p 2 collaborative of wny, inc october 7, 2010 sylvia h. regalla,...
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P2CollaborativeofWNY,IncOctober7,2010
SylviaH.Regalla,MD,MSACN,ABIHMSanfordH.Levy,MD,FACP,ABIHM
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HolmanH.JAMA2004;292:105(ProfessoratStanfordMedicalSchool)
ChronicDisease‐theNeedforaNewClinicalEducation“Itisaxiomaticthatmedicaleducationshouldpreparestudentswellfor
theclinicalproblemstheywillfaceintheirfuturepractice.However,thatisnothappeningforthemostprevalentprobleminhealthcaretoday:chronicdisease.”“Chronicdiseasereplacedacutediseaseasthedominanthealthproblem.Chronicdiseaseistheprincipalcauseofdisabilityanduseofhealthservicesandconsumes78%ofhealthexpenditures.”
Themodelwehavetodayisoutofdate!!
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StangeKC.AnnalsofFamMed.2006TheFutureofFamilyMedicineReport‐callsfora“NewModelofCare”thatisgroundedintimelessvaluesofpersonalized,patient‐centeredcare,coupledwiththeapplicationofnewtechnologicalsystems.
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FunctionalMedicine Healthcareforthe21stcentury Addressestherootcauseofchronicdisease Stopstreatingsymptomsandstartstreatingtheunderlyingcausesofchronicdiseases
Thefundamentallawsofbiologyarethedriversofdisease
Inreality–thebodyisoneintegratedwholesystem
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Thereareunderlyingphenomenathatinteractacrossallmedicalsubspecialtieslike:inflammation,oxidativestress,energyproblemsofthecellsfromabnormalmitochondrialfunction,ortoxicity
Functionalmedicineisthebridgethatconnectsthedotstogetthewholestoryofmedicalscience
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Thedifferencebetweenconventionalmedicineandfunctionalmedicineisinthedetails
Example:patientwithinflammationcausedbyautoimmunedisease Conventionalapproach‐“youhaveaninflammatorydiseasesowe’llsuppresstheinflammation”–soitshutsdown,locksdownnormalphysiologytotrytostoptheprocess
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Functionalmedicineapproach–whyisthisinflammationhappeninginthefirstplace?
Theapproachisinchangingthetriggers–poordiet,stress,environmentaltoxins
Conventionalmedicineisinterestedinsymptomsandnamingthediseasewithadiagnosisthenmatchingthedisease/diagnosiswithadrug
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Howdoesfunctionalmedicinechangethewaywetreatapatient? Functionalmedicinepractitionersuseadifferentsetoftoolsintheirtoolboxtotreatthecauseofdisease
Diet Thecauseofheartdiseaseaswellasthetreatmentforreversingheartdisease
Dietmaycauseinflammationofthebloodvesselwall Placingapatientonalowcholesterol,Mediterraneandietwithplentyoffishoilmayreversetheplaque
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Anautoimmunediseasefromgluten(wheat)sensitivitymaycauseaninflammatoryjointdiseaseandplacingapatientonaglutenfreedietwillimprovethesymptoms. Weremovedthecauseoftheinflammatoryjointdisease
Apatientmayhaveenvironmentaltoxinexposurewhichisdrivingpoormitochondrialfunctionleadingtobraindysfunction,functionalmedicinepractitionershelpthebodyremovetoxinsbysupplyingthedetoxificationmaterials
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Functionalmedicinepractitionersusethesameconceptsofscienceinmedicinebutrestructurethemtoaddressthetreatmentofthecauseofthediseaseratherthanjustaddressingthesymptomsofdisease
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SenatorTomHarkinappointedagroupofFunctionalMedicinepractitionerstothePresident'sAdvisoryGrouponPrevention,HealthPromotion,andIntegrativeandPublicHealthtoadvisetheadministrationinJune2010.FunctionalMedicinepractitionersparticipatedintheWhiteHouseForumonPreventionandWellnessin2009aswellastestifiedbeforetheSenateWorkingGroupofHealthCareReform.
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ChallengingPatients
Don’talwaysfitconventionalICD#9diagnosis
Multi‐systemsymptoms
Varyingduration
Failuretorespondtoconventionaltherapies(pharmaceuticals,surgery)
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ChallengingPatients
Theproblemisusuallynotalackofclinicaldata
Sometimesinformationmustbeorganizedinadifferentcontext,usingadifferentparadigm
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ChallengingPatients
Context:Arrangingthefilecardsdifferently
Paradigm:Changingourfocusandseeingtheforestinsteadofthetrees
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ConventionalClinicalApproach
Disease‐centered
Thetherapeuticregimeisemployedprimarilytosuppresssignsandsymptomsofanillness
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FunctionalMedicineClinicalApproach
Functionalmedicineisascience‐basedhealthcareapproachthatassessesandtreatsunderlyingcausesofillnessthroughindividuallytailoredtherapiestorestorehealthandimprovefunction.
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FunctionalMedicineClinicalApproach
Antecedents‐‐Geneticpredisposition
Triggers‐‐Toxins,hormonalimbalance,immunologicalstresses
Mediators‐‐Cytokines,prostaglandin,leukotrienes
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FundamentalKeyFactorsofFunctionalMedicine
Biochemicalindividuality
Interdependenceoforganfunction
Homeodynamic(seekstoreestablishstructural,physiologicalandcognitivebalance/function)
Patient‐centered
Viewshealthasacontinuum
Healthasapositivevitality
Healthismorethantheabsenceofdisease
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PillarsofFunctionalMedicineEvaluationandTreatment
NutritionalStatus Inflammation/ImmuneDysregulation GastrointestinalFunction HepaticDetoxification MitochondrialFunction&OxidativeStress EndocrineFunction
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NutritionalStatus
Deficiencyversusinsufficiency
Interrelationshipsofnutrients(synergists,antagonists,rate‐limitingstepinenzymaticreactions)
Relationshipofnutrientstophysiologicfunction
• Conditionallyessentialnutrients
• Cellularcommunication(nutrientsthatfunctionasinter/intracellularcommunicators)
• Diet/lifestyle
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Energy Production/ Oxidative Redux
The Functional Medicine Matrix A Question of Balance
Immune & Inflammatory Balance
Hormonal & Neuro- Transmitter Balance
Mind & Spirit
Structural Balance
Detox & Biotransformation GI Balance
Environmental Inputs (Diet, Nutrition, Exercise)
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Cardiology Pulmonary
Endocrinology
Gastroenterology
Neurology
OrganSystemDiagnosis
Urology/Nephrology
Hepatology
AllergySignsandSymptoms
Diet,Nutrients,Air/Water
Psycho‐social
EnvironmentalInputs
PhysicalExerciseTrauma
XenobioticsMicro‐organisms&Radiation
FundamentalClinicalImbalancesHormonalandNeurotransmitterImbalances
RedoxImbalance+OxidativeStress+Mitochondropathy
Detox/Biotransformation/ExcretoryImbalanceImmuneImbalance
InflammatoryImbalanceDigestive/AbsorptiveandMicrobiologicalImbalance
StructuralIntegrityImbalance
1.Communication ‐Outsidethecell ‐Insidethecell
2.Bioenergetics/EnergyTransformation3.Replication/Repair/Maintenance/
StructuralIntegrity
4.EliminationofWaste5.Protection/Defense6.Transport/Circulation
FundamentalPhysiologicalProcesses
MindandSpirit
GeneticPredispositionExperiences,Attitudes,Beliefs
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Inacutecare,thepatient’sstoryissqueezeddownto
thechiefcomplaintandhistoryofthepresentillness
whilethediagnosisincreasesinimportance.
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Example#1ChiefComplaint:
Wheezing
Diagnosis:AsthmaAttack
bronchodilators corticosteroids
tightnessinthechest
suddenonset
asthmatichistory
shortnessofbreath
HistoryofPresentIllness
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Hypercholest‐erolemia
Statin
GastroesophagealRefluxDisease
H2blocker
Depression
SSRI
HypertensionACE
inhibitor Migraines Triptan
Osteoarthritis
NSAID
IrritableBowelSyndrome
Dicyclomine
Eachindividualdiagnosisbecomesa
distinctentityuntoitself.Thepatient’swholestory
neverhasachancetobeheardandunderstood
Incontext.
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Hypercholes‐terolemia
Statin
GastroesophagealRefluxDisease
H2blocker
Depression
SSRI
HypertensionACE
inhibitor Migraines Triptan
Osteoarthritis
NSAID
IrritableBowelSyndrome
Dicyclomine
…theresultisafocusontreatingeachsymptomcomplexasa
separateanddistinct“disease”withaseparateanddistincttreatment.
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Exercise
AcupunctureManipulativeTherapies
Phytonutrients
Minerals
Vitamins
Diet
Yoga
Drugs
Surgery
Counseling Meditation
PsychologicalandSpiritual
Equilibrium
HormoneandNeurotransmitterRegulation
DetoxificationandBiotransformation
StructuralIntegrity
ImmuneSurveillance
Digestion,Absorption,andBarrierIntegrity
OxidativeReductive
Homeodynamics
InflammatoryProcess
Infectiousmicro‐organisms
Structuralorphysicaldamage
Nutrientinsufficiency
Xenobiotics
Radiation
Emotionaltrauma
Spiritualangst
Nutrientexcess
Foodtoxicants(allergens,stimulants
etc,)
Drugsideeffects
Adiposity
Toxicmetals
Aging
Geneticpre‐disposition(SNPs)
Disruptedlightcycles–circadian
dysrhythmias
Hyperglycemia
Hypoglycemia
Excessiveexercise
Excessivenoise
Situationalstress–fear,anxiety,worry
Dysbiosis
Thefunctionalmedicinemodelrecognizesand
prioritizesthepatient’sfull,uniquestoryand
usesfundamentalclinicalimbalancesasakeytotreatingcomplex,
chronicillness.
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Withoutacomprehensiveintegratedmodelforthecareofchronic,complexillnesses,
practitionersleavetheirpatients’healthcareneedsunfulfilled.