p 2 collaborative of wny, inc october 7, 2010 sylvia h. regalla,...

P2CollaborativeofWNY,IncOctober7,2010

SylviaH.Regalla,MD,MSACN,ABIHMSanfordH.Levy,MD,FACP,ABIHM

 HolmanH.JAMA2004;292:105(ProfessoratStanfordMedicalSchool)

ChronicDisease‐theNeedforaNewClinicalEducation“Itisaxiomaticthatmedicaleducationshouldpreparestudentswellfor

theclinicalproblemstheywillfaceintheirfuturepractice.However,thatisnothappeningforthemostprevalentprobleminhealthcaretoday:chronicdisease.”“Chronicdiseasereplacedacutediseaseasthedominanthealthproblem.Chronicdiseaseistheprincipalcauseofdisabilityanduseofhealthservicesandconsumes78%ofhealthexpenditures.”

Themodelwehavetodayisoutofdate!!

StangeKC.AnnalsofFamMed.2006TheFutureofFamilyMedicineReport‐callsfora“NewModelofCare”thatisgroundedintimelessvaluesofpersonalized,patient‐centeredcare,coupledwiththeapplicationofnewtechnologicalsystems.

FunctionalMedicine Healthcareforthe21stcentury Addressestherootcauseofchronicdisease  Stopstreatingsymptomsandstartstreatingtheunderlyingcausesofchronicdiseases

 Thefundamentallawsofbiologyarethedriversofdisease

  Inreality–thebodyisoneintegratedwholesystem

 Thereareunderlyingphenomenathatinteractacrossallmedicalsubspecialtieslike:inflammation,oxidativestress,energyproblemsofthecellsfromabnormalmitochondrialfunction,ortoxicity

  Functionalmedicineisthebridgethatconnectsthedotstogetthewholestoryofmedicalscience

 Thedifferencebetweenconventionalmedicineandfunctionalmedicineisinthedetails

 Example:patientwithinflammationcausedbyautoimmunedisease  Conventionalapproach‐“youhaveaninflammatorydiseasesowe’llsuppresstheinflammation”–soitshutsdown,locksdownnormalphysiologytotrytostoptheprocess

  Functionalmedicineapproach–whyisthisinflammationhappeninginthefirstplace?

  Theapproachisinchangingthetriggers–poordiet,stress,environmentaltoxins

  Conventionalmedicineisinterestedinsymptomsandnamingthediseasewithadiagnosisthenmatchingthedisease/diagnosiswithadrug

 Howdoesfunctionalmedicinechangethewaywetreatapatient?  Functionalmedicinepractitionersuseadifferentsetoftoolsintheirtoolboxtotreatthecauseofdisease

 Diet  Thecauseofheartdiseaseaswellasthetreatmentforreversingheartdisease

  Dietmaycauseinflammationofthebloodvesselwall  Placingapatientonalowcholesterol,Mediterraneandietwithplentyoffishoilmayreversetheplaque

 Anautoimmunediseasefromgluten(wheat)sensitivitymaycauseaninflammatoryjointdiseaseandplacingapatientonaglutenfreedietwillimprovethesymptoms. Weremovedthecauseoftheinflammatoryjointdisease

 Apatientmayhaveenvironmentaltoxinexposurewhichisdrivingpoormitochondrialfunctionleadingtobraindysfunction,functionalmedicinepractitionershelpthebodyremovetoxinsbysupplyingthedetoxificationmaterials

  Functionalmedicinepractitionersusethesameconceptsofscienceinmedicinebutrestructurethemtoaddressthetreatmentofthecauseofthediseaseratherthanjustaddressingthesymptomsofdisease

  SenatorTomHarkinappointedagroupofFunctionalMedicinepractitionerstothePresident'sAdvisoryGrouponPrevention,HealthPromotion,andIntegrativeandPublicHealthtoadvisetheadministrationinJune2010.FunctionalMedicinepractitionersparticipatedintheWhiteHouseForumonPreventionandWellnessin2009aswellastestifiedbeforetheSenateWorkingGroupofHealthCareReform.

ChallengingPatients

 Don’talwaysfitconventionalICD#9diagnosis

 Multi‐systemsymptoms

 Varyingduration

  Failuretorespondtoconventionaltherapies(pharmaceuticals,surgery)

ChallengingPatients

 Theproblemisusuallynotalackofclinicaldata

  Sometimesinformationmustbeorganizedinadifferentcontext,usingadifferentparadigm

ChallengingPatients

 Context:Arrangingthefilecardsdifferently

 Paradigm:Changingourfocusandseeingtheforestinsteadofthetrees

ConventionalClinicalApproach

 Disease‐centered

 Thetherapeuticregimeisemployedprimarilytosuppresssignsandsymptomsofanillness

FunctionalMedicineClinicalApproach

  Functionalmedicineisascience‐basedhealthcareapproachthatassessesandtreatsunderlyingcausesofillnessthroughindividuallytailoredtherapiestorestorehealthandimprovefunction.

FunctionalMedicineClinicalApproach

 Antecedents‐‐Geneticpredisposition

 Triggers‐‐Toxins,hormonalimbalance,immunologicalstresses

 Mediators‐‐Cytokines,prostaglandin,leukotrienes

FundamentalKeyFactorsofFunctionalMedicine

  Biochemicalindividuality

  Interdependenceoforganfunction

  Homeodynamic(seekstoreestablishstructural,physiologicalandcognitivebalance/function)

  Patient‐centered

  Viewshealthasacontinuum

  Healthasapositivevitality

  Healthismorethantheabsenceofdisease

PillarsofFunctionalMedicineEvaluationandTreatment

 NutritionalStatus  Inflammation/ImmuneDysregulation GastrointestinalFunction HepaticDetoxification MitochondrialFunction&OxidativeStress EndocrineFunction

NutritionalStatus

 Deficiencyversusinsufficiency

  Interrelationshipsofnutrients(synergists,antagonists,rate‐limitingstepinenzymaticreactions)

 Relationshipofnutrientstophysiologicfunction

•  Conditionallyessentialnutrients

•  Cellularcommunication(nutrientsthatfunctionasinter/intracellularcommunicators)

•  Diet/lifestyle

Energy Production/ Oxidative Redux

The Functional Medicine Matrix A Question of Balance

Immune & Inflammatory Balance

Hormonal & Neuro- Transmitter Balance

Mind & Spirit

Structural Balance

Detox & Biotransformation GI Balance

Environmental Inputs (Diet, Nutrition, Exercise)

Cardiology Pulmonary

Endocrinology

Gastroenterology

Neurology

OrganSystemDiagnosis

Urology/Nephrology

Hepatology

AllergySignsandSymptoms

Diet,Nutrients,Air/Water

Psycho‐social

EnvironmentalInputs

PhysicalExerciseTrauma

XenobioticsMicro‐organisms&Radiation

FundamentalClinicalImbalancesHormonalandNeurotransmitterImbalances

RedoxImbalance+OxidativeStress+Mitochondropathy

Detox/Biotransformation/ExcretoryImbalanceImmuneImbalance

InflammatoryImbalanceDigestive/AbsorptiveandMicrobiologicalImbalance

StructuralIntegrityImbalance

1.Communication ‐Outsidethecell ‐Insidethecell

2.Bioenergetics/EnergyTransformation3.Replication/Repair/Maintenance/

StructuralIntegrity

4.EliminationofWaste5.Protection/Defense6.Transport/Circulation

FundamentalPhysiologicalProcesses

MindandSpirit

GeneticPredispositionExperiences,Attitudes,Beliefs

Inacutecare,thepatient’sstoryissqueezeddownto

thechiefcomplaintandhistoryofthepresentillness

whilethediagnosisincreasesinimportance.

Example#1ChiefComplaint:

Wheezing

Diagnosis:AsthmaAttack

bronchodilators corticosteroids

tightnessinthechest

suddenonset

asthmatichistory

shortnessofbreath

HistoryofPresentIllness

Hypercholest‐erolemia

Statin

GastroesophagealRefluxDisease

H2blocker

Depression

SSRI

HypertensionACE

inhibitor Migraines Triptan

Osteoarthritis

NSAID

IrritableBowelSyndrome

Dicyclomine

Eachindividualdiagnosisbecomesa

distinctentityuntoitself.Thepatient’swholestory

neverhasachancetobeheardandunderstood

Incontext.

Hypercholes‐terolemia

Statin

GastroesophagealRefluxDisease

H2blocker

Depression

SSRI

HypertensionACE

inhibitor Migraines Triptan

Osteoarthritis

NSAID

IrritableBowelSyndrome

Dicyclomine

…theresultisafocusontreatingeachsymptomcomplexasa

separateanddistinct“disease”withaseparateanddistincttreatment.

Exercise

AcupunctureManipulativeTherapies

Phytonutrients

Minerals

Vitamins

Diet

Yoga

Drugs

Surgery

Counseling Meditation

PsychologicalandSpiritual

Equilibrium

HormoneandNeurotransmitterRegulation

DetoxificationandBiotransformation

StructuralIntegrity

ImmuneSurveillance

Digestion,Absorption,andBarrierIntegrity

OxidativeReductive

Homeodynamics

InflammatoryProcess

Infectiousmicro‐organisms

Structuralorphysicaldamage

Nutrientinsufficiency

Xenobiotics

Radiation

Emotionaltrauma

Spiritualangst

Nutrientexcess

Foodtoxicants(allergens,stimulants

etc,)

Drugsideeffects

Adiposity

Toxicmetals

Aging

Geneticpre‐disposition(SNPs)

Disruptedlightcycles–circadian

dysrhythmias

Hyperglycemia

Hypoglycemia

Excessiveexercise

Excessivenoise

Situationalstress–fear,anxiety,worry

Dysbiosis

Thefunctionalmedicinemodelrecognizesand

prioritizesthepatient’sfull,uniquestoryand

usesfundamentalclinicalimbalancesasakeytotreatingcomplex,

chronicillness.

Withoutacomprehensiveintegratedmodelforthecareofchronic,complexillnesses,

practitionersleavetheirpatients’healthcareneedsunfulfilled.