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
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© 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
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te
M
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Ph N i
os aci
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R oru
ib
of s
l
Se avi
le n
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u
Th m
ia
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Vi
ta in
Vi min
ta
A
Vi min
ta
m B6
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Vi B 1
ta
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Vi in C
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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
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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.
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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
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What is “Nutrition
“Nutrition Status” ?
A
D
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M
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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)
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© 2010, The Institute for Functional Medicine
Key Point #1
Gathering the History
When We Improve
Nutrition Status,
We Improve Patient Outcomes
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A
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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
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Tools for Gathering
• Intake Forms
•
•
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Adult Functional Medicine
Intake Form
• Let’s Take A Look
At the Key
Components!
Questionnaires
Diet Historyy
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Pediatric Intake Form
Pediatric Functional Medicine
Intake Form
• Demographics
• History
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© 2010, The Institute for Functional Medicine
Medical
Symptom
Questionnaire
Tools for Gathering
•
Intake Forms
• Questionnaires
•
Diet Historyy
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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
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Other Nutrition and Life
Questionnaires on the Toolkit
Tools for Gathering
•
•
Intake Forms
Questionnaires
• Diet Historyy
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© 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
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The Patient Encounter: Engaging the patient in the intervention Step #1:
Assess where they
are in their
“Readiness to
Change” and meet
them there
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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
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A
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A
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A
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A
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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
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© 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.
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© 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
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© 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
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Subjective Global Assessment-Nutritional
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© 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
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© 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
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Am Fam Physician 2007;75:501‐7.
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Lips
Angular Stomatitis with
Early Cheilosis
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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?
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© 2010, The Institute for Functional Medicine
Black Hairy Tongue
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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
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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.
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© 2010, The Institute for Functional Medicine
Glossitis
Glossitis: B6 Deficiency
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Riboflavin Deficiency
y
Glossitis with Taste Bud Atrophy
B12 Thiamin
B12,
Thiamin, Riboflavin
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Niacin Pellagra
Niacin,
More Tongue Signs
Geographic Tongue
Median Rhomboid
Glossitis
Erythema Migrans
Leukoplakia
Hairy tongue
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© 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.
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Am Fam Physician 2007;75:501‐7
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Periodontitis
Scurvy
Gums
Post-treatment
Pretreatment
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Hemorrhages:
g
Vitamin C
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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
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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
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© 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
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© 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?
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© 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"
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What Is Your Diagnosis? Two Different
Photos… Two Different Nutrient Deficiencies
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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
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© 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
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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)
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Nutrient Association?
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Pop Quiz 3
Pop Quiz 3
2 photos, a few nutrients
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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
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Night Blindness
Normal and Vitamin A, Zn
Deficient Vision
Zinc
Night blindness: Zinc or Vitamin A
Normal Vision After the
Car Passes Can See
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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
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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
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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
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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
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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
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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
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POP QUIZ ANSWERS AND
NOTES!
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© 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
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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
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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