Immune Health and Nutritional TestingSusan Blum, MD, MPH

April 27, 2016

Christine Stubbe, ND, FABNOMedical Education Specialist - Asheville

Susan Blum, MD

Board Certified in Preventive Medicine, Certified in Functional Medicine, is Senior Faculty with the Center for Mind-Body

Medicine, and author of The Immune System Recovery Program

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Immune Health and Nutritional TestingSusan Blum, MD, MPH

April 27, 2016

• Assistant Clinical Professor, Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai, NYC

• Integrative Medicine, Greenwich Hospital, CT.

• Medical Advisory Board, Dr Oz Show

• Senior Teaching Faculty, Center for Mind Body Medicine, Washington

• Advisory Board, Institute for Integrative Nutrition

• Council of Directors, GLiMMER/True Health Coalition

• Certified Practitioner, Institute for Functional Medicine

• Board Certified in Preventive Medicine and Integrative Holistic Medicine

Affiliations

1. Using Food As Medicine

2. Balancing Stress Hormones

3. Healing the Gut

4. Supporting the Liver

4 Step Functional Medicine Program to Treat Autoimmune Disease:

• Autoimmune conditions

• Low immune function

– Frequent colds and persistent infections

• Allergy and asthma

• Food sensitivities

Immune conditions we will discuss today:

Conventional Assessment

• Conventional testing is designed to assess disease activity and current immune function

• It is not designed to evaluate the cause of immune illness

• It is helpful for following your patient’s progress, but not for directing treatment of the disease itself

Conventional Assessment

Standard blood tests only look to assess disease activity, not triggers for disease:

1. Antibody levels: ANA as general marker; specific markers for specific diseases

2. Immune function: WBC, NK’s

3. Inflammatory markers: hsCRP, ESR

4. Celiac disease markers: deamidated gliadin antibodies

5. Vitamin D

Conventional Assessment: Autoimmune

Standard blood tests to assess activity:

1. WBC, differential, NK and lymphocyte function

2. Assays for chronic viral activity: EBV, HSV and others

3. Vitamin levels: Vitamin D

4. Inflammatory markers: ESR and hsCRP

5. Evaluating stress: DHEA-S as an adrenal marker. You can also get 24 hour urine cortisol and saliva testing

6. Evaluate methylation status: homocysteine

Conventional Assessment: Low Immune Function

Standard tests:

1. Food and environmental allergies: blood and skin testing by immunologist, IgE testing by routine labs

2. CBC: eosinophils

3. Pulmonary function if needed

Conventional Assessment: Allergy and Asthma

• Celiac disease: antibodies and genetic testing

• There is no conventional assessment or understanding of how to diagnose or address food sensitivities in the conventional arena

• From a Functional Medicine perspective: Food sensitivities originate in the GUT, and to address this, Gut assessment comes first

• Tests that are effected by gut health/malabsorption: ferritin (iron), vitamin D

• Integrative assessment is best

Conventional Assessment: Food Sensitivities

Integrative Assessment:

This webinar will focus on how to use the NutrEval:

• To assess potential causes of immune dysfunction

• To create a treatment plan that clearly outlines where to start and importance of different panels

Integrative Assessment:

Panels to look at first:

1. Dysbiosis markers

2. Oxidative stress

3. Heavy metals

4. Toxin and detoxification markers

Integrative Assessment: High Altitude View

• Gut Dysbiosis Panel: can detect overgrowth of harmful microbes: bacteria and yeast

– Dysbiosis: causes leaky gut syndrome, which triggers food sensitivities and is associated with autoimmunity, allergy and immune dysfunction

– Healthy Gut Flora: primes the immune system and keeps it toned and functioning well

• When this panel is +, treatment should be directed #1 to treating dysbiosis

– Option to Follow up with Stool Test: GI Effects or CDSA2.0 before beginning treatment

• I use combination herbal protocols for 1–2 months depending on severity

Integrative Assessment: Dysbiosis Markers

• Oxidative Stress: End result of not enough antioxidants to keep up with generation of free radicals• Triggers of Stress to the System: gut dysbiosis, toxins, infections, stress

• Balanced by Intake of Antioxidants: A, C, E, phytonutrients, lipoic acid, NAC, glutathione

• Immune cells very sensitive to free radical damage

• STRESS AND RECOVERY CYCLE

• Panel: low glutathione, high lipid peroxides and/or high 8-OHdG, all suggest your patient is losing this battle• Need to find triggers and treat them

• Support with antioxidants both in diet and supplements

Integrative Assessment: Oxidative Stress

• RBC Test: average over 3–4 months of exposure

• Lots of Studies: mercury and autoimmune disease

• Concept of total toxic load, so all metals and toxins matter

• Look at Pattern: high metals with + oxidative stress markers, the metals are likely causing a problem

• Mercury: correlated with fish consumption

• This is a great test to show people that their fish consumption is a problem

• Can track as diet changes

• One patient: high levels from fish oil supplement from low tier company

• Must counsel your patients on safe consumption of fish

Integrative Assessment: Heavy Metals

Simple way of assessing if total toxic load is beyond what the body can clear

• If Markers are High: likely your patient needs a detox program

• Look at This Panel Together with Oxidative Stress and Metals: tells a story

• If all panels are +: you have a bigger problem that is likely to be the root of your immune dysfunction and would add more antioxidants and keep them on liver support/detox program for longer

• Always treat dysbiosis first

Integrative Assessment: Toxin and Detox Markers

• Continue to Look Deeper at Nutritional Deficiencies: minerals, B’s and amino acids

• Many deficiencies despite a pretty good diet think mal-digestion/mal-absorption in the gut and would further direct your attention to the gut as a place to start

• Amino acids and minerals like zinc are critical for optimal immune function

Integrative Assessment: Next Level Panels

Case Study:

54 Year Old Female

• 54 year old white female with RA

• First ‘episode’ @35: treated with Plaquenil, then remission and off meds

• Then @49 joint pain started after dental work. After reading about autoimmune disease she was removing her amalgams

• Also has hx severe periodontal disease for many years and was regularly getting treatment including laser

• Hx lots of antibiotics as a child and eczema

• Had read my book and was already on elimination diet, with only slight improvement

Case Study: 54 Year Old Female

• Currently not on medication

• Pain 7/10: left wrist, both ankles, neck, right shoulder. Stiff hands.

• Wakes up tired, stiff and in pain. Wants a nap at 2:00, energy 3/10 by afternoon

• No gut symptoms at all. BM daily, soft and formed. No reflux, gas, bloating. Last antibiotics 10 years ago

• She’s an optimist: stress levels 3/10 past 5 years

• Doesn’t want meds

Case Study: 54 Year Old Female with RA

• hs-CRP: 41.9

• Deamidated gliadin antibodies (DGA): 27, rest of celiac panel neg

• ANA neg

• RF 124, A-CCP: >250

• Vit D: 30

• Ferritin 73 (suggests absorption in gut is ok, surprising given her DGA’s)

• DHEA-S: 108 (suggests adrenals ok)

• WBC: 6.9 (suggests NOT chronic viral issue)

Case Study: 54 Year Old Female with RA— Conventional Tests

• CDSA 2.0

• Adrenals

• Heavy metal testing

• Sent her home on a liver detox program: she had no gut symptoms

• NutrEval usually done at the 2nd visit to review at 3rd visit

Case Study: First Visit — Integrative Testing

Case Study: 2nd Visit – CDSA 2.0 Results

• High EPX

• High beta-glucuronidase

• Mild dysbiosis

Case Study: 2nd visit – Adrenocortex Stress Profile Results

Within Normal Limits

• High end of the range cortisol curve

• Slightly abnormal curve

• Low DHEA

• Additional Test Results: suggestive that Metals are indeed the issue

• Metals: very high lead and mercury (test done before the detox program)

• 21 day Detox program helped energy but no change in joints

• Sent her home on fish restriction and instructions for removing lead and mercury from environment, and continue on detox program for 3 months

• Started a mild herbal gut cleanse for just 2 weeks

• Do a NutrEval, repeat blood work and see me in 3–4 months

Case Study: 2nd Visit

• Still no change in joint pain

• Labwork: slightly improved but far from resolved. – My interpretation: still haven’t found the main trigger

• RF 107 (was 127), CCP still > 250, ESR 38, hs-CRP 26.7 (41.9), vitamin D 44

• Deamidated gliadins 25 (were 27) – Wondering where she’s getting gluten exposure

• NutrEval: finally shed some light on what’s going on

Case Study: 3rd Visit

Case Study:

My First Question: GUT vs TOXINS

• Gut panels:

– Dysbiosis ++++ Not seen in the stool test

– Severe vitamin deficiencies despite good diet • Gluten damage vs dysbiosis?

– Amino’s ok

• Suggests that the gut is much worse than I thought!

Case Study: NutrEval

• Toxin related panels?

• What about toxins? She had already done 3+ months of liver detox and on a restricted fish diet:

– Metals are low: current mercury and lead exposure is low

– Oxidative stress not impressive (GSH sl low and lipid peroxides sl high)

– Detox markers are all only slightly elevated

Conclusion:

• Toxins are not likely the main issue although these markers might have been much worse initially

• Need to circle back and focus on the GUT!

Case Study:

Case Study: Additional Testing

Case Study:

Treatment Program Based on NutrEval results

– 2 months Gut Cleanse herbal program

– Increased support for leaky gut

– Stop the detox program supplements

– Focus on supplementation with needed B’s, antioxidants, NAC and lipoic acid

– Switch protein shake to anti-inflammatory gut supportive shake and continue the high dose EPA/DHA/GLA

• At 4th visit, still NO CHANGE IN JOINT PAIN!!

• Sent her home with a Oral microbiome test kit and started on water pik program, herbal biocidin drops into the water, once daily

• Oral microbiome tested + for pathogens

• 4 weeks after starting this program, her joint pain is finally resolving!

• My understanding of her case:

• Periodontal disease seeds the gut

• Can’t fix the gut without treating the mouth in some people

• The dental work that triggered her RA relapse was related to the oral microbiome dysbiosis and likely not the mercury

Case Study: 4th Visit - Periodontal Disease

Case Study #2:

60 Year Old Female

• 60 year old woman, Holistic Nurse

• Came to see me to:– Get off meds without flaring

– Heal her gut: hx of reflux, diarrhea triggered by food

– Oversee health and supplements

• @44, swelling in hands, feet and wrists. – Started after +++STRESSFUL pregnancy

– Preeclampsia, and mother died

• OR nurse, had to quit. High RF

• Had been very healthy, running marathons. Hx asthma childhood

• Plaquenil + macrobiotic diet: remission for 3 years

Case Study #2:

60 Year Old Female with Rheumatoid Arthritis

• @47: flared, +Methotrexate. Remission again. RF normalized for the first time– Dairy free, limited processed foods. Began training to be a

holistic nurse.

– Did well for 12 years. However during this time:

• +PPD, treated INH x 7 months

• Yearly levaquin for bronchitis

• Chronic gut symptoms with endoscopy dx gastritis, GERD.

• @58: flared, after death of father and brother both within same year– Prednisone and Enbrel. Enbrel x 4 months and stopped.

– Period of time on all 4 meds.

Case Study #2:

HPI 1st Visit

• 6 months ago: finally got off Prednisone

• Now: In remission on Methotrexate 6 mg/day and Rituxan

• Last Rituxan 5 months ago, due for next dose in 1 month. Doesn’t want to take it. 0 PAIN, 0 STIFFNESS

• Gut: gas, bloating, flatulence, GERD, hoarseness

• READ MY BOOK 3 Months ago: – Started elimination diet: gluten free, vegan,

soy and corn free. Some fish. No night shades.

– Lost 10 pounds

– Gas resolved. Still gurgling and burping.

– 2 weeks ago: started Gut Cleanse with an herbal program

Case Study #2:

HPI (cont’d) 1st visit

• Continue the gut cleanse for 2 full months

• Water pick with Biocidin

• Add Ultrainflammx 360 + high dose omega oils

• Inflammatone 3 TID (DFH)

• DGL Licorice, heartburn TX powder

• Stay on same food plan (she wanted this, too)

• NUTREVAL + CONVENTIONAL LABS

Case Study #2:

Treatment plan 1st Visit

• Lipids: high risk pattern:low HDL-P, high small LDL-P

• WBC 4.7 with absolute neutrophils .4

• A1C 5.7

• HCY 15.8

• RF 214.6

• CCP >250

• hs CRP .71

• Vitamin D 63.7

• TSH 1.450/1.36/3.2 no HT

• DHEA-S 100.1

• ANA neg

Case Study #2:

CONVENTIONAL LABS

Case Study #2: NUTREVAL RESULTS

SUMMARY PAGE: Borderline or high need for all nutrients.

Case Study #2: NUTREVAL RESULTS

High dysbiosis markers bacteria and yeast. WAS ALREADY 2 WEEKS INTO THE GUT CLEANSE

Case Study #2: NUTREVAL RESULTS

• Omega index sl low

• Amino's ok, except low methionine and tryptophan

• High mercury and lead, with oxid stress: high 8-OHdG and GSH sl low 926

• Minerals good

RA: with high RF 214.6 and high CCP >250. Neg ANA

• High gut markers and high need for nutrients, suggest gut dysbiosis.

• Finish the 2nd gut box for a total of 2 months of gut cleanse.

• When you finish the gut cleanse, start probiotic, 1/day. Wait 1 month then send stool test.

• Stay on the waterpik with biocidin.

• Concerned about lead and mercury: need to find sources of lead. test your water in both homes. Use Brita filter for cooking too.

• Lead: ewg.org and explore website for sources of lead. cosmetics data base.

• Cut back on fish consumption: 2 x week for now. focus on salmon from Vital Choice. no tuna. shellfish should be ok.

• We will do a detox program at next visit and heavy metals urine test

• Increase antioxidants: vitamin C, NAC and high orac powder

• Continue inflammx, omega oils, inflammatone

Treatment Plan:

Cardiovascular: high risk lipid particle profile, borderline A1C, high homocysteine

• Continue high omega oils: will help raise HDL and improve particles

• Add B supreme and B12 sublingual to help lower homocysteine and treat deficiencies

• Add CoQ10: 200/day

• Stay on folate prescription

• Low glycemic, high fiber, high healthy fat diet: review with nutritionist

• Deeper CVD evaluation blood test for lipids and risk markers at our next visit

• Our anti-inflammatory work with your gut and supplements are cardio protective

Treatment Plan: (cont’d)

Mentorship Program for Practitioners:

• At Blum Center For Health

• Shadowing Dr. Blum or Elizabeth Greig, FNP

• Go to www.blumcenterforhealth.com/mentorship/

For Patients:

• New Digital platform offering online programs

• www.Blumhealthmd.com

• We are launching 10 and 30 day gut program with coaching mid-May 2016

• September: 3 month Immune Program based on my book The Immune System Recovery Plan

Additional Resources:

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Immune Health and Nutritional TestingSusan Blum, MD, MPH

April 27, 2016

The views and opinions expressed herein are solely those of the presenter and do not necessarily represent those of Genova Diagnostics. Thus, Genova Diagnostics does not accept liability for consequences of any actions taken on the basis of the information provided.