Susan G. Pickrel, MPH, M.D.
GOBHI Conference 5/18/2012
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, 19932000
 Clinical inpatient and outpatient practice, last 6 years in
community mental health center, 2000-2012
 Board certified Child and Adolescent Psychiatrist
 Medical Director Child and Adolescent Services at
Douglas County Mental Health Center, Roseburg
 No disclosures
Why Functional Medicine?
 20th Century health care advanced interventions for
acute care
 Providers trained to deliver acute care interventions
with increasing specialization
Why Functional Medicine?
 20th 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
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
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
Why Functional Medicine?
 In addition to prevention, many chronic diseases are
very responsive to dietary and lifestyle interventions
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
Why Functional Medicine?
 Emerging understanding of how biochemically unique we
 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
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
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
Why Functional Medicine?
 Phenotype of cell = complex process of interacting
Related to genetic expression, protein synthesis, protein
activation and metabolic regulation
Use these processes to evaluate and establish biomarkers of
health and disease
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
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
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
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
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
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
What is Functional Medicine?
 Functional Medicine Matrix
Used to obtain, sort and qualify the different kinds of patient
To generate for clinician strong indicators of most useful way
to intervene with the interconnecting issues presented
What is Functional Medicine?
What is Functional Medicine?
 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
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
What is Functional Medicine?
 Evidenced Based Medicine (EBM)= integration of best
research evidence with clinical expertise and patient
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
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
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
Practice of Functional Medicine
 Elicit all of patient’s concerns to discover
Of symptoms, signs
Illness behaviors
Demonstrable pathology
Practice of Functional Medicine
 Focus on control or reversal of each person’s
individual antecendents, triggers and mediators
rather than treatment of disease entities
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
Practice of Functional Medicine
 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
Practice of Functional Medicine
Primary task of Functional Medicine provider to help
patients identify triggers and develop strategies for
eliminating them or decreasing their effects
Practice of Functional Medicine
 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
Practice of Functional Medicine
 Anything that produces symptoms or damage to the
 Types of behavior associated with being sick
Practice of Functional Medicine
 Biochemical – organized into circuits/cascades that
subserve homeostasis
 Multifunctional – redundancy
 Lack of disease specificity
Practice of Functional Medicine
 Natural rhythm of mediator activity strongly influenced by
common components of life
Social interaction
Solar and lunar cycles
Practice of Functional Medicine
Aging and illness
 Chronic psychological
 Regular physical
Upregulates activity of
inflammatory and neuroendocrine response networks
-> Downregulates inflammatory
and neuroendocrine response
Practice of Functional Medicine
 To utilize vast data base regarding biochemical disease
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
Practice of Functional Medicine
 Attend workshops that emphasize integrative
Institute of Functional Medicine
New York Academy of Science
Center for Mind-Body Medicine
Anerican College for Advancement in Medicine
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
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
Practice of Functional Medicine
 One major imbalance influences many different
functional systems
 Multiple factors influence one single condition
Practice of Functional Medicine
Practice of Functional Medicine
 Allopathic medicine: Look for single root cause and
find a cure with a pill, surgery or
 Functional medicine: Ask what is imbalanced
Find shift of flow of biochemical
information, energy, physical
structure or emotion out of
healthy range
Practice of Functional Medicine
Functional Medicine Resources
Jones, David S., Hofmann, Laurie, and Quinn, Sheila.
21st 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.