Functional Medicine in the Age of Genomics, Biometrics, and Wearable Devices

Jeffrey Bland, PhD, FACN, FACBCo-Founder, The Institute for Functional Medicine

Founder, Personalized Lifestyle Medicine Institute

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Where We Are

Global, regional, and national incidence, prevalence, and years lived with disability for 301 acuteand chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for theGlobal Burden of Disease Study 2013.

Christopher Murray, MD, DPhilInstitute Director, Institute for Health Metrics and Evaluation

“Ageing of the world’s population is leading to a substantial increase in the number of individuals with sequelae of disease and injuries. Rates of YLDs are declining much more slowly than mortality rates. The non-fatal dimensions of disease and injury will require more and more attention from health systems.The transition to non-fatal outcomes as the dominant source of burden of disease is occurring rapidly outside of sub-Saharan Africa. Our results can guidefuture health initiatives through examination of epidemiological trends and a better understanding of variation across countries.”

Lancet 2015; 386: 743-800

The History of the New Paradigm

Roger J. Williams, PhD1883 - 1988

• Renowned Nutritional Biochemist

• Discoverer of Pantothenic Acid (Vitamin B5)

• Professor, University of Texas

• Known as the “Father” of the concepts of Biochemical Individuality and Genetotrophic Disease

• Introduced to me in 1975, an influential and inspirational figure to me since that time.

Statistical Humans are of Little Interest.”

“Medicine is for Real People:

Linus Pauling, PhD1901 - 1994• Two-time Nobel Laureate: Chemistry (1954) and Peace (1962)

• Molecular Medicine (1949)

• Orthomolecular Medicine (1968)

• My mentor and guide during my time at the Linus PaulingInstitute of Science and Medicine (1982 – 1984)

1983: A Celebration of Linus Pauling’s 82nd Birthday

Roger Williams and Linus PaulingBiochemical Individuality Meets Molecular Medicine

Houston, Texas - 1974

What We Have Learned About Chronic Disease

Health is personal.

A Global Social Movement is Underway:

A TRANSITION FROM THE AGE OF THE AVERAGE TO THE AGE OF THE INDIVIDUAL

The Creation of the Functional Medicine Model and The Institute for Functional Medicine

• Susan Bland organized two meetings in 1989 and 1990 to discuss the future of medicine.• We invited thought leaders from different disciplines to come together for “white board” sessions and discussion.• As a result of these gatherings, the concept of Functional Medicine as a systems biology approach to healthcare was

conceived.• The Institute for Functional Medicine was created in 1990.

Victoria, British Columbia

• Founded 1991. More than 100,000 practitioners have now completed CME-approved courses.

• The interaction between our genes and our environment and lifestyle gives rise to our function.

• The question is not just what is the information that we have inherited in our genes, but also how is it being expressed?

• There are many potential ways our genes can be expressed in our function, from health to disease.

• How is the expression of our genes controlled?

Characteristics of the Functional Medicine Assessment

• Antecedents

• Triggers

• Mediators

• Signs and Symptoms

Health Can Only be Determined by Measuring Functional Status

• Physical

• Physiological

• Cognitive

• Psychological

Disease Model vs Functional Medicine Model

• Diagnostic

• Diagnosis Focused• Abnormal compared to the

group• Pathway Focused• Partitioned into specialties• Pathology-based

• Functional

• Etiology Focused• Abnormal compared to the

individual themselves• Network Focused• Interconnected Organ Systems• Determination of underlying

dysfunctions leading to symptoms

The Functional Medicine Operating Model

Structure

Energy(Production & Utilization)

Cellular Transport

Assimilation/Elimination

Detoxification

Immune Defense

Cellular Communication(Hormones)

Personalized Lifestyle Healthcare/Medicine

Lifestyle Behaviors

Diet

EnvironmentGenes

Moving the Functional Medicine Model into Institutional Medicine• The Functional Medicine Clinic at the Cleveland Clinic was established in 2014

• Founder: Mark Hyman MD / Head of Clinical Services: Patrick Hanaway, MD

• Personalized Lifestyle Medicine: Diet, medical nutrition therapy, exercise, stress management, environment,

bioenergetics, Functional Medicine

• Research Focus

A Future Vision of Precision Personalized Lifestyle Medicine

• “While PM aims to incorporate individual variability in genes, environment, and lifestyle, the emphasis in current practice is on profiling risk”

• The future of PM will move us beyond “population risk” to that of understanding individual functional uniqueness– Less emphasis on “Risk” and more

emphasis on “Opportunity”

JAMA October 9, 2017

The “Gene-Environment” Paradigm

• Creation of an actionable approach to chronic disease prevention and treatment

• Moves beyond “diagnosis” to “etiology”

• Sets stage for personalized, precision lifestyle medicine

Science 2016; 354:15.

Genes Viewed as “Risk Factors”

What If We Knew The Genetic Uniqueness of Each Person?

• Eric Topol– “The Patient Will See You Now”

• “Omics” Tools– Genomics– Epigenomics– Transcriptomics– Proteomics– Metabolomics– Metagenomics

• Phenomics– Biomarkers

Cell 2014; 157: 241-53,

There is Joy in our genes

The Connection of Functional Medicine to Systems Biology

P4 Medicine:• Predictive• Preventive• Personalized• Participatory

Leroy Hood, MD, PhDLearn more:

www.systemsbiology.org

www.p4mi.org

The Institute for Systems BiologyPioneer 100 Wellness Project

Source: Institute for Systems Biology

Technologies Powering the Revolution• Genomics and its companion “omics” technologies

– Full genome sequencing– Transcriptomics– Proteomics– Kinomics– Lipidomics– Metabolomics– Nutrigenomics– Exposomics– Epigenomics

• Informatics– Cloud based computing– Artificial Intelligence and Machine Learning– Precision Public Health (Clustering of Etiopathologies)

• Biometrics– Wearable devices and new biomarkers

• Social Media– Citizen Scientist

Biomarkers Used to Assess Aging

• Biological vs Chronological Aging

• Telomere Length• Epigenetic Alterations of DNA

– Methylation Patterns

• Mutational Markers in Genome• Damaged Proteins• Metabolites of Aging

The Quantified HumanBiometrics, Biohacking, Wearable Devices

• The BIG Six– Continuous Blood Sugar Monitoring– Continuous Blood Pressure Monitoring– Fitness Assessment

• Strength• Flexibility• Endurance

– Heart Rate Variability– Sleep Cycling– Functional Neurological Testing

• Memory, Reaction time, Vibratory Sensation, Balance, Hearing, Taste/Smell

My Pioneer 100 Experience: Making the “Omics” Revolution Personal

The Start of Making Wellness Personal and Precise

Science 2017; 357: 345 Nat Biotech 2017

Pharmacogenomics and Detoxification

Constitutive or Inducible ?Phase 1 CYP 450 and Phase 2 Conjugases

NEJM 2011; 364: 1144-51

Genetic Methylation Profile

Multiple Homozygous SNPs for MTRR, AHCY, CBS

Genetic Detox Profile

Multiple Homozygous SNPs for CYP1A1, CYP2D6, CYP2E1, NAT1, NAT2

Metabolic Data (measured every 3 months)

Before and After Stress

Inflammatory Markers

Tuna Sushi

Blood Elemental Analysis

Vitamin D Receptor Polymorphism

Nutritional Assessment

9/26/2018 40

Essential Fatty Acid AnalysisSeattle Salmon

9/26/2018 41

Adrenal-Stress Indication

9/26/2018 42

Influence of Lifestyle on My Resting Heart Rate

Medical Devices, Innovation, Point of Care Measurements and Empowerment

• Do-it-yourself health technologies were rated a number 1 in the top 10 health industry developments in 2015

• Optimism must be balanced with realism– Case Study: Theranos

• Accuracy, Precision and Sensitivity are Important

• Different biometric measurements have different precision standards

NEJM 2016; 374: 305-07

Wearables as Medical Devices

• What is a “medical device” in the 21st century?– Sleep assessment– Neurological Functional assessment– Cardiac Function– Blood Sugar– Mood Assessment– Blood Pressure– Oxidative Stress– Dietary Assessment by Urinary

Excretion of Metabolites

JAMA 2018; 320: 139-41

Can Wearable Fitness Monitoring and Telephone Coaching Improve Peripheral Artery Disease?

• “Among Patient with PAD a home-based exercise intervention consisting of a wearable activity monitor and telephone coaching compared with usual care did not improve walking distance”– Do you need personal coaching

interaction?– Was the functional decline too

great to have an impact?

JAMA 2018; 319: 1665-70

Effect of Wearable Technology Combined with Lifestyle Intervention on Long-Term Weight Loss

• “Devices that monitor and provide feedback on physical activity may not offer an advantage over standard behavioral weight loss approaches”– Why not?– Is the device effectively

incorporated into an effective patient-centered approach?

JAMA 2018; 319: 1665-70

© 2018 Metagenics, Inc.

Continuous Blood Glucose Monitoring of a Type 2 Diabetic on Insulin

© 2018 Metagenics, Inc.

Chaotic Blood Glucose of a Type 2 Diabetic on Insulin

Jeff Bland’s Blood Glucose on a Metabolic Program

© 2018 Metagenics, Inc.

Jeff Bland’s Blood Glucose over 7 Days

Jeff Bland’s Average Blood Glucose Each Hour of the Day

Jeff Bland’s Diet and Lifestyle Versus Blood Glucose Over the Day

Continuous Blood Pressure Monitoring

Functional Neurological Testing

Reversal of Alzheimer’s Disease?Dale Bredesen, MD

UCLA Department of NeurologyDirector, Mary Easton Center for Alzheimer’s Disease Research

Genetic Expression is Regulated by the Epigenome

• All cells of the body have essentially the same DNA

• Cell types differ in their expression of the genetic message as dictated by epigenetic marks

• Most of the epigenetic marks are placed during embryogenesis, but there are a few that are metastable epialleles that can change with lifestyle and environmental exposure

• Methylation is a key epigenetic modulator

NEJM 2018; 378: 1324-32

Lancet 2018; 392: 777-86

Global Whole Body Methylation Patterns

Methylation Patterns In Aging

Effect of Testosterone on Genomic Methylation Patterns in Mice

Disease Diagnosis by Methylated DNA in the Plasma

eLIFE 2017; 6: e30766

J Clin Invest 2016; 125: 2851-56

Bisulfite Sequencing (Methyl-Seq) Service

Association of Altered DNA Methylation in Children with Fetal Alcohol Syndrome Using Bisulfite Analysis

Epigenomics 2015; 7: 1259-74

Plant Phytochemicals and Their Epigenetic Influence

Sci Rep 2016; 6: 26905

Nutrients 2017: 9: 452

What Might the 21st CenturyFunctional Health Assessment Look Like?

• Polygenic Analysis of SNPS of Family of Methylation Related Genes• Tissue Specific Genomic Methylation Profile• Genomic Stability Assessment • Telomere Length• Metagenome Analysis• Inflammation Biomarkers• Oxidative Stress Biomarkers• Urinary Polyphenol Analysis