Gathering Patient Information The ABCDs of Assessing Nutritional Status Mary Willis RD CDE Mary Willis RD, CDE Michael Stone MD, MS Functional Nutrition Course Hollywood, Florida December 2010 © 2010, The Institute for Functional Medicine Disclosures • MICHAEL STONE, MD has indicated he has • no financial relationships with any y relevant commercial supporter or with the manufacturer of any commercial product or provider of any commercial service relevant to this activity. MARY WILLIS, RD has indicated she has no fi financial i l relationships l ti hi with ith any relevant l t commercial supporter or with the manufacturer of any commercial product or provider of any commercial service relevant to this activity. © 2010, The Institute for Functional Medicine Objectives 1. Analyze the gathering tools for patient 2 2. 3. 4. nutrition history and status C Comprehend h d the th ABCD off nutrition t iti assessment Apply the four main components of the nutrition physical exam Identify four classic nutrition physical exam findings Setting the Stage © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Chronic Disease Nutritional Problems Setting the Stage Lord RS, Bralley JA. Laboratory Evaluations for Integrative and Functional Medicine, 2nd edition. Duluth, GA: Metametrix Institute; 2008. Adapted from Table 3.4-reports showing associations of essential element insufficiency with the top causes of death in the United States (2005). P.71. © 2010, The Institute for Functional Medicine 100 85.9 68.0 54.7 60 80 72.9 75.1 48.3 42.0 40 Heart Disease: Ca, Mg, Zn, Se, K, Cr, Cu, Vit D Malignant Neoplasms: Ca, Mg, Zn, Se, Cu, Vit D Chronic Respiratory Diseases: Mg, Se Diabetes: Ca, Mg, Zn, Se, Cr, Vitamin D Diabetes Alzheimer’s: Mg, Se, Cu Alzheimer’s Nephritis, Nephritis Nephrotic Syndrome: Syndrome Zn, Zn Se Liver Disease Disease: Zn, Se Hypertension: Ca, Mg, Zn, Se, K, Cr, Cu, Vit D Hypertension Percent of U.S. Population NOT Meeting the Dietary Reference Intake (DRI DRI)) for Specific Nutrients 35.3 34.3 28.3 24.2 21.7 21.8 20 • • • • • • • • © 2010, The Institute for Functional Medicine Percent of Population Essential Nutrient Insufficiencies Linked with Top Causes of Death in U.S. Peterlik M, et al. Int J Environ Res Public Health. 2009;6:2585-2607. 29.9 30.7 14.8 0 © 2010, The Institute for Functional Medicine (46 different studies worldwide) al ci um Fo la te M ag Iro ne n si um Ph N i os aci ph n R oru ib of s l Se avi le n ni u Th m ia m Vi ta in Vi min ta A Vi min ta m B6 in Vi B 1 ta 2 m Vi in C ta m in E Zi C nc op pe r Ames B. Arch Biochem Biophys. 2004;423:227-234. • LLow Vitamin Vit i D 30-80% 30 80% Population P l ti • Low Calcium 30-80% Population C Half the US population is deficient in at least one of the following: Vitamins - B12, B6, C, D, E, or Folic Acid Minerals - Iron or Zinc http://www.ba.ars.usda.gov/cnrg/services/cnmapfr.html Aug 10, 2009 © 2010, The Institute for Functional Medicine Modern Chronic Diseases Lifestyle Habits Diet Genes MISMATCH © 2010, The Institute for Functional Medicine ADIME The Role Of Nutrition In the Treatment and Management of Chronic Disease Nearly all (96%) PCPs believe the nation’s health care system should be placing more emphasis on nutrition when it comes to the treatment and management of chronic disease. The Role Of Nutrition In The Treatment And Management Of Chronic Disease: A Survey Among Primary Care Physicians. Conducted by Hart Research Associates, June 2009. © 2010, The Institute for Functional Medicine Nutrition Status Nutrition Status ✔Assess Diagnose Intervene Monitor & Evaluate © 2010, The Institute for Functional Medicine Nutrition Status Nutrition Status Nutrition Status © 2010, The Institute for Functional Medicine Nutrition Status Genotype Nutrition Status Nutrition Status A D I M E What is “Nutrition “Nutrition Status” ? A D I M E Nutrition Status quantifies tifi th the titissue nutrient ti t reserves, cellular function and genetic potential influenced by the interaction of diet, environment, and lifestyle lifestyle. IFM Nutrition Advisory Board (NAB) © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Key Point #1 Gathering the History When We Improve Nutrition Status, We Improve Patient Outcomes © 2010, The Institute for Functional Medicine A D I M E Initiate the Assessment of Nutritional Initiate the Assessment of Nutritional Status By Gathering a Detailed History of the Patient and Utilizing the Patient Intake Forms, Screening Questionnaires, and Exam Forms © 2010, The Institute for Functional Medicine Gather Resources in Your Toolkit Organize Synthesize Prioritize Action Track Prepare to GOSPAT © 2010, The Institute for Functional Medicine Tools for Gathering • Intake Forms • • © 2010, The Institute for Functional Medicine Adult Functional Medicine Intake Form • Let’s Take A Look At the Key Components! Questionnaires Diet Historyy © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Pediatric Intake Form Pediatric Functional Medicine Intake Form • Demographics • History © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Medical Symptom Questionnaire Tools for Gathering • Intake Forms • Questionnaires • Diet Historyy © 2010, The Institute for Functional Medicine Advantages - Questionnaire used in Functional Medicine Research • 0-50 More straight forward interventions • 50 50-100 100 Considerations • >100 Usually complicated systems related history and treatment © 2010, The Institute for Functional Medicine Other Nutrition and Life Questionnaires on the Toolkit Tools for Gathering • • Intake Forms Questionnaires • Diet Historyy © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Assessing Readiness Gather to Change and Organize Integrating Synthesize Behavioral Prioritize Modification Action Track Prepare to © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine GOSPAT “If we always do what we’ve always done, we’ll always get what we’ve always gotten.” - Unknown © 2010, The Institute for Functional Medicine The Patient Encounter: Engaging the patient in the intervention Step #1: Assess where they are in their “Readiness to Change” and meet them there © 2010, The Institute for Functional Medicine Stages of Change • Pre• • • • • © 2010, The Institute for Functional Medicine contemplation Contemplation Planning Action Maintenance Relapse Prochaska, JO et al. Changing for Good. New York; Avon Books, 1994. Main Stages of Change to Identify and Move Patient Through • P Pre-contemplation l i Encourage a reframing of the current state of change as the potential beginning of a change ‐ rather than a decision to never change © 2010, The Institute for Functional Medicine Main Stages of Change to Identify and Move Patient Through • • • • • Pre-contemplation Contemplation Preparation Action The Spiral of Change Most individuals find themselves “recycling” through the stages of change several times (“relapsing”) before change becomes truly established. M i t Maintenance Prochaska, JO et al. Changing for Good. New York; Avon Books, 1994. © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Readiness to Change How ready are you to? Significantly modify your diet Take nutrition supplements daily Keep a record of what you eat daily Practice a relaxation technique Engage in regular exercise Modify your lifestyle through improving sleep and restoration Have periodic lab tests to assess your progress The Coaching Gather Relationship Organize Synthesize Prioritize Action Track Prepare to © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine GOSPAT The Patient Encounter: Motivational Interviewing Engaging the patient in the intervention Basic Principles Basic Skills 1 Express 1. E empathy th • Ask open ended questions Step #2: 2. Develop discrepancy • Listen reflectively Ongoing use of ““Motivational Motivational Interviewing”” to engage the Interviewing patient p 3. Roll with resistance • Affirm • Summarize ( Echo Principle) • Elicit change talk Step #1 Assess where they are in their “Readiness “ to Change” C and meet them there. 4. Support self-efficacy Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. New York: Guilford Press. © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine The Patient Encounter: Dietary and Lifestyle Educator Role Support Educate Engaging the patient in the intervention Maintain Success Goal Settingg Build Rapport pp Create Trust Dietary Plan Relationship Lifestyle Modifications Inspiration © 2010, The Institute for Functional Medicine Motivation Retention Momentum Accountability p #1 Assess where they y are Step in their “Readiness to Change” and meet them there. Step #2: Ongoing use of “Motivational Interviewing” to engage the patient Step p #3: Provide an environment where the patient feels “Heard” so inspired with “Hope” for change © 2010, The Institute for Functional Medicine Patient Practitioner Relationship Key Point # 2 The ABCD’s of Nutrition Assessment LLNESS ELLNESS Anthropometric, Biomarkers, Clinical Indicators, and Diet Assessment Dean Ornish, MD 2010 © 2010, The Institute for Functional Medicine ✔ © 2010, The Institute for Functional Medicine A D I M E A D I M E A D I M E A D I M E A D I M E The ABCDs Of Nutritional Assessment Anthropometric Biomarkers & Labs Clinical Indicators Diet and Lifestyle Assessment © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine A B C D Anthropometrics Screening Exam • A Anthropometrics Anthropometrics BioMarkers & Labs Clinical Indicators Diet and Lifestyle Assessment © 2010, The Institute for Functional Medicine • • Body Mass Index Waist to Hip Ratio i i i • Waist Circumference • Hip Circumference • Bioelectrical Impedance Analysis BMI Ranges Height, Weight, BMI Vital Signs (blood pressure, pulse, temperature, respiratory rate, weight, height) • • Blood Pressure • Height and Weight © 2010, The Institute for Functional Medicine Basics • • Vitals Normal BMI 18.5‐24.9 Overweight BMI 25‐29.9 Anthropometric Measurements - Expanded: Skinfolds, abdominal girth (waist circumference), hip circumference, waist-to-hip ratio • Bioimpedance Analysis © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Obese BMI 30‐40 Morbidly Obese BMI 40‐50 Super Morbid Obesity BMI >50 Health Risk Based on Waist to Hip Ratio Male Female Health Risk Based Health Risk Based Solely on WHR = or < 0.90 = or < 0.80 Low Risk 0.90 to 1.0 0.81 to 0.85 Moderate Risk >1.0 10 >0.85 0 85 Hi h Ri k High Risk Ford ES, Giles WH, Dietz WH (2002). JAMA 287(3):356-359 Despres JP, Lemieux I, Prud'homme D. BMJ. 2001 Mar 24;322(7288):716-20. © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine P O M F B Biomarkers & Labs & Labs Anthropometrics BioMarkers & Labs Clinical Indicators Diet Assessment © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine A B Breakout Activity # 1 • Smell (Quick Card), C Clinical Indicators Anthropometrics BioMarkers & Labs Clinical Indicators Diet Assessment • Cinnamon • Mint • Coffee UPSIT Test www.sensonics.com © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Sense of Smell and Taste Vitamin A Key Point # 3 The Nutrition Physical Exam Niacin, Riboflavin, Pyridoxine Niacin, Riboflavin, Pyridoxine Pantothenic acid, Folic acid Vitamin E Copper Iodine Iron Zinc © 2010, The Institute for Functional Medicine Identify and Perform the Four Core Parts of the Nutrition Physical Exam © 2010, The Institute for Functional Medicine Things You May Need Height and Weight Thermometer Magnifier with light source (oto‐opthalmoscope) Stethoscope The Nutrition Physical Exam Gloves‐latex free Tape measure (cm/in) / Skin Fold (or bioimpedance) Coffee, cinnamon, or smell cards Blood Pressure Cuff Reflex hammer Peak Flow Meter k l Monofilament O2 Saturation Eyes to see Expectation Tuning forks (128, 512,1024) Rice crackers, Glass of water Camera with video option © 2010, The Institute for Functional Medicine Subjective Global Assessment-Nutritional © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Subjective Global Assessment Nutritional Continued World J. Gastroenterol 2009 15(28):3542‐49 © 2010, The Institute for Functional Medicine Four Core Aspects of the Nutrition Physical Exam 1) Look in the mouth 2) Look at and feel the skin 3) Look at the nails 4) Check Peripheral Sensation • Vibratory sense (128 Hz) • Light touch • Balance and walk © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Look in the MouthMouth-Homework 8 Steps 1) Lips 2) Jaw Movement 3) Soft and Hard Palate 4) Tongue 5) Gums 6) Buccal B ccal M Mucosa cosa 7) Teeth 8) Chew/swallow © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Lips 1‐Lips Cracks, Lesions, Sores Which Nutrients are Associated With Each Condition? Cheilosis: Fissuring Angular Stomatitis Perlèche‐angular cheilitis g Herpes Labialis Recurrent Aphthous Stomatitis © 2010, The Institute for Functional Medicine Am Fam Physician 2007;75:501‐7. © 2010, The Institute for Functional Medicine Lips Angular Stomatitis with Early Cheilosis © 2010, The Institute for Functional Medicine 8 Steps Angular Stomatitis 1) Lips 2) Jaw Movement 3) Soft and Hard Palate 4) Tongue 5) Gums 6) Buccal B ccal M Mucosa cosa 7) Teeth 8) Chew/swallow © 2010, The Institute for Functional Medicine 3-Soft Palate, Crypts • Movement, Enlargements, Lesions 4-TongueTongue- Color, Coverings, Buds, Size, Movement • Glossitis (Red Tongue) • • Decreased taste/smell • • • Tongue fissuring • Niacin, Gut Triggered Autoimmune issues Tongue –taste bud atrophy • Riboflavin, Niacin, Iron • • Leukoplakia • Hairy black tongue • Vitamin A,, B2,, Niacin,, B6,, Folate, and B12 Not Specific associated with smoking, sulfur granule positive bacteria, antibiotics 50 yo with Psoriasis‐considerations? © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Black Hairy Tongue © 2010, The Institute for Functional Medicine Riboflavin, Niacin, B6, Folate, B12, Iron, protein undernutrition B Burning i ttongue: Add Vitamin Vit i C, Zinc • • • • • • Defective Desquamation Bismuth Smoking Antibiotic use Radiation Candida-can have green/white association • ICD-9 (529.3), ICD-10 (K14.3) Dentures: Weight Loss © 2010, The Institute for Functional Medicine Black Hairy Tongue Fissured Tongue with Median Rhomboid Glossitis • Associated with Berry Tongue Gl Glossitis iti with ith B Burning i T Tongue Berry B ttongue immunologic food reactions and candida Biotin, riboflavin, niacin B Vitamin‐ B 6, B‐12 Donald S McLaren: Color Atlas and Text of Diet Related Disorders 2nd Edition. © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Glossitis Glossitis: B6 Deficiency © 2010, The Institute for Functional Medicine Riboflavin Deficiency y Glossitis with Taste Bud Atrophy B12 Thiamin B12, Thiamin, Riboflavin © 2010, The Institute for Functional Medicine Niacin Pellagra Niacin, More Tongue Signs Geographic Tongue Median Rhomboid Glossitis Erythema Migrans Leukoplakia Hairy tongue © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine 5-Gums & 6 6--Buccal Mucosa Health-swellings-bruising/bleeding 5-Gums and Gingiva Gingivitis This lesion comes and goes within 4‐ 5 ays. The patient has a rash on the elbows and knees that comes and goes over a month or two. © 2010, The Institute for Functional Medicine Am Fam Physician 2007;75:501‐7 © 2010, The Institute for Functional Medicine Periodontitis Scurvy Gums Post-treatment Pretreatment © 2010, The Institute for Functional Medicine Hemorrhages: g Vitamin C © 2010, The Institute for Functional Medicine Which Nutrients are in the Differential? B12, Folate, Retinoids considered for treatment What is associated with the black/gray gum line Erosive Lichen Planus‐generalized Gingival erythema and erosions Erosive lichen planus with Wickham's Striae‐central ulceration Reticular oral lichen planus © 2010, The Institute for Functional Medicine Dark Lines: Lead Am Fam Physician 2007;75:501‐7 © 2010, The Institute for Functional Medicine Which vitamin at toxic levels can cause gingival hyperplasia, cheilitis, hair coarsening, thinning of eyebrows? Diagnosis: Associated with Liver Failure Pop Quiz 2 slides, 3 photos Michael Kaplan, M.D., UpToDate. © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine 7- Teeth Is age important with this sign, what does it represent? What nutrients involved? Missing Teeth/Repairs © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Amalgam and Alloy Load The Dental Chart – Possible Antecedents and Triggers EX A GC/RC A EX EX A A A EX EX A A A EX EX A A A EX Portcullis- Nutrition PortcullisAssociation? A = Amalgam GC = Gold Crown PC = Porcelain Crown PD = Periodontal Dz RC = Root Canal EX = Extraction E t ti M. Stone, clinic photo McLaren M. Stone, clinic photo Weight Loss, Protein Undernutrition, Poorly Fitting Dentures © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine 8 Steps 1) Lips 2) Jaw Movement 3) Soft and Hard Palate 4) Tongue 5) Gums 6) Buccal B ccal M Mucosa cosa 7) Teeth 8) Chew/swallow © 2010, The Institute for Functional Medicine Under the Jaw and Neck • Under the Jaw • Down the Neck • Neck Movement • Chew and swallow • Thyroid-masses, Pemberton’s sign • Angle of thyroid below the cricoid cartilage © 2010, The Institute for Functional Medicine Breakout Activity #2 • Sit Up Tall • Raise yyour arms above yyour head and hold them there for one minute Look at and Feel the Skin I your neck Is k and d head h d turning t i a darker d k shade/complexion? What’s in your differential if it is? © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Touch the Skin on the Arm Character: Hyperkeratosis pilari Skin Seborrhea, dry scaly skin Dry eczematous rash Temperature Texture Color Hydration Lesions Hair Distribution Which Nutrients are involved? © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Nutrition Physical Exam Vitamin D-A-EFA-C-Zn Status Pop Quiz 2 Pop Quiz 2 2 photos, 2 nutrients Keratosis pilaris "chicken skin" © 2010, The Institute for Functional Medicine What Is Your Diagnosis? Two Different Photos… Two Different Nutrient Deficiencies © 2010, The Institute for Functional Medicine Scurvy: Ascorbic Acid Deficiency Seen in under‐ no rished alcohol nourished, alcohol consumers, or in patients with cancer Can be seen in children. Léger D. Can Fam Physician s2008;54:1403‐6 UpToDate and visualdx.com © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Testing for Capillary Friability (Hess Test) Look at the Nails • Place a blood pressure cuff on the right arm • • • • above b the th antecubital t bit l fossa. f 10 cm below the elbow crease draw a 1 inch circle. Inflate the cuff to midway between the diastolic and systolic pressures. W it for Wait f up to t 5 minutes. i t Count the number of capillaries that are broken within the 1 inch circle if >10 then consider testing for Vit C. or just treat. Ascorbic inadequacy is in your differential. © 2010, The Institute for Functional Medicine • Shape • Color and pattern • • • of color Texture and Strength Growth Pattern Surrounding Tissue © 2010, The Institute for Functional Medicine Examining the Fingernails When Evaluating Presenting Symptoms in Elderly Patients: Is nutrition in the differential? Beau’s Lines: Hypocalcemia, Zinc Deficiency Clubbing: Inflammatory Bowel, Sprue Koilonychia: Iron, Protein, Zinc, Cu Median nail dystrophy: Malnutrition Onychorrhexis: Iron, Folic Acid, Protein © 2010, The Institute for Functional Medicine Medscape.com © 2010, The Institute for Functional Medicine Nails and Putting Nutrition in the Differential 1: Clubbing: 5% Inflammatory GI Causes , 2: Median Canal dystrophy: malnutrition, 3:Nail Beading: B Deficiency, DM, 4: Psoriasis, chronic eczema‐Zinc, EFA, Food Sensitivities. 5:Absent Lenula‐anemia (iron), 6: Psoriasis (as above), 7: Lichen planus:A, B12, Folate 8: Thin Brittle Nail: Protein (sulfur amino acids), 9: Onycholisis: Psoriasis 10: Beaking psoriasis (as above), hyperparathyroidism (D affected). Nutrients are just part of the differential! 1 4 2 3 5 10 © 2010, The Institute for Functional Medicine Examining the Fingernails When Evaluating Presenting Symptoms in Elderly Patients Mark E. Williams, MD Medscape.com Peripheral Sensation 6 7 8 © 2010, The Institute for Functional Medicine 9 Medscape.com Examining the Fingernails When Evaluating Presenting Symptoms in Elderly Patients Mark E. Williams, MD Check Vibratory Sense (please do this at your bioimpedance station) Light touch Vibratory Sense Balance Walking Decreased vibratory sense: some of the causes for neuropathy • Heavy metals • Antioxidant inadequacy • Methylation issues with B12, Folate, B6, Rib fl i Riboflavin • Energetics: B1,2,3, Pantothenic Acid • Allergy-Autoimmune i.e. . Gluten induced autoantibodies © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Monofilament Testing for Neuropathy • 5.07 monofilament applied to the plantar l t surface f off the foot to the point of buckling (10 Gms of pressure) • Failure of patient to sense this pressure indicates Loss of Protective Sensation (LOPS) © 2010, The Institute for Functional Medicine Nutrient Association? © 2010, The Institute for Functional Medicine Pop Quiz 3 Pop Quiz 3 2 photos, a few nutrients © 2010, The Institute for Functional Medicine Let’s Look at the Nutrition Exam Chart Tool and the Toolkit Forms © 2010, The Institute for Functional Medicine Zinc on Physical Exam • • • • • • • • • • Head: Hair thinning, alopecia, increased loss with seborrhea Face: acne Eyes: photophobia, night blindness Nose: hypoanosmia Mouth: hypogeusia, cheilosis, angular stomatitis Hands: cracks, splitting on the end of fingertips Fingernails: thin, weak, bend easily, crack and chip Leukodynia: white spots General: somatic wasting Nervous system/Psych: memory loss, apathy, depression © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine • Active in over 300 enzymes • Carbohydrate, lipid, protein metabolism nucleic acid DNA synthesis • Stabilizes proteins, important in the integrity of sub-cellular organelles • Key in on immunity and white cell function © 2010, The Institute for Functional Medicine Night Blindness Normal and Vitamin A, Zn Deficient Vision Zinc Night blindness: Zinc or Vitamin A Normal Vision After the Car Passes Can See © 2010, The Institute for Functional Medicine Angular Stomatitis Koilonychia: Iron, Copper, Zinc, Protein McLaren, D Stone, M Malnutrition, Celiac, Iron Deficiency, B2, folate, B12, B6, zinc © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Nails: Leukonychia Punctata and Leukonychia Striate Zinc Deficiency © 2010, The Institute for Functional Medicine Selenium Deficiency Beau’s Lines • Zinc deficits • Other causes• Severe illness • Measles/mumps • Syphilis • Poorly P l controlled t ll d DM • Myocarditis © 2010, The Institute for Functional Medicine What do you think? The Case of the Vomiting Hallucinator Zinc deficiency: Peeling skin DDX Hyperkeratosis Pilari: Zn, Vit A, EFA © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine Initial Abnormal Laboratory on Admission • • • • • • • • • • • • • • • • • Glc K+ Ca+ Mg+ g Chol TG HDL LDL Protein Alb Globulin Bilirubin ALT Amylase TSH Ionized Ca+ Prealbumin 101 3.3 7.5 1.6 58 49 32 9 4.2 2.0 2.2 3.2 45 <5 7.22 0.92 7 • • • • • • • • • • • • • • • • • • • • • • Vitamin K Iron Transferrin TIBC WBC RBC HGB Hct MCV RDW Plt Neutrophils Lymphocytes Macrocytosis Reticulocyte count Vitamin D PTH Zn Thiamin Riboflavin Ammonia Bleeding time Initial Abnormal Laboratory on Admission <0.03 85 60 84 3.8 2.34 8.6 25.9 110.6 14.1 83 76.4 13.4 2+ 2.0 7 139 30 40 (>70) <2 146 12.5 • Glc 101 • K+ 3.3 • Ca+ 7.5 • Mg+ g 1.6 • Chol 58 • TGPain, Depression, 49 • HDL 32 Fibromyalgia Trigger • Point LDL Positive, Ant. 9 Tibial • Protein Pain 4.2 • Alb 2.0 • Globulin 2.2 • Bilirubin 3.2 • Mental ALT 45 Status Changes • Amylase <5 Hallucinations • TSH 7.22 Neuropathy0.92 • Ionized Ca+ • Prealbumin 7 © 2010, The Institute for Functional Medicine Glc K+ Ca+ Mg+ g Chol TG HDL LDL Protein Alb Globulin Bilirubin ALT Amylase TSH Ionized Ca+ Prealbumin 101 3.3 7.5 1.6 58 49 32 9 4.2 2.0 2.2 3.2 45 <5 7.22 0.92 7 © 2010, The Institute for Functional Medicine Vitamin K Iron Transferrin TIBC WBC RBC HGB Hct MCV RDW Plt Neutrophils Lymphocytes Macrocytosis Reticulocyte count Vitamin D PTH Zn Thiamin Riboflavin Ammonia Bleeding time <0.03 85 60 84 3.8 2.34 8.6 25.9 110.6 14.1 83 76.4 13.4 2+ 2.0 7 139 30 40 (>70) <2 146 12.5 © 2010, The Institute for Functional Medicine Initial Abnormal Laboratory on Admission • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Vitamin K Iron Transferrin TIBC WBC RBC HGB Hct MCV RDW Plt Neutrophils Lymphocytes Macrocytosis Reticulocyte count Vitamin D PTH Zn Thiamin Riboflavin Ammonia Bleeding time Initial Abnormal Laboratory on Admission <0.03 85 60 84 3.8 2.34 8.6 25.9 110.6 14.1 83 76.4 13.4 2+ 2.0 7 139 30 40 (>70) <2 146 12.5 • • • • • • • • • • • • • • • • • Glc K+ Ca+ Mg+ g Chol TG HDL LDL Protein Alb Globulin Bilirubin ALT Amylase TSH Ionized Ca+ Prealbumin 101 3.3 7.5 1.6 58 49 32 9 4.2 2.0 2.2 3.2 45 <5 7.22 0.92 7 © 2010, The Institute for Functional Medicine • • • • • • • • • • • • • • • • • • • • • • Vitamin K Iron Transferrin TIBC WBC RBC HGB Hct MCV RDW Plt Neutrophils Lymphocytes Macrocytosis R ti l Reticulocyte t countt Vitamin D PTH Zn Thiamin Riboflavin Ammonia Bleeding time <0.03 85 60 84 3.8 2 34 2.34 8.6 25.9 110.6 14.1 83 76.4 13.4 2+ 20 2.0 7 139 30 40 (>70) <2 146 12.5 Overaggressive Gastric Bypass Surgery D Diet Assessment Anthropometrics BioMarkers & Labs Clinical Indicators Diet Assessment © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine The ABCDs Of Nutritional Assessment Anthropometric BioMarkers & Labs Clinical Indicators Diet Assessment © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine A B C D Key Point #4 – Using the Matrix to Organize the Nutrition Assessment Thinking ADIME Assess Diagnose Intervene Monitor & Evaluate ✔ Begin organizing nutrition assessment subjective and objective information on the functional medicine matrix © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine FUNCTIONAL MEDICINE MATRIX MODEL™ Oxidative/Reductive Homeodynamics Marked oxidative stress, ?mitochondropathy Low albumin V antioxidant X 10% Immune Surveillance and Inflammatory Process IGG+ casein, gluten TGF beta 26000, expect V IgA Immune dysreg 2 to low D The Patient’s Story Retold Digestion and Absorption Severe malabsorption Probable SIBO Short Bowel Syndrome Increased gut permeability Severe vomiting pattern Volume depleted Structural/Boundary/ Membranes Poor lipid levels /gut permeability Nutrition Status Severely Undernourished Poor Intake Protein, Fats Antecedents ( (Predisposing) p g) _Family History of CVD, DM, Depression, Moderate history of smoking. Married Young, Divorced 4 years ago very saddened, Gastric Bypass in an attempt to get “Him Back” Detoxification and Biotransformation Encephalopathic, severe phase One/Two hypofunction ?Tylenol toxicity Hormone and Neurotransmitter Regulation H Hypothyroid, Depressed th id D d 2ndary hyperparathyroidism (D) Malabsorption, Fibromyalgia Triggering Events Psychological and Spiritual Equilibrium Hallucinating assess after not Encephalopathic (Activation) Severe Weight loss (450—200) with Gradual undernutrition. Detox pathways affected by that and Tylenol. Exercise Walks 10‐15 min/d Exercise limited by Pain. None for last Week. Sleep Poor, Fractured Wakens 8X/night Beliefs & Self‐Care Hopeless, Jobless, Lives with parents (per family) Relationships Mainly family Date: _2008_ Name: ___My Patient_________ Age _24_ Sex_Female__ Chief Complaints: __Vomiting and Hallucinations © Copyright 2008 Institute for Functional Medicine © 2010, The Institute for Functional Medicine © 2010, The Institute for Functional Medicine POP QUIZ # 1: Diagnosis: Associated with Liver Failure • • POP QUIZ ANSWERS AND NOTES! • • © 2010, The Institute for Functional Medicine Michael Kaplan, M.D., UpToDate. © 2010, The Institute for Functional Medicine POP QUIZ #1 B Arcus Senelis: Am J Public Health 1990; 80:120080:1200-1204. Only predictive if <39 of increased cardiac risk. Type II A hypercholesterolemia with Elevated LDL Type IIB Hypercholesterolemia and LDL. Type IIB Hypercholesterolemia and Hypertriglyceridemia. Mechanism temperature change with narrowing of Lateral capillaries in the lateral iris. NO sensitive © 2010, The Institute for Functional Medicine • • Kayser-Fleischer corneal ring Heritable defect in ceruloplasmin interferes with normal copper transport - leads to large accumulation in the liver Central nervous system involvement- choreic tremors MS like syndrome Proteinuria, hematuria • Only among 30-49 year old o d males a es • Corneal arcus appears to be a prognostic factor for CHD, independent of its association with hyperlipidemia in this age-group, off about b t the same magnitude as other common risk factors © 2010, The Institute for Functional Medicine POP QUIZ # 1 C: Early Arcus SenilisSenilisXanthomas • • • • • • • Age Xanthomas Early Arcus Seen in Type 1: hyperchylomicronemia can onset in Adolescence with lipoprotein lipase deficiency Type IIA Hypercholesterolemia with elevated LDL Type IIB ^Cholesterol, ^TG Type IV: hypertriglyceridemia Type V: ^chylomicrons, ^VLDL Associated with DM and alcoholism Perifollicular hemorrhages seen in vitamin C deficiency. Perifollicular hemorrhages seen in vitamin C deficiency Vitamin C given at 2‐5 grams a day will reverse this Finding within two weeks. Photodermatitis associated with niacin deficiency, and Beriberi. Can have the classic cape dermatitis, often Beriberi Can have the classic cape dermatitis often The hands and feet have flakey dermatitis if exposed to The sun. Seen in patients that eat mainly corn that has not been processed by adding alkali and allowing it to soak overnight. Diarrhea, Dermatitis, Delirium… Death if untreated. Rx depending on underlying metabolism: Fat Modification Cholesterol Limiting, Fat Modification Diet Change addressing body composition with fat modification Carbohydrate limiting, fat modification Diet and habit change, fat modification © 2010, The Institute for Functional Medicine POP QUIZ #3: Nutrient Association Vitamin A undernutrition‐deficiency. Still the leading cause of blindness in the world. On the left dry corneal xerosis and on the right Bitot's spot. The scoring system is as follows XN: Night Blindness (responds to vitamin A and Zinc within hours to days) X1A Conjunctival Xerosis as above. X1B Bitot’s Spot at on the right. X2 Corneal Xerosis X3A (<1/3 cornea) Corneal ulceration Keratomalacia, X3B Corneal Ulceration >1/3, XS Corneal Scar, and finally XF: Xerophthalmic Fundus. © 2010, The Institute for Functional Medicine POP QUIZ #2: What Is Your Diagnosis? Two Different Photos… Two Different Nutrient Deficiencies © 2010, The Institute for Functional Medicine