FUNCTIONAL MEDICINE Theory and Practice

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FUNCTIONAL MEDICINETheory and Practice

• Susan G. Pickrel, MPH, M.D.
• GOBHI Conference 5/18/2012

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About Me

• Trained in public health with MPH at University
  of Rochester Medical School, Rochester, NY, 1983
• Trained in medicine and then adult and child and
  adolescent psychiatry post graduate training at
  the Medical University of South Carolina (MUSC),
  Charleston, S.C., 1984 1993
• On faculty and worked within the Family Services
  Research Center at MUSC doing clinical research
  with multisystemic therapy (MST), an ecological
  based intervention, 1993-2000
• Clinical inpatient and outpatient practice, last
  6 years in community mental health center,
  2000-2012

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Disclosures

• Board certified Child and Adolescent Psychiatrist
• Medical Director Child and Adolescent Services at
  Douglas County Mental Health Center, Roseburg
• Oregon
• No disclosures

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Why Functional Medicine?

• 20th Century health care advanced interventions
  for acute care
• Providers trained to deliver acute care
  interventions with increasing specialization

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Why Functional Medicine?

• 20th Century factors created burden of chronic
  disease
• Increased stress
• Sedentary life style
• Overconsumption but undernourishment
• Fragmented family and community ties
• Industrial pollution and devitalized food

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Why Functional medicine?

• Physicians highly trained in conventional
  diagnosis and treatment
• Drugs, surgery and radiation
• Physicians not well qualified to apply prevention
  to minimize risk of major chronic diseases in
  America
• Nutrition, diet and exercise

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Why Functional Medicine?

• Disease prevention conceptualized as immunization
  and early diagnosis
• Prevention requires understanding of
• Individual genetic variabilities 20-30
  of chronic
• 
  disease risk
• Effect of lifestyle on genetic
  variabilities 70-80
• 
  of chronic disease risk

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Why Functional Medicine?

• In addition to prevention, many chronic diseases
  are
• very responsive to dietary and lifestyle
  interventions

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Why Functional Medicine?

• Emergence of New Primary Care Paradigm
• Concept that disease mechanisms originate at
• molecular biological level and are related
  to
• interaction between environment and genes
  and
• their expression
• Built on molecular medicine discoveries
• Observations of host-environment interaction
• Replace previous belief diseases hard wired into
  our genes

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Why Functional Medicine?

• Emerging understanding of how biochemically
  unique we
• are
• Lessons from the human genome illuminate
  importance of host-environment interaction
• Single Nucleotide Polymorphisms (SNP)
• Variations in which the least common allele is
  present
• in at least 1 or more of the population
• When present, person has 2 different genes
  coding
• for the same function
• How gene may be expressed dependent on
  environmental
• factors

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Why Functional Medicine?

• Each of us has 30,ooo genes
• Most common variation in genes is single base
  difference producing SNP
• Occurs once in every 1000 base pairs
• 1.8 million identified, estimate approximately 3
  million
• Because not lethal maintained in population
• SNP alters function of enzyme, increasing or
  decreasing activity, not stopping function
  completely
• gt 1/3 SNPs affect coenzyme binding sites for
  vitamins or nutrients

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Why Functional Medicine?

• One major environmental factor that modifies
  gene expression nutritional status
• Both micro and macronutrients can influence
  expression of genes
• At translational level genetic message into
  active protein
• Proteins then influence by controlling metabolic
  function

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Why Functional Medicine?

• Phenotype of cell complex process of
  interacting events
• Related to genetic expression, protein
  synthesis, protein
• activation and metabolic regulation
• Use these processes to evaluate and establish
  biomarkers of
• health and disease

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Why Functional Medicine?

• Downstream Medicine
• Search for molecules (drugs) with selective
  ability to inhibit specific mediated steps
  related to an expressed disease
• Examples are ACE inhibitors, SSRIs, H2 Blockers

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Why Functional Medicine?

• Upstream Medicine
• Find and identify tissue-selective modulators of
  gene and
• protein expression
• Develop new approaches to selectively regulate
  expression
• of significant molecules upstream in the
  metabolic process
• associated with the disease for treatment
  AND prevention

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What is Functional Medicine?

• FM is Upstream Medicine
• Assesses and improves underlying functional
  imbalances in 7 core areas seen as drivers of
  health and disease
• Synthesizes and applies scientific evidence from
  biomedical research in biochemistry, physiology,
  immunology and nutrition to increase
  understanding of these 7 areas

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What is Functional Medicine?

• Core Areas to Assess for Clinical Imbalance
• Immune Surveillance
• Inflammatory Process
• Digestion, Absorption, Barrier Integrity
• Detoxification and Biotransformation
• Oxidative/Reductive
• Hormone, Neurotransmitter Regulation
• Psychological and Spiritual Equilibrium
• Structural Integrity

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What is Functional Medicine?

• Discipline neutral Any practitioner with western
  medical science background
• Does not require provider to give up tenets of
  training
• Does provide expansion of clinicians knowledge
  of biochemistry and physiology
• Does use strong appreciation of environmental
  inputs

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What is Functional Medicine?

• Aquires, analyzes, classifies and prioritizes
  information in different ways
• Then applies therapeutic measures to correct
  imbalances in underlying organ system disease
• Utilizes the Functional Medicine Matrix as tool
  for simplifying the complex science into a
  managable clinical approach

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What is Functional Medicine?

• Functional Medicine Matrix
• Used to obtain, sort and qualify the different
  kinds of patient information
• To generate for clinician strong indicators of
  most useful way to intervene with the
  interconnecting issues presented

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What is Functional Medicine?
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What is Functional Medicine?

• Firmly grounded in scientific principles and data
• Flexible eclectic perspective integrating the
  following when science warrants
• Dietary interventions
• Clinical nutrition
• Exercise therapy
• Mind-Body-Spirit issues
• Botanical medicine
• Physical medicine
• Energy medicine

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What is Functional Medicine?

• Does not identify a single gold standard method
  for considering something relevant or useful
• Incorporates many different sources of scientific
  information into the medical decision making
  process
• Basic science
• Clinical experience
• Functional medicine principles

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What is Functional Medicine?

• Evidenced Based Medicine (EBM) integration of
  best research evidence with clinical expertise
  and patient values

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What is Functional Medicine?

• Literature on EBM creates hierarchy with most
  value to randomized controlled clinical trial
  (RCT)
• Internal/external validity conflict
• Managing patient with multiple chronic complex
  multifactorial conditions not amenable to RCT

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What is Functional Medicine?

• FM focus on science of body functioning at
  physiological and biochemical level
• FM uses core clinical imbalances as matrix upon
  which to organize the science and includes
• Clinical trials
• Case reports
• Clinical experience

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Practice of Functional Medicine

• GOAL - Person centered diagnosis
• Individualized therapy plan based on
  understanding of
• physiological, environmental and psychological
  contexts
• within which persons illness/dysfunction occur

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Practice of Functional Medicine

• Elicit all of patients concerns to discover
• Antecendents Of symptoms, signs
• Triggers ? Illness
  behaviors
• Mediators Demonstrable
  pathology

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Practice of Functional Medicine

• Focus on control or reversal of each persons
• individual antecendents, triggers and
  mediators
• rather than treatment of disease entities

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Practice of Functional Medicine

• Triggers Discrete entities or events
  that provoke
• disease or its
  symptom
• Not sufficient by themselves
• Mediators Intermediaries that contribute to
  
• manifestations of
  disease
• Antecedents Factors that presdispose to acute
  or
• chronic illness

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Practice of Functional Medicine

• ANTECEDENTS
• Congenital - inherited or acquired in utero
• Gender
• Developmental
• Age
• Intrauterine and postnatal developmental factors
• Nutrition
• Exposure to toxins
• Learned patterns of behavior
• Microbial ecology of the body

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Practice of Functional Medicine

• TRIGGERS
• Primary task of Functional Medicine provider to
  help patients identify triggers and develop
  strategies for eliminating them or decreasing
  their effects

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Practice of Functional Medicine

• TRIGGERS
• Precipitating events antecedents closely
  preceding
• 
  development of chronic illness
• Most common
• Severe psychosocial distress
• Acute infection (sometimes with antibiotic
  treatment)
• Exposure to environmental toxins
• Severe nutrient depletion
• Related to illness or crash dieting

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Practice of Functional Medicine

• MEDIATORS
• Anything that produces symptoms or damage to the
  body
• Types of behavior associated with being sick

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Practice of Functional Medicine

• MEDIATORS
• Biochemical organized into circuits/cascades
  that
• subserve homeostasis
• Multifunctional redundancy
• Lack of disease specificity

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Practice of Functional Medicine

• MEDIATORS
• Natural rhythm of mediator activity strongly
  influenced by common components of life
• Diet
• Sleep
• Exercise
• Hygiene
• Social interaction
• Solar and lunar cycles
• Age
• Gender

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Practice of Functional Medicine

• EXAMPLE Aging and illness
• Chronic psychological -gt Upregulates
  activity of
• distress
  inflammatory and neuro-
• 
  endocrine response networks
• Regular physical -gt Downregulates
  inflammatory
• activity and
  neuroendocrine response
• 
  networks

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Practice of Functional Medicine

• To utilize vast data base regarding biochemical
  disease mediators
• Maintain up to date knowledge of disease
  pathophysiology reading reviews in mainstream
  journals regarding mechanisms of disease or
  specific mediators
• Special attention to mediators involved within
  networks of inflammation, oxidative stress and
  neuroendocrine imbalance

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Practice of Functional Medicine

• Attend workshops that emphasize integrative
  physiology
• Institute of Functional Medicine
• New York Academy of Science
• Center for Mind-Body Medicine
• Anerican College for Advancement in Medicine

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Practice of Functional Medicine

• Use knowledge of most common biochemical
  imbalances in chronically ill North Americans
• Use influence of diet, nutrition and dietary
  supplements on these imbalances

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Practice of Functional Medicine

• Human body dynamic, fully interconnected,
  complex
• functioning
  organism
• Constant flow of air, fluids and energy upon a
• changeable matrix
• Model of web to understand this complexity

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Practice of Functional Medicine

• One major imbalance influences many different
  functional systems
• Multiple factors influence one single condition

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Practice of Functional Medicine
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Practice of Functional Medicine

• Allopathic medicine Look for single root cause
  and
• find a
  cure with a pill, surgery or
• 
  radiation
• Functional medicine Ask what is imbalanced
• Find
  shift of flow of biochemical
• 
  information, energy, physical
• 
  structure or emotion out of
• 
  healthy range

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Practice of Functional Medicine

• Functional Medicine Resources
• Jones, David S., Hofmann, Laurie, and Quinn,
  Sheila. 21st Century Medicine A New Model for
  Medical Education and Practice. The Institute for
  Functional Medicine, 2010.
• Jones, David S. (Ed.) Textbook of Functional
  Medicine. The Institute for Functional Medicine,
  2010.
• www.functionalmedicine.org