A good introduction to functional medicine, and the many issues plaguing the medical, insurance, and health world of today. Very stats heavy, I would have liked more actionable takeaways.
Functional Medicine guides the clinician to a more comprehensive view of the whole organism, not just organs—the whole system, not just the symptoms.
Most chronic disease is preventable, and much of it is reversible, if a comprehensive, individualized approach addressing genetics, diet, nutrition, environmental exposures, stress, exercise, and psycho-spiritual needs is implemented through integrated clinical teams based on emerging research (ACPM 2009).
I knew that the “expert model” of simply telling the patient what to do, and expecting her to follow through, wasn’t enough. (We’ll find out why later in the book.)
Our genetic code is hard-wired for a specific environment. When that environment changes faster than our genes can evolve, a mismatch occurs. As we’ll see later in the book, this mismatch is the primary driver of the chronic disease epidemic.
A paper published by researchers at the University of Southern California found that although lifespans for both men and women increased in the U.S. over the past forty years, so too did the proportion of time spent living with disability and chronic disease. “We could be increasing the length of poor-quality life more than good-quality life,” said lead author Eileen Crimmins, USC University Professor and AARP Professor of Gerontology at the USC Davis School of Gerontology (Crimmins et al. 2016).
Recent studies suggest that today’s children are the first generation expected to live shorter lifespans than their parents (Olshansky et al. 2005). This should serve as a wake-up call, since life expectancy has been on an upward trend in the industrialized world (a few temporary dips during pandemics notwithstanding) for as long as we’ve been measuring it.
One in two Americans now has a chronic disease, and one in four has multiple chronic diseases.
The financial burden of chronic disease is so enormous it’s hard to comprehend. The U.S. spends $3.2 trillion a year on healthcare (Munro 2015). This is equivalent to 18 percent of our gross domestic product, or roughly $10,000 for every man, woman, and child in America. This might not be so bad if these stratospheric expenditures led to superior results. They don’t. Although our healthcare system is the most expensive in the world by far, on many measures of performance, it ranks last out of eleven developed countries (Schneider et al. 2017).
A new report from the Centers for Disease Control (CDC) found that 100 million Americans—nearly one in three—have either prediabetes or diabetes (CDC 2017b). A full 88 percent of people with prediabetes don’t know that they have it, which is significant because statistics show that prediabetes progresses to full-fledged type 2 diabetes in just five years if untreated.
50 million Americans (approximately one in six) have an autoimmune disease. In comparison, cancer affects 9 million Americans and heart disease 22 million. Researchers have identified 80–100 autoimmune diseases and suspect at least forty additional diseases of having an autoimmune basis (AARDA 2017).
A recent study documented a 52 percent decline in sperm concentration and a 59 percent decline in total sperm count in men over a nearly forty-year period ending in 2011 (Levine et al. 2017). A decline in sperm count and concentration leads to a decreased probability of conception. The authors of the study speculated that increased exposure to endocrine disrupting chemicals in the environment may be partly to blame for this trend.
Finally, according to the latest estimates, one in forty-five children now have autism spectrum disorder, up from just one in 500 in 1999 (Zablotsky et al. 2015). This is not only due to increased rates of detection. More children will be diagnosed with autism this year than AIDS, diabetes, and cancer combined. The effects of autism are debilitating, far-reaching, and lifelong.
the goals of insurance companies are not always aligned with patient needs, nor with doctors’ needs. Insurance companies profit when healthcare expenditures grow. Because of this, there’s little motivation for insurance companies to embrace treatments that would ultimately shrink spending on health care.
Two-thirds of medical research is sponsored by pharmaceutical companies, and conflicts of interest, groupthink, and a failure to replicate many findings undermine the credibility of the studies that form the edifice of our current medical paradigm.
Because we rely on insurance companies to pay for care, the treatments offered are not necessarily the most effective or those supported by the most current evidence—they’re simply the treatments that insurance companies have agreed to reimburse. This is not evidence-based medicine, it’s reimbursement-based medicine.
Our genes and our biology adapted over tens of thousands of generations to allow us to survive and thrive in that environment. But if that environment changes faster than our genes can adapt, mismatch occurs.
If you visualize the timeline of human history as a football field, you’ll see how quickly our environment has changed. A walk across most of that field—ninety-nine-and-a-half yards out of 100—represents the amount of time we lived as hunter-gatherers. The last half-yard represents the time since agriculture was developed. The Industrial Revolution came along only in the last few inches.
The top six foods in the American diet are grain-based desserts, bread, sugar-sweetened beverages, pizza, alcohol, and chicken—primarily fried dishes like chicken nuggets (DIAG 2010).
Every cell in our body is regulated by the natural light-dark cycle. When we change that cycle, our bodies suffer.
What happens when someone lies in bed at night with their iPad before going to sleep? The iPad emits blue light, which is like the spectrum of sunlight. When blue light hits the body, it sends a “time to wake-up” message. That not only interferes with sleep but has been shown to deregulate metabolism, promote weight gain, and cause cancer (Chepesiuk 2009). Changes to the circadian rhythm mediated by light exposure can have profound effects on health.
people might decide not to use electronic devices in bed before sleep. They might avoid shift work, or at least advocate for regular, rather than alternating, shifts. They could plan to get some exposure to bright sunlight in the morning before work. Just a week of camping, for instance, can reset the circadian rhythm (Wright et al. 2013).
What might be more surprising is the recent research indicating that going to the gym isn’t an adequate solution. If we look at exercise from an evolutionary perspective, we see that our ancestors moved all the time. They walked an average of 10,000 steps a day (Cordain and Friel 2005). They didn’t sit for long periods and they stood more than half the day.
If you work at a desk but go to the gym three or four times a week, you’ll meet the conventional guidelines for exercise, but you’ll still be at increased risk of disease because of all that sitting. Even marathon runners in training who spend most of the rest of their time sitting have an increased risk of death and disease (Möhlenkamp et al. 2008).
If someone is inactive, it’s more important for them to reduce the amount of time they’re sitting than it is for them to start a workout routine. The important change for them is to move from being completely sedentary to increasing their non-exercise physical activity.
What happens when there’s a 7-Eleven on every corner selling Big Gulps and jumbo bags of potato chips? We still eat it all, as if it were scarce. Yet we live in a food-abundant environment today. The same behavioral patterns that helped us survive in a natural environment now make it very likely we’re going to become overweight and develop metabolic problems and other chronic diseases.
Choosing a diet that is more closely aligned with our genome and epigenome acknowledges that, although our ancestral diet varied according to what was available, there were some common characteristics: There was no processed food. People ate some combination of meat, fish, wild fruit and vegetables, nuts and seeds, and starchy plants, no matter where they lived. They weren’t eating Ding Dongs, Cheez Doodles, and Big Gulps.
Our current medical paradigm is based more on managing disease and suppressing symptoms than it is on preventing and reversing disease, or promoting health.
In 1900, you might have visited a doctor for an accident or injury, a gallbladder attack or appendicitis, or an infection—not because you had an autoimmune condition, allergies, or asthma.
Today, the healthcare landscape has changed dramatically. Seven of the top ten causes of death are chronic diseases(NCCDPHP 2016). Unlike acute problems, chronic diseases are difficult to manage, expensive to treat, and usually last a lifetime. They don’t lend themselves to the “one problem, one doctor, one treatment” model that worked well in the past. Today’s patient has multiple problems, sees multiple doctors, and requires multiple treatments that go on for years if not decades.
Another reason that conventional medicine hasn’t been successful is that it focuses on suppressing symptoms rather than addressing the underlying cause of disease. Imagine you get a rock stuck in your shoe, and it makes your foot hurt. If you look for help in the current medical system, you may get a description of foot discomfort along with directions to the nearest drugstore for some extra-strength ibuprofen.
Recent studies, however, have found that 84 percent of the risk of chronic disease is not genetic, but environmental and behavioral (Rappaport 2016). Our genes do play a role in determining which diseases we’re predisposed to developing, but the choices we make about diet, physical activity, sleep, stress management, and other lifestyle factors are far more important determinants of our health.
The average visit with a primary care provider (PCP) in the U.S. lasts for just ten to twelve minutes (Yawn et al. 2003), with newer doctors spending as little as eight minutes with patients (Chen 2013).
Even if a provider makes a suggestion about diet or lifestyle change, will it be successful? It is now widely accepted that knowledge is not enough to change behavior. Yet doctors are trained in the “expert model” of simply telling people what to do, and expecting them to do it.
Suspecting that nutrition played a pivotal role in her patients’ chances of recovery, she picked up The Blood Sugar Solution by Mark Hyman, MD, one of the pioneers of Functional Medicine.
With one in two Americans suffering from chronic disease, and one in four suffering from multiple chronic diseases, not one of us is untouched by this epidemic.
Consider another patient, Sujata, who comes in with a history of frequent miscarriages. After genetic testing, we might find that Sujata has two copies of a polymorphism in the MTHFR gene. This would predispose her to having low folate levels, and a higher risk of miscarriage. We would recommend that Sujata boost her dietary folate intake—eat more dark, leafy greens, organ meat, lentils, etc. We may also suggest folate supplementation. Once again, we begin with the “inside” and work out, starting with a patient’s Exposome.
Within conventional medicine, pharmaceuticals are the primary treatment for almost 90 percent of all chronic conditions. At any given moment, roughly 50 percent of American adults, including nine of ten adults older than sixty, are taking at least one prescription drug. Almost a third of adults take two or more drugs. Almost 30 percent of all teens are now on a prescription drug, as are 20 percent of young children in the United States. America spent just under $310 billion on pharmaceutical drugs during 2015 (IMS Health 2016).
In conventional medicine, two patients with the same condition are likely to receive identical treatment. If Steve and Miranda go to the doctor’s office with psoriasis, both patients get the steroid cream, regardless of the underlying cause. The cream may help in both cases, but their skin problems are unlikely to go away completely because the cause hasn’t been addressed.
Inflammation in the gut can affect the brain, and high blood sugar can cause insulin resistance. Insulin resistance in turn affects the availability of glucose in the brain, which is why some people call Alzheimer’s “type 3 diabetes.”
He has restructured his Alzheimer’s investigations using this functional perspective, and he summarizes this revolutionary approach in his book, The End of Alzheimer’s: The First Program to Prevent and Reverse Cognitive Decline (Bredesen 2017).
Over the next several years, Dr. Wahls refined and expanded her protocol, and then introduced it to the public in her book The Wahls Protocol: A Radical New Way to Treat All Chronic Autoimmune Conditions Using Paleo Principles (Wahls 2014). Since then, thousands of people around the world have successfully treated their autoimmune conditions—not just MS, but other autoimmune problems like inflammatory bowel disease, Hashimoto’s, and rheumatoid arthritis—with the Wahls protocol.
Celiac disease has been linked with a wide variety of diseases outside of the intestine, such as type 1 diabetes, multiple sclerosis, heart failure, depression, arthritis, and dermatitis. This explains why CD can manifest with symptoms outside of the digestive tract, ranging from chronic headaches to dermatitis to joint pain to insomnia (Kresser 2013a).
In Functional Medicine, we start by asking why the couple is having trouble getting pregnant. The possibilities include nutrient deficiency, thyroid problems, sex hormone imbalance, inflammation, insulin resistance and blood sugar abnormalities, chronic stress, and environmental toxins—to name a few. Since infertility may be related to either partner, it is often necessary to test both to determine what the underlying issues are.
Studies have found that higher blood mercury levels are correlated with infertility in both men and women (Choy
Approximately 10 percent of our genes have shown signs of adaptation since the dawn of agriculture, while 90 percent are the same as they were during the hunter-gather period, which represents most of human evolution (Williamson et al. 2007).
I pointed out that humans lived in sync with the natural rhythms of light and dark until roughly 100 years ago when artificial light became commonplace. Other more recent changes, such as a growing number of people working indoors during the day and working night shifts, have also profoundly affected our exposure to light.
The modern diseases that countless people suffer from today, like heart disease, diabetes, and many autoimmune diseases, are nearly nonexistent in hunter-gatherer populations. It’s tempting to think that’s because hunter-gatherers didn’t get old enough to develop those diseases, but this isn’t true. The average lifespan of people living in Paleolithic hunter-gatherer cultures was shorter than our average lifespan today, but those averages don’t take into consideration the much higher rates of infant mortality and premature deaths from trauma, warfare, exposure to the elements, and complete lack of emergency medical care. Anthropologists have found that when hunter-gatherer cultures have access to even the most rudimentary form of emergency medical care, like a clinic half-a-day’s hike away, they live lifespans that are roughly equivalent to our own, particularly if they’re living in a relatively secure, peaceful environment (Gurven and Kaplan 2007). The
Along the same lines, the idea that no Paleolithic people ate grains or legumes has been recently challenged. Archeological evidence reveals that people consumed grain and legumes well before the dawn of the agricultural revolution (Henry et al. 2010). These foods may not have been staples, but people were harvesting them and eating them. This rigid idea that Paleolithic people didn’t eat any grains or legumes is probably not true.
Think about cats as an example. Cats are true carnivores. Their digestive tract and physiology evolved in response to eating exclusively animal products. If a cat eats grains and other foods unsuitable for a carnivore, they get sick and fail to thrive. You might have noticed that most higher quality cat foods have labels that say, “meat-only diet.” Advertisers promote that because veterinarians and zoologists have acknowledged that cats are carnivores, and it’s inappropriate to feed them a grains and kibble-type of diet. (Strangely, many pet owners have begun feeding their animals a more “genetically-aligned” diet, yet they haven’t yet embraced a similar approach for themselves.)
For 77,000 generations, the human diet consisted primarily of meat and fish, some wild fruits and vegetables, nuts and seeds, and some starchy plants, which varied regionally. All of those are whole foods. They’re nutrient-dense. They’re packed with micronutrients, vitamins and minerals, antioxidants, and they’re relatively low in calories. Most of these foods contain high amounts of water and fiber, which makes us feel full when we eat them.
In contrast, the diet we eat today is the opposite. We went from eating nutrient-dense, naturally low-calorie, anti-inflammatory food, to eating nutrient-depleted, calorie-dense, pro-inflammatory food.Our physical habits are also a far cry from what they were for most of human existence. Humans have been naturally active throughout history. Hunter-gather societies walked an average of 10,000 steps a day, and that walking was punctuated by briefer periods of more intense physical activity, like chasing down prey.
For most of human history, even up until about fifty to seventy years ago, humans lived in close-knit tribal and social groups, with multiple generations. This is how humans still live in many parts of the developing world. But in the modern industrialized world, we live in isolated nuclear family living arrangements. This relative isolation has arguably led to negative effects on our health and well-being. In fact, lack of social support is a bigger predictor of early death than body mass index, blood pressure, and even smoking up to fifteen cigarettes a day (Holt-Lunstad et al. 2010).
Hunting, gathering, building shelter, or other work required for living might take up three to four hours a day, although some populations worked longer than that. Still, there was ample time for leisure activities, including games, ceremonies, music, singing, dancing, traveling to other bands to visit friends and relatives, and even time for lying around and relaxing. In many ways, the life of the typical hunter-gatherer looks a lot like the modern life of someone on vacation!
Inflammation is a natural and normal process; in fact, we need it to heal. For example, if I get a cut on my hand, that area will become inflamed. The white blood cells and all the healing substances in my body travel through the blood to that area to protect the wound from any foreign organisms that might enter it and cause infection. The rush of the healing organisms leads to inflammation and simultaneously works to heal that area. Inflammation itself is not bad or evil; we need it to survive. But when inflammation happens inappropriately or doesn’t resolve, we have a problem. In the case of my cut, the inflammation only lasts a short while. It does what it’s supposed to do, and then it resolves. In the diseases named above, the inflammation becomes chronic. The normally protective immune system starts to cause damage to its own tissues, so the body responds as if normal tissues are infected or abnormal.
Even in the U.S., obesity has only become epidemic over the last fifty years. In 1960, just 13 percent of Americans were obese, compared to nearly 37 percent today. That’s a nearly three-fold increase in just half a century. There’s no way our genes alone can explain this. Fifty years is simply not enough time for such meaningful changes to occur.
In fact, 90 percent of universities relied solely on the researchers themselves to decide whether to report their potential conflicts of interest. Half of universities don’t ask their faculty to disclose the amount of money or stock they earn from drug or device makers. True objectivity in scientific research is not as common as we think.
the Open Science Collaboration tried to replicate 100 published psychology studies under conditions identical to the original research, and 65 percent of the studies failed to replicate the results (Open Science Collaborators 2015). The problem is not just in psychology. In 2011, a group of researchers from Bayer looked at sixty-seven blockbuster drug discovery trials published in prestigious journals; they found that 75 percent of them could not be reproduced (Hartung 2013). Another study of cancer research found that only 11 percent of pre-clinical cancer research could be reproduced (Begley and Ellis 2012).
Consider the Maasai, a tribe in Kenya and Northern Tanzania that gets two-thirds of its calories from fat. They consume 600-2,000 mg of cholesterol a day. In contrast, the American Heart Association (AHA) recommends consuming under 300 mg of cholesterol a day. (As of 2017, the AHA no longer suggests restricting cholesterol intake, due to overwhelming evidence indicating that there is no benefit to doing so.) The Maasai, however, have low blood pressure, low cholesterol, few gallstones, and little atherosclerosis (Bhatia 2012).
Observational evidence like this should also spur us to critically examine other research on the topic. When we do that in the case of saturated fat and heart disease, the connection is a lot murkier than the AHA would have you believe. Although saturated fat does raise blood cholesterol levels in some studies, it has no effect in many others (Mensink et al. 2003). More importantly, large reviews have found no direct relationship between saturated fat intake and heart disease (Siri-Tarino et al. 2010), and people who eat more saturated fat have lower rates of stroke (Yamagishi et al. 2010). Should we be concerned when saturated fat increases cholesterol if that does not translate into a greater risk of heart disease (and may even reduce the risk of stroke)?
Goldhill is arguing that his cardiologist told him he needed to eat more fish, fruits, and vegetables, and less ice cream, burgers, and donuts—or, just take a statin. The implication is that these two approaches are equivalent, as if a statin will have the same impact of not eating donuts and ice cream. This exemplifies the natural consequences of a system that puts most of its emphasis on drugs.
When patients grow accustomed to being passive recipients of care, rather than being actively engaged in their own lifestyle changes, symptomatic problems will persist, and root cause healing will elude them.
How would we approach an asthmatic patient in the ADAPT Framework? Many aspects of the modern diet and lifestyle have been identified as contributors to asthma, such as processed and refined food, sensitivities to food additives and dyes, and environmental toxins (especially airborne toxins). Research has found that a sedentary lifestyle, chronic stress, and sleep deprivation can all be contributing factors, too. Our modern diet and lifestyle—so clearly mismatched to how humans were made to function—make this problem more common.
Many of the assumptions made in this scenario turned out to be problematic. Research suggests that depression is not actually caused by low serotonin (Cowen and Browning 2015). Large reviews have shown that serotonin-based antidepressants may not be any more effective than placebos, at least for mild to moderate depression (Fournier et al. 2010). Even more concerning from a Functional Medicine perspective, the drugs don’t address the underlying causes of depression in a curative way.
One of the most recent theories about potential causes of depression is called the “Immune Cytokine Model of Depression” (Smith 2010; Kresser 2016). This theory holds that inflammation, often originating in the gut, produces chemical messengers called cytokines. These cytokines then travel through the blood stream, cross the blood brain barrier, and suppress the activity of the frontal cortex. That, in turn, causes the symptoms that we label as depression. If that’s the case, then the solution to depression is not to increase serotonin availability in the brain, but to reduce inflammation, particularly in the gut.
The CDC estimates that 11 percent of children four to seventeen years of age have been diagnosed with ADHD, and that diagnoses have increased by 42 percent in the last eight years (CDC 2017a).
One such theory is known as the “Three Hit Paradigm,” in which three key influences—or “hits”—combine and contribute to not only ADHD but other behavioral conditions in both children and adults (Slattery et al. 2016). The three hits are: Biome depletion: this refers to the depletion of the microbiome due to poor diet, overuse of antibiotics, and other aspects of the modern lifestyle. Environmental stimulus at critical times in development: e.g. acetaminophen exposure, vitamin D deficiency, antibiotic exposure, and other diet and lifestyle influences. Genetic and/or epigenetic predisposition.
If chronic disease continues to grow at the current pace, an insurance-based healthcare system is destined to fail. There’s just no way to effectively pay for the care needed in a country this large, when one in two adults and one in four children have a chronic disease. This is the “dirty secret” that no one wants to acknowledge.
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