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

2. About Me Trained in public health with MPH at University of Rochester Medical School, Rochester, NY, 1983 Trained 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

3. Disclosures Board certified Child and Adolescent Psychiatrist Medical Director Child and Adolescent Services at Douglas County Mental Health Center, Roseburg Oregon No disclosures

5. Why Functional Medicine? 20th Century health care advanced interventions for acute care Providers trained to deliver acute care interventions with increasing specialization

6. Why Functional Medicine? 20 th Century factors created burden of chronic disease Increased stress Sedentary life style Overconsumption but undernourishment Fragmented family and community ties Industrial pollution and devitalized food

7. 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

8. 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

9. Why Functional Medicine? In addition to prevention, many chronic diseases are very responsive to dietary and lifestyle interventions

10. 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

11. 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

12. Why Functional Medicine? Each of us has 30,ooo genes Most 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. What is Functional Medicine? Core Areas to Assess for Clinical Imbalance Immune Surveillance Inflammatory Process Digestion, Absorption, Barrier Integrity Detoxification and Biotransformation Oxidative/Reductive Hormone, Neurotransmitter Regulation Psychological and Spiritual Equilibrium Structural Integrity

20. 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

21. 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

22. 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

23. What is Functional Medicine?

24. 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

25. 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

26. What is Functional Medicine? Evidenced Based Medicine (EBM)= integration of best research evidence with clinical expertise and patient values

27. 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

28. 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

30. Practice of Functional Medicine GOAL - Person centered diagnosis Individualized therapy plan based on understanding of physiological, environmental and psychological contexts within which person’s illness/dysfunction occur

31. Practice of Functional Medicine Elicit all of patient’s concerns to discover Antecendents | Of symptoms, signs Triggers |  Illness behaviors Mediators | Demonstrable pathology

32. Practice of Functional Medicine Focus on control or reversal of each person’s individual antecendents, triggers and mediators rather than treatment of disease entities

34. Practice of Functional Medicine Triggers: 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

35. Practice of Functional Medicine ANTECEDENTS 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

36. 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

37. Practice of Functional Medicine TRIGGERS 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

38. Practice of Functional Medicine MEDIATORS Anything that produces symptoms or damage to the body Types of behavior associated with being sick

39. Practice of Functional Medicine MEDIATORS Biochemical – organized into circuits/cascades that subserve homeostasis Multifunctional – redundancy Lack of disease specificity

40. Practice of Functional Medicine MEDIATORS Natural rhythm of mediator activity strongly influenced by common components of life Diet Sleep Exercise Hygiene Social interaction Solar and lunar cycles Age Gender

42. Practice of Functional Medicine EXAMPLE: Aging and illness Chronic psychological -> Upregulates activity of distress inflammatory and neuro- endocrine response networks Regular physical -> Downregulates inflammatory activity and neuroendocrine response networks

43. 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

44. 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

45. 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

46. 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

48. Practice of Functional Medicine One major imbalance influences many different functional systems Multiple factors influence one single condition

49. Practice of Functional Medicine

50. Allopathic medicine: Look for single root cause and find a cure with a pill, surgery or radiation Functional medicine: Ask what is imbalanced Find shift of flow of biochemical information, energy, physical structure or emotion out of healthy range

51. Practice of Functional Medicine Functional Medicine Resources Jones, David S., Hofmann, Laurie, and Quinn, Sheila. 21 st 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