[PDF] - Learning Objectives 1. Define Functional Medicine (FM) Functional PDF Document

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2/12/2018 1 Functional Medicine 101: A Primer for Pharmacists

Lauren Castle, PharmD, RPh MS – Human Nutrition & Functional Medicine (Dec 2018) University of Western States

Learning Objectives

1. Define Functional Medicine (FM)
2. Compare and contrast FM with conventional,

alternative and integrative medicine

3. List the 6 principles and 7 imbalances of FM
4. Utilize FM tools in a case study, including the Timeline,

Matrix and GO TO IT

5. Describe educational opportunities and proposed roles

for the pharmacist in FM

Case #1: 28yo WM

 Subjective:

 CC: “feels like crap”  HPI: depressed mood, insomnia/snoring, anxiety, trouble

focusing, tired all the time, soreness, sinus congestion/allergies and recurrent sinus infx (2/year), irregular BMs, struggles to lose weight with exercise and diet

 PMH: none. Current meds: none  FH: parents healthy but smokers, maternal grandfather died of

stroke at age 75, paternal grandfather died of dementia

 SH: former smoker 1ppd and daily alcohol use in college,

currently using chewing tobacco and 2-4 drinks on weekends

Case #1: 28yo WM

 Objective:

 PE: 5’10” 190lb, BP 111/71, RR 16, HR 72,

 BMI 27 (overweight), 38” waist and 39” hip

 Labs:

 Chem WNL, CBC WNL  TC 192 mg/dL, HDL 39, TG 83, LDL 136, TC/HDL 4.9, Non-

HDL 153.

 FBG 81mg/dL, A1c 5.6%

Case #1: 28yo WM

 A/P: Depressed mood, Insomnia, Anxiety

 Melatonin, OTC sleep aids, Rx sleep aids, SSRI (Lexapro?)  Refer to psych for CBM

 A/P: Sinus congestion/allergies/infection

 Saline, Flonase, Zyrtec-D for allergies  Augmentin + Prednisone for sinus infections

 A/P: Irregular BMs

 Fiber + water

 A/P: Overweight

 reduce calories, exercise 30 min a day

1. Define functional medicine

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2/12/2018 2

Modern Day FM

Jeffrey Bland, PhD, FACN, CNS

Father of FM
IFM Founder, 1991

Mark Hyman, MD

IFM Chairman
Director of the Cleveland Clinic

Center for FM, 2014

A New Approach

Chronic Disease & Morbidity Health & Economy

Definition

 Functional Medicine is a systems-biology-based model

that empowers patients and practitioners to work together to achieve the highest expression of health by addressing the underlying causes of disease.

 Functional Medicine uses a unique operating system

and personalized therapeutic interventions to support individuals in achieving optimal wellness.

2. Compare and contrast the

acute care model vs chronic care model

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2/12/2018 3

Current model: Acute Care

 Rapidly identify and treat emergent problems  Works well in emergency/hospital settings  Relies on deductive reasoning and “reductionism”  Historically developed for Infectious disease  The “Silver bullet”: antibiotics  “Name it and blame it”  “A drug for each bug”  “A pill for each ill”

FM: We must find the root cause of this broken bone!

Pharmaceutical Evolution

Antibiotics Physiologic Antagonists Receptor Modulators

Influences on Chronic Disease

Functional vs. Conventional

http://www.ibsgroup.org/other/articles/Understanding_functional_medicine.pdf

Functional vs. Conventional

http://www.ibsgroup.org/other/articles/Understanding_functional_medicine.pdf Alternative Complementary Conventional

Integrative Medicine: healing-oriented, body/mind/spirit, lifestyle approach that combined Conventional and CAM therapies Functional Medicine: emphasizes underlying cause of dysfunction, organizes assessment & treatment using FM tools

X

All Functional Medicine is Integrative, but not all Integrative Medicine is Functional

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2/12/2018 4

3. FM by the Numbers

7, 6, 5, 4, 3, 2, 1

Seven Core Imbalances

digestion, absorption, microbiota/GI, respiration

Assimilation:

immune, inflammation, infection/microbiota

Defense and repair:

energy regulation, mitochondrial function

Energy:

toxicity, detoxification

Biotransformation and elimination:

cardiovascular and lymphatic systems

Transport:

endocrine, neurotransmitters, immune messengers

Communication:

subcellular membranes to musculoskeletal integrity

Structural integrity:

Six Principles of FM

Biochemical Individuality Patient-Centered Dynamic Balance of Mind, Body, & Spirit Web-like Interconnections Health as a Positive Vitality Promotion of Organ Reserve

5R/4R Protocol

Remove

Pathogens, food sensitivities, PPI

Replace

Vitamins, minerals, enzymes, gastric acid, fatty acids, calories, antioxidants

Reinoculate

Probiotics, prebiotics, synbiotics

Repair

L-glutamine, anti-inflammatory therapy

Rebalance

Stress and lifestyle issues

5 Causes of Environmental Illness

biologic, elemental, synthetic
1. Toxins
food, mold, dust, animal products, pollens, chemicals
2. Allergens
bacteria, yeast, viruses, parasites, worms
3. Microbes
physical or psychological
4. Stress
standard American diet, or SAD
5. Poor diet

Four P’s of FM

Personalized

Genetic and environmental

variations drive and define individual treatment

Predictive

Tailored health strategy

based on personalized map

f health risks with

traditional and novel biomarkers

Preventative

Proactive vs. reactive

approaches that shift focus from illness to wellness, from disease treatment to functional enhancement

Participatory

Empowers and engages the

patient

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2/12/2018 5

“Three Legs of the Stool” Approach

Two questions

Fill an unmet need?

Nutrients
Air
Water
Sleep
Connection

Get rid of something?

Toxins
Allergens
Microbes
Poor diet
Stress

The FM Tree

4. Understand how to use

FM tools in a case

The Timeline, the Matrix, and GO-TO-IT

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2/12/2018 6

The Timeline

 Use the Timeline to put together an extensive lifetime

picture where clinical patterns emerge:  Ages, events, symptoms, diagnoses  Triggering events  ATMs: antecedents, triggers, mediators  Significant contributory lifestyle factors

Matrix

 Collect and organize patient’s history, lifestyle, S&S  S&S classified as clinical imbalances in seven core

physiological systems that transcend organ boundaries  Assimilation  Defense and repair  Transport  Communication  Structural integrity  Biotransformation and elimination  Energy

GO TO IT

Gather information from the patient

Gather

Organize patient history on the matrix and timeline

Organize

Tell the story back to the patient

Tell

Order and prioritize treatment strategies

Order

Initiate further assessment and treatment

Initiate

Track progress

Track

Gather

Purpose



GATHER ONESELF: Mindfulness; optimizing the therapeutic relationship



GATHER INFORMATION through intake forms, questionnaires, the initial consultation, physical exam, and objective data. A detailed functional medicine history taken appropriate to age, gender, and nature of presenting problems.

IFM Tools (examples)



Mindful Meditation



Health History and Intake Forms



Medical Symptom Questionnaire



Timeline 

Chronological Story



ATMs and the Patient’s Story



ABCDs of Nutritional Evaluation



Request and Report



Nutrition Physical Exam Forms

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2/12/2018 7

Gather: ABCDs

 Anthropometrics and Body Composition  Biomarkers, Labs, Functional Assessments

 PFC-MVP

 proteins, fats, carbs, minerals, vitamins, phytonutrients

 Clinical Indicators from Physical Assessment  Dietary, Nutrition, and Lifestyle Journal

Organize

Purpose

 ORGANIZE the subjective

and objective details from the patient’s story within the functional medicine

paradigm. Position the

patient’s presenting signs and symptoms, along with the details of the case history

n the timeline and functional

medicine matrix.

IFM Tools (examples)

 Functional Medicine Matrix



Antecedents, Triggers, Mediators



Modifiable Lifestyle Factors



Clinical Imbalances

Tell

Purpose



TELL the story back to the patient in your own words to ensure accuracy and understanding. The re-telling of the patient’s story is a dialogue about the case highlights, including the antecedents, triggers, and mediators identified in the history, correlating them to the timeline and matrix. 

Acknowledge patient’s goals.  Identify the predisposing factors (antecedents).  Identify the triggers or triggering events. Identify the perpetuating factors (mediators).  Explore the effects of lifestyle factors. Identify clinical imbalances or disruptions in the

rganizing physiological systems of the matrix.

 Ask the patient to join in correcting and amplifying the story, engendering a context of true partnership.

IFM Tools (examples)



The Patient’s Story Reviewed & Shared with integration of the Functional Medicine perspective (i.e. ATMs, Timeline, and Matrix)



Personal Development Exercises to: Create and Strengthen the Therapeutic Relationship Reflective 

Listening  Motivational Interviewing  Coaching & Behavioral Modifications

Order

Purpose

 ORDER and prioritization

emerges from the dialogue of professional and patient. The patient’s mental, emotional, and spiritual perspective is of primary importance for prioritizing the ‘next steps.’

IFM Tools (examples)

 Matrix

Initiate

Purpose



INITIATE further functional assessment and intervention based upon the above work: 

Perform further assessment



Initiate patient education and therapeutic intervention



Referral to adjunctive care if needed



Nutrition Professional



Lifestyle Educator



Healthcare Provider



Specialist

IFM Tools (examples)

 Prescription for Lifestyle Medicine  Referral to Functional Nutritionist for

 Additional Nutrition Evaluation  Biomarkers Laboratory Form  Dietary Interventions

 Patient Education Handouts (examples)

 Mindful Eating  Relaxation Response  Functional Nutrition Fundamentals  Core Food Plan and Therapeutic Suites

Track

Purpose

 TRACK further assessments,

note the effectiveness of the therapeutic approach, and identify clinical outcomes at each visit—in partnership with the patient

IFM Tools (examples)

 Medical Symptoms

Questionnaire

 Body Composition Tracking

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2/12/2018 8

Case #1: GO TO IT

Gather information from the patient

Gather

Organize patient history on the matrix and timeline

Organize

Tell the story back to the patient

Tell

Order and prioritize treatment strategies

Order

Initiate further assessment and treatment

Initiate

Track progress

Track

Vaginal birth & breastfed but lifelong smoke exposure

2015 work promotion: Moved

ut of state away

from friends and family

High stress job, long commutes, lack of time for self and health

2004: Attended college, increased alcohol and tobacco use 1985: good childhood but very independent, “tough love”

Lifelong allergies & congestion. Favorite foods: PB&J and milk. Lingering baseball injuries: knees and shoulder Fatigue, anxiety, insomnia, snoring, congestion, constipation,

verweight,

soreness

Poor sleep, TV for relaxation at night Tries to exercise on weekends, enjoys hiking Tries to eat healthy, but convenience is a barrier High stress/ anxiety from work, chews tobacco for relief Newly happily married but no friends outside work, family lives in another state Vaginal birth &breastfed but lifelong smoke exposure Work promotion = increased stress, moved away from family Work stress and long hours, lack of sleep, exercise, and nutrition Digestion, leaky gut, dysbiosis Poor mood, focus Soreness Blood sugar, low HDL Poor BM Low energy Inflammation, Candida infx High stress/anxiety, no spirituality but enjoys

utdoors & motorcycles

Case #1 Results

 12 week program 

Gluten and dairy sensitivities  intestinal permeability/“Leaky gut”  Candida chronic infection (IgG)  High inflammation (homocysteine): 12 µmol/L  C-reactive protein: 0.8 mg/L  Low vitamin D (31 ng/ml)

 Lipid panel: TC 192 mg/dL, HDL 39, TG 83, LDL 136, TC/HDL 4.9, Non-HDL 153.  Blood sugar testing: FBG 81mg/dL, A1c 5.6%, fasting insulin 8.1  Elimination diet 

Supplement regimen (Metagenics)  Ultraclear shakes, Probiomax, Cadibactin AR/BR, Vesselcare, Adreset, Advaclear, Glutaclear, Omega 3, VitD3 1,000 IU/drops, Turmeric, Resveratrol

 Symptoms resolved; most notably sinus/mucus clear 

BMI decreased to 24

5. Describe educational
pportunities for the

pharmacist in FM Overview

Title Cost Length UWS: MS-HNFM $24K 1-3 classes/qtr, 2-5 years IFM: IFMCP $15K Up to 7 years FMCU: FMCHC $6-7K 10 hr/wk x 12 mo FMU: CFMP $2495 10 hr/wk x 6 mo 12 mo access

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University of Western States (UWS)

 Masters of Science in Human Nutrition and Functional

Medicine (MS-HNFM)

 The only fully accredited master’s degree in functional

medicine, regional accreditation from the Northwest Commission on Colleges and Universities.

 #4 ranked online graduate nutrition program  100 percent online  Collaboration with IFM:

 2 APMs as Electives

 Cons: expensive $25k, time-consuming

Institute for Functional Medicine (IFM)

 IFM Certified Practitioner (IFMCP)  Leader in FM education  Most recognized credential within FM profession  Provider listing page  Cons: Expensive, Requires Travel

 AFMCP $2900, each module $1550 x 6, exam fees

$1600 = $13,800

Functional Medicine Coaching Academy (FMCA)  Functional Medicine Certified Health Coach (FMCHC)  Collaboration with IFM  Approved by the International Consortium for Health

and Wellness Coaching

 Integrates the art of coaching with principles of

Functional Medicine, nutrition, the psychology of eating, mind-body medicine and positive psychology.

 Somewhat expensive $6-7k

Functional Medicine University (FMU)

 Functional Medicine Certified Practitioner (FMCP)  Online only  Self paced  Less expensive $2495  10 hours CPE available  “The Functional Medicine Professional Training

Program That Meets the Highest Standards and Fits Your Busy Schedule…Helping Physicians Provide Exceptional Patient Care”

More Info

 Books, blogs, websites, podcasts, Facebook…  Izabella Wentz PharmD, Suzy Cohen RPh, Jim LaValle

RPh CCN, Grace Liu PharmD, Dr. Anh Nguyen, PharmD, BCACP

 Chris Kresser, Dan Kalish, Andrew Weil, Terry Wahls

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Describe the pharmacist’s role in FM

Gene Gresh, RPh, FIACP, IFMCP

 Practice Site: Pioneer Health Compounding Pharmacy

 Vernon, CT

 Practice Model: Consultations, Compounding  Supplements: Metagenics  Testing: KBMO Food Inflammation Test (FIT), 23andme



Physician as Lab Director… The Value of Working with a Functionally-Trained Compounding Pharmacist

 Clinical Focus: Food sensitivities, Genetics

Jenna W. Clack, PharmD A4M Regenerative Medicine Fellow

 Practice Site: Clack Co. Concierge Consulting,

 Midland, TX

 Practice Model: Concierge Medicine

 Cash pay, transparent pricing  Starting a compounding pharmacy soon

 Supplements: Private label, hard to find brands  Testing: ZRT Laboratories

 Saliva, Dried Blood, Dried Urine

 Clinical Focus: Hormones

Melody Hartzler, PharmD, AE-C, BCACP, BC-ADM

 Practice Site: Western Medicine Family Physicians



3 DO, 1 NP, 1 PA, 1 PharmD, PharmD students

 Fairborn, OH

 Practice Model: Traditional

 Medical appointment (H&P, ROS) with RPh Consult  Upcoming: group appointments, possible cash pay

 Supplements Used: Thorne, Emerson

 Probiotics, curcumin, D3, K2

 Testing: Genova

 Stool, hormone, Nutreval

 Clinical focus: Chronic diseases

 Diabetes, especially autoimmune diabetes  Asthma/COPD  Hypertension, Hyperlipidemia