2010, The Institute for Functional Medicine. Functional Nutrition Course Hollywood, Florida December 2010

Transcription

1 Case Presentation Day 2 Elizabeth Boham MD, MS, RD Mary Willis RD, CDE Functional Nutrition Course Hollywood, Florida December 2010

2 Disclosures ELZABETH BOHAM, MD, RD has indicated she has no financial relationships with any relevant commercial supporter or with the manufacturer of any commercial product or provider of any commercial service relevant to this activity MARY WLLS, RD has indicated she has no financial relationships with any relevant commercial supporter or with the manufacturer of any commercial product or provider of any commercial service relevant to this activity.

3 Building a Chronic Care Team Functional Nutrition Practitioner Patient Primary Care Provider

4 54 yo female Janet CC: Tired and overweight difficulty losing weight HP: MS Dx. age 38 and had attack of optic neuritis 1 yr ago and has gained 25 lbs each time given steroids Patient states feel consumed by my weight and previous husband wanted a thinner wife. Daily fatigue Has tried many different diet approaches

5 ADME Assess Diagnose ntervene Monitor & Evaluate

6 Tools for Assessment Completed by Patient: ntake Evaluationcontaining PMH, social Hx., 3 day food diary, fats and oils eval. MSQ Used by Health provider: Matrix- looking for pattern recognition, antecedents, triggers and mediators EATpomfab

7 Janet - PMH: Multiple sclerosis Fatigue Coronary Spasm - nitro Hypothyroid - Hashimoto s Thyroiditis - 20s Hypercholesterolemia HTN Asthma Chronic sinus issues Osteoarthritis BS GERD Pain nfertility - fertility meds for years, BCPs for years for hot flashes and irregular periods rregular Periods in the past Depression

8 Past Surgical History: Total hysterectomy y -age 45 Sinus surgery - age 50

9 Weight History Married at 110 lbs Gained 25 lbs each time she was placed on steroids for her MS Gained 80 lbs over the last 30 years Tried many different diets Weight consumes her Weighs her clothes separately and then subtracts that weight

10 Allergies and Medications: Allergies: Singulair (rash) Medications: Protonix Lipitor, Nitro, Cardizem, mdur MiraLAX, Requip Synthroid Zyrtec, Flonase, Flovent Valium, Cozaar, Femhrt Was on Copaxone and interferon for MS and recently went off and?s if she needs to go back on

11 Family History Mom - HTN, alcoholism - died 68 Dad - Heart Disease - died 49 Alcoholism Breast cancer HTN

12 MSQ

13 The ABCDs Of Nutritional Assessment A C B D Anthropometric Biomarkers & Labs Clinical ndicators Diet and Lifestyle Assessment

14 A Anthropometrics Anthropometrics BioMarkers & Labs Clinical ndicators Diet and Lifestyle Assessment

15 Anthropometrics: Ht inches Weight lbs Waist cir 36 in., Hip - 40 in. W/H BM 34

16 B Biomarkers & Labs Anthropometrics Biomarkers & Labs Clinical ndicators Diet and Lifestyle Assessment

17 Biomarkers and Labs Conventional labs 2 hr GTT glucose and insulin, HgA1C, hs- CRP, Liver enzymes, ttg ga Ab Expanded Lipid Profile, Apo A1 and Apo B Vitamin D Functional labs Food sensitivity testing - gg ntestinal Permeability Amino acids, fatty acid and organic acid profile Genetic labs HLA-DQ2 and HLA-DQ8

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19 P O M F A B

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21 gg testing

22 ntestinal Permeability

23 Labs 2 Hour GTT and nsulin: Blood sugar - fasting 85 1h 158 2h 173 nsulin - fasting 18 1h 217 2h 83 HgbA1c CRP NMR - LDL 99 - but very high small dense LDLs and pattern B on Lipitor

24 Particle Size Cholesterol - on Lipitor

25 Particle Size Testing on Lipitor it

26 C Clinical ndicators Anthropometrics Biomarkers & Labs Clinical ndicators Diet and Lifestyle Assessment

27 ROS General: nsomnia, hard to fall asleep, fatigue Skin: Dry skin, itchy hands, dark circles under eyes Head: Hair loss HEENT: Sinus congestion, PND, cough Breasts: Tenderness Respiratory: Dry cough Cardiac: Chest pain with stress esp - nitro

28 ROS (cont.) G: Constipation - MiraLAX daily, bloating, bleeding in stomach found on endoscopy from ibuprofen Urinary: ncontinence Genital: Now postmen., low libido, hot flashes, irritabilityit Musculoskeletal: Cramps, twitches Neurologic: Leg weakness and eye pain at times Endocrine: Cold hands, heat and cold intolerance Psychiatric: Anxiety and irritability

29 Physical Exam BP 148/88 Overweight women, slightly anxious General fluid retention puffy, no edema; dark circles under eyes, skin dry Thyroid normal, no masses Heart regular no murmurs Chest clear to auscultation Abdomen soft but excess abdominal weight gain

30 D Diet & Lifestyle Assessment Anthropometrics Biomarkers & Labs Clinical ndicators Diet and Lifestyle Assessment

31 E = EAT 3 Day Diet Diary

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33 Social/Lifestyle Hx: Married to second husband Good relationship now No children Has a family business Exercise - 3-4times per week k20min or aerobic with some weights; MS is somewhat limiting Drinks 7-10 drinks per week for stress management CAGE questions negative No recreational drug use or smoking

34 ADME Assess Diagnose ntervene Monitor & Evaluate

35 Come Back To The Matrix Nutrition Status- Long history of dieting, gluten intolerant, restless leg mmune / nflammation - High CRP, MS, optic neuritis, recurrent sinusitis Psychological - Emotional stress, coronary spasm Hormones History of irregular periods, perimenopausal, elevated insulin, pre-dm HbA1C, Cardiometabolic Syndrome, hypothyroid Oxidative / Reductive - Oxidative stress, HTN, hyperlipidemia Detoxification Fatty liver Digestion / Absorption - nflammatory foods, dysbiosis

36 mmune Surveillance and nflammatory Process high CRP, MS, optic neuritis, recurrent sinusitis FUNCTONAL MEDCNE MATRX MODEL - Janet Oxidative/Reductive Homeodynamics oxidative stress, HTN, hyperlipidemia, low HDL, small dense LDL Detoxification and Biotransformation Fatty liver Digestion and Absorption inflammatory foods, dysbiosis Constipation and bloating Gluten intolerant The Patient s Story Retold _ Antecedents (Predisposing) Hormone and Neurotransmitter Regulation history of irregular periods, perimenopausal p Cardiometabolic syndrome high insulin, Pre DM A1 C level, hypothyroid Structural and dmembrane ntegrity Triggering g Events (Activation) Psychological and Spiritual Equilibrium Emotional stress Coronary spasm with stress Nutrition Status long history of dieting and SAD, nflammatory foods, Gluten intolerant, Restless Legs Low RBC magnesium Exercise Sporadic Sleep Poor Sleep Beliefs & Self-Care Stress Relationships Supports Stress Date: Name: Age Sex Diagnoses: 2008 The nstitute for Functional Medicine

37 What Are Three of Janet s Antecedents? A. High alcohol intake, diet soda, yo-yo dieting B. Steroids, fertility medication, Antibiotics C. Family history CAD, HLA-DQ2+, SAD diet D. Low vitamin D, low RBC magnesium, High FGLU

38 What Are Janet s Top Three Triggers that Prevented Her from Losing Weight? A. Optic neuritis, coronary spasm, HTN B. Steroids, gluten intake, hormone imbalance C. Family Hx CAD, HLA-DQ2+, SAD Diet D. GERD, BS, chronic sinusitis

39 mmune Surveillance and nflammatory Process FUNCTONAL MEDCNE MATRX MODEL - Janet Oxidative/Reductive Homeodynamics Detoxification and Biotransformation Digestion and Absorption Structural and dmembrane ntegrity Nutrition Status The Patient s Story Retold Yo Yo Dieting St.Am.Diet Family Hx CAD _ Antecedents (Predisposing) HLA DQ2+ Triggering Events (Activation) M.S. and Steroids Chronic Sinus infections Fertility Meds and Hormone mbalance Hashimoto s Sleep Thyroiditis Multiple Medications Stress --- Alcohol Diet containing gluten Exercise Beliefs & Self-Care Hormone and Neurotransmitter Regulation Psychological and Spiritual Equilibrium Relationships Date: Name: Age Sex Diagnoses: 2008 The nstitute for Functional Medicine

40 A D A D A D A D A D A D A D A D A D A D M E M E M E M E M E M E M E M E M E M E

41 Going Back to Janet s 3 Day Food Diary and Functional Labs, What Would Be the Best Diet ntervention Strategy? A. Full elimination / cardiometabolic diet B. Calorie controlled / low fat diet C. DASH diet D. Gluten free diet

42 What Do We Do First? Change the terrain- alter the diet Food First: complete elimination diet with rice based medical food Diet to balance blood sugar and lipids Stop diet soda improved hydration Decrease alcohol Stop Protonix ncrease thyroid medication

43 What Supplement Regimen Would Best Complement Her Diet Changes to Decrease nflammation? A. High probiotic yogurt, fiber, calcium + vit D B. Complete multivitamin, calcium, OTC fish oil C. Fiber, adrenal support, iodine D. Glucomannan fiber, 2000mg of DHA + EPA fish oil, rice protein medical food

44 Supplements Glucomannan fiber- 2 with each meal Omega-3 fish oil 2000mg of DHA+EPA Vitamin D 5000U per day Vit. D3 Rice protein anti-inflammatory inflammatory medical food as part of elimination diet Magnesium citrate 150mg 1-6 per day depending on bowel tolerance Probiotics 30 billion twice a day

45 A D A D A D A D A D A D A D A D A D A D M E M E M E M E M E M E M E M E M E M E

46 What s the Most mportant Thing for You to Encourage Janet to Do to Stay Well? A. Follow up every 2 weeks with nutritionist titi i t B. Life long gluten free diet C. Cardiometabolic food plan D. 7-9 hours of good quality sleep per night E. All of the above

47 mproved Outcome: Janet 4 months later Symptoms of puffiness, bloating, constipation, sinuses pressure, GERD, chest pain ALL GONE. Fasting nsulin from to 18 to 4 Hs-CRP from 6.0 to 1.3 LFTs normal, BP normal off medication Lost 30 lbs MSQ from 137 to 22 Off all medications except thyroid Symptoms of MS relieved signs of optic neuritis gone while off of MS medication

48 Questions? Q & A