A Functional Medicine Physician's approach to an Overburdened Detoxification System

You must have heard that “we are what we eat”, but are we really just that? Actually “we are what we eat (or drink), breathe, breakdown, digest, absorb (from our gut and skin), and cannot eliminate from our body, whether it’s through our thoughts, skin, breath, urine and stool! Even though we are designed to have built-in detoxification and elimination pathways, they can get overwhelmed with years of toxin exposures which our bodies are now having to handle more so than ever before in our evolution history.

My job as a Functional Medicine physician involves around dealing mainly with chronic ailments. I usually have to be a medical detective trying to help patients who have been through the conventional medical system of diagnosis and treatment of a “disease” and have found no relief.
Below is a quick check list that I keep in my mind of patients who might have signs of an overburdened detox system. 

Those with:
1. Multiple Chemical Sensitivities (MCS):These patients react to just about everything- medications, nutritional supplements, foods, odors and chemicals in the environment!
2. Chronic neuropsychiatric conditions: Depression, Anxiety, Seasonal Affective disorders, Mood swings and refractory mood disorders, Chronic recurrent Headaches/ Migraines, ADHD, Learning Disorders, Autism Spectrum Disorders,
3. Neurodegenerative diseases: Parkinson’s disease, ALS, Alzheimer’s dementia, some forms of peripheral neuropathies, Multiple Sclerosis.
4. Mitochondrial disorders: Chronic Fatigue Syndrome, Fibromyalgia. Neurodegenerative disorders are also due to disturbances in mitochondrial energy production.
5. Immune system imbalance symptoms: frequent and chronic infections, allergies, asthma, eczema and other chronic dermatitis, autoimmune diseases (Hashimoto’s thyroiditis, Grave’s Disease, Rheumatoid Arthritis, Ulcerative Colitis to name a few), multiple food sensitivities, Dysbiosis (imbalance of gut bugs with possible Yeast Overgrowth or Small Intestinal Bacterial Overgrowth).
 6. Signs of endocrine disruption: male and female infertility, precocious puberty, PCOS, PMS, fibroids, chronic pelvic pain, endometriosis, adrenal fatigue, hypothyroidism.
7.  Metabolic Conditions: overweight, obesity, hypoglycemia, hyperglycemia, Insulin Resistance, Diabetes Mellitus Type 2.
8. Recurrent pregnancy losses, premature births9.  Cancers10. Chronic isolated low white cell counts (Leucopenia) or low red cell counts (Anemia) without any known associated cause.

You are probably aware that Functional Medicine practitioners usually take very detailed histories, do detailed examinations, and may do extensive specialized lab (Biomarker) testing. Not every test in the list below usually needs to be done on every patient. Based on clinical evaluation, the need for testing as well as the interventions are very individualized. For example, no two patients with type 2 diabetes or depression will have the same cause for it and thus testing and interventions will vary widely.

While the list below is by no means exhaustive, some general evaluation guidelines are:

1.       Detailed history and intake with the help of Medical Symptom Questionnaires, Toxicity and Exposure questionnaires, Environmental and Occupational Exposure Questionnaires.

2.       Detailed Nutritional, Dental and Physical examination.

3.       Conventional Lab tests: can be done from local labs like Labcorp/ Quest etc

·         Complete Blood Count looking for low white cell count, anemia, low patelet count.
·         Complete Metabolic Panel looking at liver enzymes, bilirubin levels, alkaline phosphatase, gamma glutamyl transferase levels.
·         Kidney Function Tests: Blood urea nitrogen, creatinine, cystatin C
·         Metabolic testing: Fasting and 2 hour post prandial insulin and blood sugar testing, fructosamine, hemoglobin A1C, detailed lipoprotein profile to assess for LDL and HDL particle numbers and sizes and other markers of inflammation specific to the vascular system
·         Indices like C-reactive protein, ferritin, fibrinogen to evaluate presence of inflammation.
·         Detailed thyroid function tests along with evaluation of antibodies against thyroid gland.
·         Iron absorption and storage assessment

4. Functional Labs to test for Biomarkers: These can be:

•  Stool Assessments: to look for growth of disease causing bacteria/yeast in the gut, and also to assess the balance of good vs bad bacteria in the gut; looking for parasites; markers of inflammation of the gut; markers of deficient detoxifications ability in the gut itself (which can lead to recirculation within our body of our own estrogens, cancer promoters and hormone mimickers from the environment, instead of them being eliminated in the stool); assessment of pancreatic enzymes production; looking for markers of healthy absorption vs malabsorption.

•  Assessment for nutritional deficiencies (of all fat and water soluble vitamins, minerals, essential amino acids, antioxidants {including the master antioxidant, glutathione}, essential fatty acids). Nutritional support is a key factor influencing the proper functioning of the different phases of detoxification as I have mentioned in my previous blog
•  Serum testing for food sensitivities (IgG), and environmental and food allergies (IgE).
•  Specialized genetic and antibody testing for Gluten as well as cross-reactive foods antibodies.
•  Saliva testing for male and female hormones and adrenal health. If you are placed on Bio-identical hormones, you must periodically also get testeded to see how the hormones are metabolized in your body, which can vary widely. If not adequately metabolized and detoxified these can increase the risk of cancer (like breast, prostate and other hormonally related cancers) development.
•  Testing for neurotransmitter levels, as well as balance/imbalance between the excitatory and inhibitory neurotransmitters. This can be helpful in patients with anxiety, depression, attention problems or chronic sleep issues.

•  Looking for heavy metal toxic burden on the body, if indicated by a detailed clinical evaluation. One example of this would be if you have silver mercury amalgam(s) in your teeth especially old ones.

•  Assessment for signs of oxidative stress or damage (similar to rusting of iron that occurs in nature on exposure to oxygen) to the body due to toxins: these tests look for markers of DNA damage, as well as damage to circulating fats (lipids) in the blood. Damage (aka oxidation) to LDL, the bad cholesterol, may lead to coronary artery disease.

•  If indicated, checking for chronic stealth infections due to bacteria, parasites and viruses which may harm the immune system and other organ systems. These could present as chronic fatigue, muscle and joint pains, autoimmune diseases and many other vague nagging symptoms.

•  If indicated, evaluating and testing for mold exposure and mycotoxins. You may need to find a physician who has experience in diagnosing and treating mold related illnesses. 

•  Genomics Testing: to assess for genetic variations known as SNPs (Single Nucleotide Polymorphisms) - like the commonly known MTHFR variants among so many others - which may lead to an increased genetic susceptibility towards accumulating toxins  and limit the detoxification capacity of our phase 1 and/or phase 2 liver enzymes.

Most of the above testing can be ordered by any physician, but the interpretation (which really is the key!) can probably only be done accurately by a trained Functional Medicine (FM) Practitioner. I strongly feel that someone with a chronic health issue, should start with a FM doctor as soon as possible, while fully realizing that in some parts of the country and many parts of the world this is not an option. Also, there are some FM practitioners who are not medical doctors and may not be able to order some of these tests. In those cases the tests could be ordered by your regular MD, with results being preferably interpreted by your trained FM Practitioner.

For some general guidelines on how to reduce and manage toxins in your life, you can read my blog..

If you feel that toxicity may be responsible for your chronic health problems, I encourage you to locate an Institute for Functional Medicine Certified Practitioner (IFMCP) in your area and get evaluated.  

Good luck in your journey towards optimal emotional, mental and physical health!

8 Tests for Heart Disease That Many Doctors Miss

Most people have their blood pressure, heart rate, lipid profile, fasting blood sugar, and even vitamin D levels measured during their yearly physical. Your physician may do an EKG or a stress test. All of these tests may be "normal," but there are other significant risk factors for metabolic issues that contribute to cardiovascular disease, that may be completely missed unless more testing is done.

Below is a list of some easily run lab tests and calculations which give insight into risk for insulin resistance, metabolic syndrome, inflammation and risk for future coronary heart disease. In my opinion, these tests should most certainly be a part of any patient's assessment for metabolic disorders and development of heart disease:

1. Triglyceride to HDL ratio

This is a simple measure of insulin resistance, risk for diabetes mellitus type 2 and cardiovascular disease. A ratio less than 3.0 is considered normal, and more than or equal to 3.0 is suggestive of insulin resistance. An elevated ratio should prompt counseling the patient about therapeutic lifestyle change with close follow-up of metabolic markers for prevention of development of diabetes, hypertension and coronary artery disease.

2. Fasting insulin levels (and, if possible, two-hour postprandial insulin levels)

Usually at the yearly physical your physician will measure fasting blood sugar, and may even measure hemoglobin A1c levels, which are markers for pre-diabetes and diabetes. In my opinion, abnormalities in these are late developments. Insulin is a hormone produced by cells in the pancreas; it's responsible for regulating blood sugar levels and for promoting uptake of glucose into the cells for use as energy or for storage as fat. Measuring insulin levels two hours after a glucose load may be the first indication of metabolic problems in your handling of sugar (or carbs).

Sometimes a two-hour insulin measurement may be difficult, so in my practice I measure fasting insulin levels, which are the second measure to go up. These two can be early markers of insulin resistance, much before fasting blood sugar starts going up. Excessive insulin levels lead to increased serum triglyceride levels, decreased serum HDL (good cholesterol) levels, increase in levels of the small dense LDL (the plaque-promoting form of bad cholesterol) particles. Insulin resistance is a risk factor for hyperlipidemia, diabetes, hypertension, all of which contribute to atherosclerosis and plaque formation, which in turn is a risk factor for heart disease development. I encourage my patients to work toward a fasting insulin level of at least less than 6 microunits per mL (ideal is 4).

3. High-sensitivity C-reactive protein (hsCRP)

CRP is produced in the liver in response to nonspecific inflammation in the body. The high-sensitivity CRP is an assay which detects low levels of CRP specific to inflammation in the blood stream i.e., vascular inflammation, which could be the cause for development and progression of heart disease. Standard lipid tests do not test for inflammation, and this marker can be easily tested through your local labs. Even if your lipid profile is normal and you do not have other cardiovascular disease risk factors like hypertension or obesity or diabetes, if this marker is elevated, it is cause for concern. If somebody has already had a cardiac event like a heart attack or stroke, and this marker stays chronically elevated, it could be predictive of a high risk for future repeat heart attack or stroke. The therapeutic goal for hs-CRP is less than 0.7 mg/L, preferably as near to 0 as possible. I like to repeat this a few times to be sure it is actually staying high.

A word of caution with hs-CRP: though a marker of inflammation, it can also be a marker for infection and acute injury, so if you've had any recent surgery or procedure; have a respiratory, gum or other infection; or have the flu, please wait until your symptoms are resolved before testing, as this marker will be elevated due to that acute event.

4. Red blood cell magnesium levels

Red blood cell magnesium levels are the best way to assess magnesium status. Clinical signs of magnesium deficiency could be fatigue, weakness, muscle cramps, seizures, numbness and tingling in the extremities, mood and sleep issues, irregular heartbeats and also spasms in the arteries which feed the heart, contributing to heart attacks. Magnesium supplementation may reduce the risk of coronary heart disease, so try to keep levels at the high end of the lab range, though I monitor clinically more often.

5. Homocysteine levels

Homocysteine is a toxic amino acid and elevated levels can be a risk factor for development of cardiovascular disease and stroke. Elevated homocysteine levels damage LDL cholesterol, causing its oxidation. Oxidized LDL leads to plaque formation in the coronary arteries. Homocysteine is produced as an intermediate in the metabolism of amino acids methionine and cysteine. Activated forms of vitamin B12 and folate are needed for the conversion of homocysteine into methionine, so elevated homocysteine can be one of the indicators of deficiency in these important vitamins (remember that there are drugs like Methotrexate and acid blockers like Nexium which block the metabolism or absorption of these vitamins and may cause elevations in homocysteine levels). Serum homocysteine is great screening test for patients who are at a risk for cardiovascular disease and stroke, especially when there is a family history but no other known risk factors. Strive to keep levels around 8 micromoles/L.

6. Ferritin levels

Ferritin is an iron-containing protein produced in the liver, and signifies the stored form of iron. Ferritin can also be a marker of inflammation. Moderate elevation of ferritin may lead to a 2-3 times increased risk for development of diabetes. Though the normal range in your lab for ferritin can be from 12-150 ng/mL in women and 12-300 ng/mL in males, studies have shown high ferritin levels increase cardiovascular risk. Lowering the iron stores to near optimal level of between 70-80ng/mL will improve outcomes in cardiovascular disease including reduced risk for heart attacks, strokes and also improve life expectancy. As a side note, I don't think that ferritin levels less than 50ng/mL are in any way normal (even though your lab may show it in the normal range) and reasons for low iron stores must be looked into.

7. Testosterone levels (in males only — no correlation with heart disease has been found in women)

In males, testosterone deficiency has been associated with a high risk for cardiovascular disease. In elderly males, lower free testosterone level has been shown to be associated with a high prevalence of cardiovascular disease. If your total and free testosterone levels are low, work within integrative or a functional medicine physician to find out why that is the case. Replacing testosterone may not be the only answer.

Males should try to keep testosterone levels between 350-600ng/dl. Remember, more is not always better with testosterone therapy if you need it, and always seek out a physician well versed in male hormonal replacement therapies, or someone who can help guide you to support your body’s hormone production naturally!

8. Testing for chronic infections

Many pathogenic bugs have been shown to have a significant correlation with development of coronary heart disease as well as acute coronary syndromes (heart attacks). Some of these are herpes simplex virus, cytomegalovirus, and H. pylori. Ask your physician to test for antibodies to these bugs through your local laboratories.

Print out and take this list to your physician to help them better evaluate your risk for heart disease, or find a functional medicine physician who is well versed in managing and counseling patients with metabolic disorders!

This article first appeared in Mind Body Green

12 Tips To Help You Prevent Breast Cancer

During 2013, a whopping 232,340 new cases of invasive breast cancer are expected to be diagnosed among women in the US; about 2,240 new cases are expected in men (yes, men!). Breast cancer is related to a state of excess estrogens, known as estrogen dominance. Uterine fibroids, breast cysts, PMS, infertility, migraines, and even prostate cancer in men can be related to estrogen dominance.
We really are what we eat, drink, breathe, think, and cannot eliminate! While food most certainly is to be regarded as the best medicine, it can also be the biggest poison. When there's diminished elimination of physical and emotional toxins, they build up, which may lead to DNA damage and ultimately cancer.
Some of the best strategies for breast cancer prevention are:
1. Food is always first!
Eat antioxidant-rich foods like organic fruits, vegetables, nuts and seeds, and healthy fats and oils like avocado and extra virgin olive oil. Eat your rainbow of 8-10 servings of vegetables and fruits every day to get optimal phytonutrient benefit. Especially include cruciferous vegetables like broccoli, cauliflower, brussels sprouts, kale, cabbage, and bok choy, which provide indole-3-carbinol (I3C), a phytonutrient which helps metabolize estrogen.
Remember: Sugar is cancer’s best buddy! It activates cancer genes and fuels growth of cancer cells. Eliminate sugar from your diet in every shape or form.
2. Quit smoking.
A study published in early 2013 in the Journal of the National Cancer Institute showed that smokers have a 24% higher risk and former smokers have a 13% higher risk of invasive breast cancer than non-smokers.
3. Avoid alcohol.
Alcohol changes the way estrogen is metabolized in our body, which can lead to estrogen dominance. Women who drink alcohol have higher body estrogen levels than those who don’t.
4. Consume a diet low in animal-based foods.
Animal-based products are extremely inflammatory and expose the body to a high dose of arachidonic acid, an inflammatory mediator. Fill half your plate with veggies!
5. Exercise regularly and develop a yoga practice.
Any amount of exercise, mild or intense, will reduce the risk of breast cancer. Aerobic exercise reduce the risk of breast cancer development, by changing the metabolism of estrogen in our body and increasing the ratio of “good” (2-hydroxyestrone) to the “bad” (16alpha-hydroxyestrone) estrogens.
Yoga balances and regulates the endocrine system, and thus our hormones. It also builds the immune system, while promoting lymph flow, the latter being extremely important for drainage of toxins from the breast and the lymph nodes in the axilla (arm pit).
6. Do regular breast self-exams and breast massage.
They can be life saving! Get clinical breast exams at your yearly physicals, and mammograms if appropriate.
7. Maintain the right body composition and fat percentage of your body.
Obesity and visceral adipose tissue (VAT, i.e., the fat accumulated around your abdominal organs) are extremely inflammatory! Find a Functional Medicine practitioner who is trained in First Line Therapy/ Therapeutic Lifestyle Change, a special program specifically targeted to reduce this fat factory of our body.
8. Reduce other inflammation-causing issues in your body.
It's important to get tested for food sensitivities and eliminate from your diet all foods to which you may have allergies or sensitivities. Get checked for, and treat chronic infections in the gut, mouth and sinuses.
Remember, inflammation makes the immune system less effective in doing its job, and a less effective immune system leads to progression of cancer cells!
9. Avoid toxins.
These can take the form of:

• Inflammatory foods that are filled with trans fats, artificial coloring and preservatives.
• Household cleaning chemicals, pesticides and insecticides.
• BPA-containing plastics, which can be used for storing food and water.
• Personal care products and perfumes: these may contain hormone-disrupting chemicals like pthalates and parabens.

10. Consume a good-quality protein at each meal.
Your body needs essential amino acids at every step to function optimally. Work with your physician to get a comprehensive stool analysis, which will tell you whether the protein you're eating is getting digested and absorbed as effectively as it should.
11. Balance mind, body and emotions with meditation, breath control and emotional freedom exercises.
Here are a few tips:

• Meditate daily.
• Learn and practice yogic breathing exercises.
• Practice forgiveness every day!
• Journal before going to bed to detoxify the mind.

12. Sleep is your best friend!
A study published in August 2012 showed an association between less sleep and development of aggressive forms of breast cancers in women.
If you suffer from chronic sleep issues, work with your physician to find the underlying cause and correct it. Using drugs isn't the answer!
I hope to have given you a message of empowerment that you can do something to prevent breast cancer. I would love to hear from you if you've used any of these measures.
You can look for a Functional Medicine practitioner in your area here.

This blog first appeared in MindBodyGreen

Do You Have Chronic Inflammation & What Can You Do About It?

Seems like everyone's talking about inflammation these days! More and more studies are coming out linking chronic inflammation to a vast majority of chronic diseases, even cancer.
But, is all inflammation bad?
Not at all! Some inflammation is absolutely necessary for our survival. It helps us overcome any acute insult or injury to the body. For example, if you cut your finger, cells are recruited to the wounded area, and through a very complex mechanism, the body heals itself quite efficiently. That's an example of inflammation working to heal you.
Similarly, if you contract a bacterial infection, the body quickly produces inflammatory chemicals known as cytokines, which help kill the foreign invaders. During this fight between the bugs and your immune system, you feel terrible, but only for a short time. Soon, you're up and on your merry way again with little long-term botheration from the incident.
It's only when this inflammation becomes chronic or long term—like a low-grade smoldering fire which does not die out—that it leads to major problems.
Normally, during a period of low-grade inflammation, the body tries to warn us that something is wrong. It does this by producing many nagging signs and symptoms, like:

• Aching of joints and muscles
• High blood pressure
• Rising blood sugars
• Headaches
• Sleep issues
• Allergies
• Skin issues
• Frequent abdominal pain and other gut issues
• Mood swings
• Difficulty with sleep
• Low energy levels

If we do not heed these symptoms and allow the inflammation to persist unchecked, after years (yes, years!), the inflammation becomes evident in the form of a heart attack, stroke, Alzheimer's disease, cancer, or an autoimmune disease like multiple sclerosis, ulcerative colitis or rheumatoid arthritis, which can no longer be ignored by us.
Some signs of chronic inflammation are:

1. Chronic fatigue and low energy.
2. Mood issues including anxiety, depression, and panic attacks.
3. Memory problems, brain fog, or loss of focus.
4. Difficulty falling asleep, waking up in the middle of the night, or unrestful sleep.
5. Gut symptoms including acid reflux, IBS, constipation, diarrhea, blood or mucus in stools, intermittent abdominal pain, gas and bloating.
6. Chronic muscle and joint pain, swelling, redness.
7. Chronic allergies and asthma requiring frequent medications.
8. Chronic skin issues like eczema, psoriasis, redness of face and cheeks, or hives.
9. Frequent or daily headaches, tremors, easy loss of balance, tingling and pain along nerves in the extremities, dizziness.
10. High blood pressure.
11. Metabolic syndrome, abdominal obesity, or diabetes mellitus.
12. Low bone density or osteoporosis.
13. Heart disease, peripheral vascular disease.
14. Diagnosis of cancer: Yes, taking action is possible even after being diagnosed with a cancer as you can still try to prevent future development of new cancers at other sites.

What should you do if you have any any signs of chronic inflammation?
1. Find a functional medicine physician who is well versed in evaluating your symptoms.
This person can help you eliminate the root cause of the chronic inflammation, rather than focusing on just suppressing symptoms.
2. Avoid all inflammatory foods.
This includes refined sugars, sugar substitutes, juices and sodas, trans-fats, dairy products, non-organic eggs and meats from grain fed animals. I also suggested you eliminate any foods to which you may be sensitive/ allergic, all GMO foods, and foods with a high glycemic index.
3. Eat real foods.
Incorporate large amounts of antioxidants, phytochemicals, and fiber-rich fruits and vegetables, nuts and seeds, small amounts of grass fed meats and wild small fish, healthy spices like turmeric, ginger, garlic, and herbs like cilantro, parsley, oregano and rosemary in your diet.
4. Stop eating microwavable lunches or dinners.
Don't eat dead packaged and processed foods which have no life force!
5. Sip green tea on a regular basis.
It cuts inflammation and calms the mind!
6. Try to avoid toxins as much as possible in your daily life.
You'll give your liver a much-needed break.
7. Incorporate a daily exercise regimen.
Do yoga, tai chi or some other form of movement exercise. Move the body whenever you get a chance!
8. Meditate daily and breathe deeply.
Who doesn't love peace of mind? It's also great for your nervous system.
9. Focus on optimal sleep.
Your body restores and regenerates itself daily when you sleep!
10. Find time for rest and rejuvenation on a regular basis.
Try to make time for mini-vacations and spending time in nature!
11. Get regular massages.
Better yet: learn the technique of self-massage and practice it daily!
12. Get your vitamin D levels checked and maintain optimal levels.
Use supplements if needed. Vitamin D is not just a vitamin, it functions as a hormone messenger molecule in crucial body processes!
13. Maintain a positive mental attitude about life and people!
Remember, just like your gut affects the brain, the brain in turn affects the gut, where the majority of our neurotransmitters are made.
Cutting down your risk of inflammation will most certainly reduce your chances of developing chronic diseases, so I urge you to take corrective action, one baby step at a time.

This blog was first published on MindBodyGreen