Getting started with functional medicine and patient nutrition
Starting a wellness program in your office is the best way to get started with functional medicine. It is a good way to begin to treat more than musculoskeletal problems. It is vital that you do so because traditional medicine is failing miserably at treating chronically ill people.
You are not treating disease
Before you get started, lose the idea that you are treating disease. You are fixing infrastructure.
Doctors always want to know protocols to treat various conditions — that is a medical concept. A patient with migraine headaches, for example, may respond to riboflavin and magnesium (there are studies that support this). It does not always work; magnesium fixes a magnesium deficiency, not migraine headaches (or course, if you are deficient in magnesium, you may get migraines). If the patient is overweight, craves sugar and gets sleepy after meals, you will probably find that addressing insulin insensitivity helps with the migraines (plus you are adjusting her (usually a her), correct?).
If the migraine patient is thin, anxious and has trouble falling asleep, you may find adrenal support helps. They may need cofactors to help them produce GABA. You are not treating the symptom; you are correcting core health issues. When you are successful and fix enough of these issues, the symptom goes away.
Diet and wellness
A well-planned wellness program will get rid of a lot of symptoms for a lot of patients. Diet is the key. Most of your patients’ chronic problems are self-inflicted.
The diet needs to be strict, but stress the fact that the wellness plan is for 30 days. Thirty days is long enough for the patient to see the connection between diet and their symptoms. The diet should be high in fresh produce, avoid sugar and additives, and avoid complex carbohydrates (this part is temporary; it is based on Elaine Gottschall’s “Specific Carbohydrate Diet” and balances the microbiome). I have a handout I use in my office. It is called the Roadmap to Health. It has meal plans and recipes, and will accomplish the following:
- Fights inflammation
- Avoids some common allergens
- Balances the microbiome
- Is high in nutrients
Most people do very well, but the diet is not perfect. It does not address lectins, and if the patient is allergic to eggs or nuts, you may need to “tweak” the program. Even if these are issues for your patient, they will still improve.
Sometimes the best “lab” is a good conversation. George Goodheart, DC, used to say, “If you listen to the patient long enough, they will tell you exactly what is wrong. If you listen a little longer, they will tell you how to fix it.”
Talking to your patient will help you determine which supplements will do them the most good. Here are a few things they might say and what you can do for them. Remember, this is high-gain, low-risk therapy, and you have time to make changes. Wellness care can be ongoing after the initial 30 days. Peeling the onion or taking straws off the camel’s back are good metaphors for what you are doing.
Here are some things patients may say to you (with responses):
- I have to insist there is no MSG in my food (Patient needs vitamin B6.)
- I get drunk easily or have terrible hangovers (Patient needs zinc.)
- I am overweight and crave sugar (Need to address insulin insensitivity.)
- I have bloating, fatigue or gas immediately after a meal (Patient needs HCl.)
- Greasy foods upset my stomach (Patient needs biliary support, usually supplements based in artichoke extract; possibly needs bile salts. Also, they may need essential fatty acids and fat-soluble nutrients.)
- I have trouble falling asleep (Possibly needs support to reduce cortisol production. He or she may need GABA or nutrients to help produce GABA.)
- I get up in the middle of the night and have trouble falling back to sleep (Patient needs B vitamins (especially thiamin). Consider support for insulin insensitivity or adrenal fatigue.)
Diet to address chief complaints
You get the idea — get them started on a strict diet and basic supplementation. Initially you just need to be in the right ballpark with their supplementation.
It doesn’t matter what their complaint is; they will experience some improvement. As time goes on, you can improve the program, addressing their chief complaints. You have time — this is not emergency medicine (but expect improvement and let the patient know you expect improvement). Each patient will teach you something and as time goes on, you will get better and better at utilizing functional medicine.
Health care is getting expensive, over $4 trillion per year and increasing. Those pursuing natural health care are usually paying out of pocket. I have had an all-cash practice since the 1980s and found that a good nutritional questionnaire saves time and money. Chiropractors need to begin to address chronic health problems as medicine does such an inadequate job treating the chronically ill; we can be the future of health care.
When to utilize labs
When your car does not start, you check to see it is not in gear, has gas and that the battery has a charge (at least you did back in the days when you could work on your own car). You do not start by replacing the fuel pump or pulling the engine. Starting with a stool test, methylation test or other lab is expensive and may not be necessary (at least initially).
It is not that labs are not useful, but addressing basic issues first will often produce results. You can run labs when you get less-than-ideal results; they can help you fine-tune your program.
Blood chemistries are inexpensive and can provide a lot of information. Harry Eidenier Jr. was involved in a project called the Biochemical Biopsy. They looked at the blood chemistries of over 10,000 people and kept track of their health over a period of years. One result was they found that a “normal” blood test may not indicate the patient is healthy. For example, an MCV that is over 100 can indicate a B12 or folate deficiency. The patient is developing pernicious anemia. What does an MCV of 99 indicate? It is technically a “normal” test. The folks doing the Biochemical Biopsy found that if the MCV is much over 90, the patient needs B12 or folate, even though it is a “normal” test. The project compiled data that helped determine “physiologic” normal. A MCV of 89 is physiologically normal; an MCV of 95 is not (even though it is a lab “normal”).
Eidenier compiled the information from the Biochemical Biopsy and put it in a manual that helps you form an accurate nutritional picture of the patient. There is even a computer program. All the information in this section is from Eidenier’s work.
Determining issues and supplementation
We look at ALT, AST and GGT to determine cell damage to the liver and other organs when they are high. We never think of them as being too low, but they can be too low. These are B6-dependent enzymes. If AST is below 10, the patient probably needs B6.
We look at alkaline phosphatase for issues involving bone. It is a zinc-dependent enzyme. “Normal” ranges vary because of the different techniques the labs use to measure it. If it is below the midline of the normal range, it is likely the patient needs zinc.
There may be as many as 13 million Americans with undiagnosed hypothyroidism. Medicine relies on TSH to test thyroid. TSH is a pituitary hormone that stimulates the thyroid gland — levels are used to screen for thyroid problems. The British Medical Journal (BMJ 2000;320:1332-1334, 13 May) published research examining the flaws in diagnosing hypothyroidism. The authors concluded there are indeed flaws with the way we diagnose hypothyroidism. Here are some findings:
- TSH: If the TSH levels are lower than 2.0 (in the presence of symptoms and low basal body temperature), it may indicate the thyroid problem is secondary to hypofunction of the anterior pituitary. This is secondary hypothyroidism. In the absence of symptoms, this is not the case.
- TSH: If the TSH is greater than 2.0 (in the presence of symptoms), the problem is with the thyroid itself. The higher the value, the more likely this is the case. When TSH values are 3.0 or more, it is very common for the patient to have symptoms and come into the office saying, “The doctor said my thyroid is fine.” Many doctors won’t diagnose the patient as being “borderline” hypothyroid until the TSH gets to be above 7.0.
- T4: If the T4 is less than the middle of the lab range (in the presence of symptoms and low temperature), there is a good chance the patient needs iodine and tyrosine.
- T3: If the T3 (free, total or uptake) is below the middle of the reference range and the T4 is above the middle of the reference range, it is a conversion problem. T4 is converted by the body to the more active form, T3. In the presence of symptoms, this needs to be addressed. The cause can be too much stress (cortisol), too much estrogen or a lack of nutrients needed for the conversion. Another test, RT3, can show the presence of reverse-T3, which is an isomer of the active form of thyroid hormone. Reverse T3 is not active and can make the thyroid panel look normal in a patient who has the symptoms of hypothyroidism.
You can base a whole practice on treating missed hypothyroidism. You’ve seen this person; she (usually a she) is tubby, tired and depressed. Her hair is brittle, skin is dry and she can’t seem to lose weight no matter what she does.
You look up hypothyroidism in the medical dictionary and her picture appears next to the two-paragraph description of the condition. She cries for no reason, catches a lot of colds, her ankles swell and she is puffy under the eyes. You notice that the lateral third of her eyebrows is missing. She may or may not be taking antidepressants or cholesterol medication. Chances are she has had her TSH checked and was told that her thyroid is “fine.”
Start your functional medicine practice today
The best way to start a functional medicine practice is to start a functional medicine practice. Start by focusing on diet and addressing simple, basic things.
A lot of patients will get better. A good history, a good diet and a blood chemistry will help a lot of people. If results are not perfect, you can do more testing, talk to colleagues for ideas or do a literature search. You are never wrong with functional medicine; you may just need to hit the problem harder.
PAUL VARNAS, DC, DACBN, is a graduate of the National College of Chiropractic and has had a functional medicine practice for 34 years. He is the author of several books and has taught nutrition at the National University of Health Sciences. For a free PDF of “Instantly Have a Functional Medicine Practice” or a patient handout on the anti-inflammatory diet, email him at email@example.com.