The Nutrition Oriented Physical Exam as Part of the ABCD of
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The Nutrition Oriented Physical Exam as Part of the ABCD of Nutrition Evaluation for Cardiometabolic Syndrome within the Functional Medicine Model P. Michael Stone, MD, MS, IFMCP Faculty, Institute for Functional Medicine 1987 graduate University of Washington with residency and fellowship in Family Medicine at UCLA Ventura. Presenter/Faculty Disclosures • Faculty: Dr. P. Michael Stone • Relationships with commercial interests: – No commercial affiliations – An honorarium for speaking and travel expenses is received from Integrative Health Symposium. ©2015 The Institute for Functional Medicine Disclosure of Commercial Support • Honoraria for speaking and travel provided by Diversified Communications • This program has not received financial support • This program has not received in-kind support • No Potential for conflicts of interest ©2015 The Institute for Functional Medicine Learning Objectives • Recognize functional medicine ABCD of nutrition evaluation • Apply the anthropometric and clinical exam portion of the ABCD of nutrition evaluation to cardiometabolic syndrome • Describe the many physical exam presentations associated with cardiometabolic syndrome through the functional medicine ABCD of nutrition evaluation ©2015 The Institute for Functional Medicine ©2015 The Institute for Functional Medicine ©2015 The Institute for Functional Medicine Community<>Culture<>World Epigenetic<>Genetic<>Atom<>Particle Barabasi, AL 2007 ©2015 The Institute for Functional Medicine ©2015 The Institute for Functional Medicine Anthropometrics Biomarkers and Functional Labs Clinical Indicators from Nutrition Physical Exam Diet and Lifestyle Assessment ©2015 The Institute for Functional Medicine The Hypertensive Web J Am Soc Hypertens. 2013 January; 7(1): 68–74. doi: 10.1016/j.jash.2012.11.007 ©2015 The Institute for Functional Medicine Beta-cell Dysfunction Type 3 Diabetes Cardiovascular Disease Fatty Liver Obesity Lipotoxicity Osteoporosis Immune Dysfunction Endothelial Dysfunction ©2015 The Institute for Functional Medicine Arterioscler Thromb Vasc Biol. 2012 September; 32(9): 2052–2059. Beta-cell Dysfunction Type 3 Diabetes Cardiovascular Disease Fatty Liver Obesity Immune Dysfunction Lipotoxicity Osteoporosis ©2015 The Institute for Functional Medicine Arterioscler Thromb Vasc Biol. 2012 September; 32(9): 2052–2059. Anthropometrics Biomarkers and Functional Labs Clinical Indicators from Nutrition Physical Exam Diet and Lifestyle Assessment ©2015 The Institute for Functional Medicine Annu Rev Pathol. 2011; 6: 275–297. ©2015 The Institute for Functional Medicine The Link Between Insulin Resistance & Hypertension Curr Atheroscler Rep. 2012 April; 142): 160–166. ©2015 The Institute for Functional Medicine Anthropometrics Biomarkers and Functional Labs Clinical Indicators from Nutrition Physical Exam Diet and Lifestyle Assessment ©2015 The Institute for Functional Medicine Systemic Effects of Dietary Fiber Nat Med. 2014 Feb 6;20(2):120-1. doi: 10.1038/nm.3472. Increase in dietary fiber dampens allergic responses in the lung. Huffnagle GB. ©2015 The Institute for Functional Medicine Diet and Lifestyle change 12 Main Modifiable-dietary lifestyle and Metabolic Risk Factors Cardiovascular Disease Blood Pressure Overweight-obesity A High blood glucose Low density lipoprotein Cholesterol.... B High dietary trans fatty acids Low polyunsaturated fatty acids Omega 3 fatty acids Fruits and vegetables D 70% Prevention or Delay... 3 months of Intervention Decreased Risk Physical inactivity Alcohol use Tobacco smoking and use. Forman D, Bulwer BE Curr Treat Options Cardiovasc Med. 8:47,2006 Danaei G et al: PLosMed 6(4):e1000058,2009. ©2015 The Institute for Functional Medicine Clinical Nutrition Findings Cardiometabolic Medical History Metabolic Syndrome, Type 2 Diabetes, Hypertension, Dyslipidemia, Obesity ATMs Family History, T2DM, CVD, HTN, Obesity, Sedentary Lifestyle, Sleep Disorder (inadequate sleep and Sleep apnea) Anthropometrics Increased: BMI, WC, WHR, Fat, Blood Pressure Biomarkers & Labs Increased: HgbA1C, FBS, insulin, hs-CRP, Trigs Decreased: HDL Clinical Indicators from Nutrition Physical Exam Diet and Lifestyle Incr: WC and WHR Skin tags, acanthosis nigricans, peripheral neuropathy. Matrix Patterns Excess simple sugar High CHO intake, GI foods, low protein, excess alcohol, elevated trans fats. Structural Integrity Transport Defend and Repair/Communication ©2015 The Institute for Functional Medicine Quality Diet, Food, Nutrient Context Company History-Timeline Network Influences Symptoms, Other Signs Current Biochemical Markers Quantity Diet, Food, Nutrient ©2015 The Institute for Functional Medicine ©2015 The Institute for Functional Medicine ABCDs of the Functional Nutrition Evaluation Anthropometrics, Vitals, and Body Composition Body Composition Assessment Body Mass IndexHeight and Weight Truncal Obesity Evaluation Waist and Hip Circumference Ratios Bioelectrical Impedance Analysis Anthropometrics Measurement Gathered information Height Track with time. Suggests adequacy of nutrition and endocrine axis. Weight Basis for assessing health and disease risk. Follow over time. Acutely for diuresis or volume retention. Change offers clues of hyper-metabolism or thyroid axis. Waist Circumference Helps to risk assess. Measured appropriately Hip Circumference Risk assess measured appropriately Waist to Hip ratio <0.8 F, <0.9 M low risk for cardio-metabolic syndrome, >0.85 F, >1.0 M higher risk for cardio-metabolic syndrome. Body Mass Index Helps with risk assessment. <18.5 and >25.0 altered and increased health risk often. <17.5 eating disorder, hypermetabolic state, or mal-absorption evaluations. >30 comorbidity risks with obesity and metabolic concern Waist to Height ratio <0.5 lower risk, >0.5 higher risk Anthropometrics Measurement Gathered information Temperature Range: 37.0’C (98.6’F) average, fluctuates from early morning to late afternoon. Rectal 0.4-0.5’C higher, axillary 1’ lower. Hyperpyrexia >41.1’C (106), Hypothermia <35’C (95’F). Blood Pressures Arms: <120/80 mm Hg. Korotkoff sounds best with bell. Arm pressure comparison should be within 5 mmHg. No smoking or drinking caffeine within 30 minutes of BP. From supine to standing <20 mm Hg drop. Leg Pressures: Ankle arm index: Blood Pressure of the Dorsalis Pedis or Posterior Tibialis artery/ mmHg Brachial <0.9 marked increased risk of peripheral vascular disease. Pulses Age dependent normal. Adult >60<100 regular, if irregular compare with cardiac apex. Respiratory Rate Normals Vary with Age. Adult 14-20, infants up to 44/m Patients Have Unique Risks for Chronic Disease based on body composition 3 Steps to Define Risk 1 2 3 • Overweight or Obese • Scale & BMI 1st Step to Define Risk: BMI 1 • Overweight or Obese • Scale & BMI 2 Weight (lb)/Height/Height (inches)X 703= BMI Or Weight (kg)/Height/Height (m)=BMI >25 Overweight >30 Obese 3 PEDIATRIC OBESITY EPIDEMIC Identify your targets early Defining Body Composition Body S Pattern Recognition Android Obesity Gynoid Obesity overfat OVER VAT overfat OVER SAT Visceral Adipose Tissue Subcutaneous Adipose Tissue OVER Weight 3 Steps to Define Risk 1 2 3 • Overweight or Obese • Scale & BMI • OverVAT- Over Visceral Adipose Tissue • Waist Circumference & Waist/Hip Ratio Waist & Hip Circumference Measure Find the: the waist midway Bottom between of the 10ththe Rib th Rib Bottom of the Top of the iliac10crest Top of the iliac crest Measure the hips over the greater trochanter Waist (cm)/Hip (cm)= Waist to Hip Ratio (WHR) Health Risk Based on Waist to Hip Ratio Male Female 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 >0.85 High Risk Ford ES, Giles WH, Dietz WH (2002). Prevalence of metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA 287(3):356-359 2nd Step to Define Risk: Fat Distribution- Visceral Fat 1 2 3 • Overweight or Obese • Scale & BMI • OverVAT • Waist Circumference & Waist/Hip Ratio Ethnic Considerations For Waist Circumference Gender Specific Waist/Hip Ratio- >0.8 Female >0.9 Male Using Waist Circumference Country/Ethnic Group Gender Ethnic South/Central America Male South Asians-Chinese, Malay, Asian-Indian. Chinese, Japanese Europids, Sub-Saharan African, Eastern Mediteranean, Middle East(Arab) populations USA Waist Circumference-Increased Healthrisk >90 cm >35.5 inches Female >80 cm >31.5 inches Male >90 cm >35.5 inches Female >80 cm >31.5 inches Male >94 cm >37 inches Female >80 cm >31.5 inches Male >102 cm >40 inches Female >88 cm >35 inches International Diabetes Federation 2006 WHR doesn’t rule out OverSAT Despres JP, Lemieux I, Prud'homme D. Treatment of obesity: need to focus on high risk abdominally obese patients. BMJ. 2001 Mar 24;322(7288):716-20. A: Waist Circumference/Hip Circumference Waist to Hip Ratios, Waist to Height Ratios • Main Purpose: to risk stratify by body shape. • Help direct the clinician to possible underlying processes • Help direct Biomarker choice • Will point toward expectations on Clinical exam and Diet History and Lifestyle patterns 3 Steps to Define Risk 1 2 3 • Overweight or Obese • Scale & BMI • OverVAT • Waist Circumference & Waist/Hip Ratio • OverFAT • BioImpedance Analysis BioImpedance Analysis ¨ ¨ Hydration status Fluid Distribution: water J ¤ Extracellular water K/L ¤ Intracellular ¨ ¨ ¨ Fat Mass Lean Body Mass Basal Metabolic Rate Bioimpedance Analysis: Increased Validity in Literature • Underwater weighing, DEXA analysis, MRI are expensive and not convenient • Since 1990 > 1600 published articles • 1994 NIH sponsored conference rec that BIA calculations be performed on NHANES III data Int J Obesity 2002;26:1596-1609 • Results immediately available and reproducible < 1% error on repeated measurements Body Composition Assessment ©2015 The Institute for Functional Medicine Body Composition Assessment YES Increased BMI? Increased WC? NO NO Increased WC or WHR? Increased BIA Fat%? YES NO YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Ideal Body Composition YES Increased BMI? NO Increased WC? <25 NO Increased WC or WHR? Increased BIA Fat%? YES NO YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Ideal Body Composition YES Increased BMI? NO NO <.8 F <.9 M Increased BIA Fat%? Increased WHR? Increased BIA Fat%? YES NO Increased WHR? YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO YES NO NO Increased WC? <25 Increased WC or WHR? YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Ideal Body Composition YES Increased BMI? NO NO NO <.8 F <.9 M Increased WHR? Increased BIA Fat%? YES NO Increased WHR? YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO YES Increased BIA Fat%? NO Increased WC? <25 Increased WC or WHR? YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Body Composition Assessment YES Increased BMI? Increased WC? NO NO Increased WC or WHR? Increased BIA Fat%? YES NO YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Assessing Body Composition Dx:Overweight/Obese YES Increased BMI? Increased WC? NO NO Increased WC or WHR? Increased BIA Fat%? YES NO YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Assessing Body Composition Dx:Overweight/Obese YES Increased BMI? Increased WC? >25 >30 NO NO Increased WC or WHR? Increased BIA Fat%? YES NO YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Assessing Body Composition Dx:OverVAT or OverSAT YES Increased BMI? Increased WC? >25 >30 NO NO Increased WC or WHR? Increased BIA Fat%? YES NO YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Assessing Body Composition Dx:OverVAT or OverSAT YES Increased BMI? Increased WC? >25 >30 NO NO Increased WC or WHR? Increased BIA Fat%? YES NO YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Assessing Body Composition Dx:OverVAT or OverSAT YES Increased BMI? Increased WC? >25 >30 NO NO Increased WC or WHR? Increased BIA Fat%? YES NO YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Assessing Body Composition Dx:OverVAT or OverSAT YES Increased BMI? Increased WC? >25 >30 NO NO Increased WC or WHR? Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES NO YES >.8 F >.9 M Increased BIA Fat%? YES YES Increased BIA Fat%? YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Assessing Body Composition Dx: OverFAT YES Increased BMI? Increased WC? >25 >30 NO NO Increased WC or WHR? Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES NO YES >.8 F >.9 M Increased BIA Fat%? YES YES Increased BIA Fat%? YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Assessing Body Composition Dx: OverFAT YES Increased BMI? Increased WC? >25 >30 NO NO Increased WC or WHR? Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES NO YES >.8 F >.9 M Increased BIA Fat%? YES YES Increased BIA Fat%? YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Assessing Body Composition Dx:OverVAT Dx:Overweight/Obese YES Increased BMI? Increased WC? >25 >30 NO NO Increased WC or WHR? Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES NO Dx: OverFAT YES >.8 F >.9 M YES YES Android Obesity Increased BIA Fat%? YES Increased BIA Fat%? NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Assessing Body Composition Dx:OverVAT Dx:Overweight/Obese YES Increased BMI? Increased WC? >25 >30 NO NO Increased WC or WHR? Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES NO Dx: OverFAT YES >.8 F >.9 M YES YES Android Obesity Increased BIA Fat%? YES Increased BIA Fat%? NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Ideal Body Composition YES Increased BMI? NO NO NO <.8 F <.9 M Increased WHR? Increased BIA Fat%? YES NO Increased WHR? YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO YES Increased BIA Fat%? NO Increased WC? <25 Increased WC or WHR? YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Normal Weight Individuals Can Have High VAT Subjects with a relatively low BMI, such as “metabolically obese” normal-weight individuals, can have gross increases in abdominal visceral fat, and others with a high BMI may have very little intraabdominal (visceral fat). Wajchenberg BL. Subcutaneous and visceral adipose tissue: their relation to the metabolic syndrome. Endocrine Reviews. 2000;21(6):697-738. The Problem with BMI Cannot differentiate muscle weight from fat The Problem with BMI Cannot differentiate muscle weight from fat Assessing Body Composition Dx:OverVAT or OverSAT YES Increased BMI? Increased WC? >25 >30 NO NO Increased WC or WHR? Increased BIA Fat%? YES NO YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES Android Obesity NO Possible High Metabolically Gynoid Obese Obesity Muscle Mass or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Assessing Body Composition Dx:OverVAT or OverSAT YES Increased BMI? Increased WC? >25 >30 NO NO Increased WC or WHR? Increased BIA Fat%? YES NO YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES Android Obesity NO Metabolically Gynoid Possible High Obesity Muscle Mass Obese or Large (OverVAT) or overSAT YES MetSyn? Skeletal Frame YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Assessing Body Composition Dx: OverVAT Dx: Overweight YES Abnormal High BMI? >30 NO NO Increased WC or WHR? YES NO YES Increased WHR? Increased BIA Fat%? NO YES YES Android Obesity (OverVAT) NO Metabolically Gynoid Possible High Increased Obesity/ Muscle Mass Obese BIA Fat%? (OverVAT) overSAT or Large Skeletal YES NO YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity/ Obese or Athlete overSAT Increased BIA Fat%? YES NO Increased WHR? Increased BIA Fat%? NO YES Increased WC? Dx: OverFAT YES MetSyn? Frame Gut/Detox/HPATGG dysfunctions? TLC Nx/ Rx The Problem with WC absolute vs. relative measurement WHR vs BMI May Be a Better Predictor of All-Cause Mortality in Older Adults “Waist Circumference "WHR, rather than BMI or WC [waist is an absolute number circumference], appears to be the more and a relative appropriate yardstick for obesity-related Waist:Hip Ratio would risk stratification of high-functioning older be more accurate.” adults, and possibly all older adults.” ~Ann Epidemiol. 2009;19:724-731. WHR doesn’t rule out OverSAT Despres JP, Lemieux I, Prud'homme D. Treatment of obesity: need to focus on high risk abdominally obese patients. BMJ. 2001 Mar 24;322(7288):716-20. Assessing Body Composition Dx:OverVAT or OverSAT YES Increased BMI? Increased WC? >25 >30 NO NO Increased WC or WHR? Increased BIA Fat%? YES NO YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Assessing Body Composition Dx:OverVAT or OverSAT YES Increased BMI? Increased WC? >25 >30 NO Increased WC or WHR? NO NO Increased WHR? Increased BIA Fat%? Increased BIA Fat%? Increased BIA Fat%? YES NO Increased WHR? NO NO YES NO YES YES YES YES Increased BIA Fat%? YES Android Obesity NO Metabolically Gynoid Possible High Obese Obesity Muscle Mass (OverVAT) or overSAT or Large Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese overSAT or Athlete Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Body Composition Assessment YES Increased BMI? Increased WC? NO NO Increased WC or WHR? Increased BIA Fat%? YES NO YES Increased BIA Fat%? YES YES Increased BIA Fat%? YES NO NO Increased BIA Fat%? NO Increased WHR? Increased WHR? YES NO YES Android Obesity NO Possible High Metabolically Gynoid Muscle Mass Obese Obesity or Large (OverVAT) or overSAT Skeletal Frame YES MetSyn? YES Ideal Skinny Fat or Possible High Gynoid Metabolically Muscle Mass Obesity or Obese or Athlete overSAT Consider Gut/Detox/Hormonal Dysfunctions Lifestyle Intervention Blood Pressure ©2015 The Institute for Functional Medicine Blood Pressure; Improving Physical Exam Skills Mark Houston, MD ©2015 The Institute for Functional Medicine Mark Houston, M.D. Patient Positioning ©2015 The Institute for Functional Medicine ©2015 The Institute for Functional Medicine ©2015 The Institute for Functional Medicine ©2015 The Institute for Functional Medicine ©2015 The Institute for Functional Medicine Where is your Blood Pressure? Do you have other Risk Factors? ©2015 The Institute for Functional Medicine Higher Blood Pressure Increased Co Morbidities ©2015 The Institute for Functional Medicine ©2015 The Institute for Functional Medicine Reducing Blood Pressure & Treating Hypertension with Nutritional Interventions ©2015 The Institute for Functional Medicine Higher Blood Pressure Increased Co Morbidities ©2015 The Institute for Functional Medicine ©2015 The Institute for Functional Medicine ABCDs of the Functional Nutrition Evaluation Clinical Indications from the Nutrition-oriented Physical Exam ©2015 The Institute for Functional Medicine What 4 PE clues of increased risk of cardiovascular disease do you see in this early 40’s Female smoker ? Shridhar D, R Jhamb: Cutaneous markers of coronary artery disease. World J Cardiol 2010 September 26;2(9):262-269. ©2015 The Institute for Functional Medicine What 4 PE clues do you see in this Female smoker in her early 40’s ? Shridhar D, R Jhamb: Cutaneous markers of coronary artery disease. World J Cardiol 2010 September 26;2(9):262-269. ©2015 The Institute for Functional Medicine C: Physical Exam Cardiometabolic • Hair: Premature graying males/females, Hair thinning, can be found in females with insulin resistance • Ear creases-diagonal lobe crease • Eyebrow loss: Arcus senilis vs. junivalis, Xanthomas • Smell (diminished in IR/DM, medications) • Mouth (8 step mouth exam): taste, glossitis, missing teeth, periodontal disease, mixed metals • Neck: skin tags, Acanthosis nigricans, Thyroid evaluation, Bruit, JVD • Lungs: Peak Flow- peak expiratory flow rate, lung sounds • Cardiac auscultation, murmurs, pulses • Abdomen: increased waist to hip ratio, enlarged aorta • Peripheral exam: hair distribution, edema, Ankle arm index, pulses. • Skin Changes: skin tags, xerosis, hyperkeratosis pilari • Peripheral nerve sensation exam: large, small fiber and mixed disease, balance ©2015 The Institute for Functional Medicine Female Pattern Hair Loss Bi-temporal Thinning Ludwig 1 Mild thinning Ludwig 2 Widened Part Ludwig 3 No Part Levy LL, J J Emer: Female pattern alopecia: current perspectives International Journal of Women’s Health 2013:5 541–556 ©2015 The Institute for Functional Medicine Nutrition Insufficiency Associations and treatments if inadequacy Protein Inadequacy Methylsulfonomethionine Minerals: Zinc, copper, iron Vitamins: B complex, Biotin Vitamin C, E, A”, D CoQ 10, Phytonutrients Levy LL, J J Emer: Female pattern alopecia: current perspectives International Journal of Women’s Health 2013:5 541–556 ©2015 The Institute for Functional Medicine ©2015 The Institute for Functional Medicine Premature Graying consider... low copper levels Consider Low Copper Levels, and Intake when there is premature greying in People 20 years or under…a minimum of 10 grey hairs… Biol Trace Elem Res. 2012 Apr;146(1):30-4 ©2015 The Institute for Functional Medicine These data provide the first clear evidence that compromised antioxidant activity in gray hair follicles simultaneously affects mature hair bulb melanocytes and their immature precursor cells in the bulge region. Shi Y, Luo L-F, Liu X-M, Zhou Q, Xu S-Z, et al. (2014) PLoS ONE 9(4): e93589. doi:10.1371/journal.pone.0093589 ©2015 The Institute for Functional Medicine Premature Graying/Whitening of Hair <55 in males Intern Med. 2013;52(1):29-36. Epub 2013 Jan 1 ©2015 The Institute for Functional Medicine Hair Changes and CIMT Associations Parameters CIMT<0.9 CIMT>0.9 Age 41 47 BMI 28.2 30.2 Waist Circumferance 97.6 107.3 HTn 15% 37% DM 5% 18% Uric Acid 5.3 6.1 LDL 123 140 Bilirubin 0.9 0.65 GGT 31 41 Onset white hair 27 30 Percentage white hair 32 78 Percentage Hair loss 12 14 Intern Med. 2013;52(1):29-36. Epub 2013 Jan 1 ©2015 The Institute for Functional Medicine C: Physical Exam Cardiometabolic • Hair: Premature graying males/females, Hair thinning, can be found in females with insulin resistance • Ear creases-diagonal lobe crease • Eyebrow loss: Arcus senilis vs. junivalis, Xanthomas • Smell (diminished in IR/DM, medications) • Mouth (8 step mouth exam): taste, glossitis, missing teeth, periodontal disease, mixed metals • Neck: skin tags, Acanthosis nigricans, Thyroid evaluation, Bruit, JVD • Lungs: Peak Flow- peak expiratory flow rate, lung sounds • Cardiac auscultation, murmurs, pulses • Abdomen: increased waist to hip ratio, enlarged aorta • Peripheral exam: hair distribution, edema, Ankle arm index, pulses. • Peripheral nerve sensation exam: large, small fiber and mixed disease, balance • Skin Changes: skin tags, xerosis, hyperkeratosis pilari ©2015 The Institute for Functional Medicine Ear Lobe Crease...where do you look? Friedlander AH, J Lopez-Lopez, E Velasco-Ortega: Diagonal ear lobe crease and atherosclerosis: a review of the medical literature and dental implications. Med Oral Patol Oral Cir Bucal 2012 Jan 1;17(1):e153-9 . ©2015 The Institute for Functional Medicine = Younger More Specific Older More Sensitive Edson E: Am J Forensic Med Pathol 2006: 27:129-133. ©2015 The Institute for Functional Medicine Ears Mouth Jaw Carotids... . Friedlander AH, J Lopez-Lopez, E Velasco-Ortega:. Med Oral Patol Oral Cir Bucal 2012 Jan 1;17(1):e153-9 ©2015 The Institute for Functional Medicine C: Physical Exam Cardiometabolic • Hair: Premature graying males/females, Hair thinning, can be found in females with insulin resistance • Ear creases-diagonal lobe crease • Eyebrow loss: Arcus senilis vs. junivalis, Xanthomas • Smell (diminished in IR/DM, medications) • Mouth (8 step mouth exam): taste, glossitis, missing teeth, periodontal disease, mixed metals • Neck: skin tags, Acanthosis nigricans, Thyroid evaluation, Bruit, JVD • Lungs: Peak Flow- peak expiratory flow rate, lung sounds • Cardiac auscultation, murmurs, pulses • Abdomen: increased waist to hip ratio, enlarged aorta • Peripheral exam: hair distribution, edema, Ankle arm index, pulses. • Peripheral nerve sensation exam: large, small fiber and mixed disease, balance • Skin Changes: skin tags, xerosis, hyperkeratosis pilari ©2015 The Institute for Functional Medicine POCKET SMELL TEST • Smell (Quick Card), – Apple – Natural Gas – Rose OR – Lemon – Lilac – Smoke UPSIT Test www.sensonics.com ©2015 The Institute for Functional Medicine SMELL TEST Pocket Smell Test 1) With the patient sitting, test nasal patency by having them cover one nostril and breath in. Listen for the sound of abnormal air flow. If present do not test, investigate cause of obstruction. 2) Open the card. Use the tongue depressor and scratch the scratch and sniff odorant. Have the client cover one nostril and sniff. Inquire as to the smell. If they are not sure, then offer choices. Repeat with the other nostril. 3) Repeat this with all three odors. The total score should be 6. If 2 or more are missed, then further work up of disordered smell and taste should begin. ©2015 The Institute for Functional Medicine Altered Smell or Taste • Smell and Taste are Closely Linked • Evaluate the History: Trauma, Exposure, Allergy, Obstruction • Other physical exam findings- peripheral neuropathy • Evaluate Medications • Evaluate Nutritional Status: Mineral Status: Zinc, Copper, Iron, Iodine Vitamin Status: A, E: B complex-B2, B3, Pantothenic Acid, Biotin, Folate, B12 Am Fam Physician 2000;61:427-36, Curr Opin Otolaryngol Head Neck Surg 2003;11(1):54-60 ©2015 The Institute for Functional Medicine Diagnoses associated with Olfactory Impairment • • • • • Alzheimers Parkinsons Sinusitis Migraines (not in cluster headaches) B12 deficiency, Olfactory groove meningiomas • DM, other causes peripheral neuropathy • Hypothyroidism ©2015 The Institute for Functional Medicine Drugs That Alter Smell Drug Group Examples Calcium Channel Blocker Lipid Lowering Antibiotic/Antifungal Nifedipine, amlodipine, diltiazem Cholestyramine, clofibrate, pravastatin Streptomycin, doxycycline, terbinafine Ciprofloxacin Carbimazole Codeine, morphine Amityptyline Dexamphetamine, phenmetrazine Phenytoin Phenylephrine, pseudoephedrine, oxymetazoline Smoking, agyria (topical silver nitrate), cadmium fumes, phenothiazines, pesticides, Betnesol-N, Cocaine snorted Antithyroid Opiate Antidepressant Sympathomimetic Antiepileptic Nasal Decongestant Miscellaneous Ackerman BH, Kasbekar, N. Pharmacotherapy 1997;17:1. z ©2015 The Institute for Functional Medicine Sense of Smell and Taste Vitamin A Niacin, Riboflavin, Pyridoxine Pantothenic acid, Folic acid Vitamin E 70% of Diabetics have some Copper smell and taste Dysfunction. Iodine Changes in smell and taste correlates with peripheral Iron neuropathy 75% unaware of Zinc the defect. Hum Nutr 1984;38C:203-214, Acta Med Scan 1979:205:361-366, Oral surg Oral Med Oral Pathol 1950;3:1299-1327, JAMA 1971:218:1303, J Am Coll Nutr 1993:12:14-20, Lancet 1967;2;1268-1271, J Oral Pathol Med 1996;25:38-43, Arch Otolaryngol 1962;75:116-124. Am.JMedSci 1976;272:285-299. ©2015 The Institute for Functional Medicine Screening Questionnaire for Loss of Taste How easily can you detect the tastes Easily Somewhat Not At All 1. Saltiness (chips, pretzels, salted nuts) 2. Sourness in vinegar, pickles, or lemons 3. Sweetness in soda, cookies, ice cream 4. Bitterness in coffee, beer, tonic water Negative Predictive value for easily: saltiness 95%, sourness 89%, Sweetness 98%, Bitterness 92%. Positive predictive values range from 5-26% (when a person can Easily taste each of the 4 senses then there is a high degree of confidence that they Can taste. Easily is negative for gustatory loss, and somewhat or not at all is positive For loss. Malaty J, IAC Malaty: Smell and Taste Disorders in Primary Care Am Fam Physician 88;12; 852-859, 2013. ©2015 The Institute for Functional Medicine Taste Loss Infection/abscess: Oral Appliances: Postsurgical: Radiation Nutrition insufficiency: Medications: Toxins: Head Trauma: Oral Candida, Periodontal disease, gingivitis, URI Dentures, prosthetics Middle ear surgery affecting corda tympany, oral or dental surgery especially 3rd molar extraction HEENT irradiation with oral mucositis, xerostomia Protein malnutrition, zinc, copper deficiency, B12, niacin deficiency Intranasal zinc, chlorhexidine, chemotherapy, ACE Inhibitors, ARBs, calcium channel blockers, diuretics, macrolides, terbinafine, fluoroquinolones, protease inhibitors, griseofulvin, PCN, tetracyclines, metronidazole, antiarrhythmics, antidepressants, anti convulsants, lipid lowering agents. Pepper gas, weed killer, ammonia, benzene, cadmium, iron, lead Ouch Malaty J. Smell and Taste Disorders in Primary Care Am Fam Physician 88;12; 852-859, 2013. Taste (TAS2R) ©2015 The Institute for Functional Medicine Reed DR, Knaapila A: Genetics of Taste and Smell: Poisons and Pleasures. Prog Mol Biol Trans ©2015 Sci: The 2010:94:213-40 Institute for Functional Medicine C: Physical Exam Cardiometabolic • Hair: Premature graying males/females, Hair thinning, can be found in females with insulin resistance • Ear creases-diagonal lobe crease • Eyebrow loss: Arcus senilis vs. junivalis, Xanthomas • Smell (diminished in IR/DM, medications) • Mouth (8 step mouth exam): taste, glossitis, missing teeth, periodontal disease, mixed metals • Neck: skin tags, Acanthosis nigricans, Thyroid evaluation, Bruit, JVD • Lungs: Peak Flow- peak expiratory flow rate, lung sounds • Cardiac auscultation, murmurs, pulses • Abdomen: increased waist to hip ratio, enlarged aorta • Peripheral exam: hair distribution, edema, Ankle arm index, pulses. • Peripheral nerve sensation exam: large, small fiber and mixed disease, balance • Skin Changes: skin tags, xerosis, hyperkeratosis pilari ©2015 The Institute for Functional Medicine 5-Gums and Gingiva Gingivitis Periodontitis IL1, IL6, IL10, VDR, genes may be associated with Chronic Peritonitis Lane, M. Et al: Int J Dent. 2010; 2010: 324719 Atlas of Clinical Oral Pathology 2nd Edition. 2003. P. 100-101 ©2015 The Institute for Functional Medicine Periodontal Disease Treating Periodontal disease aggressively and early in pregnancy increases the chance of a full term vs preterm delivery by 6 fold. M. Jeffcoat, S. Parry, M. Sammel, B. Clothier, A. Catlin, and G. MacOnes, “Periodontal infection and preterm birth: successful periodontal therapy reduces the risk of preterm birth,” British Journal of Obstetrics and Gynaecology, vol. 118, no. 2, pp. 250–256, 2011 ©2015 The Institute for Functional Medicine Periodontal Disease Associations: Periodontal disease Inflammation of Joints/Muscles Lower Apgar's Low Birthweight Asthma Cardiovascular Disease Diabetes Mellitus ©2015 The Institute for Functional Medicine Periodontal Disease is Increased by Several Risk Factors 1) Cigarette smoking 2) Systemic diseases autoimmune, diabetes, CVD... 3) Medications such as steroids, anti-epilepsy drugs cancer therapy drugs 4) Ill-fitting bridges 5) Crooked teeth and loose fillings 6) Pregnancy 7) Oral contraceptive use 8) Low Vitamin D, Vitamin A, Low Vit C, Low Fe, Zn Jemin Kim-Periodontal disease and systemic conditions: a bidirectional relationship. Odontology. 2006 September ; 94(1): 10–21. ©2015 The Institute for Functional Medicine 7- Teeth and Breath Missing Teeth/Repairs Amalgam and Alloy Load 2-28 mcg/facet/day 80 % absorbed MStone MStone RA Bernhoft: Mercury Toxicity and Treatment. J Env Public Health 2012 Ucar, Y, WA Brantley: Biocompatibility of Dental Amalgams, Int J Dentistry 2011 ©2015 The Institute for Functional Medicine 60 yo male T2DM, Arrythmia, Htn, worsening evening vision with mouth findings... What do you see and think? mstone.md • • • • • • Low Vitamin D Low ionized calcium Low Vitamin A Low Vitamin C Low pH Low salivary output secondary to beta blocker for arrhythmia • Occult infection ©2015 The Institute for Functional Medicine C: Physical Exam Cardiometabolic • Hair: Premature graying males/females, Hair thinning, can be found in females with insulin resistance • Ear creases-diagonal lobe crease • Eyebrow loss, Arcus senilis vs. junivalis, Xanthomas • Smell (diminished in IR/DM, medications) • Mouth (8 step mouth exam): taste, glossitis, missing teeth, periodontal disease, mixed metals • Neck: skin tags, Acanthosis nigricans, Thyroid evaluation, Bruit, JVD • Lungs: Peak Flow- peak expiratory flow rate, lung sounds • Cardiac auscultation, murmurs, pulses • Abdomen: increased waist to hip ratio, enlarged aorta • Peripheral exam: hair distribution, edema, Ankle arm index, pulses. • Skin Changes: skin tags, xerosis, hyperkeratosis pilari • Peripheral nerve sensation exam: large, small fiber and mixed disease, balance ©2015 The Institute for Functional Medicine Look At and Feel the Skin ©2015 The Institute for Functional Medicine Character: • Temperature • Texture • Color ©2015 The Institute for Functional Medicine Xerosis Xerosis Hyperkeratosis pilari Fats – EFA, Minerals – Zinc inadequacy, Vitamins A, C, B Stone PM, Boham E: Functional Nutrition Evaluation: Skin Exam. Institute for Functional Medicine. Federal Way WA. 2015 ©2015 The Institute for Functional Medicine Follicular Hyperkeratosis: Vitamin A, Essential Fatty Acids Arch Derm Syphiol 1933;28(5):700-708; J Am Acad Dermatol 1986;15(6):1263-1274. Pediatr Dermatol 2005. ;Jan-Feb; 22(1):60-63. Indian J Dermatol 2011; 56(4):389-92.Medscape:http://emedicine.Medscape.com/article/126004 ©2015 The Institute for overview. Functional Medicine Character: • Hydration • Lesions • Hair Distribution m.stone m.d. Medial Right Ankle©2015 The Institute for Functional Medicine Symptom: Chronic Itching Associated withDry Skin (Xerosis) 69% DM: OR 2.3 Peripheral Vascular Disease: OR 4.4 Acta Derm Vernereol 2015;95:417-21 m.stone m.d. Medial Right Ankle©2015 The Institute for Functional Medicine Clues From the Skin Exam Xanthalasma and Xanthomas Acanthosis Nigricans Skin Tags Color Changes Wounds ©2015 The Institute for Functional Medicine Shridhar D, R Jhamb: Cutaneous markers of coronary artery disease. World J Cardiol 2010 September 26;2(9):262-269. ©2015 The Institute for Functional Medicine Xanthalasma and Xanthomas Stone M, Boham E: Nutrition Evaluation: Skin Exam, 2015 IFM ©2015 The Institute for Functional Medicine Acanthosis Nigricans • Smooth, velvet-like, hyperkeratotic plaques in intertriginous areas (e.g., groin, axillae, neck). • Will resolve when insulin resistance resolves. ©2015 The Institute for Functional Medicine 25 year old Shridhar D., R Jhamb: Cutaneous markers of coronary artery disease. World J Cardiol 2010 26;2(9):262-269. ©2015 The Institute for Functional Medicine Acanthosis Nigricans • Obesity Associated AN: most common, IR • Syndromic AN: hyperinsulinemia, cushings, PCOS, lipodystrophy • Benign AN: acral acanthosis, common w/ African descent • Drug Induced AN: uncommon nicotinic acid, insulin, corticosteroids, estrogen therapies • Hereditary AN: autosomal dominant, any age • Malignant AN: internal malignancy 90% stomach cancer, 25-50% lesions in the mouth tongue, lips • Mixed AN: obese with AN and develops malignancy ©2015 The Institute for Functional Medicine Acanthosis Nigricans • Type I is associated with malignancy. Sudden onset. Extensive truncal distribution, including the face, palms, and trunk. • Type II is the familial type, with autosomal dominant transmission. Rare and appears at birth or soon after. • Type III: obesity and insulin resistance. Most Common • Drugs: systemic corticosteroids, nicotinic acid, diethylstilbestrol, and isoniazid (INH). Higgins, SP et al Dermatology Online J 14(9):2 ©2015 The Institute for Functional Medicine Acanthosis Nigricans Type 2 DM, PCOS Glucocorticoids, niacin insulin, oral contraceptives protease inhibitors Skin Tags Epidermal Growth Factor Receptor Activation Fibroblast Growth Factor Receptor Activation Higgins, SP et al Dermatology Online J 14(9):2 Severity is predicted by Fasting Insulin levels ©2015 The Institute for Functional Medicine Skin tags... • Homocysteine, Endothelin1, and Hs-CRP • -the cardiac-STs group showed the highest levels and the control group showed the least (P < 0.001). • The percent of patients with metabolic syndrome were 56.7% in the cardiac-STs, • 40% in the non-cardiacSTs, • 0% in the control group “Skin Tags may act as a physical sign of underlying raised cardiac atherogenic factors. This may indicates an ongoing risk on coronary circulation which may indicate further corrective action, hopefully early enough. The association of Skin tags with obesity and metabolic syndrome represents a Bermuda Triangle that act against the heart”. Indian J Dermatol. 2013 Jul-Aug; 58(4): 326. ©2015 The Institute for Functional Medicine Homeostasis Model Assessment (HOMA): HOMA-Insulin Resistance Fasting Blood Sugar X Fasting Insulin= IR 405 Example: 90 ( Fasting glucose) X 5 (Fasting Insulin) = 1.1 405 International Model = Fasting Blood Sugar X Fasting Insulin= IR 22.5 http://www.hcvsociety.org/files/HOMACalc.htm Matthews DR et al: Diabetologia 1985, 28:412-419 ©2015 The Institute for Functional Medicine 1) Unique Nutrient Requirement 2) Adequate Intake 3) Malabsorption 4) Maldistribution 5) Increased Loss ©2015 The Institute for Functional Medicine One Physical Exam Finding Can Lead You to Another- These are all signs of B-12 deficiency.. 1 2 3 +/- decreased vibratory sense, fatigue, memory issues or PPI use by history or poor dietary intake would make you consider additional Biomarkers... ©2015 The Institute for Functional Medicine 1. Donald S McLaren: Color Atlas and Text of Diet Related Disorders 2nd Edition p.163, Figure 320. 2,3 Kannan R, M Joo Ming Ng. Canadian Fam Physician 2008, 54:529-532 Helping Chronic Wounds Heal: 1) Adequate oxygen 2) Adequate nutrition(PFCMVP) 3) Clear infection/inflammation 4) Guard against shear force 5) Reduce edema Stone, PM: Helping Wounds Heal- The glove of wound healing. ACH Wound Conference 2009 ©2015 The Institute for Functional Medicine Poor Wound Healing Zinc, Protein, Vitamin C, A, D deficiency, Linoleic acid (omega 6), Undernutrition, calorie deficiency, Hyperglycemia, Hyperhomocysteinemia www.emedicinehealth.com ©2015 The Institute for Functional Medicine C: Physical Exam Cardiometabolic • Hair: Premature graying males/females, Hair thinning, can be found in females with insulin resistance • Ear creases-diagonal lobe crease • Eyebrow loss: Arcus senilis vs. junivalis, Xanthomas • Smell (diminished in IR/DM, medications) • Mouth (8 step mouth exam): taste, glossitis, missing teeth, periodontal disease, mixed metals • Neck: skin tags, Acanthosis nigricans, Thyroid evaluation, Bruit, JVD • Lungs: Peak Flow- peak expiratory flow rate, lung sounds • Cardiac auscultation, murmurs, pulses • Abdomen: increased waist to hip ratio, enlarged aorta • Peripheral exam: hair distribution, edema, Ankle arm index, pulses. • Skin Changes: skin tags, xerosis, hyperkeratosis pilari • Peripheral nerve sensation exam: large, small fiber and mixed disease, balance ©2015 The Institute for Functional Medicine Vinik AL: Diabetic Neuropathy in Older Adults. Clin Geriatr Med 24(3)407-v, doi:10.1016/j.cger.2008.03.011, 2008. ©2015 The Institute for Functional Medicine 3 Most common causes of Toxic Neuropathy in Adults 1) Insulin Resistance, DM 2) Alcohol 3) Occupational or Therapeutic Exposures ©2015 The Institute for Functional Medicine Vinik AL: Diabetic Neuropathy in Older Adults. Clin Geriatr Med 24(3)407-v, doi:10.1016/j.cger.2008.03.011, 2008 What Patients Do you See that are at increased risk of Neuropathy? • • • • • • IR DM Celiac B12 deficiency Alcohol consumers Bariatric Surgery Patients • Toxic exposures to heavy metals (lead, cadmium, mercury) or certain Chemotherapeutics • Chemotherapeutics • Marked increased oxidative stress (CVD, Asthma, metabolic syndrome>>mitochondrial insufficiency) • Other Malabsorption syndromes. • Anorexics, Bulemics • People over 6’4” or 195 cm. • Inadequate EFA. ©2015 The Institute for Functional Medicine Neuropathy and Retinopathy greater in the …. Homozygous Recessive Carrier Yigit, S, N Karakus, A Inanir: Association of MTHFR gene C677T with diabetic peripheral neuropathy and diabetic retinopathy. Molecular Vision 19:1626-1630, 2013 ©2015 The Institute for Functional Medicine • • • • • • • • Highly Prevalent amongst patents with DM type 1,2,3 Impaired Memory Dementia Delirium Peripheral Neuropathy Sub acute combined degeneration of the spinal cord Megaloblastic anemia Pancytopenia Kibirige, D, R Mwebaze: Vitamin B12 deficiency among patients with diabetes mellitus: is routine screening and supplementation justified. J Diabetes & Metabolic Disorders 12:17, 2013 ©2015 The Institute for Functional Medicine Metformin use alters B12 and Folate levels 1) Associated with malabsorption of B12, elevated Homocysteine and methylmalonic acid 2) Longer the cumulative use, the greater the neuropathy. 3) Adding metformin to insulin therapy reduces levels of folic acid and B12 increasing homocysteine within 12 weeks. Wile DJ, Toth C: Diabetes Care 33(1):156-161, 2010. Wulffele, MG, et al: J Intern Med 254(5):455-63, 2003. ©2015 The Institute for Functional Medicine Threshold of <5 of 8 monofilament tests (4 each foot) Positive predictive value of 87%, sensitivity of 72% and Specificity of 64% for predicting worsening neuropathy At 4 years. Perkins BA, A Orszag, M Mgo, E Ng, P New, V Bril: Prediction of incident diabetic neuropathy using the monofilament examination-a 4 year prospective study. Diabetes Care 33:1549-1554, 2010. ©2015 The Institute for Functional Medicine Nutrition associated neuropathies Nutrient Neurologic Symptoms Thiamin Beriberi (dry, wet, infantile, gastrointestinal, bariatric), Wernicke encephalopathy or Korsakoff syndrome, encephalopathy, sensorimotor distal axonal peripheral neuropathy, calf cramping, muscle tenderness, burning feet, irritability. Niacin Peripheral neuropathy, encephalopathy Pyridoxine Peripheral neuropathy, pure sensory neuropathy in toxicity Folate Similar to cobalamin deficiency, peripheral neuropathy Cobalamin Myelopathy, peripheral neuropathy, neuropsychiatric, optic neuropathy, autonomic dysfunction Vitamin D Cutaneous hyperalgesia, bone pain of osteomalacia Vitamin E Spinocerebellar syndrome, peripheral neuropathy, opthalmoplegia Copper Myelopathy/myeloneuropathy Protein Muscle wasting, weakness, hypotonia, hyporeflexia Kumar, N: Neurologic Presentations of Nutritional Deficiencies. Neurol Clin 28:107-170. 2010. ©2015 The Institute for Functional Medicine Testing and treatment for nutrition associated neuropathies Nutrient Lab Treatment Thiamin Serum Thiamin, RBC transketolase, RBC thiamin diphosphate, Urinary Thiamin Thiamin IV, IM, Oral Niacin Urinary excretion of methylated niacin metabolites Nicotinic acid oral, IM Pyridoxine Plasma pyridoxal phosphate, P5P Pyridoxine oral (P5P over Pyridoxine HCL if using higher doses) Folate Serum, RBC Folate, Plasma Hcy,…SNPMTHFR, Urine Formiminoglutamic Acid Methyl folate, folate Cobalamin Serum Cbl, MMA, plasma Hcy, CBC, MCV… IM B12, Methyl cobalamin, Hydroxy cobalamin Vitamin D 25 OH vitamin D, 1,25 DHCC, PTH, Ionized Ca Appropriate Vitamin D dosing Vitamin E Serum Vitamin E ratio (a-tocopherol to sum serum cholesterol+TG) Vitamin E oral or IM Copper Serum, RBC, Urinary Copper, serum ceruloplasmin, CBC (anemia, neutropenia, vacuolated myeloid precursors) Oral elemental copper Glucose Fasting, 2 hour GTT, Insulin, Hgb A1C, triglycerides Low Glycemic Index, Movement, Multifactorial Kumar, N: Neurologic Presentations of Nutritional Deficiencies. Neurol Clin 28:107-170. 2010. ©2015 The Institute for Functional Medicine Metabolic Correction in Diabetic Peripheral Neuropathy The Rate Limiting Step…the weakest link 1) Alpha Lipoic Acid 2) Acetyl L Carnitine 3) Benfotiamine (Thiamin) 4) L-Methyl Folate, Methyl Cobalamin,Pyridoxine 5 Phosphate Miranda-Massari, JR, MJ Gonzalez, FJ Jimenez, MZ Allende-Vigo, J Ducounge: Metabolic correction in the management of diabetic peripheral neuropathy: Improving clinical results beyond symptom control. Curr Clin Pharmacol. 2011. Medicine ©20156(4):260-273, The Institute for Functional Type 2 diabetic peripheral neuropathy and methylation factors for 6 months led to improved neuropathy with nerve growth, decreased pain, increased function At the end of their treatment, 73% of patients showed an increase in calf Endothelial Nerve Fiber Density, 82% of patients experienced both reduced frequency and intensity of paresthesias and/or dysesthesias. Greater improvement after 1 year Methyl Folate: 3 mg, Methyl Cobalamin 2mg, Pyridoxine 5 Phosphate 35 mg twice a day Jacobs AM, Cheng D Rev Neurol Dis. 2011;8(1-2):39-47. Walker MJ, Morris LM, Cheng D Rev Neurol Dis. 2010;7(4):132-9 Abstracts of the Diabetic Foot Global Conference. Oral Presentations 2009. Metanx® is an orally administered medical food for use only under medical supervision for the dietary management of endothelial dysfunction in patients with diabetic peripheral ©2015 The Institute for Functional Medicine neuropathy. Growing New Nerves in Diabetics with DPN Nutrient Mechanism Methyl Folate Enhances production of tetrahydrobiopterin, enhances endothelial nitric oxide synthase. Counteracting oxidativenitrosamine stress through restoration of endothelial nitric oxide synthase coupling vasonervorum. Methyl Cobalamin Neutralization of superoxide and peroxynitrite, promotes myelination and transport within the cytoskeleton of the peripheral nerves Pyridoxine 5 Phosphate Chelation of transition metals and traps 3 deoxygluosone to inhibit the formation of Advanced Glycosylation End products. Jacobs AM, Cheng D Rev Neurol Dis. 2011 8(1-2):39-47 .Miranda-Massari JR:® Curr Clin Pharmacol 6 (4):260-273, 2011 Metanx is an orally administered medical food for use only under medical supervision for the Shevalye, H, et al:.Foot Diabetes 61:2126-2133, 2013Presentations Walker MJ, Morris LM, Cheng D Rev Neurol Dis. 2010;7(4):132-9 dietary management of endothelial dysfunction in patients with diabetic peripheral Abstracts of the Diabetic Global Conference. Oral ©2015 The Institute for Functional Medicine neuropathy. 2009. Vibratory Sense, Light Touch Testing • 128 Hz tuning • Normal Peripheral vibratory sense of the fork thumb and 5th distal finger, and the great toe and the 5th toe. • Normal Monofilament • 5.07 sensation Feet and SemmesHands Weinstein Monofilament ©2015 The Institute for Functional Medicine P.M. Stone, M.D. Monofilament and Vibratory Sense ©2015 The Institute for Functional Medicine Pain, Nutritional Insufficiency with Neuropathy 1) Expect to Uncover the Neuropathy on Physical Exam 2) Assess the Stacked Vulnerabilities with your Patient 3) Look for Confirmatory Laboratory 4) Intervene with Nutritional Therapies when appropriate 5) It is possible to promote the growth of new nerves 6) It is possible to prevent neuropathies with appropriate Interventions. ©2015 The Institute for Functional Medicine Anthropometrics Biomarkers and Functional Labs Clinical Indicators from Nutrition Physical Exam Diet and Lifestyle Assessment ©2015 The Institute for Functional Medicine ©2015 The Institute for Functional Medicine Functional Nutrition ©2015 The Institute for Functional Medicine ©2015 The Institute for Functional Medicine ABCD Evaluation Medical History Nutrition Status Gather ©2015 The Institute for Functional Medicine Food is medicine. “Let food be your medicine and medicine be your food.” - Hippocrates ©2015 The Institute for Functional Medicine Food is Medicine for the Heart ©2015 The Institute for Functional Medicine Attributions and Recognized Contributors to IFM Content Development • Kristi Hughes, N.D.,Shilpa Saxena, MD, Deanna Minich PhD, Michael Stone, MS, MD, Elizabeth Boham, MD, Ruth Debusk PhD, RD, Kara Fitzgerald, N.D., Mary Willis RD, Dan Lukaczar ND, Mark Houston, M.D. • Staff at Institute for Functional Medicine ©2015 The Institute for Functional Medicine Nutritional defects, “like deer in the forest” do not announce their presence but must be looked for” (Sanstead 1969) ©2015 The Institute for Functional Medicine
