The Functional Medicine Approach to Patient Care

1. The Functional Medicine Approach to Patient Care Scott Antoine, DO, FACEP Vine Healthcare, LLC

2. Objectives • To provide a definition of Functional Medicine • To define the need for a paradigm shift in healthcare and the role of Functional Medicine in that shift • To show that Functional Medicine is Osteopathic Medicine • To outline the Functional Medicine approach to patient evaluation and treatment

3. Functional Medicine Also known as: Functional and Integrative Medicine, Holistic Medicine, Systems Medicine

4. The 4 P’s of Functional Medicine • Personalized- genetic and environmental variations drive individual treatments • Predictive- tailored health strategies based upon a personalized map of health risks with traditional and novel biomarkers • Preventive- proactive vs. reactive approaches which shift from illness to wellness, from disease treatment to functional enhancement • Participatory- empowers and engages the patient

5. Ultimately…. Functional Medicine is about balance: • Removes what is NOT supposed to be in the system • Adds (or maintains) what IS supposed to be in the system

6. Osteopathic Medicine • DOs practice a "whole person" approach to medicine. Instead of just treating you for specific symptoms or illnesses, they regard your body as an integrated whole • Osteopathic physicians focus on preventive health care --From the website of the American Osteopathic Association

7. Academic Interest in Functional Medicine Institute of Functional Medicine (IFM) • Basic and advanced courses in Functional Medicine • Attendees from 60 academic centers and residencies including: Albert Einstein (NY), Duke, Johns Hopkins, Harvard, UCLA, Penn, UNC, Des Moines Osteopathic, Lake Erie College of Osteopathic Medicine

8. Corporate and Government Interest • Medical insurers such as CIGNA are considering pilot programs using Functional Medicine • VA is exploring research in Functional Medicine • Supported by 12 Senators, Medicare has expressed interest in pilot programs for intensive lifestyle change programs

9. Traditional Approach to the Patient Encounter • The patient presents with symptom(s) • A history of the “chief complaint” is taken • “Pertinent” past medical history is obtained • A physical examination is performed • A differential diagnosis is made and testing is performed • A named ‘disease’ may or may not be found • Medicine is given to treat the disease or lessen symptoms

10. Traditional Approach to the Patient Encounter • Relies on deductive reasoning and “reductionism” • “Name it and blame it” • “A drug for each bug” • “A pill for each ill” • Sherlock Holmes and the “Clue” analogy • Works well for acute illness or injury

11. You Have a Flat Tire • Call a “specialist” • Look at the tire • Decide if it is a nail, sidewall damage, etc • Fix the problem and (hopefully) stop the leak • This is an acute care situation

12. Several Problems • Tire is flat • Brakes are bad • Hole in the muffler • Need a bunch of “specialists” • If we fix these 3 problems, is the car in good shape? • This is the chronic illness model

13. The Burden of Chronic Illness • Data compiled in the “World Health Organization Non-Communicable Disease (NCD) Country Profile” report (2011) • Described mortality causes for 193 member states to the WHO • Data compiled for causes and risk factors

14. Causes of Mortality (Kenya)

15. Causes of Mortality (USA)

16. Change in BMI (USA)

17. Change in Blood Glucose (USA)

18. Risk Factors

19. The Burden of Chronic Disease • March 14, 2002 Study NEJM by R. Sinha et al (Vol 346 (11);802-810) showed that: • 55 obese children (4-10 years old) --25% had impaired glucose tolerance • 112 obese teens (11-18 years old) -–21% had impaired glucose tolerance. Four were diagnosed with type II DM • Recent estimates indicate that 1/3 of people born in 2000 will eventually be diabetic

20. How Sick is Sick?

21. The Problem • We are treating chronic illness with the acute care model • Patients are broken into organ systems (GI, Cardiac..) • There is a failure to recognize web-like interactions of multiple comorbidities, antecedents, and triggers, in chronically-ill patients • Consequences • Polypharmacy leading to non-compliance and adverse drug reactions • Coordination of care among specialists may be difficult • Duplication of tests and therapies • The “fire” may be out, but the embers are still smoldering

22. How Could Your Car be Restored? • Comprehensive inspection (unique to your car) • Examine each system from the inside, look for problems (take it all apart), and look for connections • Add what is missing and needed • Get rid of what does not belong and causes problems • Keep up maintenance and “buy good gas” • This is Functional Medicine

23. Basic Principles of Functional Medicine • The “Continuum of Wellness” • Pre-Diabetes • Pre-Hypertension • Pre-Dementia • Are these all separate “diseases” or are they just pit-stops along a continuum from optimal wellness to illness?

24. Basic Principles of Functional Medicine In August 2009, after six years of planning, Johns Hopkins University School of Medicine rolled out the Genes to Society Curriculum.  This novel curriculum rejects the notion that there is "normal" or "abnormal" in medicine.  Rather, everyone is on a continuum.  The curriculum takes a systems approach to understanding all levels of the human being - from genes, molecules, cells, and organs of the patient on one end, to the familial, community, societal, and environmental components at the other end.  The GTS curriculum integrates all of these variables to help students understand why patients present the way they do.  http://www.hopkinsmedicine.org/som/admissions/md/curriculum/gts.html

25. Basic Principles of Functional Medicine • Wellness is a positive vitality and not merely the absence of disease • The decline of ICD-9 (and 10) and the emergence of models of systems medicine • Recognition of a web-like interconnectivity of bodily systems

26. Basic Principles of Functional Medicine The NIH Roadmap. Science, vol 302, Oct 2003, Elias Zerhouni “New Pathways to Discovery. This theme addresses the need to understand complex biological systems. Future progress in medicine will require quantitative knowledge about the many interconnected networks of molecules that comprise cells and tissues, along with improved insights into how these networks are regulated and interact with each other.”

27. Basic Principles of Functional Medicine • Underlying Causes of Disease • The “Exposome” • Toxins (drugs, chemicals, radiation, EMF) • Nutrition (as a toxin) • Stress • Allergens • Infections • Trauma **Damage is from direct mechanical effects, gene interaction, or metabolic effects**

28. The Exposome What is the exposome? Success in mapping the human genome has fostered the complementary concept of the "exposome". The exposome can be defined as the measure of all the exposures of an individual in a lifetime and how those exposures relate to health. An individual’s exposure begins before birth and includes insults from environmental and occupational sources. Understanding how exposures from our environment, diet, lifestyle, etc. interact with our own unique characteristics such as genetics, physiology, and epigenetics impact our health is how the exposome will be articulated. Source: The Centers For Disease Control (CDC) website

29. Basic Principles of Functional Medicine • Underlying Causes of Disease (continued) • The Genome (genetic variation) • Inherited (Familial) differences • SNPs (Single Nucleotide Polymorphisms)- must occur in at least 1% of the population http://ghr.nlm.nih.gov/handbook/genomicresearch/snp http://www.cancer.gov/cancertopics/understandingcancer/geneticvariation

30. Single Nucleotide Polymorphisms (SNPs)

31. SNPs and Cancer Risk

32. SNPs and Drug Interactions

33. Facts About SNPs • Occur about 1 time per 1000 base pairs • Make up the bulk of the 3 million variations found in the genome • One third or more effect coenzyme-binding sites for vitamins or nutrients and therefore have a role in disease or dysfunction* * B Ames. Cancer Prevention and Diet: help from single nucleotide polymorphisms. ProcNatlAcadSci USA 1999;96(22):12216-18

34. SNPs and Nutrients • “Our analysis of metabolic disease that affects cofactor binding, particularly as a result of polymorphic mutations, may present a novel rationale for high-dose vitamin therapy, perhaps hundreds of times the normal dietary reference intakes (DRI) in some cases..”* *B Ames. High dose vitamin therapy stimulates variant enzymes with decreased coenzyme binding affinity (increased Km): relevance to genetic disease and polymorphisms. Am J ClinNutr. 2002;75:616-658

35. MTHFR – A Case in Point • Methelenetetrahydrofolatereductase • Responsible for donating a methyl group to B12 which then converts homocysteine to methionine • SNP results in thermolabile enzyme which is 50% less active than normal • Increased homocysteine results

36. The Homocysteine Cycle Folate THF Methionine B12 5,10-CH2-THF CH3-B12 MTHFR Homocysteine 5-CH3-THF B12

37. MTHFR – A Case in Point HomocysteineandIschemic Heart Disease : Results of a Prospective Study With Implications Regarding Prevention ArchIntern Med. 1998;158(8):862-867 • 229 men without CAD who went on to die of CAD • Matched to 1126 men of similar age • Continuous dose-response relationship. Higher homocysteine = more CAD ML Silaste, et al, Polymorphisms of key enzymes in homocysteine metabolism, affect diet responsiveness of plasma homocysteine in healthy women. J Nutr 2001;131:2643-47 • Group of patients with MTHFR and Methionine Reductase SNPs • Low folate vs. high folate diet (similar homocysteine at baseline) • High folate group had 18% reduction in homocysteine. Low folate group reduced 11%

38. Basic Principles of Functional Medicine • Underlying Causes of Disease (continued) • Epigenetics (the effect the exposome has on your genome and genetic expression)

39. Epigenetics

40. Epigenetics

41. Epigenetics Diabetes and Epigenetics “100% of the increase in prevalence of type II diabetes and obesity in the U.S. during the latter half of the 20th century must be attributed to a changing environment interacting with genes, since 0% of the human genome changed during this time period..” FW Booth, et al. Waging war on modern chronic diseases: primary prevention through exercise biology. J Appl Physiol. 2000; 88:774-87.

42. Basic Principles of Functional Medicine • Underlying Causes of Disease (continued) • Loss of Functional Reserve (will affect your response to the exposome) MC Creditor. Hazards of Hospitalization of the Elderly. Annals of Internal Medicine. 1993; 118(3):219-223

43. Basic Principles of Functional Medicine Epigenetics + Loss of Functional Reserve =

44. Basic Principles of Functional Medicine • Underlying Causes of Disease (continued) • Deficiency States • Hydration • Proteins • Carbohydrates • Fats • Vitamins • Cofactors and enzymes

45. Basic Principles of Functional Medicine The “Macro/Micro” Paradox • Symptoms are experienced at the “macro” or whole body level (nausea, diarrhea, allergies, etc.) • Causes of symptoms (and abnormal function) occur at the ‘micro’ level, often with individual chemical reactions and processes

46. Basic Principles of Functional Medicine The “Macro/Micro” Paradox • These ‘micro’ changes may create whole system malfunction, even though they may not seem related • Drugs directed at symptom relief (stop the diarrhea or heartburn) rarely fix the underlying pathology

47. Basic Principles of Functional Medicine The first component of this challenge is to recognize that inadequate intakes of specific nutrients may produce more than one disease, may produce diseases by more than one mechanism, and may require several years for the consequent morbidity to be sufficiently evident to be clinically recognizable as “disease.” Because the intakes required to prevent many of the long-latency disorders are higher than those required to prevent the respective index diseases, recommendations based solely on preventing the index diseases are no longer biologically defensible. RP Heaney, Long-latency deficiency disease: insights from calcium and vitamin D. Am J ClinNutr 2003;78:912–9

48. Basic Principles of Functional Medicine B. Ames. The Metabolic Tune-Up: Metabolic Harmony and Disease Prevention. J. Nutr. 133: 1544S–1548S, 2003. (University of California, Berkeley and Children’s Hospital and Research Center at Oakland)

49. Basic Principles of Functional Medicine TO RECAP: • Underlying Causes of Disease • The Exposome • The Genome (Genetic Variation) • Epigenetics • Loss of Functional Reserve • Deficiency States

50. Basic Principles of Functional Medicine • Nutrigenomics (the “epigenetics of food and nutrients”) • Advanced by Linus Pauling • Nutrients modulate physiologic processes at the molecular level • This modulation gives rise to the phenotype of health or disease “There has been a growing recognition that both macronutrients and micronutrients can be potent dietary signals that influence metabolic programming of cells and have and important role in the control of homeostasis…” M Muller, S Kersten. Nutrigenomics: goals and strategies. Nat Rev Genet. 2003; 4:315-322