optimal health: functional medicine and nutritional genomics

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AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: USING PRINCIPLES OF FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS PART 2 2012 gastropathy 71 , gastric carcinoma 72 and lymphoma 73 and a variety of extradigestive disorders, including ischemic heart disease 74 , ischemic cerebrovascular disorders 75 , rosacea 76 , Sjogren's syndrome 77 , Raynaud's syndrome 78 , food allergy 79 , vitamin B12 deficiency 80 and open angle glaucoma 81 . For elderly patients with open angle glaucoma and incidental H. pylori infection of the stomach, eradication of H. pylori by antibiotics was associated with improved control of glaucoma parameters at 2 years. 82 The mechanism by which H. pylori aggravates open-angle glaucoma is unknown, but may result from the ability of H. pylori colonization of the gastric tract to trigger the local and systemic release of Platelet Activating Factor, inflammatory cytokines, and vasoactive substances. In the case of untreated H. pylori infection, noninvasive screening tests, including serum antibodies, stool antigens and C-14 breath testing, are available. For other types of infection, inquiring about the previous response of a given symptom or symptom complex to antibiotics may be useful. In 1988, physicians at the University of Minnesota conducted a study in which they administered intravenous cephalosoprins to patients with various types of arthritis who also manifested antibodies to Borrelia burgdorferi. Most of these patients were not thought to have Lyme disease. Some met diagnostic criteria for rheumatoid arthritis, some for osteoarthritis, some for spondyloarthropathies. The response to antibiotics was quite variable and ranged from no response to dramatic and sustained improvement. The authors noted that improvement in arthritis following antibiotics was not related to the patient's clinical diagnosis or the level of anti-Borrelia antibody. The best predictor of a positive response to the experimental treatment was a previous history of improvement of arthritis associated with the use of antibiotics 83 . The most comprehensive way to ask the antibiotic question is: "During the time you have had symptom X, have you taken antibiotics for any reason? Which antibiotic? Did symptom X change while you were taking the drug?" Among patients with chronic diarrhea of unknown cause, for example, some will report that their gastrointestinal symptoms improved when taking a specific antibiotic, others will report that they worsened. The first case suggests that bacteria or protozoa sensitive to the antibiotic may be causally related to the patient's gastrointestinal problems. Repeating the antibiotic prescription can establish if this response is replicable. If so, therapy can focus on treating the microbe and understanding why a single course of antibiotics was ineffective. The second case suggests that depletion of bacteria by antibiotics and concomitant increase in antibioticresistant organisms, including yeasts, may be contributing to diarrhea and treatment can focus on restoration of a normal intestinal flora. ASSESSMENT OF PSYCHOSOCIAL MEDIATORS: Useful questions for eliciting a person's beliefs about her illness are: "What do you think has caused your problem?" "What do you most fear about your problem?" "How much control do you think you have over your symptoms?" Useful questions for eliciting information about the nature and sources of social support include: "Are there people in whom you can confide?" "How satisfied are you with your marriage/family/friends/social life?" "How much support do you receive in dealing with your health problems?" 182
AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: USING PRINCIPLES OF FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS PART 2 2012 "How often do you feel loved or cared for?" ASSESSMENT OF BIOCHEMICAL MEDIATORS Understanding the biochemical alterations associated with a conventional disease diagnosis can be helpful in understanding the biochemical mediators of each person's illness. Inflammation is believed to play a critical role not only in response to infection and in the classic inflammatory diseases, but also in the pathogenesis of coronary artery disease, diabetes, cancer and depression and the negative health 84 85 effects associated with obesity and with aging. 86 87 88 89 90 The orchestration of mediator signals in the inflammation and neuroendocrinestress networks, as they interact with one another, is critical for normal physiological functions, like the architecture of sleep, the repair of injury and the response to infection, and for the dysfunctional physiology central to the pathogenesis of most of 91 92 the major chronic diseases. Most chronic diseases is associated with chronic inflammation, but the patterns of immune response that underlie inflammation are not always the same. Patients with Type 1 diabetes mellitus, Crohn's disease or any other disorder categorized by granuloma formation or excessive cell mediated immune responses are likely to have an immune response to common triggers in which the TH1 component is upregulated and not subject to the normal downregulation provided by TH2 activity. Their mediator response to inflammatory stimulation produces excessive levels of gamma-interferon (g-IFN) and interleukin-12 (IL-12), key TH1- related cytokines. 93 Patients with severe depression often show a loss of negative feedback in the HPA axis. Urine free cortisol is elevated; the diurnal pattern may be disrupted, with increased P.M. cortisol secretion and blunting of dexamethasone suppression. This phenomenon appears to be driven at the level of the hypothalamus, not the adrenals, because spinal fluid Corticotrophin Releasing Hormone (CRH) is elevated. 94 Several groups of researchers have speculated that impaired synaptic function due to a deficit of omega-3 fatty acids may contribute to the CNS dysfunction of patients with depressive illness. Their Omega-3 fatty acid levels tend to be lower in blood samples than in control populations; administration of omega-3 supplements derived from fish oil has been shown beneficial in placebo-controlled studies of patients with depression, schizophrenia and attention deficit disorder. The key component appears to be eicosapentaenoic acid (EPA). 95 To utilize the vast database of available information about biochemical disease mediators, integrative clinicians should consider three strategies. First, maintain up-to-date knowledge of disease pathophysiology by reading reviews in mainstream journals on mechanisms of disease or on specific mediators. In reading these, pay special attention to the types of mediators mentioned and their functions within the networks that subserve inflammation, oxidative stress, and neuroendocrine balance. Second, attend workshops and courses that emphasize integrative physiology, sponsored by institutions like IFM, the New York Academy of Sciences, the Center for Mind-Body Medicine, and the American College for Advancement in Medicine 96 Third, employ knowledge of the commonest biochemical imbalances in chronically ill North Americans and the influence of diet, nutrition and dietary supplements on these imbalances. TREATMENT PLANNING A Functional Medicine treatment plan should be collaborative and dynamic. Collaborative means that patient and practitioner work together to set 183
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