clinical integration and functional medicine matrix model integration and functional medicine matrix...
TRANSCRIPT
Clinical Integration and Functional
Medicine Matrix Model
Monique Class, ARNP
Applying Functional Medicine in Clinical Practice London, England
October 2015
Biotransformation & Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Triggering Events
The Patient’s Story Retold
Personalized Lifestyle Factors
Nutrition & Hydration
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mediators/Perpetuators Spiritual
Sleep & Relaxation
Name:____________________________ Date:___________ CC:_____________________________________ © Copyright 2011 Institute for Functional Medicine
Transport
Stress & Resilience
Family History:
• Depression
• Hypothyroidism
• Diabetes II
Mother’s
pregnancy: SAD
and smoker
Major life stressors: • Single mother • Divorce • Job • Isolation Extra weight
Chronic antibiotics 3 Children born between 25-29 Mother dying from BrCA. Divorce Major Job change
In the past but too tired now
Poor sleep hygiene, reads in bed, falls asleep but then wakes frequently, takes naps; un-refreshed.
Diverse diet but she does have significant carb cravings (candy etc.)
Divorce Single mother Job change
Lives alone No hobbies Uses Facebook casually to stay in touch with children
Carb Cravings Hurried eating Long Hx. of IBS Chronic ABX use early in life Bottle Fed
Possible exposure to toxins as a nurse/instructor Sensitive to scents/perfume Depressed Mood NSAIDs for HA Fluoxitine for Depression Acne
Severe fatigue Un-refreshing sleep Depressed Mood
Hashimoto’s? Adiposity=inflammation
IBS symptoms 3 children in short order NSAIDs=Increased IP
Divorce Single mother
Job change
Hypothyroidism Post? Menopause Hx. of Dysmenorrhea Acne
Hyperlipidemia
Nutrition, A Deep Dive
PFC-MVP Biomarkers
Your Functional Medicine Prescription
Nutrition
Assessments
PFC-MVP
Biomarkers
Gather
Organise
Re-Tell
Order/Prioritise
Initiate
Functional
Nutrition
Therapeutic
Interventions
The ABCDs of
Nutrition Evaluation
Food Is…
Food Is…
Food Is…
Food is information.
We are not our genes.
We are the expression of our genes.
Food Is…
Food is connection.
We are who our friends are.
We are what our friends eat.
Food Is…
Food is medicine.
“Let food be your medicine and
medicine be your food.”
- Hippocrates
Plant
Plan
Preparation
Portion
Pleasure
Phytonutrient Spectrum Patient Education Resources
©2015 The Institute for Functional Medicine
Personalising
the IFM Food Plans
Considerations for Personalising
the Food Plans
• Choose Food List Based on Features
• Provide Tailored Food List
– Consider Macronutrient Percentages
– Targeted Calories when Appropriate
– Provide Serving Allowances
– Remove Triggering Foods
• Discuss Therapeutic Foods
• Provide Practical Tools such as Weekly Menu
Plan, Recipes, and Shopping List
Considerations for Personalising
the Food Plans
• Choose Food List Based on Features
• Provide Tailored Food List
– Consider Macronutrient Percentages
– Targeted Calories when Appropriate
– Provide Serving Allowances
– Remove Triggering Foods
• Discuss Therapeutic Foods
• Provide Practical Tools such as Weekly Menu
Plan, Recipes, and Shopping List
Considerations for Personalising
the Food Plans
• Choose Food List Based on Features
• Provide Tailored Food List
– Consider Macronutrient Percentages
– Targeted Calories when Appropriate
– Provide Serving Allowances
– Remove Triggering Foods
• Discuss Therapeutic Foods
• Provide Practical Tools such as Weekly Menu
Plan, Recipes, and Shopping List
Functional Nutrition Food Plans
Medical History ABCDs of Nutrition Evaluation
Anthropometrics
Biomarkers and Labs
Clinical Indications from NPE
Diet and Lifestyle Review
Matrix Review
Chief Complaints
Conditions
Timeline and ATMs
Medication Review
Choosing a Food Plan
Taking a Tour
through the
Food Plans • Ideal Patient
Population
• Food Plan Features
• Introduction to the
Food Plan List
• Comprehensive
Guide
• Suite resources
The Core Food Plan
Functional Nutrition Food Plans
Medical History ABCDs of Nutrition Evaluation
Anthropometrics
Biomarkers and Labs
Clinical Indications from NPE
Diet and Lifestyle Review
Matrix Review
Chief Complaints
Conditions
Timeline and ATMs
Medication Review
Choosing a Food Plan
Profile for when to use the Core
Food Plan
Gather/GOTOIT
Core Food Plan
Chief Complaint and
Medical History
Weight Gain / Weight loss
Fatigue
Conditions Non-specific
Medical History Seeking Healthy Diet, All
Ages, Athletic, Pregnancy,
Overweight, Underweight
ATMs
Anthropometrics Non-specific
Biomarkers & Labs Normal screening values
Clinical Indicators from
Nutrition Physical Exam
Non-specific
Diet and Lifestyle Inadequate nutrients
Prepared food
Matrix Patterns Non-specific
Your Functional Medicine Prescription
x x
The Elimination Diet
Functional Nutrition Food Plans
Medical History ABCDs of Nutrition Evaluation
Anthropometrics
Biomarkers and Labs
Clinical Indications from NPE
Diet and Lifestyle Review
Matrix Review
Chief Complaints
Conditions
Timeline and ATMs
Medication Review
Choosing a Food Plan
Identifies Food Triggers
Reduces Inflammation
Repairs Intestinal Permeability
Phytonutrients to Heal the Gut
Reduces Toxic Burden
No Calorie Restriction
Promotes Body Awareness to Foods
Profile for
when to use
Gather/GOTOIT
Elimination Diet
Chief Complaint and
Medical History
GI sxs-bloating, indigestion, Joint pain, Muscle aches
Immune dysregulation, Fatigue
Conditions
Gastrointestinal
• Irritable Bowel Syndrome
• Intestinal Permeability
Immune/Inflammation
• Auto-immune Diseases
• Asthma
• Atopy &Skin Inflammation
• Myalgias and Arthralgias
Mood Disorders
• Depression
Medical History Allergies, Atopy, Asthma, GI Distress, Pain and Fatigue,
AI Diseases.
ATMs Antibiotics, Multiple infections, Trauma, Stress, Familial
allergies, Mother with Group B strep, Acid Blocking
Medication, Maternal use of PPI during pregnancy
Anthropometrics Increased BMI, Increased ECW/ICW
Biomarkers & Labs Inc.. IgG or IgE food reactions, Celiac, Autoantibodies,
Dysbiosis.
Clinical Indicators from
Nutrition Physical Exam
Dry Skin, thin eyebrows, Fluid retention, and skin
inflammation.
Diet and Lifestyle Food Triggers, Allergy Exposures. Excess reliance on
one food.
Matrix Patterns Assimilation
Biotransformation
Communication/Defense and Repair
©2015 The Institute for Functional Medicine
The next step…
Reintroduction of foods
©2015 The Institute for Functional Medicine
Food Reintroduction
Functional Nutrition Food Plans
Medical History ABCDs of Nutrition Evaluation
Anthropometrics
Biomarkers and Labs
Clinical Indications from NPE
Diet and Lifestyle Review
Matrix Review
Chief Complaints
Conditions
Timeline and ATMs
Medication Review
Choosing a Food Plan
©2015 The Institute for Functional Medicine
Profile for
when to use
Gather/GOTOIT
Cardiometabolic Food Plan
Chief Complaint and
Medical History
Elevated Blood Sugar, Increased Blood
Pressure, Increased Waist Line, Fatigue
Conditions Obesity, Metabolic Syndrome, Type 2
Diabetes, Essential Hypertension, Dyslipidemia
Medical History Metabolic Syndrome, Type 2 Diabetes,
Hypertension, Dyslipidemia, Obesity
ATMs Family History, T2DM, CVD, HTN, Obesity,
Sedentary Lifestyle, Sleep Disorder (inadequate
sleep and Sleep apnea)
Anthropometrics Inc..: BMI, WC, WHR, Fat, Blood Pressure
Biomarkers & Labs Inc..: HgbA1C, FBS, insulin, hs-CRP, Trigs
Decr.: HDL
Clinical Indicators from
Nutrition Physical Exam
Inc..: WC and WHR
Skin tags, acanthosis nigricans, peripheral
neuropathy.
Diet and Lifestyle Excess simple sugar, high CHO intake, GI
foods, low protein, excess alcohol, elevated
trans fats.
Matrix Patterns Structural Integrity
Transport
Defend and Repair/Communication
Arteriosclerosis Thromb Vasc Biol. 2012 September; 32(9): 2052–2059.
Fatty Liver
Obesity
Type 3 Diabetes
Cardiovascular Disease
Immune Dysfunction
Endothelial Dysfunction
Beta-cell Dysfunction
Lipotoxicity Osteoporosis
©2015 The Institute for Functional Medicine
Modified Mediterranean Approach
Mediterranean Diet
• The most well-studied dietary approach • Over 3800 articles on PubMed (as of 8/17/15) • Over 1400 articles for its connection to
cardiovascular disease (as of 8/17/15)
Taken from The Practitioners Guide to Personalizing the IFM Food Plans
Macronutrient Distribution for 40/30/30 Approach
©2015 The Institute for Functional Medicine Taken from The Practitioners Guide to Personalizing the IFM Food Plans
©2015 The Institute for Functional Medicine
THE CARDIOMETABOLIC
FOOD PLANS
with Caloric Targets
Low glycemic index and
glycemic load
Targeted calories
Eating regular times
High in fibre
Low in simple sugars
Balanced Quality Fats
Condition-specific
phytonutrients
PLACEHOLDER FOR CMS FOOD PLAN
©2015 The Institute for Functional Medicine
Core Food Plan Elimination Diet Cardiometabolic
Chief Complaint and Medical History
Weight Gain / Weight loss Fatigue
GI sxs-bloating, indigestion Joint pain Muscle aches Immune dysregulation Fatigue
Elevated Blood Sugar Increased Blood Pressure Increased Waist Line Fatigue
Conditions
Non-specific Gastrointestinal • Irritable Bowel Syndrome • Intestinal Permeability
Immune/Inflammation • Auto-immune Diseases • Asthma • Atopy &Skin Inflammation • Myalgias and Arthralgias
Mood Disorders • Depression
Obesity Metabolic Syndrome Type 2 Diabetes Essential Hypertension Dyslipidemia
Differentiating Food Plans
Allows you to Personalise all other
food plans
Clinical Nutrition Findings
Core Food Plan Elimination Diet Cardiometabolic
Medical History Seeking Healthy Diet, All Ages, Athletic,
Pregnancy, Overweight, Overweight,
Underweight.
Allergies, Atopy, Asthma, GI Distress,
Pain and Fatigue, AI Diseases.
Metabolic Syndrome, Type 2 Diabetes,
Hypertension, Dyslipidemia, Obesity
ATMs Antibiotics, Multiple infections, Trauma,
Stress, Familial allergies, Mother with
Group B strep, Acid Blocking
Medication, Maternal use of PPI during
pregnancy
Family History, T2DM, CVD, HTN,
Obesity, Sedentary Lifestyle, Sleep
Disorder (inadequate sleep and Sleep
apnea)
Anthropometrics Non-specific Increased BMI, Increased ECW/ICW Inc.: BMI, WC, WHR, Fat, Blood
Pressure
Biomarkers & Labs Normal screening values Inc.. IgG or IgE food reactions, Celiac,
Autoantibodies, Dysbiosis.
Inc.: HgbA1C, FBS, insulin, hs-CRP, Trigs
Decr: HDL
Clinical Indicators from Nutrition
Physical Exam
Non-specific Dry Skin, thin eyebrows, Fluid retention,
and skin inflammation.
Inc.: WC and WHR
Skin tags, acanthosis nigricans,
peripheral neuropathy.
Diet and Lifestyle Inadequate nutrients
Prepared food
Food Triggers, Allergy Exposures. Excess
reliance on one food.
Excess simple sugar
High CHO intake, GI foods, low protein,
excess alcohol, elevated trans fats.
Matrix Patterns Non-specific Assimilation
Biotransformation
Communication/Defense and Repair
Structural Integrity
Transport
Defend and Repair/Communication
Food Plans
Get together with a member
Of your group:
• Which of the 3 featured Food Plans could you implement within your patient base?
• What challenges or resistance could you imagine with your patients if you recommend these Food Plans?
©2015 The Institute for Functional Medicine
Let’s Go Back to the Case,
What Functional Nutrition
Tools Would You Give Her?
54 year old white female
• CC: long term fatigue x 15 years
• Irritable Bowel Syndrome x 40 years
• Depression x 24 years
• Chemical Sensitivity x 19 years
• Hypothyroidism x 6 years
• Hyperlipidemia & High Triglycerides x 5 years
• Hypertension x 5 years
• Also reports long term history of Weight Gain, Memory Changes, Emotional Lability, and Headaches
D
Pre
con
cep
tio
n
Current Concerns
Antecedents
Triggers or Triggering Events
Signs, Symptoms or Diseases Reported
Pre
nat
al
Bir
th
7-10 14-18
30 54
Depression, Headaches Insomnia & ‘Brain Fog’ Resistant Weight Loss
48
Chronic Antibiotic use for 2+ years;
25-29
HTC, Dyslipidemia, Increased trigs,
& Hypothyroidism
LMP
52 1-3
Chronic OM
3 Children born; at ages of 25, 27, 29
Colic
IBS, Abd Pain
Dysmenorrhea, Acne
37-39 42
40
Major Life Stressors
• Diet • Smoking
47
“Chemical Sensitivity”
35
Severe Fatigue Began
Exposure?
FHx.: • Depression • Hypothyroidism • Diabetes (dad) • HTN (dad) • Breast CA (mom)
©2015 The Institute for Functional Medicine
D
Pre
con
cep
tio
n
Current Concerns
Antecedents
Triggers or Triggering Events
Signs, Symptoms or Diseases Reported
Pre
nat
al
Bir
th
7-10 14-18
30 54
Depression, Headaches Insomnia & ‘Brain Fog’ Resistant Weight Loss
48
Chronic Antibiotic use for 2+ years;
25-29
Dx: Dyslipidemia, Increased trigs,
& Hypothyroidism
LMP
52 1-3
Chronic OM
3 Children born; at ages of 25, 27, 29
Colic
IBS, Abd Pain
Dysmenorrhea, Acne
37-39 42
40
Major Life Stressors
• Diet • Smoking
47
“Chemical Sensitivity”
35
Severe Fatigue Began
Exposure?
FHx.: • Depression • Hypothyroidism • Diabetes (dad) • HTN (dad) • Breast CA (mom)
Biotransformation & Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Triggering Events
The Patient’s Story Retold
Personalized Lifestyle Factors
Nutrition & Hydration
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mediators/Perpetuators Spiritual
Sleep & Relaxation
Name:____________________________ Date:___________ CC:_____________________________________ © Copyright 2011 Institute for Functional Medicine
Transport
Stress & Resilience
Family History:
• Depression
• Hypothyroidism
• Diabetes II
Mother’s
pregnancy: SAD
and smoker
Major life stressors: • Single mother • Divorce • Job • Isolation Extra weight
Chronic antibiotics 3 Children born between 25-29 Mother dying from BrCA. Divorce Major Job change
In the past but too tired now
Poor sleep hygiene, reads in bed, falls asleep but then wakes frequently, takes naps; un-refreshed.
Diverse diet but she does have significant carb cravings (candy etc..)
Divorce Single mother Job change
Lives alone No hobbies Uses Facebook casually to stay in touch with children
Carb Cravings Hurried eating Long Hx. of IBS Chronic ABX use early in life Bottle Fed
Possible exposure to toxins as a nurse/instructor Sensitive to scents/perfume Depressed Mood NSAIDs for HA Fluoxitine for Depression Acne
Severe fatigue Un-refreshing sleep Depressed Mood
Hashimoto’s? Adiposity=inflammation
IBS symptoms 3 children in short order NSAIDs=Increased IP Hypertension Visceral Adiposity
Divorce Single mother
Job change
Hypothyroidism Post? Menopause Hx. of Dysmenorrhea Acne
Hyperlipidemia Hypertriglyceridemia
Hypothyroidism Post? Menopause Hx. of Dysmenorrhea Acne Insulin Resistance
Your Functional Medicine Prescription
x
Your Functional Medicine Prescription
x
x
Biotransformation & Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Triggering Events
The Patient’s Story Retold
Personalized Lifestyle Factors
Nutrition & Hydration
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mediators/Perpetuators Spiritual
Sleep & Relaxation
Name:____________________________ Date:___________ CC:_____________________________________ © Copyright 2011 Institute for Functional Medicine
Transport
Stress & Resilience
Family History:
• Depression
• Hypothyroidism
• Diabetes II
Mother’s
pregnancy:
SAD and
smoker
Major life stressors: • Single mother • Divorce • Job • Isolation Extra weight
Chronic antibiotics 3 Children born between 25-29 Mother dying from BrCA. Divorce Major Job change
In the past but too tired now
Poor sleep hygiene, reads in bed, falls asleep but then wakes frequently, takes naps; un-refreshed.
Diverse diet but she does have significant carb cravings (candy etc..)
Divorce Single mother Job change
Lives alone No hobbies Uses Facebook casually to stay in touch with children
Carb Cravings Hurried eating Long Hx. of IBS Chronic ABX use early in life Bottle Fed
Possible exposure to toxins as a nurse/instructor Sensitive to scents/perfume Depressed Mood NSAIDs for HA Fluoxitine for Depression Acne
Severe fatigue Un-refreshing sleep Depressed Mood
Hashimoto’s? Adiposity=inflammation
IBS symptoms 3 children in short order NSAIDs=Increased IP Hypertension Visceral Adiposity
Divorce Single mother
Job change
Hypothyroidism Post? Menopause Hx. of Dysmenorrhea Acne Insulin Resistance
Hyperlipidemia Hypertriglyceridemia
Your Functional Medicine Prescription
x
x
Your Functional Medicine Prescription
x x x
Why Not Start with the Elimination Diet ?
Your Functional Medicine Prescription
x
x
x
Taken from The Practitioners Guide to Personalizing the IFM Food Plans
Macronutrient Distribution for 40/30/30 Approach
Macronutrient Ratio?
Your Functional Medicine Prescription
x
x
x x
Taken from The Practitioners Guide to Personalizing the IFM Food Plans
Macronutrient Distribution for 40/30/30 Approach
Caloric Target?
©2015 The Institute for Functional Medicine
Which Areas of the Matrix
Would You Consider
Key Points of Leverage?
Biotransformation & Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Triggering Events
The Patient’s Story Retold
Personalized Lifestyle Factors
Nutrition & Hydration
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mediators/Perpetuators Spiritual
Sleep & Relaxation
Name:____________________________ Date:___________ CC:_____________________________________ © Copyright 2011 Institute for Functional Medicine
Transport
Stress & Resilience
Family History:
• Depression
• Hypothyroidism
• Diabetes II
Mother’s
pregnancy: SAD
and smoker
Major life stressors: • Single mother • Divorce • Job • Isolation Extra weight
Chronic antibiotics 3 Children born between 25-29 Mother dying from BrCA. Divorce Major Job change
In the past but too tired now
Poor sleep hygiene, reads in bed, falls asleep but then wakes frequently, takes naps; un-refreshed.
Diverse diet but she does have significant carb cravings (candy etc.)
Divorce Single mother Job change
Lives alone No hobbies Uses Facebook casually to stay in touch with children
Carb Cravings Hurried eating Long Hx. of IBS Chronic ABX use early in life Bottle Fed
Possible exposure to toxins as a nurse/instructor Sensitive to scents/perfume Depressed Mood NSAIDs for HA Fluoxitine for Depression Acne
Severe fatigue Un-refreshing sleep Depressed Mood
Hashimoto’s? Adiposity=inflammation
IBS symptoms 3 children in short order NSAIDs=Increased IP Hypertension Visceral Adiposity
Divorce Single mother
Job change
Hypothyroidism Post? Menopause Hx. of Dysmenorrhea Acne
Hyperlipidemia Hypertriglyceridemia
Hypothyroidism Post? Menopause Hx. of Dysmenorrhea Acne Insulin Resistance
What does stress do?
It messes with the Matrix!
Summary: Stress and the Matrix
It is pro-inflammatory and causes immune dysregulation.
Stress and the Immune System
Stress and the Energy Node
Stress is a source of oxidative stress and diminishes mitochondrial
function but it is reversible!
Stress and Detoxification Stress impairs Detoxification and increases toxic burden through
poor dietary choices.
Stress and Transport
Stress increases BP and Increases Carotid Artery Intima Thickness
Stress and Communication Stress causes alterations in the HPATG axis
Stress and Structural Integrity Stress decreases bone density in postmenopausal women
Stress and Assimilation Stress causes increased intestinal permeability
Your Functional Medicine Prescription
Biotransformation & Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Triggering Events
The Patient’s Story Retold
Personalized Lifestyle Factors
Nutrition & Hydration
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mediators/Perpetuators Spiritual
Sleep & Relaxation
Name:____________________________ Date:___________ CC:_____________________________________ © Copyright 2011 Institute for Functional Medicine
Transport
Stress & Resilience
Family History:
• Depression
• Hypothyroidism
• Diabetes II
Mother’s
pregnancy: SAD
and smoker
Major life stressors: • Single mother • Divorce • Job • Isolation Extra weight
Chronic antibiotics 3 Children born between 25-29 Mother dying from BrCA. Divorce Major Job change
In the past but too tired now
Poor sleep hygiene, reads in bed, falls asleep but then wakes frequently, takes naps; un-refreshed.
Diverse diet but she does have significant carb cravings (candy etc.)
Divorce Single mother Job change
Lives alone No hobbies Uses Facebook casually to stay in touch with children
Carb Cravings Hurried eating Long Hx. of IBS Chronic ABX use early in life Bottle Fed
Possible exposure to toxins as a nurse/instructor Sensitive to scents/perfume Depressed Mood NSAIDs for HA Fluoxitine for Depression Acne
Severe fatigue Un-refreshing sleep Depressed Mood
Hashimoto’s? Adiposity=inflammation
IBS symptoms 3 children in short order NSAIDs=Increased IP Hypertension Visceral Adiposity
Divorce Single mother
Job change
Hypothyroidism Post? Menopause Hx. of Dysmenorrhea Acne
Hyperlipidemia Hypertriglyceridemia
Hypothyroidism Post? Menopause Hx. of Dysmenorrhea Acne Insulin Resistance
In your Toolkit
Biotransformation & Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Triggering Events
The Patient’s Story Retold
Personalized Lifestyle Factors
Nutrition & Hydration
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mediators/Perpetuators Spiritual
Sleep & Relaxation
Name:____________________________ Date:___________ CC:_____________________________________ © Copyright 2011 Institute for Functional Medicine
Transport
Stress & Resilience
Family History:
• Depression
• Hypothyroidism
• Diabetes II
Mother’s
pregnancy: SAD
and smoker
Major life stressors: • Single mother • Divorce • Job • Isolation Extra weight
Chronic antibiotics 3 Children born between 25-29 Mother dying from BrCA. Divorce Major Job change
In the past but too tired now
Poor sleep hygiene, reads in bed, falls asleep but then wakes frequently, takes naps; un-refreshed.
Diverse diet but she does have significant carb cravings (candy etc.)
Divorce Single mother Job change
Lives alone No hobbies Uses Facebook casually to stay in touch with children
Carb Cravings Hurried eating Long Hx. of IBS Chronic ABX use early in life Bottle Fed
Possible exposure to toxins as a nurse/instructor Sensitive to scents/perfume Depressed Mood NSAIDs for HA Fluoxitine for Depression Acne
Severe fatigue Un-refreshing sleep Depressed Mood
Hashimoto’s? Adiposity=inflammation
IBS symptoms 3 children in short order NSAIDs=Increased IP Hypertension Visceral Adiposity
Divorce Single mother
Job change
Hypothyroidism Post? Menopause Hx. of Dysmenorrhea Acne
Hyperlipidemia Hypertriglyceridemia
Hypothyroidism Post? Menopause Hx. of Dysmenorrhea Acne Insulin Resistance
Your Functional Medicine Prescription
Biotransformation & Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Triggering Events
The Patient’s Story Retold
Personalized Lifestyle Factors
Nutrition & Hydration
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mediators/Perpetuators Spiritual
Sleep & Relaxation
Name:____________________________ Date:___________ CC:_____________________________________ © Copyright 2011 Institute for Functional Medicine
Transport
Stress & Resilience
Family History:
• Depression
• Hypothyroidism
• Diabetes II
Mother’s
pregnancy: SAD
and smoker
Major life stressors: • Single mother • Divorce • Job • Isolation Extra weight
Chronic antibiotics 3 Children born between 25-29 Mother dying from BrCA. Divorce Major Job change
In the past but too tired now
Poor sleep hygiene, reads in bed, falls asleep but then wakes frequently, takes naps; un-refreshed.
Diverse diet but she does have significant carb cravings (candy etc.)
Divorce Single mother Job change
Lives alone No hobbies Uses Facebook casually to stay in touch with children
Carb Cravings Hurried eating Long Hx. of IBS Chronic ABX use early in life Bottle Fed
Possible exposure to toxins as a nurse/instructor Sensitive to scents/perfume Depressed Mood NSAIDs for HA Fluoxitine for Depression Acne
Severe fatigue Un-refreshing sleep Depressed Mood
Hashimoto’s? Adiposity=inflammation
IBS symptoms 3 children in short order NSAIDs=Increased IP Hypertension Visceral Adiposity
Divorce Single mother
Job change
Hypothyroidism Post? Menopause Hx. of Dysmenorrhea Acne
Hyperlipidemia Hypertriglyceridemia
Hypothyroidism Post? Menopause Hx. of Dysmenorrhea Acne Insulin Resistance
Lets us now consider
each node of the Matrix
Biotransformation &
Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Relationships
Modifiable Personal Lifestyle Factors
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mental
Spiritual
Name:____________________________ Date:___________ CC:_____________________ © Copyright 2014 Institute for
Functional Medicine
Emotional
Transport
Retelling the Patient’s Story
FUNCTIONAL
MEDICINE MATRIX
Stress
Nutrition
Exercise &
Movement
Sleep & Relaxation
Mediators/Perpetuators
Triggering Events
Antecedents
Stool Analysis
Digestion/Absorption
Digestive enzyme levels/fibers, Bile acids
Immunology/Inflammation
Calprotectin, Lactoferrin, Fecal sIgA
Metabolic and Microbiome
Parasites: O&P, EIA,
Bacteria, yeast: culture and sensitivity,
SCFAs
5Rs
Remove-Elimination Food Plan,(Oligoantigenic diet),
pathogenic organisms
Replace-digestive enzymes, HCl, Bile Salts, Fiber,
Bromelain
Reinoculate-Probiotics, Prebiotics, Synbiotics
Repair-Glutamine, Zinc, Vit. A,D,E, plantain, EPA/DHA
Rebalance-relaxation, mindful eating, Psychotherapy, Stress
management
Assimilation/Structural
Integrity
Assessment
• Are symptoms frankly associated with food/eating? From what we now
know, could those symptoms possibly be associated with food?
• Does the patient have high scores in the MSQ sections for
“digestive tract” and “weight” sections?
• Are there medications or surgeries that may impair digestion and/or
absorption
• Assessing the patient’s diet, is it deficient/insufficient?
Inflammatory? Hurried, emotional eating?
Interventions
Questions to Ask
Biotransformation &
Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Relationships
Modifiable Personal Lifestyle Factors
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mental
Spiritual
Name:____________________________ Date:___________ CC:_____________________ © Copyright 2014 Institute for
Functional Medicine
Emotional
Transport
Retelling the Patient’s Story
FUNCTIONAL
MEDICINE MATRIX
Stress
Nutrition
Exercise &
Movement
Sleep & Relaxation
Mediators/Perpetuators
Triggering Events
Antecedents
Assessment
Signs of inflammation:
• Allergic shiners, boggy mucosa, pain, congestion
Labs:
• Autoantibodies
• Increased levels of inflammatory mediators such as histamine and various cytokines
and Interleukins.
• AA:EPA ratio >3
• Elevated hs-CRP, Leukocytosis
• Elimination Diet Food Plan
• Avoid Triggers
• EFAs: EPA/DHA
• Alpha-Lipoic acid, NAC,
• Antioxidants
• Probiotics
• Botanicals/phytonutrients:
• Quercitin, Scute, Curcumin, Ginger, Catechins, Devil’s
Claw
• Boswellia, Ginkgo, Licorice, Grape Seed Extract
Questions to Ask: • Does the patient have an Inflammatory diet such as high fried, processed,
high simple sugar, high GL?
• Does the patient have a highly antigenic diet? (Gluten, Milk etc..)
• Has the patient had environmental exposure to potentially inflammatory
triggers? (smoking, pesticides, solvents, alcohol)
• Is there a traumatic event in the patient’s Timeline?
Interventions
Defense &
Repair
Biotransformation &
Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Relationships
Modifiable Personal Lifestyle Factors
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mental
Spiritual
Name:____________________________ Date:___________ CC:_____________________ © Copyright 2014 Institute for
Functional Medicine
Emotional
Transport
Retelling the Patient’s Story
FUNCTIONAL
MEDICINE MATRIX
Stress
Nutrition
Exercise &
Movement
Sleep & Relaxation
Mediators/Perpetuators
Triggering Events
Antecedents
Communication/Transport
Assessment
NCEP ATP III:
Increased waist circum., Inc.. Blood Pressure, Elevated FBS, Elevated
Triglycerides, Decreased HDL
Visceral Adiposity, Bio impedance Analysis, Hyperinsulinemia
Dysglycemia
• Elevated Inflammatory markers such as hs-CRP.
• Elevated A1C.
• Insulin resistance
• Elev TG/HDL (>=3)
• Apo B/Apo A-1 > 0.8
• Cardiometabolic Food Plan
• Exercise Prescription
• Essential Fatty Acids
• Blood Glucose Log
• Stress Management
• Correct Nutritional Insufficiencies
• Insulin sensitizing phytonutrients: Cr, Mg,
Vit D, catechins, cinnamon
Questions to Ask:
• Is there a pattern of dysinsulinemia and dysglycemia?
• Is there a family or personal history of Cardiovascular or
Cardiometabolic disease?
• Is there a history or suspicion of sleep apnea or other sleep
disturbances?
• High saturated fat/high sugar/high GL?
Interventions
Biotransformation &
Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Relationships
Modifiable Personal Lifestyle Factors
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mental
Spiritual
Name:____________________________ Date:___________ CC:_____________________ © Copyright 2014 Institute for
Functional Medicine
Emotional
Transport
Retelling the Patient’s Story
FUNCTIONAL
MEDICINE MATRIX
Stress
Nutrition
Exercise &
Movement
Sleep & Relaxation
Mediators/Perpetuators
Triggering Events
Antecedents
More Communication/Transport
Assessment
Abnormal findings in sex steroid
hormones or Thyroid/Adrenal
hormone levels.
• TSH, T4, fT4, rT3
• Estrogen fractions, PROG, Test,
SHBG
• Cortisol and DHEA
Clinical evidence of abnormal
endocrine function (even with
apparently “normal” levels).
Fasting Blood Glucose and Insulin
SNPs in Detoxification pathways.
Questions to Ask:
• Are there seemingly vague and broad-spectrum symptoms?
• Is there a history of removal or injury to any endocrine
organ?
• Is the patient taking any hormones of any kind, or
medications that affect hormones?
• Is there un-refractory fatigue?
• Cardiometabolic Food Plan
• Optimize bowel function
• Aromatase inhibitors: Anastrazole, green tea,
mushrooms, curcumin, chrysin, crucifers,
resveratrol, omega-3s.
• Treat insulin resistance and obesity
• Hormone replacement
Interventions
Biotransformation &
Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Relationships
Modifiable Personal Lifestyle Factors
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mental
Spiritual
Name:____________________________ Date:___________ CC:_____________________ © Copyright 2014 Institute for
Functional Medicine
Emotional
Transport
Retelling the Patient’s Story
FUNCTIONAL
MEDICINE MATRIX
Stress
Nutrition
Exercise &
Movement
Sleep & Relaxation
Mediators/Perpetuators
Triggering Events
Antecedents
Assessment
• Evidence of Dysbiosis
• SNPs that impair detoxification
• Toxic exposure questionnaire implies a past or ongoing
exposure.
• Direct measurement of toxins.
• Impaired hepatic function: GGT.
• Toxic Metals (hair, stool, blood, urine)
• Minimize exposure to toxins
• Maximize Organic foods, Fresh foods
• Judicious intake of fish and shellfish
• Avoid amalgam fillings
• Optimize bowel function
• Antioxidants
• Consume Sea and Cruciferous vegetables
• Clean air with plants/devices
• Use natural cosmetics
• Adequate Exercise & Sauna
• D-glucaric Acid, NAC, Alpha-Lipoic Acid, Taurine
• Botanicals/phytonutrients
• Berberine, Globe Artichoke, Turmeric, Milk thistle,
Dandelion
Questions to Ask:
• Is there exposure in the patient’s history? Home? Work? Hobby?
Childhood?
• Is the patient “sensitive” to perfumes etc.?
• Are the patient’s TEQ-20 and MSQ suspicious for toxicity?
Interventions
Biotransformation
Biotransformation &
Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Relationships
Modifiable Personal Lifestyle Factors
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mental
Spiritual
Name:____________________________ Date:___________ CC:_____________________ © Copyright 2014 Institute for
Functional Medicine
Emotional
Transport
Retelling the Patient’s Story
FUNCTIONAL
MEDICINE MATRIX
Stress
Nutrition
Exercise &
Movement
Sleep & Relaxation
Mediators/Perpetuators
Triggering Events
Antecedents
Energy
Assessment
Questions to Ask:
• Is the patient experiencing: prolonged inflammation? An
increased need for detoxification? Or increased stress?
• Is there a toxic exposure (increases the need for cellular
energy and potentially inhibits it’s production)?
• Chronic shallow breathing?
Total Antioxidant Capacity (TAC); GSH:GSSG; Cysteine:Cystine
Antioxidant Enzymes:
• Superoxide Dismutase
• Glutathione Peroxidase
• Catalase
Oxidative Damage:
• Lipid peroxides, oxidized LDL
• HgbA1c, AGEs
• 3-Nitrotyrosine
• 8-OH Deoxyguanosine
NAC, vitamin C, Vitamin E
Milk Thistle
Pyridoxyl-5-Phosphate
CoQ10, Lipoic Acid
Curcumin and Cayenne, Carotene
Methylation factors (B-Vitamins), EGCG, Resveratrol
Adequate Protein and Mineral co-factors
Interventions
What are the next steps?
Diagnostically?
Therapeutically?
rack assessments, note the effectiveness of the therapeutic
approach, and identify clinical outcomes at
each visit—in partnership with the patient
“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
©2015 The Institute for Functional Medicine
Unconscious
Incompetence Conscious
Incompetence
Discovery Learning
(You don’t know what you
don’t know.)
(You know what you need
to do but you don’t have
the skills to do it.)
(You know what to do and
how to do it and it flows
naturally from you.)
Conscious
Competence Unconscious
Competence
Disciplined Effort Skilled Application
(You know what you
should do, and how to do
it, but it takes a lot of
conscious effort.)
Both you and your patient are on a Journey
©2015 The Institute for Functional Medicine
General Challenges in Follow-up
• What do you do when the patient doesn’t
improve?
• What do you do if they do?
• Following up on a lifestyle program
• Following up on a dietary program
©2015 The Institute for Functional Medicine
General Challenges in Follow-up
• Navigating symptom control vs. long term
resolution
• Giving the patient too much change vs. not
enough
– Doing too much vs. doing too little
©2015 The Institute for Functional Medicine
Follow up with our Patient
What do you do if your initial treatment approach of…
– An elimination diet, probiotics, and glutamine for the gut
– Omega 3 fatty acids and B-complex for depression
– Nutritional support for the thyroid
– Magnesium for headaches
– Stress reduction techniques and sleep hygiene
Did not work, or did not work well enough?
©2015 The Institute for Functional Medicine
Follow up with our Patient
What lab would you get?
What else would you do?
©2015 The Institute for Functional Medicine
Functional Nutrition Biomarkers
©2015 The Institute for Functional Medicine
Taking a Functional Medicine History
Using a Timeline and Matrix
Take the time to complete
Your Own Timeline
“Perhaps the most basic skill of the physician is the ability to have comfort with uncertainty; to recognise with humility the uncertainty inherent in all situations; to be open to the ever-present possibility of the surprising, the mysterious and even the holy; and to meet people there.”
Rachel Naomi Remen