© 2008, the institute for functional medicine david s. jones, md president and director of medical...

© 2008, The Institute for Functional Medicine

David S. Jones, MDPresident and Director of

Medical Education

Fundamentals of Functional Medicine:

From Organ System to

Systems Biology

Dan Lukaczer, NDAssociate Director of Medical Education

Institute for Functional Medicine


David Jones MD Dan Lukaczer ND


Functional Medicine is personalized medicine that deals with primary

prevention and underlying causes

instead of symptoms for serious chronic disease


THE UNMET NEED

Holman H. JAMA. 2004;292:1057-1059.

Chronic Disease:The Need for a New Clinical Education

“It is axiomatic that medical education should prepare students well for the clinical problems they will face in their future practice. However, that is not happening for the most prevalent problem in health care today: chronic disease.”

“Chronic disease replaced acute disease as the dominant health problem. Chronic disease is now the principal cause of disability and use of health services and consumes 78%

of health expenditures.”

© 2008, The Institute for Functional MedicineStange KC. Ann Fam Med. 2006;4:98-100

“The Future of Family Medicine Report calls for a New Model of care that is

grounded in timeless values of personalized, patient-centered care coupled with the application of new

technologies and systems.”

THE UNMET NEED


ESSENTIAL COMPONENTS FOR FUNCTIONAL MEDICINE PRACTITIONER

COGNITIVE SKILLS NEEDED:• An analytical, iterative process of careful

construction & clinical response• A disciplined methodology of organizing

information for more comprehensive evaluation and treatment of chronic illness

• Reframing of patient’s story to reflect antecedents, triggers & mediators

• Integration of intellectual curiosity, academic rigor, and the use of pattern recognition to improve clinical judgment

• Facile in the use of the FM Matrix for organizing and understanding the indicators of dysfunction


PATIENT-CENTERED CLINICAL SKILLS• Primacy of therapeutic partnership & patient

empowerment• Eliciting and then retelling the patient’s story using the

ATM (antecedents, triggers & mediators) model• Understand the application of “readiness to change”

models for establishing patient rapport• Use of appropriate functional medicine assessment

procedures for clinical assessment• Use of core therapeutics including: nutritional/dietary

interventions, physical medicine, toxin avoidance and mitigation, mind-body-spirit interventions, bioenergetic treatments, appropriate use of drugs and surgery

ESSENTIAL COMPONENTS FOR FUNCTIONAL MEDICINE PRACTITIONER


THE UNMET NEED

The need is for a new kind of CHRONIC CARE TEAM

Physicians who approach disease from a systems biology perspective rather than organ system taxonomy

Nutritionists/dietitians who can evaluate & educate patients for their nutritional status, cellular health

and design nutritional programs

Practitioners skilled in structural, exercise, and bioenergetics principles

Biologic-Functional dentists skilled in non-toxic restoration of dental/oral function

Pharmacists who can compound Rxs specific to the patient’s need

Psychologists/mind-body-spirit practitioners skilled in training patients in techniques for achieving and

maintaining wholeness

Para-medical practitioners skilled in specific functional practices


FUNCTIONAL MEDICINE:A Patient-Centered,

Comprehensive Chronic-Care Model

© 2007


THE PRINCIPLES: A SCIENCE USING FIELD OF

HEALTHCARE Biochemical individuality based on genetic and

environmental uniqueness Patient centered versus disease centered Dynamic balance of internal and external factors Web-like interconnections of physiological factors Health as a positive vitality – not merely the absence

of disease Promotion of organ reserve – healthspan

Textbook of Functional Medicine: Chap 2


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…


That Story Is Typically Told As … Chief Complaint (CC) History of Present Illness (HPI) Past Medical History (PMH) Review of Organ Systems (RS) Family History (FH) Dietary History (DH) Medication and Supplement History Social, Lifestyle, and Exercise History Physical Exam Findings (PE) Laboratory and Imaging Evaluations

Assessment and Diagnosis


In conventional medicine, the primary 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 often truncated when other information is seen as superfluous to reaching the diagnosis.


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.


Example #1Chief Complaint:

Wheezing

Diagnosis:Acute Asthma Attack

bronchodilators corticosteroids

tightness in the chest

sudden onset

asthmatic history

shortness of breath

History of Present Illness

oxygen


The clinician proceeds directly to the diagnosis—naming the disease—in order to identify as quickly as possible a medication to treat that disease.

Problems arise when the acute-care model is used to address chronic, long-term health issues.


The Story Is Truncated Chief Complaint History of Present Illness Past Medical History Review of Organ Systems Family History Dietary History Medication and Supplement History Social, Lifestyle, and Exercise History

Physical Exam Findings Laboratory and Imaging Evaluations Assessment DIAGNOSIS BY ORGAN SYSTEM


THE RESULTS OF USING THE ACUTE CARE MODEL:

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 major issue becomes a discrete diagnosis, dealt with in isolation from the others.


Hypercholes-terolemia

Statin

GastroesophagealReflux Disease

H2 blocker

Depression

SSRI

HypertensionACE inhibitor

Migraines Triptan

Osteoarthritis

NSAID

Irritable Bowel Syndrome

Dicyclomine

… the result is a focus on treating each symptom

complex as a separate and distinct “disease” with a

separate and distinct treatment.


Hypercholest-erolemia

Statin

Gastroesophageal Reflux Disease

H2 blocker

Depression

SSRI

HypertensionACE

inhibitor Migraines Triptan

Osteoarthritis

NSAID

Irritable Bowel Syndrome

Dicyclomine

Each individual diagnosis becomes a

distinct entity unto itself. The patient’s whole storynever has a chance to be

heard and understoodin context.


It is apparent that—in its rush to diagnose—conventional medicine is focused on the

branches and leaves of the tree …

Cardiology Pulmonary

Endocrinology

Gastroenterology

Neurology

Organ System Diagnosis

Urology/Nephrology

Hepatology

Allergy

Signs and Symptoms

and not the trunk and roots21st Century Medicine

Systems Biology Diagnosis



Endocrinology

Gastroenterology

Neurology


Urology/Nephrology

Hepatology

Allergy

Signs and Symptoms

Psychosocial

Environmental Inputs

Physical Exercise,Trauma

Xenobiotics, Micro-organisms,

Radiation

Diet, Nutrients, Air/Water

Mind and Spirit

Genetic PredispositionExperiences, Attitudes, Beliefs



Endocrinology

Gastroenterology

Neurology


Urology/Nephrology

Hepatology

Allergy

Signs and Symptoms

Psychosocial


PhysicalExercise,Trauma

Xenobiotics, Micro-organisms, Radiation


1. Communication- Outside the cell- Inside the cell

2. Bioenergetics/Energy Transformation

3. Replication/Repair/Maintenance/ Structural Integrity

4. Elimination of Waste5. Protection/Defense

6. Transport/Circulation

Fundamental Physiological Processes

Mind and Spirit




Endocrinology

Gastroenterology

Neurology


Urology/Nephrology

Hepatology

Allergy

Signs and Symptoms

Psychosocial


Physical Exercise,Trauma

Xenobiotics,Micro-organisms, Radiation



2. Bioenergetics/Energy Transformation

3. Replication/Repair/Maintenance/ Structural Integrity




Mind and Spirit


Fundamental Clinical Imbalances 1. Immune and Inflammatory Imbalance2. Redox Imbalance + Oxidative Stress +

Mitochondropathy3. Digestive/Absorptive and Microbiological

Imbalance4. Detox/Biotransformation/Excretory Imbalance5. Structural /Membrane Imbalance6. Hormonal and Neurotransmitter Imbalances7. Psychological and Spiritual Imbalance


Core Clinical Imbalances Hormonal and neurotransmitter imbalances Oxidation-reduction imbalances and

mitochondropathy Detoxification and biotransformational imbalances Immune and inflammatory imbalances Digestive, absorptive, and microbiological

imbalances Structural imbalances from cellular membrane

function to the musculoskeletal system Mind-body/body-mind imbalances


Psychological and Spiritual Equilibrium

Hormone andNeurotransmitter Regulation

Detoxification and

Biotransformation

Structural/Boundary and Membranes

Immune Surveillance

and InflammatoryProcess

Digestion and

Absorption

Oxidative/Reductive Homeodynamics

These fundamental clinical imbalances are the underlying mechanisms of disease …


??? 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 allostatic balance point the patient is locked into? That is, what are the underlying points of

leverage where intervention can be most effective?

In the functional medicine model, the patient’s full story is of central importance.

Instead of a preoccupation with how to namethe disease, the critical questions become:


Triggers

Affecting Antecedents(predisposing factors)

Sending out signals as Mediators

Creating Imbalance/Dis-ease

Fundamental Approach


Biological Mediators

(cytokines, prostanoids, nitric oxide, kinins,

hormones, neurotransmitters,

free radicals)

Antecedents

(genetics, experiences, past illnesses, occupational exposure,

nutrition, lifestyle)

Triggers (microbes, allergens, trauma, toxins)

Feed-forwardcycle




Detoxification and

Biotransformation

Structural/Boundary and Membranes

Immune Surveillance

and InflammatoryProcess

Digestion and

Absorption


These fundamental clinical imbalances are the underlying mechanisms of disease …

The diagnosis becomes a systems biology assessment


The Functional Medicine Story Is Developed with a Different Focus

Chief Complaint (CC) History of Present Illness (HPI)

Antecedents, Triggers, and Mediators Past Medical History (PMH) Review of Organ Systems (RS) Family History (FH) Dietary History Medication and Supplement History Social, Lifestyle, and Exercise History Physical Exam Findings Laboratory and Imaging Evaluations Diagnosis by Organ System Disease DIAGNOSIS of Fundamental Clinical

Imbalances (Systems Biology)


ExercisePrescriptions

Acupuncture

Manipulative Therapies

Phytonutrients

Nutritionals:Vitamins & Minerals

Nutraceuticals

Yoga

Drugs

Surgery

Counseling

The expanded Functional Medicine Model

permits the clinician to choose from an enlarged tool kit of

therapies because the patient’s problems are seen from a

perspective of underlying mechanisms

of imbalance.

MeditationCompounded, Personalized Prescriptions

Personalized Diet

Interventions


Functional medicine should not be viewed as alternative medicine, but as a bridge to a more

effective chronic-care model.


Let’s Explore How to Use the Functional Medicine Matrix

Model®


Functional Medicine ‘Expands the Accordion’

In Functional Medicine, the goal is to expand the patient’s story sufficiently to clarify the often multiple dysfunctions that must be addressed.

For patients with chronic, complex illnesses, the ‘accordion file’ of the patient history is opened out to evaluate the important antecedents, triggers and mediators, and to clarify the underlying mechanisms of dysfunction


In complex chronic disease there is often

significant information buried in the story



Endocrinology

Gastroenterology

Neurology


Urology/Nephrology

Hepatology

AllergySigns and Symptoms

Fundamental Clinical Imbalances Hormonal and Neurotransmitter Imbalances

Redox Imbalance + Oxidative Stress + MitochondropathyDetox/Biotransformation/Excretory Imbalance

Immune ImbalanceInflammatory Imbalance

Digestive/Absorptive and Microbiological ImbalanceStructural Integrity Imbalance


Mind and Spirit


Psycho-socialPhysical Exercise

TraumaDiet, Nutrients,

Air/Water

Xenobiotics Micro-organisms Radiation


2. Bioenergetics/Energy Transformation3. Replication/Repair/Maintenance/

Structural Integrity





Functional Medicine focuses on antecedents, triggers and mediators

Antecedents are factors, genetic or acquired, that predispose to illness

Triggers are factors that provoke the symptoms and signs of illness

Mediators are factors, biochemical or psychosocial, that contribute to pathological changes and dysfunctional responses


And the Core Clinical Imbalances

These core clinical imbalances underlie the expression of disease

These clinical imbalances form a pattern of dysfunction and are the result of underlying antecedents, triggers and mediators

It is the recognition of these patterns that is the art and science of medicine




Detoxification and Biotransformation

Structural/Boundary/ Membranes

Immune Surveillanceand Inflammatory Process

Digestion

and Absorption


____________________________________________________________

___

Antecedents(Predisposing)

______________________________________________________

Triggering Events(Activation)

______________________________________________________

The Patient’s Story Retold

_________________________________________________________

___

ExerciseNutrition Status Beliefs & Self-CareSleep Relationships

Date: ____ Name: ___________________ Age _____ Sex______ Chief Complaints: ___________________________

FUNCTIONAL MEDICINE MATRIX MODEL™


Case Study Progression

Take a careful, ‘expanded’ case Assess signs and symptoms in the case and

filter to appropriate clinical imbalances Evaluate for the most important antecedents,

triggers and mediators Prioritize the clinical imbalances in the case

(pattern recognition) From this prioritization, decide what further

evaluation would be useful Explain and frame the story to the patient

based upon the matrix; with antecedents, triggers, mediators and prioritizations


32 year old white male with a lifelong history of irritable bowel syndrome. Multiple work-ups as a child with little relief.

5 years ago he was diagnosed by stool exam with Blastocystis hominis and intestinal yeast. Treated with lactobacillus and Flagyl and reported significant improvement. (No follow-up lab performed)

However, over the course of 6-12 months his digestive symptoms returned. Currently he experiences episodic gas, bloating, and intermittent diarrhea.

Case ExampleChief Complaint/History of PI


Adult onset asthma started about 6 years ago. Prescribed multiple inhalers and antihistaminics with improvement. Relatively asymptomatic until the last 6 months during which he has had 3 asthmatic attacks unresponsive to bronchodilators. Placed on prednisone dose packs on three occasions. Currently mildly symptomatic.

Multiple antibiotics as child for ear and throat infections.

History of depression (and past treatment) but not currently on pharmacological treatment.

Past Medical History


Family History/Dietary History

Family history : • Paternal: asthma and chronic sinusitis• Maternal: obesity

Dietary history: Typical standard American diet (SAD):

high in simple carbohydrates

Often has fast food for lunch and dinner

Drinks 3-5 cups of caffeinated beverages daily

Does not eat fish or other significant sources of Omega

3 oils


Prescriptive medications: Proventil prn

Non prescriptive medications and supplements: Aspirin 2-3x weekly for headaches Tums 2-3x weekly for indigestion

Supplement and Medication History


Lives alone

Works as a physician and has inconsistent and long work hours; little social life and few hobbies.

No regular aerobic exercise. Occasionally uses a Stairmaster (1-2 times/weekly) for 30 minutes. No resistive training.

Does not smoke or drink. No other recreational drug use.

Lifestyle, Social, and Exercise History


Physical Exam: 70” 175# BP 130/86 EENT: Nasal mucosa boggy and

edematous. Slight erythema noted in posterior pharynx.

Skin: dry in general, posterior arms have cobble-stone texture. Fingernails have multiple white spotting.

Rest of physical exam is non-contributory

Previous Laboratory : CBC, Chemistry panel within normal limits

Physical Exam/Laboratory Evaluation


Clarify the most important antecedents, triggers and

mediators in the case


Assessing for Potential Antecedents, Triggers and Mediators

Antecedents: Multiple antibiotics Genetic atopic propensity

Triggers: Blastocystis hominis, Food sensitivity, Dysbiosis

Mediators: Medications: Aspirin- increase in intestinal

permeability Medication: Proventil-increase Detox load Adiposity-increased inflammatory mediators Depression-hormonal GI effects Nutritional insufficiencies: multiple effects on

immune competence, intestinal permeability etc.


Prioritize the clinical imbalances in the case (pattern recognition):


Is Blastocystis a pathogen?

Clinical Significance of Blastocystis hominis J Clin Micro 1989;Nov:2407-2409

Screening of a large population group for protozoa infection revealed that 515 were infected with the single protozoa Blastocystis hominis.

However, only 239 (46%) were found to be symptomatic, suggesting differential pathogenicity.

43 of these symptomatic patients were treated with Metronidazole. All patients became asymptomatic with negative stools on follow-up.


Does Blastocystis increase intestinal permeability?

Protozoon infections and intestinal permeability. Acta Trop. 2002 Jan;81(1):1-5.

Thirty nine patients with protozoan infections were compared to ten healthy controls.

Intestinal permeability (IP) was found to be increased in patients with protozoan infections compared with the control patients; specifically IP was increased in the Giardia and Blastocystis groups, although not in Entamoeba coli group.

The increase in IP in patients with B. hominis suggests that it can be a pathogenic protozoal infection and have systemic consequences


Healthy Gut

Healthy Cell Junctions

Healthy Cell Junctions

Healthy Villi/ Good Absorption


Leaky Gut

Damaged Villi / Poor Absorption

Damaged Cell

Junctions


AlteredIntestinal

Permeability

Poor Dietary ChoicesPoor Dietary Choices

Stress & EmotionsStress & Emotions

InfectionInfection

LectinsLectins

Systemic DiseaseSystemic Disease

Toxic ExposureToxic Exposure

Food AllergyFood Allergy

MalnutritionMalnutrition

Dysbiosis Dysbiosis

Toxic OverloadToxic Overload

Elevated TotalToxic & Antigenic

Burden

Elevated TotalToxic & Antigenic

Burden

Low Stomach AcidLow Stomach Acid

Systemic DiseaseSystemic Disease

Leaky Gut - Pathophysiology


Is intestinal permeability linked to asthma?

Intestinal permeability is increased in bronchial asthma. Arch Dis Child. 2004

Mar;89(3):227-9.

Thirty two asthmatic children, and 32 sex and age matched controls were assessed using the dual sugar (lactulose and mannitol) test.

Intestinal permeability was increased in children with asthma, suggesting that the whole mucosal system may be affected.

Previous reports have shown increased intestinal permeability in adult asthmatics.







Digestion

and Absorption








Food allergenYeast sensitivityZinc insufficiencyEFA InsufficiencyExcess adiposity

Genetic propensity

Multiple antibioticsGenetic atopic propensity

Increased intestinal permeability secondary to?

DysbiosisProtozoa infection

IBS trigger: B. hominis, Food sensitivity Asthma trigger: B. hominis, Food sensitivity

Overweight, DepressionMedications: Aspirin

Nutritional insufficiencies: zinc, etc

History of Depression, Little Social Life, Lives Alone

History of Depression

Medications


further evaluation to consider?


Case Study ProgressionReflecting back the patient’s story:Explain and frame the story back tothe patient based upon the matrix.

Start with the antecedents to the chief complaint(s) and review the important triggers and mediators that build on that story.

Emphasize the main elements of the matrix in the story.

The objective is to accurately and concisely reflect a story that a patient can understand.







Digestion

and Absorption


____________________________________________________________

___


______________________________________________________


______________________________________________________


_________________________________________________________

___




Food antibodiesYeast antibodies

Bioelectrical impedance RBC Fatty Acids

WBC zincSNP assessment

Amino Acid analysis

O&PLactulose MannitolDigestive function


Initial Intervention

• Comprehensive elimination diet • Non dairy/non gluten functional food containing:• supplemental antioxidants• conditional essential nutrients for GI tract• anti-inflammatory nutrients and phytonutrients

• O&P X 3


5 week follow-up• Considerable improvement in IBS with a decrease

in gas, bloating, and decreased frequency of episodic diarrhea.

• Decreased asthmatic complaints. • Overall ≈ 50% improved• Laboratory Results:

• O and P:• Microscopy:

• Rare endolimax nana cysts and trophozoites

• Many Blastocystis hominis• EIA Giardia, Cryptosporidium, and

Entamoeba negative


“A therapeutic intervention is fitting the treatment to the individual. In that sense it is like tailoring … measuring and trying it on until you get a good fit…. You don’t always get it the first time.”

Sid Baker, MD


Continue on dietary and functional/medical food protocol.

Add:• Botanical anti-protozoal therapy: berberine, artemesia, and citrus seed extract in combination

• Probiotics: lactobacillus and bifidobacteria in combination

5 week follow-up


Can probiotics affect intestinal permeability?

Probiotics in the atopic march: highlights and new insights Dig Liver Dis. 2006 Dec;38 Suppl

2:S288-90. Probiotics positively affect the host by

enhancing the microbial balance and therefore restore the normal intestinal permeability and gut micro ecology.

In clinical trials probiotics appear to be useful for the treatment of various clinical conditions such as food allergy, AD and allergic rhinitis,

It may be possible, in the future, to use probiotics in primary prevention of asthma.


12 week follow-up

Asthma and IBS essentially asymptomatic Food reintroduction showed sensitivity to

caffeine, chocolate, and eggs. Further consideration would include

continuation of reinoculation and repair of gastrointestinal system and rotation diet.

To discontinue functional/medical food and antiparasitic protocol.

F/u O&P: negative


“It is much more important to know what sort of person has a disease, than what

sort of disease a person has.” Sir William Osler







Digestion

and Absorption


____________________________________________________________

___


______________________________________________________


______________________________________________________


_________________________________________________________

___




© 2008, the institute for functional medicine david s. jones, md president and director of medical...

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