ABCD of Nutrition Evaluation

-Anthropometrics -Biochemical Markers -Clinical Findings -Diet Evaluation

Anthropometrics

Possible High Muscle Mass

or Athlete

Increased BIA Fat%?

Abnormal High BMI?

YES YES YES

Gut/Detox/HPATGG dysfunctions?

Assessing Body Composition

NO YES

Ideal Skinny Fat or Metabolically

Increased WHR?

TLC Nx/ Rx

Increased BIA Fat%?

Increased WHR?

Increased BIA Fat%?

Metabolically Obese

(OverVAT)

YES NO

Gynoid Obesity/ overSAT

or Large Skeletal Frame

Increased BIA Fat%?

Android Obesity (OverVAT)

MetSyn?

>25 Overwt >30 Obese

Dx: OverFAT Dx:OverVAT or OverSAT Dx: Overweight

Increased WC?

Increased WC or WHR?

Environmental Toxins Affect Obesity

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.

Abdominal Obesity>Inflammation >Cardiometabolic Syndrome>CVD

Anthropometrics

Biomarkers and Functional Labs (PFC-MVP)

BioMarkers and Functional Labs

B O H Y

T D O I L R

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

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.

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.

Higher V.A.T. = Higher Glucose and Insulin

Clinical Indicators from Nutrition Physical Exam

Anthropometrics

Diet and Lifestyle Assessment

Clinical Indicators from Nutrition Physical Exam

Anthropometrics

Diet, Nutrition, and Lifestyle

Journal

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

The Functional Medicine

Matrix

Biotransformation & Elimination

(e.g., Toxicity, Detoxification)

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)

Nutrition Evaluation

Functional Nutrition

Case Based Learning

O T T G

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

Weight Gain/Inc Waist Circ Hypertension Dyslipidemia

Fatigue/Reduce Stamina

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

or Athlete

Increased BIA Fat%?

Abnormal High BMI?

YES YES YES

Gut/Detox/HPATGG dysfunctions?

Assessing Body Composition

NO YES

Ideal Skinny Fat or Metabolically

Increased WHR?

TLC Nx/ Rx

Increased BIA Fat%?

Increased WHR?

Increased BIA Fat%?

Metabolically Obese

(OverVAT)

YES NO

Gynoid Obesity/ overSAT

or Large Skeletal Frame

Increased BIA Fat%?

Android Obesity (OverVAT)

MetSyn?

Dx: OverFAT Dx:OverVAT or OverSAT Dx: Overweight

Increased WC?

Increased WC or WHR?

O T T G

Nutrition Assessments

PFC-MVP Biomarkers

Gather Organize Re-Tell

Order/Prioritize The ABCDs of

Where’s the Ink?

Pattern Recognition

Undernourished

Reduce Exposures

Ensure a Safe Detox

Pattern Recognition

Undernourished

Reduce Exposures

Ensure a Safe Detox

TOTAL TOXIC LOAD equals

Total Toxic Exposure minus

Ability to Detoxify and

Eliminate Toxins

Where’s the Ink?

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

Pattern Recognition

Undernourished

Reduce Exposures

Ensure a Safe Detox

Functional Nutrition

Macronutrients

Micronutrients & Phytonutrients

Pattern Recognition

Undernourished

Reduce Exposures

Ensure a Safe Detox

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

• 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

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)

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

Pattern Recognition

Undernourished

Reduce Exposures

Ensure a Safe Detox

O T T G

PFC-MVP Biomarkers

Nutrition Therapeutic Interventions

PFC-MVP Biomarkers

Nutrition Therapeutic Interventions

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

O T T G

Track Progress

CHANGING THE WAY WE DO MEDICINE, AND THE MEDICINE WE DO

www.functionalmedicine.org

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

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