The Case of the Concentration Camp Survivor with Diarrhea

Transcription

1 The Case of the Concentration Camp Survivor with Diarrhea Ruth DeBusk, PhD, RD Michael Stone, MD, MS Functional Nutrition Course Hollywood, Florida December 2010

2 Disclosures RUTH DEBUSK, PHD, RD is an Independent Contractor and/or on the Speakers Bureau for Interleukin Genetics, Inc. and is a Scientific Advisory Board Member for Nutrilite/Alticor. MICHAEL STONE, MD has indicated he has no financial relationships with any relevant commercial supporter or with the manufacturer of any commercial product or provider of any commercial ilservice relevant tto this activity.

3 Antecedents Triggers Mediators Preconception Prenatal Birth Current concerns 89 y/o white female with nonspecific abdominal pain, diarrhea Signs, Symptoms or Disease Reported

4 High functioning 89 y/o white female concentration camp survivor CC: nonspecific abdominal pain, diarrhea PMH: irritable bowel syndrome throughout life, recurrent UTIs with Abx therapy, pernicious anemia, arsenic exposure, peripheral p neuropathy, depression Diet: thin, poor intake/quality, food sensitivities Rx: proton pump inhibitor, statin, sensitivities

5 Past Medical History Irritable bowel Sx Recurrent UTIs, ABx Sinusitis/allergic rhinitis, bronchitis Peripheral neuropathy Pernicious anemia Osteoarthritis Osteoporosis Hypothyroidism Hyperlipidemia Hypertension Hiatal hernia w/ GERD Carpal tunnel Colonic polyps w/ diverticuli Hemorrhoid Arsenic exposure

6 Previous Events Concentration camp: inadequate food, unprotected sex Recurrent UTIs, recent hx Abx Past Surgical Hx remarkable for: Hysterectomy, t 43 yr ago Carpal tunnel release, 1 yr ago Wt Hx Lifelong thinness Allergies Intolerant to most foods Multiple med allergies Current Medications PPI: Esomeprazole T4: Thyroid hormone Statin combo: anti-lipidemic Anti-hypertensive: valsartan Sleep aid: zolpidem Anxiolytic: clonazepam Bone builder: risedronate Antihistamine: fexofenadine Corticosteroid: fluticasone

7 ADIME Assess Diagnose Intervene Monitor & Evaluatel t

8 The ABCDs Of Nutritional Assessment A C B D Anthropometric Biomarkers & Labs Clinical Indicators Diet & Lifestyle Assessment

9 A Anthropometrics Anthropometrics Biomarkers & Labs Clinical Indicators Diet & Lifestyle Assessment

10 Anthropometrics & Vitals Ht/Wt 64 in/103 lb BMI 17.7 Body Fat 21% Fat-free Mass 79% Dehydration Yes

11 Question 1. Which h patterns do you recognize and which labs would you key in on?

12 B Biomarkers & Labs Anthropometrics Biomarkers & Labs Clinical Indicators Diet Assessment

13 Biomarkers and Labs What are our options? Conventional labs Functional labs Comprehensive Digestive Stool Analysis Food sensitivity testing Nutrigenetic labs Phase I and Phase II detoxification panel

14 P O M F A B R I I A T N T V I O T E I I O X L N S O E L S R U I A B D A T A M I N L L N E T S S N

15 P WNL O HDL-C 42, LDL-C 162 RBC FAs: n-3 and n-9, n-6:n-3 M Hgb, g, Hct, ferritin; Cu:Zn; ; RBC Mg g 4.4 F 25-OH D 35.7 A dietary antioxidants B B12 and folate

16 P O M WNL HDL-C, LDL-C TG RBC fatty acids: n-3, n-9, n-6:n-3 3 Hgb, Hct, Cu:Zn, RBC Mg F 25-OH vitamin D A Low B B , folate 10.9; MCV 92, MCH 31, MCHC 34, MPV 9, RDW 14.7

17 Comprehensive Digestive Stool Analysis

18 Stool Analysis Friendly fl flora 2010, The Institute for Functional Medicine Pathogens

19 Microbial Susceptibilities

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21 Stool Analysis: Inflammatory Markers Lactoferrin WBC WNL Mucus WNL Secretory IgA WNL

22 Stool Analysis: Inflammatory Markers Lactoferrin

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24 Butyrate 2010, The Institute for Functional Medicine

25 Food Sensitivity Panel IgG positive for multiple foods: Egg whites Almonds Banana Beef Lactose-intolerant

26 C Clinical Indicators Anthropometrics Biomarkers & Labs Clinical Indicators Diet Assessment

27 Clinical Indicators MSQ 169, Digestive Tract 26 Underweight, sarcopenia Irritable bowel syndrome Essential fatty acids signs B12 signs Iron signs Hypothyroid signs Joint swelling and pain TMJ pain, ill-fitting dentures

28 Clinical Indicators MSQ 169 w/ emphasis on digestive tract symptoms Nutrition physical exam Underweight, sarcopenia Dehydrated d Irritable bowel Sx Hypothyroid indicators (dull hair, dry skin) B12 indicators (foot drop, anemia, decreased d vibratory sense) Iron indicators (pale skin) Essential fatty acid indicators (dry skin) Joint swelling and pain (shoulder, hands) Carpal tunnel Sx Rt. hand TMJ pain Ill-fitting dentures

29 Multi-system Questionnaire total score = 169 Head 11 Eyes 11 Ears 5 Nose 12 Mouth/throat 12 Skin 7 Energy/activity 12 Mind 10 Heart 8 Lungs 12 Digestive tract 26 Joints 20 Weight 2 Emotions 14 Goal = <50 total

30 MSQ GI Tract Digestive tract Nausea/vomiting 2 Diarrhea 4 Constipation 4 Bloated feeling 4 Belching/gas 4 Heartburn 4 Intestinal/stomach pain 4 Total score 26

31 D Diet & Lifestyle Assessment Anthropometrics BioMarkers & Labs Clinical Indicators Diet and Lifestyle Assessment

32 Diet Inadequate calories Restricted diet Many food intolerances Craves sweets, breads Food/Med Interactions Proton pump p inhibitor Sleep Nocturia, fatigue

33 Diet (see EAT worksheet) Inadequate caloric intake Restricted diet, with inadequate energy, e protein, carbs, essential fatty acids, vitamins, minerals, dietary fiber Few fruits and vegetables Numerous food intolerances Craves sugar, chocolate, bread No MVI w/ min Food/Med Interactions PPI Physical Activity Sedentary Sunshine Limited exposure Sleep Nocturia, fatigue Social connections Positive relationships Other Potential ti Problems Ill-fitting dentures

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35 EAT Worksheet, p. 2

36 ADIME Assess Diagnose Intervene Monitor & Evaluatel t

37 Question 2. What s your diagnosis?

38 Question 3. What are your top 3 priorities?

39 ADIME Assess Diagnose Intervene Monitor & Evaluatel t

40 Liver detoxification pathways and supportive nutrients

41 Question 4. What is an appropriate intervention plan?

42 5R Gut Restoration Program Remove Pathogens, food sensitivities, proton pump inhibitor Replace Digestive enzymes, gastric acid, essential fatty acids Calories, antioxidant foods, daily multi Reinoculate Probiotics with prebiotics Repair L-glutamine Anti-inflammatory therapy Rebalance

43 5R Program Remove Eliminate pathogenic microbes Eliminate foods to which sensitive Proton pump inhibitor Replace Digestive enzymes and gastric acid Essential fatty acids Food in general see next slide Daily multivitamin w/ minerals Reinoculate Probiotics w/ prebiotics Repair L-glutamine Anti-inflammatory therapy Rebalance

44 Food pattern Other Indications Increased calories Small frequent meals Protein higher at breakfast, moderate at lunch, lightest at dinner, with high carb dinner (depression) Essential fatty acids diet and supplements B12 food, injection, or supplementation Replace minerals d/t low intake + PPI Sunshine + supplemental vitamin D3; light box? Physical activity, as tolerated Work w/ PCP on medication list

45 Summary of Therapy Diet improvement + 5R GI program Other issues: Suspected achlorhydria Amino acid panel (neurotransmitter problems) Nutrigenetic panel (methylation, impaired detox) Adrenal testing

46 Summary of Therapy Diet improvement + 5R gut restoration program Other issues: Any other issues the nutrition professional should discuss with the physician? Suspected achlorhydria: Gas, bloating, cramping Dull hair and hair loss Labs told us low minerals (Fe, Mg, Cr, Se, Zn:Cu ratio) Amino acid panel (neurotransmitter problems) Nutrigenetic panel (methylation, impaired detoxification) Adrenal testing

47 ADIME Assess Diagnose Intervene Monitor & Evaluatel t

48 Subsequent MSQ % decrease Post (Pre) Digestive tract Nausea, vomiting 0 (2) Diarrhea 0 (4) Constipation 0 (4) Bloated 3 (4) Belching/gas 3 (4) Heartburn 2 (4) Intestinal stomach pain 2 (4) Total Score (original score) 9 (26)

49 A D I A D I A D I A D I A D I A D I A D I A D I A D I A D I I M E I M E I M E I M E I M E I M E I M E I M E I M E I M E

50 Nutrition Status Nutrition Status Nutrition Status Nutrition Status Nutrition Status Nutrition Status Nutrition Status Nutrition Status

51 Nutrition Professional and the Primary Provider working the complexity of the problem: What additional changes would you introduce in the Continued dhealth Improvement Program in light of the detox challenges? Which interventions would you delay until the patient is physiologically stronger? How would you assess when she is ready for more aggressive interventions?

52 Other Options to Consider Hypochlorhydria/Small Intestinal Bacterial Overgrowth Organic acids testing Protein malnutrition, mood imbalances Amino acid panel Adrenal insufficiency Adrenal panel Mitochondrial insufficiency, fatigue symptoms Organic acids testing for Krebs cycle intermediates Arsenic toxicity 24 hr urine heavy metal testing, with challenge Detoxification capability Nutrigenetic profile for Phase I and II

53 Organic Acids Panel Small Bowel Overgrowth

54 Amino Aid Acid Panel Low across the board:

55 Adrenal Insufficiency i

56 Arsenic toxicity

57 REASSESSMENT and RETESTING Returning to the Matrix HPATG Axis evaluation Biotransformation and Detoxification Assessment Nutrigenetic testing of Phase 1 and Phase 2 biotransformation

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59 Phase I Detox Nutrigenetic Panel

60 Phase II Detox Nutrigenetic Panel

61 Nutrition Professional and the Primary Provider working the complexity of the problem: Outline one or two additional changes in the Continued Health Improvement Program that you would suggest in light of the HPATG and biotransformation challenges. What interventions would you stage and delay until the patient is physiologically stronger? How would you assess when she is ready for more aggressive interventions?