Integrative Nutrition in an Holistic Family Practice Setting: Guiding Principles & Case Studies

2. Integrative Nutrition in an HolisticFamily Practice Setting: Guiding Principles & Case Studies • Ranan D. Cohen, MS, RD, LDN • Clinical nutritionist in private practice • Holistic Family Practice, Newbury MA • March 11, 2011

3. 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

4. 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.

5. Nutritional challenges • Suboptimal intake • Malabsorption • Depletional factors • Food sensitivities • Toxic/environmental exposure • Iatrogenic • Genetic • Emotional-spiritual /Stress

6. PLAN FUNCTIONAL QUESTIONS Nutritional adequacy? Digestive efficiency? Microbiological balance? Detoxification improvement? Absorptive efficiency?

7. Suboptimal intake assessment • Water/hydration • Vitamin/mineral sources • EFA/EPA/DHA sources • Phytochemical sources • Ancillary nutrient sources • Fiber intake level

8. Fruit smoothieSpelt toast + butterSalad Bar (field greens, carrots, other vegetables, cottage cheese, kidney beans, EVOO + balsamic + rosemary + garlic)Chana masala over brown rice with mango lassiYogurt + fruit + whole-grain graham crackers

10. Whole-grain pancakes (include wheat germ + flaxmeal) + berriesTurkey sandwich (on whole grain with grass-fed turkey) + carrot sticksYogurt + cashews + banana + kiwiSalmon + roasted red potatoes + broccoli salad+ Red Wine

13. 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

14. Depletional factors • Pregnancy/lactation • Alcoholism • Smoking • Surgical-metabolic/disease/other stress • Medications • Pollution • Intensive exercise

15. 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

16. 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

17. 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

18. 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-

19. 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

20. Available (& worthwhile) labs (2) • Plasma retinol • 25-hydroxy vitamin D • Prothrombin time/INR • RBC-EFA levels

21. 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??

22. 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

23. Food sensitivity: potential diagnostic connections • Migraine • Eczema; Acne • Sinus; Asthma; Bronchitis • Arthritis • IBS; IBD • ADD/ADHD • Auto-immune disease

24. Allergy/sensitivity symptoms • Throat irritation/closure • Nausea/vomiting • Hives/rash • Headache • Constipation/diarrhea/stomach ache/indigestion • UR congestion/stuffiness • Joint pain

25. Symptoms of Food Allergy Respiratory Manifestations Rhinitis Asthma Cough Laryngeal edema Milk-induced syndrome with respiratory disease (Heiner’s syndrome) Systemic Manifestations Anaphylaxis Hypotension Controversial or Unproven Manifestations Behavioral conditions Tension-fatigue syndrome Attention-deficit and hyperactivity disorder (ADHD) Otitis media Psychiatric disorders Neurologic disorders Musculoskeletal disorders Migraine headache Gastrointestinal Manifestations Abdominal pain Nausea Vomiting Diarrhea Gastrointestinal bleeding Protein-losing enteropathy Oral and pharyngeal pruritus Cutaneous Manifestations Urticaria (hives) Angiodema Eczema Erythema (skin inflammation) Itching

26. Common allergenic foods • Cow’s milk dairy • Peanuts/Soy • Tree nuts • Crustaceans/Mollusks • Fish • Eggs • Wheat

27. 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

28. 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??

29. 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 minimal • scratching 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.

35. 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

36. 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”

37. 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

38. 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

39. 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.

40. 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

41. 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??

42. 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’.

43. 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)

44. 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.

45. 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.

46. 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)

47. 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”

48. IBS profile #3 • Excellent dietary history/food group balance • Adequate baseline supplementation • Weight stable • IBS • Poor energy and sleep • Recently divorced • Peri-menopausal

49. 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

50. 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