At the heart of medicine lies the individual and each patient’s unique story…

1. At the heart of medicine lies the individual and each patient’s unique story… At the heart of medicine lies the individual and each patient’s unique story…

2. That Story Is Typically Told As… • Chief Complaint (CC) • History of Present Illness (HPI) • Past Medical History (PMH) • Family History (FH) • Dietary History • Supplement and Medication History • Lifestyle, Social, and Exercise History • Physical Exam Findings • Laboratory Evaluation

3. In conventional medicine, the aim is to arrive quickly at the diagnosis • This emphasis on diagnosis is particularly critical in the acute care setting; rapid diagnosis leads to rapid treatment • Treatment in this setting must be prompt, as it is often designed to “lock down” and control physiology • The chief complaint and history of the present illness become the critical aspects of the story; the rest of the patient’s story is truncated when other information is seen as superfluous to reaching the diagnosis

4. In acute care, the patient’s story is squeezed down to the chief complaint and history of the present illness while the diagnosis increases in importance.

5. Example #1Chief Complaint: Wheezing History of Present Illness sudden onset asthmatic history tightness in the chest shortness of breath Diagnosis:Asthma Attack bronchodilators corticosteroids

6. Example #2Chief Complaint: Chest Pain History of Present Illness arm numbness shortness of breath sweating Diagnosis:Heart Attack angioplasty thrombolytics

7. Problems arise when the acute-care model is used to address chronic long-term health issues • The clinician proceeds directly to the diagnosis –naming the disease – in order to identify as quickly as possible a medication to treat that disease THE RESULTS: • Little attention is paid to the patient’s story beyond the chief complaint and history of the present illness • The patient’s whole story is not understood • Each complaint becomes a discrete issue, dealt with in isolation from the others

8. Dicyclomine NSAID Irritable Bowel Syndrome Osteoarthritis …the result is a focus on treating each symptom complex as a separate and distinct “disease” with a separate and distinct treatment. ACE inhibitor Hypertension Migraines Triptan Depression Hypercholest- erolemia Gastroesophageal Reflux Disease Statin SSRI H2 blocker

9. Dicyclomine NSAID Irritable Bowel Syndrome Osteoarthritis ACE inhibitor Hypertension Migraines Triptan Depression Hypercholest- erolemia Gastroesophageal Reflux Disease Statin SSRI H2 blocker Each individual diagnosis becomes a distinct entity unto itself. The patient’s whole story never has a chance to be heard and understood In context.

10. It is apparent that – in its rush to diagnose –conventional medicine is focused on the branches and leaves of the tree, and not the trunk and roots. Cardiology Pulmonary Endocrinology Urology/Nephrology Hepatology Gastroenterology Organ System Diagnosis Neurology Allergy Signs and Symptoms Fundamental Clinical Imbalances Hormonal and Neurotransmitter Imbalances Redox Imbalance + Oxidative Stress + Mitochondropathy Detox/Biotransformation/Excretory Imbalance Immune Imbalance Inflammatory Imbalance Digestive/Absorptive and Microbiological Imbalance Structural Integrity Imbalance Fundamental Physiological Processes 1. Communication - Outside the cell - Inside the cell 2. Bioenergetics/Energy Transformation 3. Replication/Repair/Maintenance/ Structural Integrity 4. Elimination of Waste 5. Protection/Defense 6. Transport/Circulation Mind and Spirit Genetic Predisposition Experiences, Attitudes, Beliefs Xenobiotics Micro-organismsRadiation Physical ExerciseTrauma Diet, Nutrients, Air/Water Psycho-social Environmental Inputs

11. Functional medicine should not be viewed as an alternative, but as a bridge to a more effective chronic-care model.

12. ? ? In the functional medicine model, the patient’s full story is of central importance • Where does the symptom come from? • That is, what are the antecedents and triggers? • What keeps it going? • That is, what are the mediators? • And what can be done to change that dis-eased homeostatic balance point the patient is locked into? • That is, what are the underlying points of leveragewhere intervention can be most effective? Instead of a preoccupation with how to namethe disease, the critical questions become: ?

13. To answer these questions requires a new perspective on the chronic-care model First, the full story must be understood within the context of antecedents, triggers, and mediators antecedents and triggers mediators

14. Nutrient excess Excessive exercise Infectious micro- organisms Nutrient insufficiency Dysbiosis Spiritual angst Structural or physical damage Situational stress–fear, anxiety, worry Xenobiotics The story is no longer just the CC and HPI, but is expanded to encompass all the patient’s history that may reveal the source(s) of symptoms. Adiposity Hypoglycemia Aging Disrupted light cycles—circadian dysrhythmias Drug side effects Toxic metals Radiation Excessive noise Hyperglycemia Genetic pre- disposition (SNPs) Emotional trauma Food toxicants (allergens, stimulants, etc,)

15. These fundamental clinical imbalances are the underlying mechanisms of disease… Detoxification and Biotransformation Structural Integrity InflammatoryProcess Nutrient excess Excessive exercise Infectious micro- organisms Nutrient insufficiency Dysbiosis Spiritual angst Situational stress–fear, anxiety, worry Xenobiotics Next, the patient’s story is filtered through these antecedents, triggers, and mediators, which leads to an understanding of where key imbalances may reside Structural or physical damage Adiposity Disrupted light cycles—circadian dysrhythmias Psychological and Spiritual Equilibrium Immune Surveillance Drug side effects Hypoglycemia Hyperglycemia Toxic metals Noise Radiation Genetic pre- disposition (SNPs) Emotional trauma Food toxicants (allergens, stimulants, etc,) Aging Digestion, Absorption,and Barrier Integrity Oxidative/Reductive Homeodynamics Hormone andNeurotransmitter Regulation The diagnosis remains useful, but is less important.

16. Counseling Exercise Phytonutrients Minerals Meditation The expanded model permits the clinician to choose from an enlarged toolkit of therapies. Drugs Diet Surgery Yoga Acupuncture Vitamins Manipulative Therapies

17. Let’s apply the functional medicine model to an apparently simple case… …a 37 year old female with a chief complaint of chronic headaches.

18. We’ve already seen how she might be treatedusing the existing model. Chief Complaint:Headaches History of present illness Diagnosis: Migraines Treatment: Triptan

19. But her case may not be as simple as it appears…

20. Detoxification and Biotransformation InflammatoryProcess Structural Integrity From a functional medicine perspective, the CC and HPI must be filtered through the relevant antecedents, triggers, and mediators. To understand the patient’s complete picture, past medical history, family history, diet, medications, and lifestyle all need to be viewed through this lens as well. Psychological and SpiritualEquilibrium Immune Surveillance Digestion, Absorption, and Barrier Integrity Oxidative/Reductive Homeodynamics Hormone and Neurotransmitter Regulation

21. Detoxification and Biotransformation InflammatoryProcess Structural Integrity A variety of potential antecedents, triggers, and mediators might be present in a woman with a chief complaint of chronic headaches: Psychological and SpiritualEquilibrium Immune Surveillance Digestion, Absorption, and Barrier Integrity Oxidative/Reductive Homeodynamics Hormone and Neurotransmitter Regulation

22. Detoxification and Biotransformation InflammatoryProcess Structural Integrity Headaches triggered by menstrual cycle Estrogen dominance Headaches triggered by exposure to toxins MSG, aspartame, smoke, perfume Headaches triggered by changes in sleep Psychological and SpiritualEquilibrium Immune Surveillance Circadian rhythm Circadian rhythm Exposure to toxins Exposure to toxins Headaches triggered by food allergen Headaches triggered by fasting Hypoglycemia Food allergen Food allergen Food Allergen Headaches triggered by stress Digestion, Absorption, and Barrier Integrity Situational stress Oxidative/Reductive Homeodynamics Hormone and Neurotransmitter Regulation

23. Detoxification and Biotransformation Exposure to toxins Inflammatory Process Food Allergen Circadian Rhythm Structural Integrity Exposure to toxins Surgeries Adiposity Adiposity Accidents, injuries Past medical history leads to additional clues: Accidents, injuries Exposure to toxins Surgeries Psychological and Spiritual Equilibrium Chronic antibiotic use Adiposity Situational Stress Immune Surveillance Accidents or Injuries Adiposity Food Allergen Emotional trauma Past or recurrent infections Past or recurrent infections Chronic disease Exposure to toxins Chronic antibiotic use Exposure to toxins Oxidative/Reductive Homeodynamics Emotional trauma Digestion, Absorption, and Barrier Integrity Chronic Disease Past or recurrent infections Accidents, injuries Exposure to toxins Food Allergen Chronic disease Hormone and Neurotransmitter Regulation Surgeries Chronic antibiotic use Emotional trauma Chronic antibiotic use—dysbiosis Estrogen dominance Circadian Rhythm Hypoglycemia Adiposity Emotional trauma Exposure to toxins

24. Detoxification and Biotransformation Exposure to toxins Inflammatory Process Food allergen Circadian Rhythm Structural Integrity Exposure to toxins Surgeries Adiposity Adiposity Accidents, injuries Family history may indicate genetic predispositions: Accidents, injuries Exposure to toxins Predisposition to inflammation Psychological and Spiritual Equilibrium Allergies Situational Stress Immune Surveillance Adiposity Food allergen Inflammatory conditions such as RA, UC, etc. Emotional trauma Past or recurrent infections Chronic disease Exposure to toxins Chronic antibiotic use Oxidative/Reductive Homeodynamics Digestion, Absorption,and Barrier Integrity Past or recurrent infections Accidents, injuries Exposure to toxins Food allergen Chronic disease Hormone andNeurotransmitter Regulation Surgeries Chronic antibiotic use Emotional trauma Chronic antibiotic use—dysbiosis Estrogen dominance Circadian Rhythm Hypoglycemia Adiposity Emotional trauma Exposure to toxins

25. Detoxification and Biotransformation Exposure to toxins Nutrient insufficiencies –sulfur, amino acids, etc. Inflammatory Process Food allergen Dietary toxin-mercury Circadian Rhythm Structural Integrity Exposure to toxins Surgeries Adiposity Adiposity Accidents, injuries Accidents, injuries Exposure to toxins Predisposition to inflammation Dietary History Nutrient insufficiencies—EFAs, etc. Nutrient excess—saturated fat Dietary insufficiencies…antioxidants, magnesium, fiber, EFAs, etc. Psychological and Spiritual Equilibrium Immune Surveillance Food allergen Situational Stress Past or recurrent infections Dietary toxins…mercury, exogenous estrogens, etc. Adiposity Exposure to toxins Emotional trauma Chronic antibiotic use Chronic disease Nutrient insufficiencies Dietary toxin—mercury Dietary excesses: saturated fat, simple sugars, caffeine, alcohol, etc. Oxidative/Reductive Homeodynamics Digestion, Absorption, and Barrier Integrity Past or recurrent infections Accidents, injuries Exposure to toxins Food allergen Chronic disease Surgeries Hormone andNeurotransmitter Regulation Chronic antibiotic use Emotional trauma Nutrient insufficiencies antioxidants Chronic antibiotic use—dysbiosis Estrogen dominance Nutrient insufficiencies – zinc, glutamine–leaky gut Circadian Rhythm Dietary toxin –mercury Dietary toxins – exogenous estrogens Hypoglycemia Nutrient excess—alcohol Adiposity Dietary toxin—mercury Nutrient excess –simple sugars Emotional trauma Exposure to toxins Nutrient insufficiencies Nutrient excess—caffeine

26. Detoxification and Biotransformation Exposure to toxins Nutrient insufficiencies –sulfur, amino acids, etc. Inflammatory Process Food allergen Dietary toxin-mercury Circadian Rhythm Structural Integrity Drug side effects-inhibit or promote Exposure to toxins Surgeries Adiposity Adiposity Accidents, injuries Accidents, injuries Exposure to toxins Predisposition to inflammation Medication History Nutrient insufficiencies—EFAs, etc. Nutrient excess—saturated fat Drug side effects Psychological and Spiritual Equilibrium Immune Surveillance Food allergen Situational Stress Past or recurrent infections Drug side effects Adiposity Exposure to toxins Emotional trauma Chronic antibiotic use Chronic disease Nutrient insufficiencies Dietary toxin—mercury Oxidative/Reductive Homeodynamics Digestion, Absorption, and Barrier Integrity Past or recurrent infections Accidents, injuries Food allergen Exposure to toxins Surgeries Chronic disease Emotional trauma Hormone andNeurotransmitter Regulation Chronic antibiotic use Chronic antibiotic use—dysbiosis Nutrient insufficiencies antioxidants Nutrient insufficiencies – zinc, glutamine–leaky gut Estrogen dominance Circadian Rhythm Dietary toxin –mercury Dietary toxins – exogenous estrogens Nutrient excess—alcohol Hypoglycemia Adiposity Drug side effects Dietary toxin—mercury Nutrient excess –simple sugars Emotional trauma Exposure to toxins Drug side effects Nutrient insufficiencies Nutrient excess—caffeine

27. Detoxification and Biotransformation Exposure to toxins Inflammatory Process Nutrient insufficiencies –sulfur, amino acids, etc. Food allergen Circadian Rhythm Dietary toxin-mercury Exposure to toxins Drug side effects-inhibit or promote Adiposity Structural Integrity Lack of exercise Accidents, injuries Inhibit or promote Surgeries Exposure to toxins Adiposity Predisposition to inflammation Accidents, injuries Nutrient insufficiencies—EFAs, etc. Over or improper exercise Nutrient excess—saturated fat Lifestyle Drug side effects Psychological and Spiritual Equilibrium Immune Surveillance Hobbies Situational Stress Food allergen Adiposity Past or recurrent infections Emotional trauma Exposure to toxins Chronic disease Relationships Recreational Drugs Chronic antibiotic use Lack of exercise Nutrient insufficiencies Loneliness Dietary toxin—mercury Spiritual angst Lack of exercise Exercise Spirituality Oxidative/Reductive Homeodynamics Loneliness Digestion, Absorption, and Barrier Integrity Past or recurrent infections Accidents, injuries Exposure to toxins Food allergen Chronic disease Surgeries Chronic antibiotic use Emotional trauma Hormone andNeurotransmitter Regulation Nutrient insufficiencies antioxidants Chronic antibiotic use—dysbiosis Nutrient insufficiencies – zinc, glutamine–leaky gut Estrogen dominance Dietary toxins – exogenous estrogens Dietary toxin –mercury Circadian Rhythm Nutrient excess—alcohol Hypoglycemia Nutrient excess –simple sugars Drug side effects Adiposity Dietary toxin—mercury Lack of exercise Drug side effects Lack of exercise Emotional trauma Lack of exercise Alcohol-leaky gut Exposure to toxins Loneliness Nutrient insufficiencies Spiritual angst Nutrient excess—caffeine

28. Hair toxic Elements Urinary Provocation/Challenge Caffeine Clearance, Glucuronidation, Sulfation SNP Cyp P450 High-sensitivity CRP RBC Fatty Acids X-ray Fecal Calprotectin N-telopeptide Fecal Lactoferrin Gait Motion Analysis Magnetic Resonance Imaging Serum Amino Acids IgG and IgG food allergy RBC Fatty Acids Chemical antibodies Homocysteine, folate, B12 Salivary Secretory IgA Urinary Serotonin, Dopamine Natural Killer Cell Cytotoxicity Activity 8-OHdG Fecal Ova and Parasites Lipid peroxides Lactulose Mannitol Reduced glutathione Bacterial Overgrowth Small Intestine Isoprostanes Candida Antibodies TSH, Free T3, Free T4 Estrogen, Progesterone, Testosterone 2/16 ratio Glucose, insulin, HA1C Cortisol, DHEA Detoxification and Biotransformation Inflammatory Process Structural Integrity Psychological and Spiritual Equilibrium Immune Surveillance A variety of potential laboratory assessments can then be useful in confirming key imbalances on which to focus. Oxidative/Reductive Homeodynamics Digestion, Absorption, and Barrier Integrity Hormone andNeurotransmitter Regulation

29. Detoxification and Biotransformation Inflammatory Process Structural Integrity Specifically, what was this37 year old female’s story? Psychological and Spiritual Equilibrium Immune Surveillance Food allergen Headaches triggered by diet Oxidative/Reductive Homeodynamics Digestion, Absorption, and Barrier Integrity Food allergen Hormone andNeurotransmitter Regulation

30. Detoxification and Biotransformation Inflammatory Process Inflammatory damage Structural Integrity Structuraldamage What are the clues in her past medical history? Psychological and Spiritual Equilibrium Immune Surveillance Food allergen History of chronic sinusitis History of multiple antibiotics History of osteoarthritis of the knee Gas and bloating Oxidative/Reductive Homeodynamics Digestion, Absorption, and Barrier Integrity Food allergen Dysbiosis Drug side effects leaky gut Hormone andNeurotransmitter Regulation Digestive enzyme/HCL insufficiency

31. Detoxification and Biotransformation Inflammatory Process Inflammatory damage Structural Integrity Nutrient insufficiency – low EFAs, high AA Structuraldamage What are the clues in her diet and medications? Psychological and Spiritual Equilibrium Immune Surveillance Food allergen NSAIDS for OA Standard American Diet Oxidative/Reductive Homeodynamics Digestion, Absorption, and Barrier Integrity Food allergen Dysbiosis Digestive enzyme/HCL insufficiency Hormone andNeurotransmitter Regulation Drug side effects – leaky gut

32. Detoxification and Biotransformation Inflammatory Process Inflammatory damage Structural Integrity Nutrient insufficiency – low EFAs, high AA Structuraldamage Inflammatory genetic predisposition What are the cluesin her family history? Psychological and Spiritual Equilibrium Immune Surveillance Food allergen Ulcerative Colitis Eczema Oxidative/Reductive Homeodynamics Digestion, Absorption, and Barrier Integrity Food allergen Dysbiosis Digestive enzyme/HCL insufficiency Hormone andNeurotransmitter Regulation Drug side effects – leaky gut

33. Detoxification and Biotransformation Inflammatory Process Inflammatory damage Structural Integrity Nutrient insufficiency – low EFAs, high AA Structuraldamage Psychological and Spiritual Equilibrium Through critical thinking and pattern recognition, a therapeutic plan can be developed. In this case, the primary focus centers on three areas Immune Surveillance Food allergen Oxidative/Reductive Homeodynamics Digestion, Absorption, and Barrier Integrity Food allergen Dysbiosis Digestive enzyme/HCL insufficiency Hormone andNeurotransmitter Regulation Drug side effects – leaky gut

34. Detoxification and Biotransformation Inflammatory Process Inflammatory damage Structural Integrity Nutrient insufficiency – low EFAs, high AA Structuraldamage Hs-CRP RBC fatty acids Psychological and Spiritual Equilibrium Immune Surveillance Laboratory analysis can be used to help confirm the prioritization Food allergen IgG/IgE food allergy Oxidative/Reductive Homeodynamics Digestion, Absorption, and Barrier Integrity Food allergen Dysbiosis Digestive enzyme/HCL insufficiency Hormone andNeurotransmitter Regulation Drug side effects – leaky gut Digestive stool analysis Ova and parasite Intestinal permeability

35. Dietary changes to lower arachidonic acid and the inflammatory cascade Phytonutrients such as rutin and quercitin to decrease IP Detoxification and Biotransformation Botanicals such as bromelain and curcumin to decrease inflammation Omega-3 fatty acids to decrease inflammation InflammatoryProcess Structural Integrity Foodeliminationdiet The prioritization of certain key clinical imbalances then leads to potential treatment options Psychological and SpiritualEquilibrium Immune Surveillance Digestion, Absorption, and Barrier Integrity Oxidative/Reductive Homeodynamics Decrease alcoholto decrease intestinal permeability Hormone and Neurotransmitter Regulation Pre and probiotics Hydrochloric acid/digestive enzyme

36. Functional medicineenlarges thechronic care model to encompass the full and uniquestory of the patient It integrates underlying mechanisms of disease into the differentialdiagnosis paradigm Finally it increases the range of potential treatment options

37. Meditation Counseling Phytonutrients Exercise Detoxification andBiotransformation InflammatoryProcess StructuralIntegrity Excessive exercise Nutrient excess Vitamins Infectious micro- organisms Spiritual angst Dysbiosis Minerals Nutrient insufficiency Situationalstress – fear, anxiety, worry The functional medicine model recognizes and prioritizes the patient’s full, unique story and uses fundamental clinical imbalances as a key to treating complex, chronic illness Xenobiotics Psychological and Spiritual Equilibrium ImmuneSurveillance Structural or physical damage Adiposity Disrupted light cycles – circadian dysrhythmias Drug side effects Hypoglycemia Diet Toxic metals Hyperglycemia Drugs Excessive noise Radiation Digestion,Absorption,and BarrierIntegrity Genetic pre-disposition (SNPs) Emotional trauma OxidativeReductiveHomeodynamics Food toxicants (allergens, stimulants etc,) Aging Yoga Hormone and Neurotransmitter Regulation Surgery Manipulative Therapies Acupuncture

38. Functional Medicine and the Healthcare System: Additional Important Benefits • Functional Medicine creates a level playing field among practitioners • The Functional Medicine model makes readily apparent that there is a need for many different approaches to helping people become and stay well • Functional Medicine helps to create and disseminate a shared set of concepts and a common language • Ultimately, Functional Medicine can contribute greatly to our ability to create an integrated healthcare system

39. Cardiology Pulmonary Endocrinology Urology/Nephrology Hepatology Gastroenterology Organ System Diagnosis Neurology Allergy Signs and Symptoms Fundamental Clinical Imbalances Hormonal and Neurotransmitter Imbalances Redox Imbalance + Oxidative Stress + Mitochondropathy Detox/Biotransformation/Excretory Imbalance Immune Imbalance Inflammatory Imbalance Digestive/Absorptive and Microbiological Imbalance Structural Integrity Imbalance Fundamental Physiological Processes 1. Communication - Outside the cell - Inside the cell 2. Bioenergetics/Energy Transformation 3. Replication/Repair/Maintenance/ Structural Integrity 4. Elimination of Waste 5. Protection/Defense 6. Transport/Circulation Mind and Spirit Genetic Predisposition Experiences, Attitudes, Beliefs Xenobiotics Micro-organismsRadiation Physical ExerciseTrauma Diet, Nutrients, Air/Water Psycho-social Environmental Inputs