functional nutrition -...

©2014 The Institute for Functional Medicine

FunctionalNutrition:

“Seeing More” During the Functional Nutrition Physical ExamP. Michael Stone M.D., M.S P. Michael Stone M.D., M.S.

Sydney Australia


Please note the videos included in this presentation have been

removed for copyright reasons.


Nutritional defects, “like deer in the forest” do not announce their presence but must be looked for” (Sanstead 1969)

http://sjhigbee.files.wordpress.com/2013/05/deer-in-clapham-woods.jpg


Nutrition Evaluation


Pattern Recognition

Undernourished

Reduce Exposures

Ensure a Safe Detox


Core Aspects of the Nutrition Physical Exam

1) Vitals and Body Composition2) Evaluate Smell and taste3) Look in the Mouth4) Look at and feel the Skin5) Look at the Nails6) Evaluate Peripheral Sensation


Test Smell


Altered Smell or Taste• Smell and Taste are Closely Linked• Evaluate the History: Trauma, Exposure,

Allergy, Obstruction• Other physical exam findings- peripheral

neuropathy• Evaluate Medications• Evaluate Nutritional Status:

Mineral Status: Zinc, Copper, Iron, IodineVitamin Status: A, E: B complex-B2, B3, Pantothenic Acid, Biotin, Folate, B12


Causes of Abnormal Smell Test(*most common)

• Obstruction: Allergies, Nasal polyposis*, Deviated Septum*, Intranasal tumor

• Sensory: Viral infection*, Chronic sinusitis*, Allergic Rhinitis*, Cigarette Smoke*, Toxic Chemical exposure, heavy metals (Al, Si, Pb, As, Cd)Drugs-calcium channel blockers

• Neural: Head Injury*, Alzheimer's disease, Parkinson’s disease, Intracranial tumor, Schizophrenia

• Endocrine: Hypothyroidism, DM• Nutritional: Iron, Zinc, Copper, Vitamin A, B1,12


Drugs That Alter SmellDrug Group Examples z Calcium Channel Blocker Nifedipine, amlodipine, diltiazemLipid Lowering Cholestyramine, clofibrate, pravastatinAntibiotic/Antifungal Streptomycin, doxycycline, terbinafineAntithyroid CarbimazoleOpiate Codeine, morphineAntidepressant AmityptylineSympathomimetic Dexamphetamine, phenmetrazineAntiepileptic PhenytoinNasal Decongestant Phenylephrine, pseudoephedrine,

oxymetazolineMiscellaneous Smoking, agyria (topical silver nitrate),

cadmium fumes, phenothiazines, pesticides, Betnesol-N, Cocaine

snorted


SMELL TESTPocket Smell Test1) With the patient sitting, test nasal patency by having

them cover one nostril and breath in. Listen for the sound of abnormal air flow. If present do not test, investigate cause of obstruction.

2) Open the card. Use the tongue depressor and scratch the scratch and sniff odorant. Have the client cover one nostril and sniff. Inquire as to the smell. If they are not sure, then offer choices. Repeat with the other nostril.

3) Repeat this with all three odors. The total score should be 6. If 2 or more are missed, then further work up of disordered smell and taste should begin.


• Smell (Quick Card), – Apple – Natural Gas– RoseOR– Lemon– Lilac– Smoke

UPSIT Test www.sensonics.com

POCKET SMELL TEST


Bitter BitterBitterTest Taste


Screening Questionnaire for Loss of Taste

How easily can you detect the tastes Easily Somewhat Not At All

1. Saltiness (chips, pretzels, salted nuts)

2. Sourness (vinegar, pickles, or lemons)

3. Sweetness (soda, cookies, ice cream)

4. Bitterness (coffee, beer, tonic water)

Negative Predictive value for easily: saltiness 95%, sourness 89%, Sweetness 98%, Bitterness 92%. Positive predictive values range from 5-26% (when a person can Easily taste each of the 4 senses then there is a high degree of confidence that they Can taste. Easily is negative for gustatory loss, and somewhat or not at all is positive For loss. Malaty J, IAC Malaty: Smell and Taste Disorders in Primary Care Am Fam Physician 88;12; 852-859, 2013.


Taste (TAS2R)

Genetics of Taste

3


Are you a supertaster?Bitter (phenylthiocarbamide-PTC)

Supertasters vs non tasters: Vegetable avoidance, increased fat and sweet intake, disinhibited eating behavior among women, More Alcohol dependence.

m.stone md


Why Check Bitter-Taste?1) Taste perception affects food selection2) Supertasters have a tendency to eat less

vegetables, eat vegetables more with sauces, dislike coffee, moderate to little like for sweets, pepper/chili and alcohol are more irritating, and perceive feel not tast of fat.

3) Non bitter tasters more susceptible to eating spoilage, and poisonous alkaloids.

4) Can change your therapeutic interventions.


Genetics and Taste

Reed DR, Knaapila A: Genetics of Taste and Smell: Poisons and Pleasures. Prog Mol Biol Trans Sci: 2010:94:213-40

Chemical Gene Allele Sucrose TAS1R3 -1572 C/T Glutamate TAS1R3 R757C Isothiocyanate TAS2R38 A49P, V262A, 1296V Isovaleric acid OR11H7P C/T at nt 679 Androstenone OR7D4 R88W

YUCK!

YUM!

Gene Quality Genotype Rating of Good Child 1 Child 2 Taste

TAS1R3 Sweet in Onion +/+ -/- TAS1R3 Umami in Tomato +/+ -/- TAS2R38 Bitter in Watercress -/- +/+ OR11H7P Sweat odor in Cheese -/- +/+ OR7D4 Boar Taint in Ham -/- +/+


Taste LossInfection: Oral Candida, Periodontal disease, gingivitis oral abscess,

viral URI, HIVOral Appliances: Dentures, prostheticsPostsurgical: Middle ear surgery affecting corda tympany, oral or

dental surgery especially 3rd molar extractionRadiation: HEENT irradiation with oral mucositis, xerostomiaNutrition insufficiency: Protein malnutrition, zinc, copper deficiency, B12,

niacin deficiencyMedications: Intranasal zinc, chlorhexidine, chemotherapy,

ACE Inhibitors, ARBs, calcium channel blockers, diuretics, macrolides, terbinafine, fluoroquinolones, protease inhibitors, griseofulvin, PCN, tetracyclines, metronidazole, antiarrhythmics, antidepressants, anti convulsants, lipid lowering agents.

Head Trauma:Toxins: pepper gas, weed killer, ammonia, benzene,

cadmium, iron, leadMedical Conditions: Cancers, Type 2 DM, Hypothyroidism, Renal Failure

Malaty J, IAC Malaty: Smell and Taste Disorders in Primary Care Am Fam Physician 88;12; 852-859, 2013.


Eight Step Mouth Exam


8 Steps in Evaluation of the Mouth

1) Jaw Movement2) Lips3) Soft and Hard Palate4) Tongue5) Gums6) Buccal Mucosa7) Teeth8) Chew/swallow


Nutrition-oriented Physical Exam;

8 Step Mouth Exam


Oral Mucosal Lesions and Micronutrient Deficiency

Oral mucosal condition Associated micronutrient deficiency

Angular Cheilitis Cheilosis (dry cracking)

Riboflavin, Nicotinic acid, Folic Acid, Biotin Cobalamin, Vit C, Fe, Zn. /Riboflavin, Niacin, Pyridoxine

Burning Mouth Syndrome Pyridoxine

Candidiasis Folic acid , cobalamin, Iron

Glossitis Riboflavin, nicotinic acid, pyridoxine, folic acid, cobalamin, iron, protein energy malnutrition

Lip fissures Pyridoxine

Oral Sensitivity Thiamine, pyridoxine

Recurrent apthae Riboflavin, Folic acid, Cobalamin, Ascorbic Acid

Stomatitis Nicotinic acid, Folic acid, Cobalamin.

Periodontal disease Vitamin A, D, E, B-Carotene, Thiamin, Folate B12, E, C, Ca, Se

Poor mucocutaneous border

Riboflavin, Niacin, pyridoxine, Zinc

Moynihan P. : Nutrition and its effect on oral health and disease. Ch 5, pp 83-99. In M. Wilson: Food constituents and oral health. Current status and future prospects. CRC Press Boca Raton Fl 2009.


Herpes Labialis

Recurrent Aphthous Stomatitis

Perlèche-angular cheilitis

Which Nutrients are Associated

With Each Condition?

2-Lips Cracks, Lesions, Sores

Am Fam Physician 2007;75:501-7.

Zinc, Vitamin A, C

Lysine/Arginine BalanceLower levels of A,E,C

Riboflavin, B-6, B-12Folate, Minerals: Zinc, Fe


4-Tongue-What do I look for?

• Movement • Color • Coating • Fissuring • Scalloping • Piercing • Taste Bud

Distribution • Lesions


Color

m.stone md


Tongue CoatingTongue Coating Score

0= No tongue coating1= Thin tongue coating2= Thick tongue

coating difficult to see papillae

J Oral Rehabil 2007 Jun;34(6):442-7.

Significantly more anaerobic bacteria the thicker the coat,

No significant difference in candida


B12, Thiamin, Riboflavin Niacin, Pellagra

4-TongueGlossitis with Taste Bud Atrophy

mstone


Hairy tongue

Erythema Migrans

Median RhomboidGlossitis

Leukoplakia

Am Fam Physician 2007;75:501-7, Head Face Med. 2006 Oct 16;2:33.

Iron and Selenium

Candidiasis

Allergy-Intolerance

Oral Hygeine, Candida, AbxDysbiosis-oral

4-Tongue Additional Patterns


Scalloping• Macroglossia- any cause• Hypothyroid, acromegaly,

amyloidosis, down syndrome

• Sleep apnea• Increased in autoimmune

conditions*• Increased in food allergy

and hypersensitivity*

*clinical experience

m.stone md


mstone


Taste Bud DistributionCircumvallateVallate (Inverted V)

FoliateFungiform (spots)

Filiform (coating)

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• Tendency toward Allergy• If painful and geographic: -Iron, folic acid, B2, B12, Niacin

• Associated with systemic inflammation

NEJM 361:20, 2009

4-TongueGeographic Tongue


Tongue Coating, pH, Caries and Metabolomics

Evid Based Complement Alternat Med. 2013; 2013: 204908 BMC Complement Altern Med. 2013; 13: 227 Sci Rep. 2012; 2: 936


Lichen Planus Tongue Cancer

•

Wikipedia images: Lichen Planus and Oral Cancers

http://upload.wikimedia.org/wikipedia/commons/5/59/Lichen_Planus_Fig7.tiff

http://upload.wikimedia.org/wikipedia/commons/3/3c/ZungenCa2a.jpg


4 –TongueColor, Coverings, Buds, Size, Movement

• Glossitis (Red Tongue) Protein Undernutrition, Iron, Riboflavin, niacin, B6, folate, B12

• Decreased taste/smell Burning tongue: Zinc, Vitamin C

• Tongue fissuring Niacin, gut triggered immune issues

• Tongue –taste bud atrophy Iron, Riboflavin, niacin, B12

• Leukoplakia Vitamin A, B2, niacin, B6, Folate, B12

• Hairy black tongue Not Specific; associated with smoking, sulfur granule positive bacteria, antibiotics

PFC-MVP


Gingivitis Periodontitis

5-Gums and Gingiva

Atlas of Clinical Oral Pathology 2nd Edition. 2003. P. 100-101, Lane, M. Et al: Int J Dent. 2010; 2010: 324719

IL1, IL6, IL10, VDR, genes may be associated with Chronic Peritonitis


Periodontal Disease

Treating Periodontal disease aggressively and early in pregnancy increases the chance of a full term vs preterm delivery by 6 fold.

M. Jeffcoat, S. Parry, M. Sammel, B. Clothier, A. Catlin, and G. MacOnes, “Periodontal infection and preterm birth: successful periodontal therapy reduces the risk of preterm birth,” British Journal of Obstetrics and Gynaecology, vol. 118, no. 2, pp. 250–256, 2011


Periodontal Disease is Increased by Several Risk Factors

1) Cigarette smoking2) Systemic diseases autoimmune, diabetes, CVD... 3) Medications such as steroids, anti-epilepsy drugs

cancer therapy drugs4) Ill-fitting bridges 5) Crooked teeth and loose fillings 6) Pregnancy7) Oral contraceptive use8) Low Vitamin D, Vitamin A, Low Vit C, Low Fe, Zn

Jemin Kim-Periodontal disease and systemic conditions: a bidirectional relationship. Odontology. 2006 September ; 94(1): 10–21.


Hemorrhages: Vitamin C Bleeding gums and...

5-Gums, Gingival findings can cause you to look elsewhere...

m.stone md


5- Gums-Scurvy

Pretreatment Post-treatment

Weinstein, M. et al.: Pediatrics 2001;108(3). 108/3/e55


Dark Lines: Lead (Burton’s Line)

5-Gums

Some discolorations from other heavy metals toxicity and therapeutics have been documented-cadmium, bismuth, mercury, cis-platinum

. J A Regezi, J L Sciubba and RCK Jordan: Oral Pathology Clinical Pathologic Correlations. 2008. 5th Edition


60 y.o. male T2DM, Arrhythmia, Htn, worsening evening vision with mouth findings...What do you see and think?

• Low Vitamin D• Low ionized calcium• Low Vitamin A• Low Vitamin C• Low pH• Low salivary output

secondary to beta blocker for arrhythmia

• Occult infection

m.stone md


7- Teeth

Missing Teeth/Repairs Amalgam and Alloy Load

MStone MStone


7- Tooth Enamel and Celiac Disease

• 1 in 5 Celiacs have Enamel DystophicChanges. Those without celiac 1/100

.El-Hodhod, MA et al: Screening for celiac disease in children with dental enamel defects. ISRN Pediatr.2012:763783. Epub2012 Jun7.


• Methamphetamine

• Erosions of Recurrent Vomiting- Bulemia

©2014 The Institute for Functional MedicineDenBesten P. , Wu Li: Chronic Fluoride Toxicity: Dental Fluorosis. Monogr Oral Sci. 2011 ; 22: 81–96.

Consider Background Water or Food Levels of Fluoride


Possible Antecedents and Triggers

A = AmalgamGC = Gold CrownPC = Porcelain CrownPD = Periodontal DzRC = Root CanalEX = Extraction

EX EX EX EX

A

A GC/RC

A A

A EX EX

EX EX

A A A A

A A

7-Teeth and the Dental Chart


7- Teeth and Breath

Missing Teeth/Repairs Amalgam and Alloy Load

MStone MStone

RA Bernhoft: Mercury Toxicity and Treatment. J Env Public Health 2012Ucar, Y, WA Brantley: Biocompatibility of Dental Amalgams, Int J Dentistry 2011

2-28 mcg/facet/day80 % absorbed


Marek, M. "Interactions Between Dental Amalgams and the Oral Environment." Advances in Dental Research Sept. 1992: 100-09. A.sagepup.com. Web. 19 Nov. 2011. <doi: 10.1177/08959374920060010101>. Courtesy of : Mary Ellen Chalmers

Illustrating Galvanic Currents


If Amalgam Fillings might be a root cause of health problems…

For a Biologic Dentist near you!

International Academy of Oral Medicine & Toxicology www.iaomt.org

Mercuryexposure.info

http://www.iaomt.org/


Why Check pH?1) The pH of the mouth helps determine and is

determined in part by the microflora- oral dysbiosis, infection, salivary flow, and buffering capacity of the saliva.

2) pH<6.8-7.4 is associated in increased endothelial dysfunction, inflammation, and oxidative stress.

3) pH<5.8 associated with enamel disruption and cariogenesis

4) Intervention with increased vegetable intake, alkalization of the diet, and treating causes of low salivary flow or poor buffering improves pH and oral dysbiosis


7- Teeth and Salivary pH

• pH paper or sticks• Different Techniques- Touch, Spit, Collect• Compare to the pH guide• pH>6.8-7.4 “ideal”• pH <6.8 is acidic• pH<5.8 enamel erosion

“Alters environment”

.Oscillating pH Conditions in the Mouth


Look At and

Feel the Skin


Touch the Skin on the Arm

Character:• Temperature• Texture• Color• Hydration• Lesions• Hair Distribution


Skin and Nutrition

• Barrier Health• Membrane Health• Cellular Health• Requires Cofactors

– Elongases– Desaturases

Psoriasis

Atopic Dermatitis

http://missinglink.ucsf.edu/lm/DermatologyGlossary/img/Dermatology Glossary/Glossary Clinical Images/xerosis-J.jpg


Xerosis

Hyperkeratosis pilari

P. , F:EFA, C, M:Zinc inadequacy, V:Vitamin A Vitamin C, B, P.

Xerosis


Seborrhea, dry scaly skin Dry eczematous rash

Which nutrients are involved?

EFA, Zinc, Vit A, Biotin Zinc, food intolerances (atopia), vitamin A, probiotics, EFA

Skin Dry Rash


Seborrheic Dermatitis

+Deficiency in EFAs, Vit A, zinc, biotin +Dysbiosis +Food allergy / sensitivity


Beta carotene Retinol• Highly variable• BCMO1 – encodes enzyme converts beta carotene to

retinol• In summary, a range of SNPs can influence the

effectiveness of using plant-based carotenoids to increase vitamin A status in at-risk population groups and this effect may vary depending on ethnic origin.

• Other influences – food source, BMI (increased BMI = decreased conversion), hypothyroidism, zinc, copper and selenium

• Zinc deficiency limits bio availability of vitamin A• Often give vitamin A and zinc together

Beta carotene Retinol

Lietz, G. J Nutr. 2012;142:161S-165C

©2014 The Institute for Functional Medicine©2014 The Institute for Functional Medicine

Celiac Dermatitis Herpetiformis

Atopy:PermeabilityImmune BalanceProtein lossEFA/GLA,Zinc, Vit. A/DHoming, C

Gluten Sensitivity vs.Celiac;Innate vs.AdaptiveImmune Balance

Atopy/Eczema Infected Severe Atopy


Acanthosis Nigricans

• Smooth, velvet-like, hyperkeratotic plaques in intertriginous areas (e.g., groin, axillae, neck).

• Will resolve when insulin resistance resolves.

http://clevelandclinicmeded.com/medicalpubs/diseasemanagement/dermatology/dermatologic-signs-of-systemic-disease/images/dermatologic-signs-fig12_large.jpg

http://dermatology.cdlib.org/DOJvol6num1/original/acanthosis/figure04.jpg


Acanthosis Nigricans• Type I is associated with malignancy. Sudden

onset. Extensive truncal distribution,including the face, palms, and trunk.

• Type II is the familial type, with autosomal dominant transmission. Rare and appears at birth or soon after.

• Type III: obesity and insulin resistance. Most Common

• Drugs: systemic corticosteroids, nicotinic acid, diethylstilbestrol, and isoniazid (INH).


Acanthosis Nigricans

Type 2 DM, PCOS

Glucocorticoids, niacininsulin, oral contraceptivesprotease inhibitors

Severity is predicted byFasting Insulin levels

Higgins, SP et al Dermatology Online J 14(9):2

Skin Tags


Follicular Hyperkeratosis: EFA, Zn, Vit. A, C, B complex



S Ragunatha,1 V Jagannath Kumar,2 and S B MurugeshA CLINICAL STUDY OF 125 PATIENTS WITH PHRYNODERMA

Indian J Dermatol. 2011 Jul-Aug; 56(4): 389–392.

Vitamin A, B complex, EFA, Vitamin C undernutrition


Skin- Vitamin C Deficiency

Actas Dermosifiliogr. 2005 Jul-Aug;96(6):400-2.

Swan neck hairs

Léger D. Can Fam Physician 2008;54:1403-6

Follicular Purpura

Bruising


ACNE

Deficiency in Zinc, Vit A, EFAs.

Dietary Allergens, High GL diet, Dairy.

Photos by James Heilman, MD


Gut / Brain / Skin Connection• Hypochlorhydria results in increase risk of SIBO /

gut infections• SIBO leads to decreased absorption of protein,

fats, carbs and vitamins secondary to inflammation• Injury to enterocytes in small intestine = increased

intestinal permeability• SIBO associated with depression and anxiety and

eradication improves emotional symptoms• SIBO is associated with a 10X increase in acne

rosacea• LPS endotoxins are more common in people with

acneBowe + Logan. Gut Pathogens. 2011;3:1.


Acne vulgaris, Probiotics, and the gut-brain-skin axis-back to the future?

Bowe and Logan. Gut Pathogens. 2011;3:1.


Other Causes of AcneiformConditions


Dioxin Poisoning Typical blood dioxin level: 15-45 units / gram of blood fat

Yushchenko: 100,000 units / gram AP Photo/Viktor Podedinsky/Efrem Lukatsky

March 28, 2002 Dec 6 2004

21 Months


Chloracnegenic Chemicals• Chlorinated phenols• Chloronaphthalenes• Polychlorinated biphenols• Other polychlorinated compounds:

polyhalogenated dibenzofuranes,polychlorinated dibenzo-p-dioxins, chlorinated azo and azoxybenzenes.

• Location of the halogen on the benzene rings determines the acnegenicity.


Dioxin• Chloracne is most consistent

manifestation of dioxin intoxication• Absorbed by direct contact, inhalation,

ingestion• Normally TCDD <10 ppt (parts per trillion)

in patients with chloracne levels in the several hundreds.

• Dioxin: highly lipophilic• Half life 7-11 years


Chloracne Distribution• Early: face and neck• Later: trunk, extremities, genitalia• Comedone appearance more often on the face

and neck, below and to the outer side of the eye (malar crescent), Posterior auricular triangles.

• Ear lobes, suboccipital hairline and groin involved.• Nose, perioral skin and supraorbital regions

usually spaired.• Other skin lesions: xerosis from decreased sebum

secretion, pigmentation, porphyrinopathy,hirsutism, skin thickening , palmoplantar hydrosis,palmoplantar hyperkeratosis.


ChloracneClinical Features Acne Vulgaris Chloracne Age group Adolescent and childhood Any age, children susceptible

Predilection site Localized, face, chest, back Generalized: retroauricular, malar, axillae, groin, extremities

Major Lesions Limited comedones, papules, pustules, cysts

Myriad comedones

Pathogenic factors

Inflammatory lesions common Very rare

Sebum production Increased Decrease

Microflora Propionibacterium acnes Propionibacterium granulosum

No bacteria

Androgen sensitivity Dependent Unknown

Therapy Effective under treatment of antibiotics, Resistant to therapy retinoids and other treatment

Calorie Restriction and Dietary fat substitute (Olestra) up to a 30 fold increase in excretion

Ju Q, CC Zouboulis, L Xia: Environmental pollution and acne: Chloracne Dermato-Endocrinology 1:3,125-128, 2009


Drug Induced Acneiform EruptionsDu-Thouh A, N Kluger, H Bensalleh, B GuillitAm J Clin Derm 2011; 12(4)233-245

Categories Causitive Agents

Hormones Corticosteroids, Corticotropin(ACTH), Androgens/Anabolic steroids, Hormone contraceptives, TSH

Neuropsychotherapeutics Tricyclic antidepresents, Lithium, Antiepileptics, SSRI...

Vitamins Excess Vitamin A, Thiamine, Pyridoxine, B12

Cytostatic Drugs Azathioprine, thiourea, thiouracil, Dactinomycin (actinomycin D)

Immune Modulators Cyclosporin

Antituberculin Isoniazide, Rifampin, Ethionamide

Halogens Iodine, Bromine, Chlorine, Halothane, Lithium


Iodine

• Cold dry skin• Sparse hair• Decreased

perspiration• Frank Myxedema

• Iododerma (multiple nodular, ulcerating, pustular, fungating lesions

• Kelp Acne

Low Iodine High Iodine


Skin and Heavy Metals: Mercury

• Increased dermatographia• Acrodynia of the hands and feet• Xerosis and peeling palms and soles of

feet• Autonomic dysfunction with increased

flushing/sweating/hypersalivation (acute)• Methyl mercury, ethyl mercury, elemental

mercury with different findings dependent on exposure.

Weinstein M, S Bernstein CMAJ • JAN. 21, 2003; 168 (2) 201.

©2014 The Institute for Functional MedicineH

g+ D

ose

Burd

en

Curr Probl Pediatr Adolesc Health Care 2010 September; 40(8):186-215.


Skin and Heavy Metals: What About…Arsenic?

©2014 The Institute for Functional Medicinepmstone, md,ms 2013 92

Seborrheic keratosis: common benign epithelial tumors. Do not appear until age 30 and over the lifetime. Small to large barely elevated papules to “stuck on” Plaques Lesions do not require treatment except for cosmetic reasons. They can become irritated or traumatized with pain and bleeding, squamous cell cancer should be ruled out. Wolff, K, RA Johnson: Benign Tumors pp 215-218. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. 6th ed 2009


Seborrheic Keratosis Key Question….. When Did They Appear? All at once, over a short period of time…? Patient…Why do you ask? Provider…I am wondering, what was the trigger?

pmstone, md,ms 2013 93


Significant associations between low intakes of various nutrients (retinol, calcium, fiber, folate, iron, riboflavin, thiamin, vitamins A, C, and E) and Keratotic skin lesion incidence in people exposed to environmental arsenic. Greater intakes of methionine, Cysteine, protein and vitamins such as thiamin and niacin increased arsenic secretion Mekonian S et al: J Nutr 142:2126-2134,2012

What About Nutrition Imbalance in the setting of the toxic exposure?


Further Considerations for this physical exam finding of Seborrheic Keratosis

Timing of Appearance Defense and Repair Exposures-toxins Structural Integrity -Repair-methylation status Nutrition Adequacy- Protein Fat Minerals Vitamins Phytonutrients



Seborrheic Keratosis: When Did They Appear?


Physical Exam Finding of Seborrheic Keratosis Ask when they appeared- all at once or gradual Ask about water- well or city Ask about diet- adequate protein, essential fats Carbohydrates, Minerals, Vitamins, Phytonutrients Ask about cancer in family, consider MTHFR Status Ask about toxins (environmental, water, air, occupation) particularly heavy metals including arsenic Clinical Findings that may be associated: fatigue, peripheral neuropathy, digestive symptoms-nausea, vague tenderness Consider heavy metal testing (random serum), provoked urine collection of urine following oral chelator dose like DMSA at 20-30 mg/kg if creatinine is normal to harvest high levels of arsenic, lead, or mercury, cadmium, or tin Discuss Dietary and Lifestyle Changes which will aid in the repair of DNA, the excretion of arsenic and heavy metals and the adequacy of micronutrients in the setting of unique SNP patterns in the patient. Consider Evaluating other Abdominal Pathology.


Seborrheic Keratosis

Nutrition Deficiency or Toxicity Sign?


SK, SSC, Melanoma Skin Cancer MTHFR and VDR polymorphisms

• UVA breaks down plasma folate – Folate is involved in DNA

synthesis and repair• UVB can synthesize

vitamin D in the skin – Vit D has anti-proliferative

effects• Highest risk for SCC

(squamous cell carcinoma) with MTHFR 677TT polymorphism and low folate intake

Han J. Carcinogenesis. 2007;28:390-7mstone

VDR Receptor SNP’s Fokl T Increased risk of MM Bsml Decreased risk of MM, Increased Sq Cell CA Taq1 Increased risk of S.K.

Dermato-Endocrinology 3:1, 11-17, 2011


Inspectthe NAILS“Rings of our physiology”

6 Months of your medical record


Look at the Nails

• Shape• Color • Pattern of Color• Texture and

Strength• Growth Pattern• Surrounding Tissue

Lunula

Cuticle

Distal Edge

Eponychium

Lateral recess


Nails• Koilonychia Fe, Cu, Zn, Protein• Transverse pigmentation Protein• White spots leukonychia Zinc, selenium, protein, niacin

(pellagra)• Psoriatic nails Vitamin D• Beau’s lines Zinc• Pale nail beds Iron• Muehrcke's lines (bands) Protein, stationary and paired• Mees’ lines Transverse white lines: arsenic• Splinter hemorrhages Vitamin C• Onycholysis Iron, niacin• Chronic paronychia Zinc• Red lunula (CHF) CoQ10, Ribose, Mg, Carnitine (if DD)• Terry nails (white) Liver Failure, Hep B, DM, CHF • Brittle nails (onychorrhexis) Malnutrition, protein, calcium, low HCl• Diffuse milky white nails Niacin (pellagra), zinc, malnutrition• Variable white Hypocalcemia• Diffuse brown/black bands Malnutrition• Blue nails Wilson’s disease


Nails Leukonychia Punctata & Leukonychia Striate

Zinc Deficiency Selenium Deficiency

Shape, Color and Pattern of Color, Texture and Strength, Growth Pattern, Surrounding Tissue Differential:


Onychorrhexis: Iron, Folic Acid, Protein

Median nail dystrophy: Malnutrition

Koilonychia: Iron, Protein, Zinc, Cu

Beau’s Lines: Hypocalcemia, Zinc Deficiency

Clubbing: Inflammatory Bowel, Sprue

Examining the Fingernails When Evaluating Presenting Symptoms in Elderly Patients Mark E. Williams, MD Medscape.com

Beau’s Lines: Hypocalcemia, Zinc DeficiencyBeau’s Lines: Hypocalcemia, Zinc DeficiencyBeau’s Lines: Hypocalcemia, Zinc Deficiency

Nail InspectionPutting Nutrition in the Differential


• Deficiency: Zinc, Selenium• Toxicity: Arsenic, Selenium• Systemic disease: Renal

(hemodialysis), Liver Disease

• Medications: Chemotherapy

• Trauma, manicure, biting tapping.

Engle, K:Transverse Leukonychia NEJM July 13. P.100, 1995


Shape, Growth Pattern: Beau’s Lines

• Zinc deficits

• Other causes-

• Severe illness

• Measles/mumps

• Syphilis

• Poorly controlled DM

• Myocarditis

Shape, Color and Pattern of Color, Texture and Strength, Growth Pattern, Surrounding Tissue


Mees Lines, Arsenic Toxicity and More

Arsenic poisoning, Hodgkin’s disease, CHF, leprosy, malaria, chemotherapy, carbon monoxide poisoning, other systemic insults


Peripheral Sensation

Light touchHot/ColdPosition SenseVibratory SenseReflexesMuscle StrengthBalanceWalking


Vibratory Sense, Light Touch Testing

• 128 Hz tuning fork

• 5.07 Semmes-Weinstein Monofilament

• Normal Peripheral vibratory sense of the thumb and 5th distal finger, and the great toe and the 5th toe.

• Normal Monofilament sensation Feet and Hands


Abnormal Vibratory Sense or Monofilament Testing consider:Monofilament Testing consider:

Routine-Tier One• Hbg A1C, hsCRP, CBC dif• Serum B12, Methylmalonic acid, Homocysteine• Serum Heavy metals: Arsenic, Lead, Mercury, • Celiac Panel-gluten induced autoantibodies.

Tier Two or Three• RBC Lipids,• RBC Minerals• Organic Acid Testing

– (metabolism of valine, leucine, and isolucine blocked by insufficiency of B1,B2,B3, Pantothenate, and Lipoate),

– Isoleucine catabolism (blocked by deficiency of Biotin)

• Serum Amino acids

Further w/u with Nerve Conduction Studies may be warranted.

©2014 The Institute for Functional MedicineVinik AL: Diabetic Neuropathy in Older Adults. Clin Geriatr Med 24(3)407-v, doi:10.1016/j.cger.2008.03.011, 2008.

http://upload.wikimedia.org/wikipedia/commons/7/76/Vasculitic_neuropathy_-_plastics_-_intermed_mag.jpg


Peripheral Neuropathy: Presentation

1) Symmetry, sensory level dependent peripheral neuropathy

2) Proximal Weakness vs. Distal Weakness3) Muscle loss4) Periosteal Tenderness5) Multilevel neurologic change vs isolated


Peripheral Neuropathy: Small Fiber

1) Prominent pain: burning, superficial and associated allodynia (painful touch)

2) Hypoalgesia late in the condition3) Defective autonomic function with decreased sweating,

dry skin, impaired vasomotion and blood flow and cold feet.

4) Intact reflexes, motor strength5) Silent electrophysiology6) Reduced sensitivity to monofilament and pricking

sensation using the Waardenberg (Wartenburg) wheel or similar instrument

7) Abnormal warm thermal perception, neurovascular function, pain, quantitative autonomic function tests.

Vinik AL: Diabetic Neuropathy in Older Adults. Clin Geriatr Med 24(3)407-v, doi:10.1016/j.cger.2008.03.011, 2008



Peripheral Neuropathy: Large Fiber

1) Impaired vibration perception and position sense2) Depressed tendon reflexes3) Dull (like a toothache), crushing or cramp like pain in the

bones of the feet4) Sensory ataxia (waddling like a duck)5) Wasting of small muscles of the feet with hammertoes

and weakness of hands and feet6) Shortening of the Achilles tendon with equines7) Increased blood flow to the foot (hot foot) increased risk

of charcot neuroarthropathy)

Vinik AL: Diabetic Neuropathy in Older Adults. Clin Geriatr Med 24(3)407-v, doi:10.1016/j.cger.2008.03.011, 2008


Peripheral Neuropathy: Presentationoften mixed large and small fiber

1) reduced vibration sense2) reduced position sense3) reduced light touch4) weakness5) muscle wasting6) depressed tendon reflexes


Type 2 diabetic peripheral neuropathy and methylation factors for 6 months led to

improved neuropathy with nerve growth, decreased pain, increased function

Abstracts of the Diabetic Foot Global Conference. Oral Presentations 2009.

Metanx® is an orally administered medical food for use only under medical supervision for the dietary management of endothelial dysfunction in patients with diabetic peripheral neuropathy.

At the end of their treatment, 73% of patientsshowed an increase in calf Endothelial NerveFiber Density, 82% of patients experienced both reduced frequency and intensity of paresthesias and/or dysesthesias. Greater improvement after 1 year

Jacobs AM, Cheng D Rev Neurol Dis. 2011;8(1-2):39-47.Walker MJ, Morris LM, Cheng D Rev Neurol Dis. 2010;7(4):132-9

Methyl Folate: 3 mg, Methyl Cobalamin 2mg, Pyridoxine 5 Phosphate 35 mg twice a day


Growing New Nerves in Diabetics with DPN

Nutrient Mechanism

Methyl Folate Enhances production of tetrahydrobiopterin, enhances endothelial nitric oxide synthase. Counteracting oxidative-nitrosamine stress through restoration of endothelial nitric oxide synthase coupling vasonervorum.

Methyl Cobalamin Neutralization of superoxide and peroxynitrite, promotes myelination and transport within the cytoskeleton of the peripheral nerves

Pyridoxine 5 Phosphate

Chelation of transition metals and traps 3 deoxygluosone to inhibit the formation of Advanced Glycosylation End products.

Abstracts of the Diabetic Foot Global Conference. Oral Presentations 2009.

Metanx® is an orally administered medical food for use only under medical supervision for the dietary management of endothelial dysfunction in patients with diabetic peripheral neuropathy.

Jacobs AM, Cheng D Rev Neurol Dis. 2011 8(1-2):39-47 .Miranda-Massari JR: Curr Clin Pharmacol 6 (4):260-273, 2011Shevalye, H, et al:. Diabetes 61:2126-2133, 2013 Walker MJ, Morris LM, Cheng D Rev Neurol Dis. 2010;7(4):132-9


• Highly Prevalent amongst patents with DM type 1,2,3

• Impaired Memory

• Dementia

• Delirium

• Peripheral Neuropathy

• Sub acute combined degeneration of the spinal cord

• Megaloblastic anemia

• Pancytopenia

Kibirige, D, R Mwebaze: Vitamin B12 deficiency among patients with diabetes mellitus: is routine screening and supplementation justified. J Diabetes & Metabolic Disorders 12:17, 2013


M

Biotransformation & Elimination

Energy

Communication

Defense & Repair

Structural Integrity

Assimilation Antecedents

Triggering Events

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

Stress & Resilience Relationships & Networks

Exercise & Movement

Nutrition & HydrationNutrition & Hydration

M

Communication Biotransformation Spiritual

• Renal Failure, many causes, VAT,

• Obesity, • Endothelial dysfunction

• Food Allergy• Celiac, IBD/Crohn's with

malabsorption. Postherpetic neuralgia

• RA, SLE, Intrinsic Factor Autoantibodies, low ADE

• CoQ10 /statin• B12

transcobalamin deficiency,

• Methylation factors

• Heavy metals, MSG, Gentamicin, Cisplatinum, Alcohol

• Salicylates, arsenic, gout,occupational

• Inflammatory bowel diseases leading to poor

absorption of nutrients.

• IR and DM• Low testosterone

Decreased Vibratory Sense

MTHFR, Methylation SNPs FHx DM

Retelling the Patient’s Story

3 Most common causes of Neuropathy in Adults 1) Insulin Resistance, DM 2) Alcohol 3) Occupational or Therapeutic Exposures


Romberg, Balance, Get up and Go


Workshop- Peripheral Sensation

Light touch- Monofilament Testing


Why Check Light Touch with a Monofilament?

1) Helps determine adequacy of one of the protective senses.

2) Helps determine whether there is large or small fiber involvement.

3) If abnormal points to heavy metal burden, dysglycemia, drug associated causes for neuropathy, mitochondrial dysfunction, or nutritional underlying cause of system dysfunction.


Reducing Oxidative Stress Reducing the Biologic Dysfunction Promoting Growth and Repair…

Acetyl L Carnitine

Thiamin

Pyridoxine 5 phosphate

L methyl folate

Methycobalamin

Protein Copper

Vitamin E

Niacin

Taurine

Magnesium

Low Glycemic Diet

Omega 3 Fatty Acids

Alpha Lipoic Acid

Nicotinamide

Rosemary

Green Tea

Grape seed extract

Curcumin

Resveratrol

Zinc

Selenium

Inositol

Choline

Riboflavin

Hyperbaric Oxygen

Glutathione

Manganese Vitamin C

Vitamin A

Asparagine

Biotin

Vitamin K

Glutamine

Spices

CoQ10

Propolis

Gamma Linoleic Acid Sodium

Microbiome Balance

Pantothenic Acid



Context History-Timeline Network Influences

Company Symptoms, Other Signs Current Biochemical Markers

Quality Diet, Food, Nutrient

Quantity Diet, Food, Nutrient


Thank You

“Seeing More” During the Functional Nutrition Physical ExamP. Michael Stone M.D., M.S.

functional nutrition -...

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