IFM: The New Paradigm of Medicine

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) Family History (FH) Dietary History Supplement and Medication History Lifestyle, Social, and Exercise History Physical Exam Findings Laboratory Evaluation

In conventional medicine, the 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 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:Asthma Attack

bronchodilators corticosteroids

tightness in the chest

sudden onset

asthmatic history

shortness of breath

History of Present Illness

Example #2Chief Complaint:

Chest Pain

Diagnosis:Heart Attack

angioplasty thrombolytics

sweating

arm numbness

shortness of breath

History of Present Illness

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

THE RESULTS: 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 complaint becomes a discrete issue,

dealt with in isolation from the others

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

Hypercholest-

erolemia

Statin

Gastroesophageal

Reflux Disease

H2 blocker

Depression

SSRI

HypertensionACE

inhibitorMigraines 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

inhibitorMigraines 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, and not the trunk and roots.

Cardiology Pulmonary

Endocrinology

Gastroenterology

Neurology

Organ System Diagnosis

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

1. Communication- Outside the cell- Inside the cell

Mind and Spirit

Genetic PredispositionExperiences, Attitudes, Beliefs

Psycho-socialPhysical Exercise

TraumaDiet, Nutrients,

Air/Water

Xenobiotics Micro-organisms

RadiationEnvironmental Inputs

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

Structural Integrity

4. Elimination of Waste5. Protection/Defense6. Transport/Circulation

Fundamental Physiological Processes

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

effective chronic-care model.

Paula White

Dan likes this picture. The words should appear first, then the photo comes in and you see the bridge first, then it expands out so the picture then takes up the whole slide. SO you focus on the bridge, then zoom out to see the rest. The words go away when the bridge comes on.

??? 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 homeostatic 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:

First, the full story must be understood within the context of

antecedents, triggers, and mediatorsantecedents and triggers

mediators

To answer these questions requires a new perspective on the chronic-care model

Infectious micro- organisms

Structural or

physical damage

Nutrient insufficiency

Xenobiotics

Disrupted light cycles—circadian

dysrhythmias

Radiation

Emotional trauma

Spiritual angst

Nutrient excess

Food toxicants

(allergens, stimulants, etc,)

Drug side effects

Adiposity

Toxic metals

Aging

Situational

stress–fear, anxiety, worry

Genetic pre-

disposition (SNPs)

Hyperglycemia

Hypoglycemia

Excessive exercise

Excessive noise

Dysbiosis

The story is no longer just the CC and HPI, but

is expanded to encompass all the

patient’s history that may reveal the source(s)

of symptoms.


Structural or

physical damage


Xenobiotics

Radiation

Emotional trauma

Spiritual angst

Nutrient excess

Food toxicants

(allergens, stimulants, etc,)

Drug side effects

Adiposity

Toxic metals

Psychological and Spiritual Equilibrium

Hormone andNeurotransmitter Regulation

Detoxification and Biotransformation


Immune Surveillance

Digestion, Absorption,and Barrier Integrity

Oxidative/Reductive Homeodynamics

InflammatoryProcess

Aging

Genetic pre-

disposition (SNPs)

Next, the patient’s story is filtered through these

antecedents, triggers, and mediators, which leads to an understanding of where key imbalances may reside

Disrupted light cycles—circadian

dysrhythmias

HyperglycemiaHypoglycemia

Excessive exercise

Noise

Situational stress–fear, anxiety,

worry

Dysbiosis

The diagnosis remains useful, but is less important.

These fundamental clinical imbalances are the underlying mechanisms of disease…

Exercise

Acupuncture

Manipulative Therapies

Phytonutrients

Minerals

Vitamins

Diet

Yoga

Drugs

Surgery

Counseling

The expanded model permits the clinician to choose from an enlarged toolkit of

therapies.

Meditation

Let’s apply the functional medicine model to an apparently simple case…

…a 37 year old female with a chief complaint of chronic headaches.

Diagnosis: Migraines

Treatment: Triptan

Chief Complaint:Headaches

History of present illness

We’ve already seen how she might be treatedusing the existing model.

But her case may

not be as simple as it appears…

From a functional medicine perspective, the CC and HPI must be

filtered through the relevant antecedents, triggers, and mediators.

To understand the patient’s complete picture, past medical history, family

history, diet, medications, and lifestyle all need to be viewed through

this lens as well.

Psychological and SpiritualEquilibrium



Immune

Surveillance

InflammatoryProcess

Hormone and

Neurotransmitter Regulation

Digestion, Absorption,

and Barrier Integrity

Oxidative/Reductive

Homeodynamics




Immune

Surveillance

InflammatoryProcess

A variety of potential antecedents, triggers, and

mediators might be present in a woman with a chief complaint

of chronic headaches:

Hormone and




Oxidative/Reductive

Homeodynamics


Hormone and




Immune

Surveillance



Oxidative/Reductive

Homeodynamics

InflammatoryProcess

Food allergenFood AllergenFood allergen

Circadian rhythm

Situational stress

Exposure to toxinsExposure to toxins Headaches triggered by food

allergen

Headaches triggered by menstrual cycle

Headaches triggered by stress

Headaches triggered by exposure to toxins

MSG, aspartame, smoke, perfume

Headaches triggered by changes in sleep

Headaches triggered by fasting

Estrogen dominance

Circadian rhythm

Hypoglycemia


Hormone and




Immune Surveillance



Oxidative/Reductive

Homeodynamics

Inflammatory Process

Past medical history leads to additional clues:

Food Allergen

Food Allergen

Food Allergen

Estrogen dominanceCircadian Rhythm

Circadian Rhythm

Situational Stress

Hypoglycemia

Exposure to toxins

Exposure to toxins

Past or recurrent infections

Adiposity

Surgeries

Surgeries

Surgeries



AdiposityAdiposity

Adiposity

AdiposityAccidents or Injuries

Emotional trauma

Exposure to toxins

Accidents, injuriesAccidents, injuries

Accidents, injuries

Emotional trauma

Emotional trauma

Emotional trauma

Exposure to toxins

Exposure to toxins

Exposure to toxins

Exposure to toxins

Chronic Disease

Chronic disease

Chronic disease

Chronic antibiotic use

Chronic antibiotic use—dysbiosis







Immune Surveillance

Digestion, Absorption,and Barrier Integrity




Circadian Rhythm

Situational Stress

Hypoglycemia

Exposure to toxins

Exposure to toxinsSurgeries

Surgeries



AdiposityAdiposity

Adiposity

Adiposity


Accidents, injuries

Emotional trauma

Emotional trauma

Emotional trauma

Exposure to toxins

Exposure to toxins

Exposure to toxins

Exposure to toxins Chronic disease

Chronic disease




Family history may indicate genetic predispositions:

Food allergen

Food allergen

Food allergen

Inflammatory conditions such as RA, UC, etc.

Allergies

Predisposition to inflammation





Immune Surveillance

Digestion, Absorption, and Barrier Integrity




Circadian Rhythm

Situational Stress

Hypoglycemia

Exposure to toxins


Surgeries



AdiposityAdiposity

Adiposity

Adiposity


Accidents, injuries

Emotional trauma

Emotional trauma

Emotional trauma

Exposure to toxins

Exposure to toxins

Exposure to toxins

Exposure to toxins

Chronic disease

Chronic disease




Food allergen

Food allergen

Food allergen

Predisposition to inflammation

Dietary History

Dietary insufficiencies…antioxidants, magnesium, fiber, EFAs, etc.

Dietary excesses: saturated fat, simple sugars, caffeine, alcohol, etc.

Nutrient insufficiencies—EFAs, etc.

Nutrient insufficiencies –sulfur, amino acids, etc.

Nutrient insufficiencies

Nutrient insufficiencies – zinc, glutamine–leaky gut

Nutrient insufficienciesantioxidants


Nutrient excess—alcohol

Nutrient excess—caffeine

Nutrient excess –simple sugars

Nutrient excess—saturated fat

Dietary toxins…mercury, exogenous estrogens, etc.

Dietary toxin—mercury

Dietary toxin-mercury


Dietary toxins –exogenous estrogens

Dietary toxin –mercury





Immune Surveillance





Circadian Rhythm

Situational Stress

Hypoglycemia

Exposure to toxins


Surgeries



AdiposityAdiposity

Adiposity

Adiposity


Accidents, injuries

Emotional trauma

Emotional trauma

Emotional trauma

Exposure to toxins

Exposure to toxins

Exposure to toxins

Exposure to toxins

Chronic disease

Chronic disease




Food allergen

Food allergen

Food allergen

Predisposition to inflammationNutrient insufficiencies—EFAs, etc.












Dietary toxin—mercuryDietary toxins –exogenous estrogens


Medication History

Drug side effects

Drug side effects-inhibit or promote

Drug side effects

Drug side effects

Drug side effects





Immune Surveillance





Circadian Rhythm

Situational Stress

Hypoglycemia

Exposure to toxins

Surgeries

Surgeries



Adiposity

Adiposity

Adiposity

Adiposity

Accidents, injuries

Accidents, injuries

Accidents, injuries

Emotional trauma

Emotional trauma

Emotional trauma

Exposure to toxins

Exposure to toxins

Exposure to toxins

Exposure to toxins Chronic disease

Chronic disease




Food allergen

Food allergen

Food allergen

Predisposition to inflammationNutrient insufficiencies—EFAs, etc.













Dietary toxins –exogenous estrogens


Drug side effects-inhibit or promote

Drug side effects

Drug side effects

Drug side effects

Hobbies

Exercise

Relationships Recreational Drugs

Spirituality

Lack of exercise

Lack of exercise

Lack of exerciseLack of exercise

Lack of exercise

Lack of exercise

Spiritual angstLoneliness

Loneliness

Loneliness

Spiritual angst

Over or improper exercise

Lifestyle

Alcohol-leaky gut

Inhibit or promote

Exposure to toxins





Immune Surveillance




A variety of potential laboratory assessments can then be useful in confirming key imbalances

on which to focus.

Cortisol, DHEAGlucose, insulin, HA1C

TSH, Free T3, Free T4Estrogen, Progesterone, Testosterone 2/16 ratio

8-OHdG

IsoprostanesReduced glutathioneLipid peroxides

Gait Motion AnalysisN-telopeptide

Magnetic Resonance Imaging

X-ray

Bacterial Overgrowth Small Intestine

Fecal Ova and Parasites

Candida Antibodies

Lactulose Mannitol

IgG and IgG food allergyChemical antibodiesSalivary Secretory IgANatural Killer Cell Cytotoxicity Activity

High-sensitivity CRPRBC Fatty Acids

Fecal LactoferrinFecal Calprotectin

Urinary Serotonin, Dopamine

Serum Amino Acids

Homocysteine, folate, B12RBC Fatty Acids

Caffeine Clearance, Glucuronidation, Sulfation

Hair toxic ElementsUrinary Provocation/Challenge

SNP Cyp P450





Immune Surveillance




Food allergen

Food allergen

Specifically, what was this37 year old female’s story?

Headaches triggered by diet





Immune Surveillance




Dysbiosis

What are the clues in her past medical history?

History of chronic sinusitis

Food allergen

Food allergen

History ofmultiple antibiotics

Drug side effectsleaky gut

Structural damage

Gas and bloating

Digestive enzyme/HCL insufficiency

Inflammatory damage

History of osteoarthritis of the knee





Immune Surveillance




Dysbiosis

Food allergen

Food allergen

Structural damage


Inflammatory damage

Nutrient insufficiency –low EFAs, high AA

Standard American DietNSAIDS for OA

Drug side effects – leaky gut

What are the clues in her diet and medications?





Immune Surveillance




Dysbiosis

Food allergen

Food allergen

Structural damage


Inflammatory damage



What are the cluesin her family history?

Ulcerative Colitis

Eczema

Inflammatory genetic predisposition





Immune Surveillance




Dysbiosis

Food allergen

Food allergen

Structural damage


Inflammatory damage



Through critical thinking and pattern recognition,

a therapeutic plan can be developed. In this case, the primary focus centers on three areas





Immune Surveillance




Dysbiosis

Food allergen

Food allergen

Structural damage


Inflammatory damage



Laboratory analysis can be

used to help confirm the

prioritization

Hs-CRPRBC fatty acids

IgG/IgE food allergy

Digestive stool analysisOva and parasiteIntestinal permeability


Hormone and




Immune

Surveillance



Oxidative/Reductive

Homeodynamics

InflammatoryProcess

The prioritization of certain key

clinical imbalances then leads to potential

treatment options

Dietary changes to lower arachidonic acid and the inflammatory cascade

Omega-3 fatty acids to decrease inflammation

Botanicals such as bromelain and curcumin to decrease inflammation

Phytonutrients such as rutin and quercitin to decrease IP

Pre and probiotics

Decrease alcoholto decrease

intestinal permeability

Hydrochloric acid/digestive enzyme

Foodelimination

diet

Functional medicineenlarges the

chronic care model to encompass the full

and uniquestory of the patient

Finally it increases the range of potential treatment options

It integrates underlying mechanisms of disease into the differential

diagnosis paradigm

Exercise

Acupuncture

Manipulative Therapies

Phytonutrients

Minerals

Vitamins

Diet

Yoga

Drugs

Surgery

Counseling Meditation


Hormone and Neurotransmitter Regulation

Detoxification andBiotransformation

StructuralIntegrity

ImmuneSurveillance

Digestion,Absorption,and Barrier

Integrity

OxidativeReductive

Homeodynamics

InflammatoryProcess


Structural or

physical damage


Xenobiotics

Radiation

Emotional trauma

Spiritual angst

Nutrient excess

Food toxicants (allergens, stimulants

etc,)

Drug side effects

Adiposity

Toxic metals

Aging

Genetic pre-disposition

(SNPs)

Disrupted light cycles – circadian

dysrhythmias

Hyperglycemia

Hypoglycemia

Excessive exercise

Excessive noise

Situationalstress – fear, anxiety, worry

Dysbiosis

The functional medicine model recognizes and prioritizes the patient’s full, unique story and

uses fundamental clinical imbalances as a key to treating complex,

chronic illness

Functional Medicine and the Healthcare System: Additional Important Benefits

Functional Medicine creates a level playing field among practitioners

The Functional Medicine model makes readily apparent that there is a need for many different approaches to helping people become and stay well

Functional Medicine helps to create and disseminate a shared set of concepts and a common language

Ultimately, Functional Medicine can contribute greatly to our ability to create an integrated healthcare system

Cardiology Pulmonary

Endocrinology

Gastroenterology

Neurology

Organ System Diagnosis

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

1. Communication- Outside the cell- Inside the cell

Mind and Spirit

Genetic PredispositionExperiences, Attitudes, Beliefs

Psycho-socialPhysical Exercise

TraumaDiet, Nutrients,

Air/Water

Xenobiotics Micro-organisms

RadiationEnvironmental Inputs

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


4. Elimination of Waste5. Protection/Defense6. Transport/Circulation

Fundamental Physiological Processes

IFM: The New Paradigm of Medicine

Health & Medicine

Transcript of IFM: The New Paradigm of Medicine