Susan G. Pickrel, MPH, M.D. GOBHI Conference 5/18/2012

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


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


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


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


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


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


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


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


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


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?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


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


Evidenced Based Medicine (EBM)= integration of best research evidence with clinical expertise and patient values


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


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


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


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


MEDIATORS

Anything that produces symptoms or damage to the body

Types of behavior associated with being sick


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 neuroendocrine response

networks

Regular physical -> Downregulates inflammatory activity and neuroendocrine

response networks


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


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


Use knowledge of most common biochemical imbalances in chronically ill North Americans

Use influence of diet, nutrition and dietary supplements on these imbalances


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


One major imbalance influences many different functional systems

Multiple factors influence one single condition


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


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

Documents

Susan G. Pickrel, MPH, M.D. GOBHI Conference 5/18/2012