Functional Medicine: A 21st Century Systems Biology Approach to Individualized Clinical Care.
Dr. Mark Hyman’s latest book, The UltraMind Solution (Scribner’s, 2009) presents a highly convincing argument, backed by hundreds of peer-reviewed studies published within the last five years, for the validity of a functional medicine approach to treating brain disorders of all types.
Functional medicine (www.functionalmedicine.org) utilizes cutting-edge systems biology to provide truly personalized clinical care. It is based, not upon the 20th century ICD-9 disease classification system, but on identifying malfunction(s) in the body’s underlying, core, interlocking, physiological systems—the true root cause of all disease.
Core system imbalances arise as each individual processes environmental inputs (diet, nutrients [including air and water], exercise, trauma, and exposure to xenobiotics, micro-organisms and radiation) through his or her unique physiology, which is affected by genetic predisposition, attitudes and beliefs.
The core clinical imbalances that occur as a result of processing malfunctions within this web of complex interactive systems present as:
- Digestive, absorptive, and microbiological imbalances
- Immune imbalances
- Inflammatory imbalances
- Detoxification and biotransformational imbalances
- Oxidation-reduction imbalances and mitochondropathy
- Hormonal and neurotransmitter imbalances
- Structural imbalances from cellular membrane function to the musculoskeletal system
These imbalances are the precursors of the signs and symptoms appearing in the patient, which, in 20th century medicine, are used to name (diagnose) chronic disease. Then the indicated drug is prescribed. Straightforward, but unfortunately, not curative.
Addressing the root causes of imbalance, by addressing the patient’s unique set of environmental inputs and fundamental physiological processes, restores health—but involves much more than a prescription directed at the proximate cause, the symptoms associated with the chief complaint.
Functional medicine is a clinician’s discipline—a definable and teachable process that utilizes a systems matrix to evaluate each individual’s functionality at many levels.
In the functional medicine model, the question is not what disease can be blamed for the chief complaint, but where does the symptom come from? What are its antecedents and triggers? Why are these triggers continually reactivated? What processes of mediation are causing chronic re-stimulation?
Or more simply, what is this individual getting and/or missing that is provoking dysfunctional homeostasis? What needs to be removed and/or provided to restore healthful system function?
In the diagnose-and-drug model, virtually no attention is paid to the patient’s physiology beyond the chief complaint and history of the present illness, with the result that each health issue is treated as a discrete diagnosis to be dealt with by the appropriate specialist in isolation from the others. The same patient sees a psychologist for depression and is given an SSRI, sees a gastroenterologist for GERD and gets an H2 blocker, sees a cardiologist for hypercholesterolemia and hypertension and is put on a statin and ACE inhibitor, goes to a rheumatologist for aching joints and is prescribed a NSAID.
In this piecemeal approach, the patient is an elephant diagnosed by an array of blind men. No one recognizes that all the above chronic complaints derive from an interactive web in which dysfunction in one system is affecting the others.
For the clinician practicing functional medicine, review of the chief complaint includes ferreting out the antecedents, triggers and mediators of the present illness. And the goal of diagnosis is not to name a disease, but to reveal the underlying imbalances in the body’s seven fundamental systems.
Thus, diagnosis expands to include all aspects that could reveal the source(s) of a patient’s signs and symptoms, including:
- Infectious micro-organisms
- Dysbiosis
- Genetic pre-disposition (SNPs)
- Toxic metals
- Xenobiotics
- Drug side effects/nutrient interactions
- Food toxicants (allergens, stimulants, etc.)
- Nutrient imbalance—excess, insufficiency
- Energy imbalance—hyperglycemia, hypoglycemia
- Exercise imbalance—insufficient, excessive
- Adiposity
- Structural misalignment or damage
- Stress—excessive noise, circadian dysrhythmias, emotional trauma
The UltraMind Solution: Heal the Body, Heal the Brain
In The UltraMind Solution, Dr. Hyman poses a question: What if most “brain diseases” are not localized in the brain but have their root cause in the rest of the body—in treatable imbalances in the body’s key systems?”
If this is true, our attempt to treat brain disorders by controlling brain chemistry with psychiatric or psychotropic drugs (the second most prescribed class of drugs after cholesterol medication) is doomed to be ineffective.
And it is. Clinicians just aren’t hearing about it. A recent study in the New England Journal of Medicine revealed that drug companies selectively publish the positive studies on antidepressants, but not those with negative results. (Turner EH, et al. NEJM 2008)
Even the “positive” results aren’t all that positive. A 50% improvement in half the symptoms is considered a positive outcome, and this minimal result is achieved in less than half the patients taking these medications. Plus, 86% of those who experience some relief from depression also experience side-effects including sexual dysfunction, fatigue, insomnia, loss of mental abilities, nausea and weight gain.
As Dr. Hyman notes, “the real question that manipulating brain chemicals with drugs begs is never asked…Why are those chemicals out of balance in the first place and how do we get them back to their natural state of balance?”
After providing an overview of the environmental and dietary influences that affect brain function in Part I, in Part II the book, Dr. Hyman takes us on a tour de force journey through the seven core systems—nutrition, hormones, immune function, digestion, detoxification, energy metabolism, and mind-body—that not only deeply answers this question, but enables effective individualized treatment as each chapter opens with a quiz to help identify where the patient is out of balance.
A New Clinical Landscape
First, we need to recognize that the brain is not disconnected from the rest of the body, that brain disorders are almost always systemic disorders, and that their cure will be found outside the brain—in the body—with the help of a functional medicine/systems biology differential diagnosis.
We need to explore a new clinical landscape, one in which all the ICD-9 brain disorder “entities” do not exist but are simply names we give to collections of symptoms commonly produced in response to various insults and deficiencies that disrupt balance in one of the seven core systems.
We need to address the clinical implications of the fact that, as Dr. Thomas Insel, M.D., Director of the National Institutes of Mental Health remarked to Dr. Hyman, “the DSM-IV has 100% accuracy, but 0% validity—it provides a perfect way to describe symptoms, but has nothing to tell us about the underlying biology for what causes them.”
We need a new medical model because our current limited model of diagnosis no longer reflects the science or our understanding of how the body works—and, most importantly, it is ineffective in treating our patients’ with chronic disease.
So why are we experiencing an epidemic of “broken brains?”
Dr. Hyman explains why in one of the most heavily referenced chapters in The UltraMind Solution, which could serve as the basis for a course syllabus in environmental and dietary influences on brain function. The list of brain toxins includes:
- Brain-toxic foods, such as high-fructose corn syrup and trans/hydrogenated fats
- Excessive consumption of sugar, caffeine, alcohol and nicotine
- Sleep deprivation
- Sedentary lifestyle, which lowers IGF-1 and brain-derived neurotropic factor
- Chronic stress, which chronically elevates cortisol
- OTC and prescription medications, which lower coenzyme Q10, B vitamins, glutathione
- Heavy metals, including lead, mercury, cadmium
- Toxic chemicals (more than 80,000 have been introduced since 1990; 500 have been tested for safety)
- Additives and toxins in our foods (more than 3,500 can be added to food; more than 3,000 are in our homes)
- Mycotoxins, which, according to a number of very current studies, cause severe symptoms of brain damage in 70%, and autonomic nervous system abnormalities in 100% of patients living with them.
The Proof is in the Patient(s)
To demonstrate the validity of this thesis, Dr. Hyman provides numerous examples of patients with a wide variety of apparently disparate brain disorders, ranging from autism to depression to eating disorders to addictions to ADHD to dementia, Parkinson’s and Alzheimer’s disease, all of whom experienced not just resolution of symptoms, but recovery of healthful function as a result of his application of the functional medicine matrix to their unique physiology, history and current circumstances.
Dr. Hyman’s functional diagnosis of one such patient—Clayton—will give you the general idea.
Clayton, a 12-year-old boy who had been diagnosed with ADHD, asthma, and “environmental allergies,” presented with a long list of symptoms, including sinus congestion, postnasal drip, frequent sore throats, eczema, nausea, stomach pains, diarrhea, headaches, anal itching, canker sores, muscle aches, muscle cramps, hypersensitivity to noises and smells, sneezing, hives, itchy skin with bumps, frequent infections, insomnia and sleep apnea, anxiety, fearfulness and carbohydrate cravings.
His symptoms were being treated with seven different medications prescribed by five different doctors, including Ritalin for ADHD, antihistamines (Zyrtec and Tagamet) for his allergies and hives, a bronchodilator and steroid inhaler for his asthma, an acid-blocker for his stomach problems, and acetaminophen and ibuprofen for his headaches.
Though the lens of the functional medicine matrix, Dr. Hyman sought the sources of Clayton’s symptoms in the core systems affected.
Nutritional Imbalances
Like many kids with ADHD, Clayton’s typical diet included lots of trans fats, food additives, refined carbohydrates and sugar. Blood tests confirmed significant deficiencies in key nutrients including:
- Omega-3s (60% of the brain consists of DHA)
- Tryptophan (needed to produce serotonin)
- B6 (needed to convert tryptophan to serotonin)
- A, D, and zinc (a factor in Clayton’s lowered immunity, eczema, allergies and bumpy skin [hyperkeratosis pilaris])
- E, beta carotene (indicative of a diet low in vegetables and whole grains)
- Magnesium (contributing to Clayton’s headaches, anxiety, insomnia, muscle spasms, cramps, hypersensitivity to noise)
Immune and Inflammatory Imbalances
Clayton’s history revealed intolerance to baby formula, diaper rash and frequent ear infections—clear evidence that his current asthma, allergies, hives, itchy skin, and canker sores were a continuation of an hyperactive immune system that was being chronically challenged.
Potential triggers include food, environmental allergens, molds, toxins, chronic low-grade infections or a combination of these factors.
In Clayton’s case, IgG testing revealed reactions to 18 foods including dairy, peanuts, yeast, citrus, and especially gluten, which can trigger a low-grade immune response that provokes inflammation in the brain as well as other systems. (Canker sores were one clue pointing to celiac disease or gluten intolerance.)
Digestive Imbalances
Clayton’s multiple symptoms of digestive dysfunction (nausea, diarrhea, anal itching, sensitive stomach) were the result of treatment for his many infections with frequent courses of antibiotics, which provided a gut environment conducive to the development of pathogenic flora and yeast overgrowth. Clayton’s dysbiosis resulted in a leaky gut (excessive intestinal permeability), which then led to his food allergies, systemic allergies and chronically over-stimulated immune system.
Detoxification Imbalance
Tests showed Clayon had high levels of both mercury and lead. Although his exposure was likely similar to that of other children his age, he nutritionally and/or genetically lacked the resources to eliminate these heavy metals.
Mercury has been associated with auto-immune and gastrointestinal ailments, and both mercury and lead have been clearly linked to cognitive and behavioral problems. Children born between 1989 and 2001 were exposed to mercury in the form of the preservative thimerosal, which, until 2001, was used in a multitude of vaccinations typically received by 2 years of age. Other sources of mercury include coal-burning industrial plants, large predatory ocean fish, river fish, and dental amalgams.
Sources of lead include toys made in China and coated with lead paint, and crawling around on the floor where shoes drag in lead pollution from outside.
Having identified the sources of irritation to Clayton’s core systems (nutritional deficiencies, toxic foods, food allergies, gluten intolerance, environmental toxins, food additives, yeast overgrowth) and the missing ingredients needed to restore normal physiological function (a multivitamin, omega-3s, B6, zinc, magnesium, vitamin D, probiotic bacteria, and 5-hydroxytrptophan for serotonin production), Dr. Hyman’s treatment protocol was simple.
Clayton’s Treatment
A whole-foods diet free of additives, sugar, trans fats, processed foods and his specific allergic foods—gluten, dairy, citrus, peanuts, and yeast.
A course of antifungal medication to clear his low-grade yeast infection.
A multivitamin, omega-3s, B6, zinc, magnesium, vitamin D, probiotic bacteria, and 5-hydroxytrptophan for serotonin production.
After restoration of gut health, chelation using dimercaptosuccinic acid (DMSA), the FDA-approved medication for lead chelation in children.
Within two months, when his mother brought Clayton in for his follow-up visit, all physical symptoms—the hives, asthma, chronic runny nose, anal itching, stomachaches, nausea, diarrhea, headaches, muscle cramps, sensitivity to loud noise—had completely resolved, and he had discontinued all medications.
His mood and behavior had returned to that of a typical 12-year-old. His attention improved, disruptiveness at home and in school disappeared, irritability and anxiety vanished completely, and he was able to fall asleep easily and stay asleep throughout the night. His dysgraphia completely resolved, and he began to succeed in school both socially and academically.
Clinical Pearl
As Clayton’s case—and those of the other complex patients whom Dr. Hyman highlights in The UltraMind Solution (and who regularly appear in your office)—demonstrates, “many symptoms are caused by a multitude of irritants, and a variety of irritants cause a multitude of symptoms. Success is not possible unless all the factors are addressed.”
A Few More Clinical Pearls
The UltraMind Solution is packed with clinical insights, all of which are reference-validated. The scope of this review only allows mention of the following few to whet your appetite:
“One disease can have many, many different causes, all of which manifest the same symptoms.”
“New research on statin drugs shows they are mitochondrial poisons…even in people without any symptoms or abnormal blood tests, muscle biopsy shows cell injury.”
“According to the MIND Institute at the University of California at Davis, more than 70% of children on the autistic spectrum have altered immune function.”
“Cytokines increase the function of an enzyme (IDO) that breaks down tryptophan, leading to less serotonin in the brain and an increased risk of depression.”
“The barrier between the body and the brain is no iron curtain. It is more like cheesecloth.”
“Partially digested dairy and wheat particles (called caseomorphins and gliadomorphins) are found in the urine of severely depressed patients (as well as children with autism and ADHD). These odd proteins change brain function and can lead not only to depression, but also psychosis and autism.”
“Ninety-five percent of the body’s serotonin is produced by the gut nerve cells, and every class of neurotransmitters found in the brain is also found in the gut.”
“Bacterial mischief in the small intestine (from bacteria that migrate up from the large intestine into a normally sterile territory) triggers an immune and nervous system response that sends messages back to the brain.”
“New research links mood disorders to problems with insulin and blood-sugar control. In fact, some researchers suggest calling depression “metabolic syndrome type II…”
“Fifteen percent of American women of childbearing age have toxic levels of mercury in their blood. That means that 15% of the 4 million children born in the USA each year or 600,000 children are exposed to toxic levels of mercury in the womb.”
“More than 92% of Americans are deficient in one or more vitamins. That doesn’t mean they are receiving less than the amount they need for optimal health. It means they receive less than the minimum amount necessary to prevent deficiency diseases.”
“Having enough of a nutrient to prevent one of the deficiency diseases, but not enough to optimize cellular function, will lead to ‘long-latency’ deficiency diseases…For example, if you don’t have enough folic acid for optimal function over thirty to forty years, you will double your risk of Alzheimer’s disease.”
“Sunblock stops 97% of the skin’s production of vitamin D.”
“Genes load the metabolic gun and the environment pulls the trigger.”
“Up to 50% of schizophrenics have a biochemical quirk called the mauve factor (a chemical by-product from oxidation injury to our fats and proteins). These odd compounds, [discovered by Abram Hoffer, MD], can bind to zinc and vitamin B6, leading to a functional zinc deficiency.”
“About one-third (or 1 million) of your SNPs [single nucleotide polymorphism] are dedicated solely to the job of determining how effectively your enzymes are controlled by the nutrients you consume.”
“Those who have a SNP of the enzyme THP2 have an 80% reduction in ability to make serotonin, which can be overcome by taking folate and 5-hydroxytroptophan.”
“Apo E4, a high-risk gene for Alzheimer’s disease, predisposes people to dementia for a number of reasons, including difficulty lowering cholesterol and detoxifying mercury. Twenty percent of the population has apo E4.”
“Problems with methylation and sulfation are involved in virtually all mental illness and neurological dysfunction…as well as heart disease and cancer…Every important function in our bodies is regulated by or depends upon these simple processes….Even if you have “bad genes,” these processes can be almost completely fixed through diet, detoxification, and special nutritional supplements.”
“Glutathione deficiency is found in nearly all very ill patients…Glutathione can only be produced if both the methylation and sulfation cycles are running smoothly…The enzymes involved in glutathione production as well as the genes involved in producing enzymes that allow the body to manufacture and produce glutathione can be tested.”
“In addition to the environmental and dietary influences that deplete glutathione, half of us (and most of the people with broken brains) are missing a key gene, GSTM1, which helps the body rebuild its stores of glutathione.”
“A study in the American Journal of Psychiatry found that 27% of severely depressed women over sixty-five years old were B12 deficient. This was found not by blood levels of B12, but by the functional indicator of whether B12 was doing its job—methylmalonic acid.”
“Acid-blockers used to treat reflux prevent B12 absorption.”
“One study of 2,632 men and women over five years published in the Journal of the American Medical Association found that those with metabolic syndrome (or insulin resistance) and inflammation had dramatic declines in cognitive function.”
“The most powerful tool you have to change your brain and your health is your fork. Why? Food is not just calories or energy. Food contains information that talks to your genes, turning them on or off and affecting their function moment to moment.”
Conclusion
Like the Functional Medicine matrix it presents, The UltraMind Solution cannot be distilled into a few separate points. It’s a web, and a reference you will want to read cover-to-cover and have on your bookshelf.
If you are a Functional Medicine practitioner, The UltraMind Solution will provide an excellent review of the use of the functional medicine matrix to treat brain disorders and an array of useful intake forms, resources, a diet plan and many tools that could greatly improve patient compliance.
If you are not familiar with Functional Medicine, this book offers insights that could truly revolutionize your medical practice.
Dr. Hyman is doing a special six-part webinar series on clinical applications of functional medicine to brain and mood disorders. In particular, Dr. Hyman will go into detail about ADD/ADHD, autism, dementia and depression, and will discuss exactly what to do diagnostically and therapeutically. You will learn such things as the two questions to ask each patient, the five causes of most disease, the seven ingredients for optimal function and the seven core physiologic systems that must be in balance. Access to this special series of webinars is complimentary for practitioners who obtain a copy of the book by going to the website below:
Practitioner version: http://www.ultramindhealth.com/lmr
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