Susan G. Pickrel, MPH, M.D.GOBHI Conference 5/18/2012
About MeTrained in public health with MPH at University of
Rochester Medical School, Rochester, NY, 1983Trained in medicine and then adult and child and
adolescent psychiatry post graduate training at the Medical University of South Carolina (MUSC), Charleston, S.C., 1984 – 1993
On faculty and worked within the Family Services Research Center at MUSC doing clinical research with multisystemic therapy (MST), an ecological based intervention, 1993-2000
Clinical inpatient and outpatient practice, last 6 years in community mental health center, 2000-2012
Disclosures
Board certified Child and Adolescent Psychiatrist
Medical Director Child and Adolescent Services at Douglas County Mental Health Center, Roseburg
Oregon
No disclosures
Why Functional Medicine?
20th Century health care advanced interventions for acute care
Providers trained to deliver acute care interventions with increasing specialization
Why Functional Medicine?
20th Century factors created burden of chronic disease
Increased stress Sedentary life styleOverconsumption but undernourishmentFragmented family and community tiesIndustrial pollution and devitalized food
Why Functional medicine?
Physicians highly trained in conventional diagnosis and treatment
Drugs, surgery and radiation
Physicians not well qualified to apply prevention to minimize risk of major chronic diseases in America
Nutrition, diet and exercise
Why Functional Medicine?Disease prevention conceptualized as immunization
and early diagnosis
Prevention requires understanding of Individual genetic variabilities = 20-30% of chronic disease risk Effect of lifestyle on genetic variabilities = 70-80% of chronic disease risk
Why Functional Medicine?
In addition to prevention, many chronic diseases are
very responsive to dietary and lifestyle interventions
Why Functional Medicine?Emergence of New Primary Care Paradigm
Concept that disease mechanisms originate at
molecular biological level and are related to
interaction between environment and genes and
their expression
Built on molecular medicine discoveries Observations of host-environment interaction Replace previous belief diseases hard wired into our genes
Why Functional Medicine?Emerging understanding of how biochemically
unique we are
Lessons from the human genome illuminate importance of host-environment interaction
Single Nucleotide Polymorphisms (SNP) Variations in which the least common allele is present
in at least 1% or more of the population When present, person has 2 different genes coding for the same function How gene may be expressed dependent on environmental factors
Why Functional Medicine?Each of us has 30,ooo genesMost common variation in genes is single base
difference producing SNP Occurs once in every 1000 base pairs 1.8 million identified, estimate approximately 3 million Because not lethal – maintained in population
SNP alters function of enzyme, increasing or decreasing activity, not stopping function completely > 1/3 SNPs affect coenzyme binding sites for vitamins
or nutrients
Why Functional Medicine?
One major environmental factor that modifies gene expression = nutritional status
Both micro and macronutrients can influence expression of genes
At translational level – genetic message into active protein
Proteins then influence by controlling metabolic function
Why Functional Medicine?
Phenotype of cell = complex process of interacting events
Related to genetic expression, protein synthesis, protein
activation and metabolic regulation
Use these processes to evaluate and establish biomarkers of
health and disease
Why Functional Medicine?
Downstream Medicine
Search for molecules (drugs) with selective ability to inhibit specific mediated steps related to an expressed disease
Examples are ACE inhibitors, SSRIs, H2 Blockers
Why Functional Medicine?
Upstream Medicine
Find and identify tissue-selective modulators of gene and
protein expression Develop new approaches to selectively regulate
expression of significant molecules upstream in the metabolic
process associated with the disease for treatment AND
prevention
What is Functional Medicine?
FM is Upstream Medicine
Assesses and improves underlying functional imbalances in 7 core areas seen as drivers of health and disease
Synthesizes and applies scientific evidence from biomedical research in biochemistry, physiology, immunology and nutrition to increase understanding of these 7 areas
What is Functional Medicine?Core Areas to Assess for Clinical Imbalance
Immune SurveillanceInflammatory ProcessDigestion, Absorption, Barrier IntegrityDetoxification and BiotransformationOxidative/ReductiveHormone, Neurotransmitter RegulationPsychological and Spiritual EquilibriumStructural Integrity
What is Functional Medicine?
Discipline neutral: Any practitioner with western medical science background
Does not require provider to give up tenets of training
Does provide expansion of clinician’s knowledge of biochemistry and physiology
Does use strong appreciation of environmental inputs
What is Functional Medicine?
Aquires, analyzes, classifies and prioritizes information in different ways
Then applies therapeutic measures to correct imbalances in underlying organ system disease
Utilizes the Functional Medicine Matrix as tool for simplifying the complex science into a managable clinical approach
What is Functional Medicine?
Functional Medicine Matrix
Used to obtain, sort and qualify the different kinds of patient information
To generate for clinician strong indicators of most useful way to intervene with the interconnecting issues presented
What is Functional Medicine?
What is Functional Medicine?Firmly grounded in scientific principles and data
Flexible eclectic perspective integrating the following when science warrants
Dietary interventions Clinical nutrition Exercise therapy Mind-Body-Spirit issues Botanical medicine Physical medicine Energy medicine
What is Functional Medicine?
Does not identify a single gold standard method for considering something relevant or useful
Incorporates many different sources of scientific information into the medical decision making process Basic science Clinical experience Functional medicine principles
What is Functional Medicine?
Evidenced Based Medicine (EBM)= integration of best research evidence with clinical expertise and patient values
What is Functional Medicine?
Literature on EBM creates hierarchy with most value to randomized controlled clinical trial (RCT) Internal/external validity conflict Managing patient with multiple chronic complex
multifactorial conditions not amenable to RCT
What is Functional Medicine?
FM focus on science of body functioning at physiological and biochemical level
FM uses core clinical imbalances as matrix upon which to organize the science and includes Clinical trials Case reports Clinical experience
Practice of Functional Medicine
GOAL - Person centered diagnosis
Individualized therapy plan based on understanding ofphysiological, environmental and psychological
contextswithin which person’s illness/dysfunction occur
Practice of Functional MedicineElicit all of patient’s concerns to discover
Antecendents | Of symptoms, signs Triggers | Illness behaviors Mediators | Demonstrable pathology
Practice of Functional Medicine
Focus on control or reversal of each person’s individual antecendents, triggers and
mediators rather than treatment of disease entities
Practice of Functional MedicineTriggers: Discrete entities or events that
provoke disease or it’s symptom
Not sufficient by themselves
Mediators: Intermediaries that contribute to manifestations of disease
Antecedents: Factors that presdispose to acute or chronic illness
Practice of Functional MedicineANTECEDENTS
Congenital - inherited or acquired in utero Gender
Developmental Age Intrauterine and postnatal developmental factors
Nutrition Exposure to toxins Learned patterns of behavior Microbial ecology of the body
Practice of Functional Medicine
TRIGGERS
Primary task of Functional Medicine provider to help patients identify triggers and develop strategies for eliminating them or decreasing their effects
Practice of Functional MedicineTRIGGERS
Precipitating events = antecedents closely preceding
development of chronic illness
Most common Severe psychosocial distress Acute infection (sometimes with antibiotic treatment) Exposure to environmental toxins Severe nutrient depletion Related to illness or crash dieting
Practice of Functional Medicine
MEDIATORS
Anything that produces symptoms or damage to the body
Types of behavior associated with being sick
Practice of Functional Medicine
MEDIATORS
Biochemical – organized into circuits/cascades that
subserve homeostasisMultifunctional – redundancyLack of disease specificity
Practice of Functional MedicineMEDIATORS
Natural rhythm of mediator activity strongly influenced by common components of life Diet Sleep Exercise Hygiene Social interaction Solar and lunar cycles Age Gender
Practice of Functional MedicineEXAMPLE: Aging and illness
Chronic psychological -> Upregulates activity of distress inflammatory and neuro- endocrine response
networks
Regular physical -> Downregulates inflammatory activity and neuroendocrine
response networks
Practice of Functional Medicine
To utilize vast data base regarding biochemical disease mediators
Maintain up to date knowledge of disease pathophysiology reading reviews in mainstream journals regarding mechanisms of disease or specific mediators
Special attention to mediators involved within networks of inflammation, oxidative stress and neuroendocrine imbalance
Practice of Functional Medicine
Attend workshops that emphasize integrative physiology
Institute of Functional Medicine New York Academy of Science Center for Mind-Body Medicine Anerican College for Advancement in Medicine
Practice of Functional Medicine
Use knowledge of most common biochemical imbalances in chronically ill North Americans
Use influence of diet, nutrition and dietary supplements on these imbalances
Practice of Functional Medicine
Human body = dynamic, fully interconnected, complex
functioning organism
Constant flow of air, fluids and energy upon a changeable matrix
Model of web to understand this complexity
Practice of Functional Medicine
One major imbalance influences many different functional systems
Multiple factors influence one single condition
Practice of Functional Medicine
Practice of Functional MedicineAllopathic medicine: Look for single root cause and find a cure with a pill, surgery
or radiationFunctional medicine: Ask what is imbalanced Find shift of flow of
biochemical information, energy,
physical structure or emotion out of healthy range
Practice of Functional Medicine
Functional Medicine Resources Jones, David S., Hofmann, Laurie, and
Quinn, Sheila. 21st Century Medicine: A New Model for Medical Education and Practice. The Institute for Functional Medicine, 2010.
Jones, David S. (Ed.) Textbook of Functional Medicine. The Institute for Functional Medicine, 2010.
www.functionalmedicine.org