The Wisdom of Self-Care June 14, 2014 Saratoga, NY

1. The Wisdom of Self-CareJune 14, 2014 Saratoga, NY Part I: Practical Application of Functional Medicine Part II: Is gluten-free for me?

2. Wellness …..is an active process of becoming aware of and making choices toward a more successful existence. Definition from the National Wellness Institute The Institute for Functional Medicine reminds us that health is a positive vitality rather than merely the absence of disease.

3. What is Functional Medicine:? • FM is the clinical application of Systems Biology • Systems Biology is an interdisciplinary field of study with a focus on complex interactions within biological systems • FM recognizes biochemical individuality • FM is science-based and patient-centered • FM understands that there are web-like connections among biological systems that partly determine human health • FM honors the whole person; mind-body-spirit

4. The global leader in functional medicine education 4411 Pt. Fosdick Dr NW #305Gig Harbor, WA  98335 800 228 0622 functionalmedicine.org

5. Self Care with a Functional Medicine Approach • Aims to avoid chronic disease or at least delay onset and reduce severity ( diabetes is a good example—more later) • Seeks to optimize vitality • Seeks to understand each person’s unique mind-body-spirit • Works to allow genes to express in beneficial ways

6. Functional Medicine Assessment—Patient always in the center Antecedents, Triggers, Mediators Modifiable lifestyle choices Core Clinical Functions Cognitive, Spiritual, Emotional

7. Modifiable Lifestyle Factors: • Sleep and Relaxation • Exercise and Movement • Nutrition and Hydration • Stress and Resilience • Relationships and Networks

8. The Seven Core Clinical Functions • Assimilation ( digestion, absorption, microbiota/gi, respiration) • Defense and repair ( immune, inflammation, infection/microbiota) • Energy ( energy regulation, mitochondrial function) • Biotransformation and elimination (toxicity, detoxification) • Transport ( cardiovascular, lymphatic system) • Communication ( endocrine, neurotransmitters, immune messengers) • Structural integrity (from subcellular membranes to musculoskeletal structure)

9. How to Simplify • Though this seems very complex, as we assess our own state of health, we can ask two very basic questions:

10. Question one: What might be harming me or preventing me from achieving optimal health? Some examples: toxins, (external and internal), stress, improper food, infection, allergy, gluten, tobacco, inflammation, injury, drugs, electromagnetic fields

11. Question two: • Is there something I need that I am not getting, in order to achieve optimal health? • Some examples: sleep, water, macro-nutrients (protein, fats, carbohydrates), specific nutrients (such as vitamin D, essential fatty acids in proper balance, fiber, B vitamins), strategies to manage stress, exercise, probiotics, light, connection, purpose

12. Applying Functional Medicine to Digestive Health • The core function of assimilation includes digestive health (gastrointestinal, or GI) • Imbalances are very common in our modern world • Consequences of poor digestive health are potentially serious and certainly uncomfortable • Symptoms may include those easily identifiable as GI in nature, such as difficulty swallowing, GERD, pain, gas, diarrhea, constipation. • Other symptoms such as fatigue, rashes, joint pain, etc. may also be related to GI imbalances

13. Self Care: 5 R program • Remove: foods and additives that may be causing problems. Common examples: processed foods, MSG, pesticides, gluten, dairy, corn, soy, citrus, seafood, peanuts, eggs. Also, infections with bacteria, viruses, yeast/fungi, parasites • Replace: stomach acid, enzymes, saliva • Re-inoculate: friendly bacteria (probiotics); enhance with prebiotic fiber, also beneficial yeast • Repair: supply nutrients necessary for cellular regeneration—n-butyrate, zinc, glutamate are examples • Re-balance: stress reduction, proper attention to relationship with food, friends, family

14. Is it possible to do the 5R program on one’s own? • For the most part, yes! • Try an elimination diet (one important point, however, is to strongly consider being tested for celiac disease prior to eliminating gluten) • Try good quality digestive enzymes, probiotics, prebiotics • See how you feel • Or, consult a practitioner of FM for guidance

15. The continuum: Insulin resistance/diabetes • In CM, there is little if any attention given to patients who are in the process of developing diabetes • This is very unfortunate, as there is demonstrably a long lead-up period of time during which: a) harm is being done to the body and b) intervention is very effective; this applies to most instances of type II diabetes • What can we do as individuals interested in self-care? • A lot!

16. Insulin Resistance—simplified explanation • Insulin is the hormone that reduces blood sugar, but its main purpose is to store fuel; it allows cells such as muscle and liver cells to take in glucose (sugar) and change it to stored fuel • The first step in this process is the binding of insulin to receptors on cell membranes • In genetically susceptible individuals, lifestyle factors may cause the cells to have more difficulty binding insulin to their membranes • Therefore more and more insulin is necessary to process sugar (and carbohydrates which are rapidly turned into sugar) • The pancreas, which secretes insulin, does its best to keep up with demand

17. Key points—the continuum of insulin resistance type 2 diabetes • Very important!!!! In most cases of diabetes, insulin levels increase LONG before blood sugar rises. Current definition of “pre-diabetes” is a fasting blood sugar higher than 100; of “diabetes”—fasting blood sugar greater than 126. Clearly, these are arbitrary numbers; should we ignore a blood sugar of 125? 99? In the same person, fasting blood sugar varies day to day The insulin resistance itself is harmful long before blood sugar is consistently high

18. The Good News • In most cases, insulin resistance may be greatly improved, perhaps even reversed • Therefore, in many people, diabetes may be prevented • The harmful effects of insulin resistance may be avoided • More vitality! Healthier life. • The lifestyle factors I mentioned earlier are primarily dietary and exercise related • Obesity, improper diet, and lack of exercise are the main culprits

19. What to do? Self-Care! Very wise • First step—self evaluation • Ask yourself if you have any risk factors/associated conditions for insulin resistance: family history, overweight, belly fat (even if you are normal weight or thin), history of gestational diabetes, polycystic ovarian syndrome, hypertension, heart disease, abnormal lipids (esp high triglycerides or low HDL), inactive lifestyle, history of elevated blood sugar, peripheral neuropathy, sugar or carbohydrate craving • Some numbers to keep in mind: BMI greater than 25; waist circumference greater than 35 for women or 40 for men; waist to hip ratio greater than 0.8 for women or 1.0 for men—associated with greater risk for IR, diabetes, illness in general

20. Glucose and insulin tolerance test • Fasting glucose is measured at a lab—this is a blood test • Fasting insulin is also measured • A sugary drink is consumed • Samples of blood are then drawn one hour later and two hours later • Fasting insulin should be less than 10; one hour and two hour insulin levels less than 35 • Fasting blood sugar should be less than 100 (in general, the lower the better); one hour and two hour blood sugars should be less than 130. • NB—this test is very helpful, but very infrequently ordered; the lab will give different normal—I am giving you the normal advocated by FM

21. Beneficial Lifestyle Modifications • Regular exercise—30 minutes daily; check with your doctor to be sure you are healthy enough • Reduce your weight if you are overweight • Dietary changes: low glycemic load, reduce or eliminate grains, eliminate processed foods, reduce or eliminate sugar in all of its forms (especially HFCS), high quality protein at every meal, lots of leafy green vegetables, minimize dairy (this seems to be very important for some people—remember that we are all different biochemically) • Reduce exposure to toxins (for example, pesticides, heavy metals)

22. Glycemic load and Glycemic index • Glycemic index refers to the ability of a given food to increase blood sugar levels as compared to a known substance (typically white bread or pure sugar) • As an example—a white potato has a higher glycemic index than a piece of chicken • Glycemic load refers to the total amount of carbohydrate in a serving of a particular food multiplied by the glycemic index

23. Additional Self-Care for insulin resistance/diabetes • Certain nutritional supplements may be helpful • Will not get into details, but some examples are chromium, vanadium, alpha-lipoic acid, magnesium, cinnamon • Increasing fiber may be very helpful in several ways • Certain fibers, for example glucomannan, actually slow the absorption of carbohydrate • Certain pharmaceuticals also helpful and are appropriate for some individuals

24. Autoimmune disease—a FM perspective on an increasingly common condition • Autoimmune disease—the body attacks its own tissue due to a dysregulated immune response • Some examples—Hashimoto’s thyroiditis, celiac disease, rheumatoid arthritis, lupus, Sjogren’s syndrome, alopecia, ulcerative colitis • Emerging science tells us that in almost all cases, 3 elements are necessary for an autoimmune disease to develop—genetic susceptibility, “leaky gut” (aka increased intestinal permeability), and a trigger or triggers • Celiac disease is an instructive example: genetically susceptible individuals develop autoimmunity triggered by gluten—leaky gut is a factor

25. Self-Care for autoimmunity • Conventional medicine will often try to suppress the immune system to treat autoimmunity, and sometimes this is necessary • However many people benefit by improving digestive function—back to the 5R program • Also, if a trigger can be determined and removed, the disease may be improved or reversed • Triggers may be singular but usually multiple—dietary, toxins, infections, stress

26. Self care—heart disease—still a huge health problem in the USA • Functional medicine seeks to understand the underlying imbalances that lead to heart disease • Most heart disease, which is more properly called cardiovascular disease, is associated with atherosclerosis • The underlying problem that leads to atherosclerosis is endothelial dysfunction • Endothelium is the single cell lining of arteries—very biologically active • If we can keep our endothelium functioning well—we will be healthier in general

27. Web-like connections—a simplified example • Three underlying causes of endothelial dysfunction: inflammation, oxidative stress, immune dysfunction • Insulin resistance is a huge cause of inflammation • Toxins are a huge cause of oxidative stress; think tobacco • The digestive system is very important in detox—recall the 5R program • Recall the discussion about autoimmunity—genetics, leaky gut, trigger • Most of the immune system is located in the lamina propria of the small intestine

28. How it comes together • Paying close attention to all of the factors we already discussed helps the endothelium to function properly • Heart disease may be avoided in some cases, and certainly the symptoms may be reduced greatly by all of the healthy lifestyle modifications we discussed • Always collaborate with your health care provider if you are diagnosed with or may have heart disease, but remember that you can do a lot for yourself! • It is possible to measure and track endothelial function, which is a dynamic process, by means of a non-invasive test, EndoPat

29. Part II: Is Gluten-free for me? • Just to review: gluten is a storage protein found in wheat, rye, barley, triticale • Gluten consists of glutenin and gliadin • Celiac disease is a particular autoimmune condition found in about 1% of the population • Celiac disease is the only autoimmune disease with a known trigger—gluten • In celiac disease, the body forms “auto-antibodies”, that is, antibodies which attack the self, typically the small intestinal lining, but also other tissues

30. Non-Celiac gluten sensitivity • Growing phenomenon of individuals who test negative for celiac disease yet clinically react to gluten • Many people are trying a gluten-free lifestyle (GF) and finding great benefit • Massive confusion and some disbelief in the medical community • Controversial topic, but emerging research suggests this is a real phenomenon • Then, of course, there is the emerging market for GF products—huge!

31. Consensus on new nomenclature and classification--2012 • Sapone,er al. BMC Medicine 2012, 10:13 • Suggests evaluating patients suspected of gluten sensitivity thoroughly to look for celiac disease and wheat allergy • If CD and allergy are not found, a gluten challenge is tried • If patient reacts, gluten sensitivity is confirmed • This is a simplified explanation for a complicated process

32. What this means in real life • Both celiac disease and non-celiac sensitivity are manifestations of a dysregulation in the immune system, but in different ways • Both may cause both gastrointestinal and non-gastrointestinal symptoms • Examples: abdominal pain, IBS, diarrhea, weight loss, joint pain, bone pain, fatigue, anemia, brain fog, headache, depression, problems with gait, peripheral neuropathy, muscle cramps, behavioral problems • Many more people are affected by non-celiac gluten sensitivity than are truly celiac; probably at least 30% of people to some extent, but most don’t realize the problem • Some studies show inflammation 100% of the time when samples of small intestine are incubated with gluten in a lab setting • Human beings do not have the ability to break gluten down into its component amino acids, that is, we cannot fully digest gluten

33. Food for thought • Gluten-containing grain was introduced to the human food supply about 10,000 years ago • We have not yet evolved (and maybe we never will) to be able to utilize gluten as food in a healthy way • Wheat has been genetically modified to contain more and more gluten—currently 14% of dry weight of wheat • The prevalence of celiac disease has increased 400% in the last 50 years • Gluten-induced ataxia and dermatitis herpetiformis are two clinical problems related to gluten that have been recognized in conventional medicine for many years • There is a continuum of celiac disease, with some individuals manifesting either damage to the small intestine induced by gluten, or positive blood tests, but without the full manifestation of the disease

34. My advice to patients (and to my family) • My own bias is that gluten is harmful to all humans; it’s just a matter of degree • Therefore, I do not view GF diets for non-celiacs as a fad; I view GF diets as a good choice for one and all • I urge most of my patients to try GF, especially if they have gastrointestinal symptoms, fatigue, brain fog, autoimmunity, chronic pain • There is not any loss of nutrition when one removes gluten if the diet is otherwise well-balanced • Beware of GF processed food that is full of sugar, high glycemic index, addictive. The GF chocolate chips and brownies are just too delicious! • It is possible to learn to bake with alternative flours such as almond and coconut, and with minimum sweetener, to enjoy truly healthful baked goods

35. Testing for Celiac Disease • I strongly urge people contemplating a trial of GF to discuss testing for CD with their health care provider first • Celiac patients may convert to negative blood tests quickly on a GF diet • The issue may become confused • Often people feel so much better on a GF diet that they do not want to resume eating gluten in order to have a blood test

36. Conclusions • We have been introduced to the concepts used in Functional Medicine • We have discussed self-care approaches to several common health problems: poor digestive health, insulin resistance and diabetes, autoimmunity, and heart disease • We have discussed the effect of gluten on human health and why a gluten-free diet may be beneficial to many people • I will post sources, slides, suggested reading on my website: www.healthyendeavorsmed.com • Please feel free to contact us if you have further questions