102 Sult Intro FxMed AFMCP2019sep

Introduction to Functional Medicine:
Redefining Disease Applied Systems Medicine
TOM SULT, MD
Applying Functional Medicine in Clinical Practice

Seattle, WA
September 2019
Disclosures
Tom Sult, MD, disclosed he was a medical advisor for

Before and After.
©2019 The Institute for Functional Medicine
Performance Objectives
Following this activity, successful participants will be able to…
1. Distinguish the key differences between conventional medicine and

functional medicine
2. Clarify how a systems based approach can effectively treat illness and
promote wellness
3. Understand broadly how to apply concepts of patient-centered care

for patients with chronic disease
A Fundamental Problem
at the base of
Conventional Medicine
The Original Evidence-Based Medicine
Evidence based medicine:
What it is and what it isn’t
“Evidence-based medicine is the conscientious, explicit, and judicious use

of current best evidence in making decisions about the care of individual
patients. The practice of evidence-based medicine means integrating
individual clinical expertise with the best available external clinical
evidence from systematic research…

Good doctors use both individual clinical expertise and the best
available external evidence and neither alone is enough.
Sackett, D., Rosenberg, W., Gray, J., Haynes, R. and Richardson, W. (1996). Evidence based medicine: what it is and what it isn't. BMJ, 312(7023), pp.71-72.
Transition from Oracle
Evidence based medicine in primary care:
An Overview Medicine to Evidence-
Based Medicine
Clinical
Expertise
Geyman, J. (1998). Evidence-Based Medicine in Primary Care: An Overview. The Journal of the American Board of Family Medicine, 11(1), pp.46-56.
Transition to Oracle Medicine
Progress in Evidence Based Medicine
Evidence-based medicine
deemphasizes intuition, unsystematic clinical experience, and
patho-physiologic rationale as sufficient grounds for clinical
decision-making and stresses the examination of evidence from

clinical research.
Montori VM, Guyatt GH. Progress in evidence-based medicine. JAMA. 2008 Oct 15;300(15):1814-6. doi: 10.1001/jama.300.15.1814.
X
Clinical
X
Expertise
Why Most Published
Research Findings Are False
• There is increasing concern that most current published research findings

are false.
• Simulations show that for most study designs and settings, it is more likely
for a research claim to be false than true.

• Moreover, for many current scientific fields, claimed research findings may
often be simply accurate measures of the prevailing bias.
Ioannidis JP. Why most published research findings are false. PLoS Med. 2005 Aug;2(8):e124.
Why Most Published
Research Findings Are False
Furthermore, even in the absence of any bias,

when ten independent research teams perform
similar experiments around the world, if one of
them finds a formally statistically significant

association, the probability that the research
finding is true is only 1.5 × 10−4.
Ioannidis JP. Why most published research findings are false. PLoS Med. 2005 Aug;2(8):e124.
A Decade of Reversal: An Analysis of 146
Contradicted Medical Practices
Conclusion:
“The reversal of established medical practice is common

and occurs across all classes of medical practice.”
Prasad V, Vandross A, Toomey C, Cheung M, Rho J, Quinn S, Chacko SJ, Borkar D, Gall V, Selvaraj S, Ho N, Cifu A. A decade of reversal: an analysis of 146 contradicted medical practices. Mayo Clin Proc. 2013 Aug;88(8):790-8. doi: 10.1016/j.mayocp.2013.05.012.
MAYO CLINIC PROCEEDINGS
How many Contemporary Medical Practices Are Worse
Than Doing Nothing or Doing Less?
An empirical evaluation of Cochrane reviews in 2004 showed

that most (47.8%) concluded that there is insufficient evidence
to endorse the examined interventions.
A repeated evaluation in 2011 showed that this trend has not
changed, with the percentage of insufficient evidence remaining

as high as 45%.
John P. A. Ioannidis, MD, DSc
Ioannidis JP. How many contemporary medical practices are worse than doing nothing or doing less? Mayo Clin Proc. 2013 Aug;88(8):779-81. doi: 10.1016/j.mayocp.2013.05.010.
Analysis of Overall Level of Evidence Behind Infectious
Diseases Society of American Practice Guidelines
Conclusions:
More than half of the current recommendations of the IDSA are
based on level III evidence only. Until more data from well-
designed controlled clinical trials becomes available, physicians

should remain cautious when using current guidelines as the
sole source guiding patient care decisions.
Lee DH, Vielemeyer O. Analysis of overall level of evidence behind Infectious Diseases Society of America practice guidelines. Arch Intern Med. 2011 Jan 10;171(1):18-22. doi: 10.1001/archinternmed.2010.482.
Parachute use to prevent death and major trauma related
to gravitational challenge: systematic review of
randomized controlled trials
Conclusions:
As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to
rigorous evaluation by using randomized controlled trials. Advocates of evidence based medicine have criticized the
adoption of interventions evaluated by using only observational data.
We think that everyone might benefit if the most radical protagonists of evidence- based medicine organized and
participate in double blind, randomized, placebo-controlled crossover trials of the parachute.
Results:
Our search strategy did not find
any randomized controlled trials of
the parachute.
Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomized controlled trials. BMJ. 2003 Dec 20;327(7429):1459-61.
Transition from Oracle Medicine to
Evidence-Based Medicine
X X
Clinical
X
Expertise
Distinguish the key differences
between Conventional Medicine
and Functional Medicine
Modern Medicine is a Wondrous Thing
• Modern medicine is an excellent tool for acute care.
• Modern medicine is a technological marvel when applied properly
• Every tool has it highest purpose
John’s Story
• John is a 37 year old Dx with ulcerative colitis 2 years ago.

• He started with his primary care and was placed on
sulfasalazine.
• Initially he had improvement
• Within 3 months he had a relapse with symptoms worse

than before while ON meds  he was referred to GI
John’s Story
• He was placed on an escalating number and strength of meds.

• He was placed on a succession of biologics
• He continues to have severe symptoms
• A surgical consult was obtained
• He was scheduled for a colectomy with ostomy

• A friend of his (a patient of mine) had suggested he see me for
years…In desperation he delays his colectomy and sees me.
John’s Story
• John is desperate to avoid a colectomy

• I am afraid he is a day late and a dollar short. He is up against
surgery with severe sx ON meds and biologics.
• His sleep quality is poor due to anxiety about his condition
• However, he does have a strong social support network

including his wife and work colleagues
John’s Story
• I used the IFM tools and techniques

• Listen, Timeline, Matrix, ATMs, The Story Retold, MLS
John’s Story
• Full term, breast fed

• Atopic at 5 years
• Multiple OM from age 5 – 7, treated with antibiotics
• “sensitive stomach” 5 until present
• Developed anxiety in junior high that escalated throughout life

• Company he works for purchased 2.5 years ago with increasing
stress and concern over job stability
John’s Story
• Family History
• PGF had DM2 with CAD
• PGM IBS
• F Stress, Type A, Angry
• MGF CAD, HTN
• MGM Depression, Anxiety

• M Depression, Anxiety
John’s Story
• Symptoms of IBS developed at time of job stress.

• Symptoms escalate until dx with UC 2 years ago
John’s Story
• Elemental diet
• He is already underweight so we added fats to increase
calorie count
• Significant fatigue and muscle weakness. No energy to
exercise.
• Glutamine, Probiotic, Serum Derived Immunoglobulins, Fish

Oil, Vit D, Multivitamin
• I ordered some tests…
Chronic stress
Standard American Diet
Sedentary
FHx of DM, CVD, IBS,
HTN, depression,
anxiety Stress, Job transitions
Maternal
depression 5 7 13 34 35 37
and anxiety
Full term Frequent
Anxiety
birth, OM IBS Symptoms

Breast fed
• Ulcerative colitis
Became atopic
Sensitive stomach Diagnosed

with UC, Rx
sulfasalazine
Retelling the Patient’s Story Physiology and Function: Organizing the Patient’s Clinical Imbalances
Antecedents Assimilation Defense & Repair
Ulcerative colitis
Dysbiosis
• FHx of DM, CVD, IBS, HTN, depression, anxiety
• Hx of atopy
Triggering
• Frequent Events
OM Rx’d with antibiotics
Structural Integrity Anxiety
Fatigue Energy
Muscle Weakness
Antibiotic use
Company is sold
Mediators/Perpetuators Communication Spiritual Biotransformation & Elimination

• Job stress Transport
• Limited diet
Personalizing Lifestyle Factors

Sleep & Relaxation Nutrition & Hydration Stress & Resilience
No energy/strength • High fat diet due Job insecurity Strong relationship
Poor sleep quality to exercise to being
with wife and
underweight
• Standard coworkers
American food
choices
Name:____________________________ Date:___________ CC:_____________________________________ © Copyright 2011 Institute for Functional Medicine
John’s Story
• ATMs
• Multiple family members with inflammatory disorders
• Multiple OM with antibiotic
• Dysbiosis
• IBS
• UC
John’s Story
• In the first week John stabilizes and starts to improve slightly

• At 6 weeks we liberalize his diet to an elimination diet
• Within the next 12 weeks we start to wean from the biologics
• He is improving and continues to do well off of the biologics
• At 9 months he is still doing well so we wean of the meds.

• Symptoms increase.
• We escalate his supplements with no improvement
John’s Story
• After a lot of dietary, supplement, and life style manipulation

we are not able to get him off of his sulfasalazine
• Did he show up a day late and a dollar short?
• Was this a failure?
• No Colectomy
• Off biologics
• Off most of his meds
• Stable and better than when on his multiple meds, and biologics.
• He calls it a screaming success
Robin’s Story
• The definition of health, absolutely asymptomatic.
• Dx with Stage 4b Colon cancer with mets to ovary, liver and
lung
• Prognosis weeks
• Massive surgery removed ½ of colon, pelvic organs, and 1/3
of liver.
• Chemo
Found to be NED
• Prognosis upgraded to 2 years
Robin’s Story
• Added Functional Medicine
• Full Meal Deal with Laps around the Matrix
• NED lasted 1 years (longer than her oncologist thought it might)
• It’s not either/or  It’s yes/and
• Over the next 8 years, Robin had 3 more grandchildren (total of 4)
• She had great quality of life up until the end with only one regret
• She wished she could have been a grandmother just a little longer.
• Not every story is “lived happily ever after”…but this is a good
outcome.
• Functional Medicine STARTS with good medicine

• It is not a substitute for conventional medicine
• It is a new model to use with chronic complex disease.
• Functional Medicine is not for acute care
• Functional Medicine is not as good as conventional medicine

for acute care (end stage care)
• Trauma, Acute MI, Acute CVA, Sepsis
• Conventional Medicine = big problems that need big

intervention, you have to expect big side effects.
• Applying the acute care model to chronic complex
disease
• Episodic care
• Fragmented care
• More tests
• More cost
“If the only tool
you have is a
hammer, every
problem begins to
look like a nail.”

-Mark Twain
What is the conventional medicine answer
for chronic care?
• Name it.
• What is a Disease, Disorder, Syndrome,
Condition?
• Blame it.
• Is this named thing really a thing? Can it be
removed?
• Tame it.
• Do most drugs cure or control or harm?
• The 4-6 leading cause of death is the
APPROPRIATE us of Rx drugs
Used with Permission.

McDowell I. Public Health and Preventive Medicine. Health Promotion.
http://www.med.uottawa.ca/sim/Data/Pub_PublicH_Prevention_e.ht
m. Accessed November 28, 2018. Painting by: Erica Laycock
Fundamentally Different
No matter how you improve a candle it will never be a light bulb
Hippocrates – The Father of Modern Medicine
The Father of Modern Medicine
• Useful known and unknown views of the father of modern
medicine, Hippocrates and his teacher Democritus.
> Hell J Nucl Med. 2008 Jan-Apr;11(1):2-4.
• Hippocrates, (born c. 460 bce, island of Cos, Greece—died c.
375 bce, Larissa, Thessaly), ancient Greek physician who
lived during Greece's classical period and is traditionally
regarded as the father of medicine.

• He died 2,394 years ago.
• Maybe we need to rethink Modern…
WE NEED A NEW MAP
WE HAVE MAP OF CHINA BUT WE ARE STANDING HERE

What is the conventional medicine answer
for chronic care?
• Functional Medicine is a systems biology-based approach that
focuses on identifying and addressing the root cause of
physiologic dysfunction that contribute to disease.
• Systems Biology is based on the understanding that the
whole is greater than the sum of its parts
The False Dichotomy
Reductionism Holism
Knowing More and More about Knowing less and less about
less and less until you know more and more until you know
everything about nothing nothing about everything
Systems Approach
The False Dichotomy A biology-based interdisciplinary
field of study that focuses on
complex interactions within
biological systems, using a holistic
approach (holism instead of the
more traditional reductionism) to
biological research.[1]
Reductionism Holism
Knowing More and More about Knowing less and less about more
less and less until you know and more until you know nothing
everything about nothing about everything
1 Essays in Biochemistry. 62 (4): 487–500.

From “Sick Care” to Health Care: Reengineering
Prevention into the U.S. System.
The New England Journal of Medicine.
We must teach aspiring physicians about systems science…Medical

school curricula should emphasize homeostasis and health, rather
than only disease and diagnosis….Embedding prevention in the
teaching, organization and practice of medicine can stem the
unabated, economically unsustainable burden of disease.
Marvasti FF, Stafford RS. From “Sick Care”

to Health Care: Reengineering Prevention
into the U.S. System. The New England
journal of medicine. 2012;367(10):889-
891. doi:10.1056/NEJMp1206230.
One Disease Many Causes Omega 3
Fatty acid
Social Isolation Low Thyroid
Vitamin D
Antibiotic use Depression Deficiency
Autoimmune
Disease Pre-Diabetes
Arthritis
One Cause Many Disease
Cancer
Diabetes Cardiovascular
Inflammatory
Pancreatitis Chronic
Bowel
Inflammation Disease
Autoimmune Renal
Disease Disease
Arthritis
Clarify how a systems based
approached can effectively treat
illness and promote wellness
We Once Thought
DNA (Transcribes to)

RNA (Translates to)
Protein (Results in)

Function
Now we understand (at least this…)
Environment (most of the control) Protein
• DNA
• Methylation control • Methylation control
• Copy number variation • Epigenetic effects
• Epigenetic effects • Post translational modification
• RNA
Function
• Methylation control
• Epigenetic effects
…and every step is under more control, feedback and

interdependent interaction than previously understood.
We need tools to cope with the complexity
WE ARE TAUGHT THIS BUT EVEN THIS IS SIMPLIFIED
The Undiscovered Organ…

Pharmacogenomics
The Promise of Personalized Medicine
Biochemical Individuality
• Most drugs work really well

for about 30-40% of the
population (+/- 0.5 SD)
• They work increasingly less
well as you fall off of the
tails of the normal

distribution.
• This is well recognized by
pharma scientists.
Dots
Connect the
Diseases Don’t Exist!
Loss of adaptive homeodynamic balance

So what is disease? In old times people used to think that
a disease was some actual entity or thing which had got
into the body in some way, and was there lying hidden
and secreted, and was to be cast out. This idea, which
we now know to be true only in a few specific instances,
was at one time general.
…The conclusion is that all disease is disordered function.

“Here, then, I say, is the highest justification for all
treatment being based upon the principle of
restoring disordered functions to order, and this is
what I have ventured to term Functional Medicine.”
Clinical Lecture on Functional Medicine
By Willoughby F. Wade, B.A., M.B. 1871
Willoughby F. Wade, BA, MB, Physician to the General

Hospital, Birmingham, England
Delivered as a Clinical Lecture on Functional Medicine,

March 5, 1870
Published in the July 1,1871 issue of The Lancet
Clinical Lecture ON FUNCTIONAL MEDICINE. The Lancet. 1871;98(2496):3-5. doi:10.1016/s0140-6736(02)77096-7.

Age-adjusted Prevalence of Obesity and Diagnosed
Diabetes Among US Adults
Obesity (BMI ≥30 kg/m2)
1994 2000 2013
No Data <14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9% > 26.0%

Diabetes
1994 2000 2013
No Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% >9.0%

Data: World Economic Forum 2011

Why? Have our Genes Changed?

Genes
Big + Phenotype =
Genes + Environment
Data Results
Actionable
Environment –Toxins, Phenotype –Attributes,

conditions, diseases, etc.
diet, etc.
Low-level Mercury Exposure
IMPACT ON 17 YEAR-OLDS
WITH HIGH RISK GENE MARKERS
WHO safe level of urinary Hg = 50 ug/l

17 year olds
performing as
if they were:
Low Genetic Risk
Medium Risk Age 17 (normal)
Age 14 (3yr delay)
High Genetic Risk Age 11 (6yr delay)
Average performance on standard Based on “Casa Pia”

clinical trial – 7 yrs,
neuro-behavioral test at age 17 500 subjects, funded
by the NIH
Increasing mercury levels (creatinine-adjusted urinary Hg -ug/l)

*Unpublished Ecoeos data analysis of Casa Pia Trial © 2013 Ecoeos, Inc.
Sperm Count Zero

Sperm Count Zero
• A strange thing has happened to men over the past few decades:
We’ve become increasingly infertile, so much so that within a
generation we may lose the ability to reproduce entirely. What’s
causing this mysterious drop in sperm counts—and is there any
way to reverse it before it’s too late?
• GQ Magazine
• BY DANIEL NOAH HALPERN
• September 4, 2018
Research into Systems Biology
• Reductionist analysis prevents study of multi-interventional
approaches
• Clinical practice must piece together research into discrete
interventions (fiber, folate, phytonutrients, redox status, vitamin D)
• Inherent limitations in translation of research into clinical protocols
• Research needed into systems approaches for chronic diseases

Long-Term Effects of Intensive Glucose Lowering on
Cardiovascular Outcomes
As compared with standard therapy, the use of intensive

therapy (glucose lowering) ...increased 5-year mortality.
Such a strategy cannot be recommended for high-risk
patients with advanced type 2 diabetes.
The ACCORD Study Group. Long-Term Effects of Intensive Glucose Lowering on Cardiovascular Outcomes. The New England journal of medicine. 2011;364(9):818-828. doi:10.1056/NEJMoa1006524.
200,000
DEATHS
since 1999
81% of Americans take at least one

medication a day…
40% of Cleveland Clinic patients take 10
medications or more
©2019
Used with permission from the

collection of Stanford Research Into
the Impact of Tobacco Advertising
(tobacco.stanford.edu).
Cumulative Incidence of Diabetes According to Study Group
Diabetes Prevention Program Research Group. N Engl J Med 2002;346:393-403

Effectiveness and Safety of a Novel Care Model for the
Management of Type 2 Diabetes at 1 Year: An Open-Label,
Non-Randomized, Controlled Study
Results:
• 60% of patients reversed their T2DM
• 94% of patients reduced or eliminated their insulin
• 1.3% = average reduction in HbA1c after one year
• 30 pounds = average weight loss after one year

• 3+ improved metabolic conditions
Hallberg SJ, McKenzie AL, Williams PT, et al. Author Correction: Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized,
Controlled Study. Diabetes Ther. 2018 Apr;9(2):613-621. doi: 10.1007/s13300-018-0386-4.
Do Drugs Fix Diabetes?
• Not a disease but a systemic disorder

• Multi-factorial etiology
• Treat causes or downstream symptoms?
• ACCORD study N Engl J Med. 2008 Jun 12;358(24)2545-59.
• 10,000 diabetics intensive glucose control

• Intensive treatment group had more deaths and heart attacks
• NAVIGATOR TRIALS: No benefit to risk factor reduction:

N Engl J Med. 2010 May 6;362(18):1748.
Statins and Diabetes
• 26,000 healthy people given statins to prevent
heart disease
• Result in 87% increase in type 2 diabetes!
• Women’s Health Initiative RCT:
• Statins increase diabetes risk 48%

Arch Intern Med. 2012 Jan 23;172(2):144-52.
PHARMAGEDDON
“It ain’t what you don’t know that gets you
into trouble. It’s what you know for sure
that just ain’t so.
Mark Twain
“The fox knows many little things, but
the hedgehog knows one big thing.
Isaiah Berlin
Complex vs Complexity
COMPLEX COMPLEXITY
• One can understand the • The final conditions are not
final condition by understood by
understanding the initial understanding the initial
condition conditions
• Linear • Chaos
“Complex issues are not merely sets of discrete elements. If we
are to have a genuine and lasting effect on obesity [chronic
disease] we need to change the fox-hedgehog ratio, develop our
understanding of complex adaptive systems, build on the
biomedical paradigm and move beyond linear thinking to create
new ways to conceptualize, explain and address these issues.”
Harry Rutter
Lancet, Vol 378, Aug 27, 2011
Now that you are depressed…
• As the infomercial says…

• But wait!...There’s more
• We have a plan
• And after the group activity we will get into that…
Who are You? How did you get Here?
• Go around your table

and introduce
yourselves to the
group
• Facilitators will rotate

to their tables and
introduce themselves
Understand broadly how to apply the
concepts of patient-centered care for
patients with chronic disease
Trying to
capture this
complexity
• The 10
component
Matrix
• Antecedents
• Triggers
• Mediators
• Modifiable
Personal Lifestyle
Factors
Functional Medicine
Whole Systems and Balance
Remove what causes imbalance

Provide what creates balance
The Exposome
90% of chronic disease is driven by environment – the exposome, not the genome.
Exposome:
External
Environment: Internal
Reactive
Chemical Electrophiles,
Radiation Environment: Metals,
Xenobiotics,
Stress Endocrine
Inflammation,
Life-Style Preexisting Disruptors,
Drugs disease, Lipid Immune
peroxidation,
Diet Oxidative
Modulators,
Pollution Stress, Gut Receptor
flora Binding
Proteins
Rappaport SM. Implications of the exposome for exposure science. J Expo Sci Environ Epidemiol. 2011 Jan-Feb;21(1):5-9. doi: 10.1038/jes.2010.50.
Used with permission

Used with permission
Used with permission from Fine Art America. http://bit.ly/2sy3T62

Epigenetics: Feed Your Genes

21st Century Medicine
• Emergence: How genes are translated into our health and
disease patterns
• Exposome: How internal metabolic factors and
environment influences on our gene expression
• Epigenetics: How our environment shapes our structure
and function
• Nutrigenomics: How nutrients and phytochemicals speak

to our genes
• Sociogenomics: How social networks influence health and
disease
Chronic disease results from the emergence of
a disturbed metabolism
Lifestyle and environment are the

major factors altering gene
expression that results in

disturbed metabolism.
The Epigenetics Revolution

Epigenetics are inherited
• Epigenetics between the generations: We inherit more than just genes
• Date: July 17, 2017
• Source: Max-Planck-Gesellschaft
• Summary: We are more than the sum of our genes. Epigenetic
mechanisms modulated by environmental cues such as diet, disease or
our lifestyle take a major role in regulating the DNA by switching genes
on and off. It has been long debated if epigenetic modifications

accumulated throughout the entire life can cross the border of
generations and be inherited to children or even grand children. Now
researchers show robust evidence that not only the inherited DNA
itself but also the inherited epigenetic instructions contribute in
regulating gene expression in the offspring.
1.Zenk F, Loeser E, Schiavo R, Kilpert F, Bogdanovic O, Iovino N. Germ line-inherited H3K27me3 restricts enhancer function during maternal-to-zygotic transition. Science, Vol. 357, Issue 6347, pp.
212-216; July 14th, 2017 DOI: 10.1126/science.aam5339
How does food influence
human biology?
Beyond Calories
Food as Information
Dietary Composition
Properties of Food
• Energy – Calories
• Macronutrients (protein, fat, CHO)
• Micronutrients (vitamins and minerals)
• Fiber
• Phytonutrients
• Plant genome
• “Anti-nutrients”
• Epigenetic influence
• Influence on the microbiome
Food as Medicine
Through the Lens of the Matrix
HYPOTHESIS:
DISEASES DON’T EXIST!!
One Cause Many Disease
Cancer
Diabetes Cardiovascular
Inflammatory
Pancreatitis Chronic
Bowel
Inflammation Disease
Autoimmune Renal
Disease Disease
Arthritis
Is depression a Prozac deficiency?
I took my
I took my
Prozac
Prozac today!today
One Disease Many Causes Omega 3
Fatty acid
Social Isolation Low Thyroid
Vitamin D
Antibiotic use Depression Deficiency
Autoimmune
Disease Pre-Diabetes
Arthritis
“Functional medicine is a disruptive
technology that will overthrow the
tyranny of the diagnosis.”
Jeffrey Bland, PhD

Functional Medicine:
The Matrix
Principles
Fundamental Physiological Processes

Core Clinical Imbalances
SYSTEM IMBALANCES
UNDERLYING
CAUSES OF GENE Assimilation
DISEASE EXPRESSION Defense & Repair
Energy
Toxins Genomics Biotransformation
Allergens Proteomics Communication

Microbes Metabolomics Transport
Nutrition Epigenetics Structural
Stress Psycho-spiritual
Functional Medicine:
A Clinical Application of Systems Biology
• Networks of function and causality
• New architecture of thinking and evaluation
• Two key questions to identify imbalances
• Environment (primary causes) affects gene expression and basic
physiological systems
• Basic ingredients for optimal function
• 10 core clinical systems in health and disease
Antecedents
Triggers or Triggering Events
Prenatal
Preconception Birth
Current concerns
Signs, Symptoms or Diseases Reported

Principles
• Biochemical individuality – unique gene expression

• Patient centered vs. disease centered
• Dynamic balance between external and internal factors
• Web-like interconnectedness
• Health as positive vitality

• Enhancement of organ reserve
The Two Questions

Two Simple Questions:
Causes and Function
• Does this person need to be rid of something (toxic,

allergic, infectious, poor diet, stress)?
• Does this person have some unmet individual need

required for optimal function (SNP, epigenetic)?

Causes of Disease
Primary (Proximal)
Primary Causes of Disease
What do You Need to Get Rid of?
• Toxins (biologic, elemental, synthetic)

• Allergens (food, mold, dust, animal products,
pollens, chemicals)
• Microbes (bacteria, ticks, yeast, parasites, prions)
• Stress (physical, psychological)

• Poor diet (SAD)
“Ingredients”
for Optimal Function
What do You Need to Get to Thrive?
• Foods (protein, fats, carbohydrates, fiber)
• Vitamins, minerals, accessory or conditionally essential
nutrients, hormones
• Light, water, air
• Movement
• Sleep
• Rhythm
• Restoration
• Love, community, connection
• Meaning, purpose
Mastering Clinical Medicine
•Mastering the Story

•Mastering the Tools
•Mastering the Therapy
Mastering Functional Medicine

Mastering Medicine

Master of Healing

Mastering the Story: The Art of Healing
• Listen to the story

• Discover through dialogue
• Be inclusive vs. exclusive in the history
• Look for patterns that connect
• Assess the readiness to change

• Tell the story: Re-create meaning
• Connect, educate, inspire, motivate
• Activate nature – the greatest pharmacy
Ask Unexpected Questions
• What life events occurred just before or around the onset of

your illness?
• When were you last well?
• If you could erase 3 problems with a magic wand, what
would they be?

• What do you think caused or might be contributing to your
illness?
Important Clues: Follow the Trail
• Childhood illnesses/antibiotics/stresses
• Chemical/environmental sensitivities and history
(work, home, childhood)
• Digestive history
• Allergy history
• 7-day dietary history (food additives, gum, sweeteners, fiber,
carbohydrates, patterns of eating, stress and eating, eating disorders)
Important Clues: Follow the Trail
• Dental history (amalgams, root canals, etc.)

• Skin/ hair/ nails exam & history
• Medication use (NSAIDs, etc.)
• Supplement use (vitamins, etc.)
• Habits, stress, exercise

• The nutrition physical exam
Patterns that Connect: The Web
“It is a wonderful feeling to

recognize the unity of
complex phenomena that, to
direct observation, appear
to be quite separate things.
Albert Einstein
Antecedents
’
The Problem with Diagnostic Medicine
• Diagnosis is the end of inquiry, not a waypoint in the process of
understanding disease.
• It should be the beginning of asking a new set of questions,

based on systems theory.
• First, we can inquire about the pathology, but we must explore

the underlying mechanisms

leading to the observed Diagnosis is not the end, but the
pathology or dysfunction.
beginning of practice.
Martin H Fischer
MONDAY
Monday Morning
This is what it looks like…
Tools from the IFM Toolkit

The Map: The Journey
• Functional Medicine is NOT a test or treatment or

supplement
• It is a NEW WAY OF THINKING
• Focus on the map – the Matrix
• Focus on patterns and connections

• Focus on finding the causes that lead to the clinical
imbalances
• Focus on learning how to create balance
THE SOCIAL CURE
Chronic Illness is a Social Disease

What is the Social Cure?
How do you create sustainable biological

and behavior change?
SOCIOgenomics
How do people change behavior?
• Social networks
• Feedback systems
Christakis NA, Fowler JH. The spread of obesity in a large social network over
32 years. N Engl J Med. 2007 Jul 26;357(4):370-9. Epub 2007 Jul 25.
Network or systems medicine
Framingham Data > 12,000
• 171% increase risk

obesity if friend is obese
• 40% risk if sibling is
obese
• 20% risk if friend of
friend is obese
Barabási AL. Network medicine--from obesity to the "diseasome".
N Engl J Med. 2007 Jul 26;357(4):404-7. Epub 2007 Jul 25.
How Would You Treat Disease “X”?
I do not treat disease. I treat people and their unique relationship
to the world.
• How?
• Take a comprehensive history.
• Do a comprehensive physical exam.
• Include a nutritional physical exam.

• Look at current diagnosis list and do test/consults as need to
rule in or out. Come to solid diagnosis (The Beginning)
Nutrition-Oriented Physical Exam- N Sight
• Free automatic
enrollment when you
registered for this
conference
• Available through
 Free instructional videos your account

 Free quick reference guides for: “Dashboard” on the
• Blood Pressure website (IFM.org)
• Dental
• Skin
• Nails
• Listen carefully to the patient’s story.
• Create a timeline.
• Create a matrix.
• Pull out the most important ATMs.
• Look for areas of leverage.
• Unless there is a compelling reason to do otherwise,

start with the gut.
• Be the copy editor to the re-authoring of their story. (Story
Retold)
• Re-ignite hope.
Ask Unexpected Questions
• What life events occurred just before or around the onset of your
illness?
• When were you last well?
• Explore this for clues to ATM
• Create a list of problems ranked in important to the patient
• Look at progression (TIMELINE).

• What do you think caused or might be contributing to your illness?
• Employ the wisdom of your patients.
Following Important Clues
• Childhood illnesses/antibiotics/stresses
• Chemical/environmental sensitivities and history (work, home,
childhood)
• Digestive history
• Allergy history
• 7-day dietary history (food additives, gum, sweeteners, fiber,
carbohydrates, patterns of eating, stress and eating, eating
disorders)
Following Important Clues
• Dental history (amalgams, root canals, etc.)

• Skin/ hair/ nails exam & history
• Medication use (NSAIDs, etc.)
• Supplement use (vitamins, etc.)
• Habits, stress, exercise

• The nutrition physical exam (to come)
• GoToIt
• Timeline
• Matrix
• ATMs
• Unless there is a compelling reason to do

otherwise start in the gut
• DIGIN
• 5R
• Look at other parts of the Matrix
•Tell
•Track
•Order
•Gather
•Initiate
•Organize
Birth
Genes
Environment
Genes
“You”
“Phenotype”
Environment
What Are Our Points Of Leverage?
Look to the
• Timeline
• Matrix
• ATMs
Points Of Leverage
Touch back to the model to clarify the
most important ATMs
Antecedents
experiences, past illness, occupational exposure,
nutrition, lifestyle
Triggers
microbes, allergens, trauma, toxins, etc.
Feed-
Mediators forward
cycle
cytokines, prostanoids, nitric oxide, kinins,
hormones, neurotransmitters, free radicals
Antecedents, Triggers, And Mediators
Antecedents Triggers Mediators
Congenital Trauma Hormones, Cytokines, etc.

Microbes Ions
Demographic
Antigens ROS
Dietary
Environmental Toxins Metabolites
Habitual
Radiation Thoughts
Environmental Social Interactions Beliefs
Occupational Memories Social Reinforcement

Learned Diverse Sensory Stimuli Classical Conditioning
Traumatic
Disease-induced
Drug-induced
Do I Have Enough Information?
Can I treat empirically?

Family history (genetic predisposition), trauma, toxicity, intrauterine
history, sexual abuse, intestinal permeability, infection, dietary
insufficiencies, drug use
Antecedents
Triggers or Triggering Events
Physical or psychic trauma, microbes, toxins, memories,
stressful event, surgery, infection, etc.
Mediators/Perpetuators
Inflammatory cytokines, ongoing psychological stress,
ongoing exposure to environmental insults i.e. mold,
chronic sleep deprivation.
Triggering Events
Structural Integrity Energy
Clues about etiology:

“Why are they having a problem?”
Transport


Physiology and Function: Organizing the Patient’s Clinical Imbalances
Antecedents
(Predisposing Factors-
Genetic/Environmental)
Who is the patient on a

fundamental level?
Triggering Events
What is their individual
(Activators)
experience?
How do they relate to
the problem?
Mediators/Perpetuators
(Contributors)

Sleep & Relaxation Nutrition & Hydration Stress & Resilience Relationships & Networks

Points Of Leverage
• Touch back to the model to clarify the most important ATMs.

• Touch back to the model to clarify who this patient is?
• Touch back to the model to focus on foundational lifestyle
factors for that particular patient.
©1998 Rob Rogers / www.robrogers.comReprinted with permission.

Triggering Events
Structural Integrity Energy
Mediators/Perpetuators These are things we can do

Spiritualto help the
Communication Biotransformation & Elimination
Transport
patient or how the patient can help
themselves.

(Predisposing Factors- (e.g., Digestion, Absorption, (e.g., Immune, Inflammation,
Genetic/Environmental) Microbiota/GI, Respiration) Infection/Microbiota)
Triggering Events
(Activators) Structural Integrity Energy
(e.g., from Subcellular Membranes to (e.g., Energy Regulation,
e.g., cognitive e.g., emotional
Musculoskeletal Structure) Mitochondrial Function)
function, regulation, grief,
perceptual patterns sadness, anger, etc.
e.g., meaning & purpose,

relationship with something
greater
(Contributors) (e.g., Endocrine, Neurotransmitters, (e.g., Toxicity, Detoxification)
Circulation
Immune messengers)
(e.g., Cardiovascular, Lymphatic System
Fluid Balance)

Nutrition & Hydration Stress & Resilience Relationships & Networks
Sleep and
Relaxation

Triggering Events
Musculoskeletal Structure) e.g., cognitive function, e.g., emotional
Mitochondrial Function)
perceptual patterns regulation, grief,
sadness, anger, etc.

greater
(Contributors) (e.g., Endocrine, Neurotransmitters, Immune (e.g., Toxicity, Detoxification)
messengers) Transport
(e.g., Cardiovascular, Lymphatic System)

Sleep & Relaxation Nutrition & Hydration Stress & Resilience Relationships & Networks
Exercise &
Movement

Triggering Events
Musculoskeletal Structure) e.g., cognitive e.g., emotional

greater
Immune messengers) Circulation
(e.g., Cardiovascular, Lymphatic System

Fluid Balance)

Sleep & Relaxation Stress & Resilience Relationships & Networks
Nutrition &
Hydration
Nutrition

Triggering Events
Musculoskeletal Structure) e.g., cognitive e.g., emotional

greater
Immune messengers) Transport
(e.g., Cardiovascular, Lymphatic System)

Sleep & Relaxation Nutrition & Hydration Relationships & Networks
Stress &
Resilience
Stress

Relationships
Do I Have Enough Information?
Can I treat empirically?

More Powerful Than Many Biomarkers
• Story
• Meaning
• Validation
• Context
• Relationship
• Empathy
• Compassion
• Love
A subpopulation of the town of
Roseto had vary low risk of heart
disease.
The
Roseto
A decades-long investigation showed
that it was not the diet, lifestyle or
Story other conventional risk factors

responsible for the low disease rate.
An Anatomy of Health
It was the multigenerational family
John G. Bruhn and Stewart Wolf life, strong community ties and a
sense of purpose, community and
place.
Points Of Leverage
• Touch back to the model to clarify the most important ATMs.
• Touch back to the model to clarify who this patient is?
• Touch back to the model to focus on foundational lifestyle
factors for that particular patient.
• Touch back to the model to be comfortable with the clinical
imbalances of ‘assimilation and structural integrity’ and the GI

tract first.
Functional Medicine
Changing the way we do medicine,
and the medicine we do.
If you want to travel swiftly, travel alone.
If you want to travel far, travel together.
African Proverb

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Introduction to Functional Medicine:

Redefining Disease Applied Systems Medicine

Applying Functional Medicine in Clinical Practice

Tom Sult, MD, disclosed he was a medical advisor for

1. Distinguish the key differences between conventional medicine and

3. Understand broadly how to apply concepts of patient-centered care

“Evidence-based medicine is the conscientious, explicit, and judicious use

evidence from systematic research…

decision-making and stresses the examination of evidence from

• There is increasing concern that most current published research findings

for a research claim to be false than true.

Furthermore, even in the absence of any bias,

them finds a formally statistically significant

“The reversal of established medical practice is common

An empirical evaluation of Cochrane reviews in 2004 showed

changed, with the percentage of insufficient evidence remaining

designed controlled clinical trials becomes available, physicians

• John is a 37 year old Dx with ulcerative colitis 2 years ago.

• Within 3 months he had a relapse with symptoms worse

• He was placed on an escalating number and strength of meds.

• He was scheduled for a colectomy with ostomy

• John is desperate to avoid a colectomy

• However, he does have a strong social support network

• I used the IFM tools and techniques

• Full term, breast fed

• Developed anxiety in junior high that escalated throughout life

• MGM Depression, Anxiety

• Symptoms of IBS developed at time of job stress.

• Glutamine, Probiotic, Serum Derived Immunoglobulins, Fish

birth, OM IBS Symptoms

Sensitive stomach Diagnosed

Mediators/Perpetuators Communication Spiritual Biotransformation & Elimination

Personalizing Lifestyle Factors

• In the first week John stabilizes and starts to improve slightly

• At 9 months he is still doing well so we wean of the meds.

• After a lot of dietary, supplement, and life style manipulation

• Functional Medicine STARTS with good medicine

• Functional Medicine is not as good as conventional medicine

• Conventional Medicine = big problems that need big

look like a nail.”

Used with Permission.

regarded as the father of medicine.

WE HAVE MAP OF CHINA BUT WE ARE STANDING HERE

1 Essays in Biochemistry. 62 (4): 487–500.

We must teach aspiring physicians about systems science…Medical

unabated, economically unsustainable burden of disease.

Marvasti FF, Stafford RS. From “Sick Care”

DNA (Transcribes to)

Protein (Results in)

…and every step is under more control, feedback and

The Undiscovered Organ…

• Most drugs work really well

tails of the normal

Loss of adaptive homeodynamic balance

was at one time general.

…The conclusion is that all disease is disordered function.

Willoughby F. Wade, BA, MB, Physician to the General

Delivered as a Clinical Lecture on Functional Medicine,

Published in the July 1,1871 issue of The Lancet

Clinical Lecture ON FUNCTIONAL MEDICINE. The Lancet. 1871;98(2496):3-5. doi:10.1016/s0140-6736(02)77096-7.

No Data <14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9% > 26.0%

No Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% >9.0%

Data: World Economic Forum 2011

Why? Have our Genes Changed?