During the last weekend of May, the Institute for Functional Medicine (IFM) held its Annual International Conference in Hollywood, FL.  This highly anticipated event attracted physicians, dietitians, acupuncturists, chiropractors, research scientists (and more!) the world over for three days of lectures and intense study focused on the emergent therapies and research in autoimmune related diseases.  IFM has been a pioneer in adapting systems-based thinking to understand and address chronic illness.  Specifically, Functional Medicine seeks to determine not only what disease a person may have, but also why and how illness occurs.

This year’s Annual Conference was entitled ” Solving the Puzzle of Autoimmunity: The Interplay of Gut, Genes and the Environment.”  True to form, the conference organizers and featured speakers delivered compelling presentations focused on identifying triggers and mediators of autoimmune disease. Utilizing the Functional Medicine paradigm, we can both appreciate the inherent complexity of disease, and untangle the many pieces of the puzzle (genes, environmental triggers and the body’s susceptibility to outside insults) that potentially contribute to the development of disease. The conference was three, jam-packed days of learning with some of the leading practitioner-scientists who shared research, theory and patient success stories of overcoming some of the most debilitating autoimmune diseases known to medicine.

What is Functional Medicine? “Changing the Way We Do Medicine and the Medicine We Do”

By Rachael Gollub -Medical Student at Northeast Ohio Medical University

Functional Medicine is a systems-based approach to medicine that seeks to understand how and why illness occurs.  It is individualized, patient-centered and rigorously rooted in the emergent medical research.  Employing new and evolving personalized models of understanding the science and personal experience of disease, it enables patients and practitioners to collaborate toward the goal of optimum wellness.

Because one condition can have many causes, and one cause may result in many different manifestations of a given condition, it becomes imperative to target the root cause rather than just the symptoms of disease. In this approach to medicine, the interventions and treatments may be as diverse as the individual etiologies of the disease/illness itself.  Functional Medicine starts with the standard of care in medicine and adds new tools and strategies—from genetic testing, to diet and lifestyle interventions—to direct and empower the patient/practitioner partnership towards optimal health and wellness. One of the major concepts that Functional Medicine has delivered is an understanding of the ways in which genetics, individual biochemistry, and environmental exposures combine to affect individual health and well-being, or lack thereof.

Our current healthcare system is obsessed with a reductionist approach to illness—finding the one “magic pill” to take away the presenting symptoms.  This model, while it may be well-suited for acute care medicine, consistently misses the mark when it comes to answering to the challenges of chronic disease. Chronic disease represents a huge burden to the healthcare system with roughly 86% of all healthcare costs ($3.2 trillion and growing) spent on chronic disease management.  It is estimated that 50% of adults have at least one chronic health condition, and 25% have 2 or more chronic health conditions.  Because chronic conditions commonly involve more than one body system, the siloed medical system leaves the practitioner poorly suited to understand and address imbalances due to the inherent interconnectedness of such disease processes.  For example, inflammation may be the link between the frequently co-occurring states of pain, fatigue and depression, but patients do not usually arrive in the care of a rheumatologist or immunologist to treat their depression.  Functional Medicine reminds us that the body’s systems are all connected, and that we are in dynamic interaction with the world around us through the food we eat, our social relationships and the environments in which we live.  Such data points have traditionally been ignored in western medicine, but the science is beginning to reveal just how crucial things like diet, lifestyle and the physical environment are, not only to achieving a state of wellness, but also to treating chronic conditions from multiple sclerosis, rheumatoid arthritis, to depression and even thyroid disease.

Why Functional Medicine for Autoimmune disease?

The Functional Medicine approach offers a promising solution to chronic disease.  Notably, autoimmune diseases account for a large portion of the chronic disease burden in this country.  According to the American Autoimmune Related Diseases Association (AARDA) up to 50 million Americans suffer from an autoimmune condition.  Treatment costs for this patient population are estimated to total $110 billion.  There are nearly 100 distinct diseases that have been classified as autoimmune in nature, with another 40 more suspected.  Autoimmune diseases are among the top five leading causes of death for women up to 64 years of age. As IFM puts it, through “Connecting science, evidence and clinical practice, ” functional medicine offers the promise of a roadmap to translate research into practice and to prevent and treat the many triggers of autoimmune disease.

It was recently discovered in a now famous study from the National Academy of Medicine that it takes an average of 17 years from the time scientists establish a significant and clinically relevant discovery to implement such knowledge into practice.  Tom Blue, an IFM executive member astutely illustrates the absurdity of this gap using the analogy of cell phone technology.  It would be as if we were all walking around today using the first pocket sized nokia cell phone, despite having the technology available to create the supercomputing smart devices we all carry today.  Most of us are hard-pressed to imagine our lives without the conveniences of these technological masterpieces.  Imagine, then, what we are missing in our toolboxes that will allow us to effectively and efficiently treat and prevent disease.  Overwhelmingly, however, this conference reminds us of the complexity of the human systems and although advanced technology may be useful in aiding pattern recognition, the solutions are often surprisingly simple: understand your personal biology, avoid toxins and other stressors, and nourish your body with clean, healthy food.

Who? The Incredible Minds of Functional Medicine

The International Annual Conference offers an incredible opportunity to meet and learn from the many passionate and brilliant pioneers in Functional Medicine.  And, while they hail from many different corners of the world, they share a common passion for discovery—always asking the question “why?” so that they may provide insight and practical solutions to patients and practitioners faced with challenging clinical problems.  Each speaker offered a wealth of knowledge, but their lessons are too numerous to outline in their entirety.  I chose just a few to highlight and share for an overall taste of just how fascinating the presentations were.

Alessio Fasano, MD, the W. Allan Walker Chair of Pediatric Gastroenterology and Nutrition and Chief of the Division of Pediatric Gastroenterology and Nutrition at MassGeneral Hospital for Children (MGHfC) gave the opening keynote presentation.  His pioneering research in celiac disease and other autoimmune and inflammatory conditions has helped to establish new models of understanding autoimmune disease processes.  During research efforts to develop a vaccine for cholera, he and his research team serendipitously discovered zonulin, a molecule that is now known to regulate intestinal permeability by modulating intercellular tight junctions.  The activity of this tiny molecule can be affected by interactions with many different substrates, from cholera toxin to gluten and is now recognized as a gateway for understanding autoimmune disease through the lens of dysfunctional barriers and “promiscuous antigen trafficking.” His area of research has thus shifted to focus on these molecular mechanisms and the resultant host immune response and the development of preventive strategies for autoimmune disease

His keynote highlighted the staggering exponential rise in the incidence of immune-mediated disease in the last 50 years which has reached epidemic proportions.  This rate of increase cannot be explained by genetics alone.  He suggests several factors that affect host tolerance and the immune response leading such disease conditions:  (1) genome – which is inherited from your mother and father and is static (you cannot change your genes), (2) microbiome—which is dynamic (changes), is inherited from your mother at birth, but influenced by your surroundings,  (3) dysfunctional barriers—gut permeability can be mediated by stress, dysbiosis,  and microbial toxins, and (4) environmental factors—the food you eat, antibiotic use, and exposure to environmental toxins.  He goes on to remind us you are only born once (genes), you may alter your microbiome through the use of antibiotics 5-10 times in a year (average use), but you eat several times in a day. Therefore, diet is the “lowest hanging fruit,” and the easiest place to intervene for improvement of overall health.

Building upon this knowledge that the food we eat can affect the permeability of the gut barrier, trigger an inflammatory immune response and mediate disease, Dr. Aristo Vojdani and Datis Kharrazian, DC, DHSc, MS, MNeuroSci elucidated the science behind the multiple pathways to autoimmunity.   The antigenicity of a food can be altered through cooking, through combination with other foods and through unintentional contamination with toxins.  This is the case in the formation of Rheumatoid Factor which is implicated in Rheumatoid Arthritis.  Aggregation of IgG (one of the many types of immunoglobulins produced by our B cells) through combination with aluminum causes the body to develop IgM (auto) antibodies against the aggregate IgG.  While the body’s systems for distinguishing self from non-self are the key to mounting a defense against outside insults, their research suggests that our bodies’ mechanisms for recognition may not be as sophisticated as we might like them to be.  Immune reactions are mounted to a particular sequence of amino acids, not the food itself.  And, because many proteins may share similar amino acid sequences, it is possible through this “molecular mimicry” that the body may develop reactive antibodies to foods that have never even been consumed, or worse, to human tissue proteins, thus triggering the progression of autoimmune processes.

Reaction to everyday dietary proteins is not a normal process, so what causes us to lose “oral tolerance” and mount a reaction to everyday foods such as spinach, wheat, corn or tomatoes? Kharrazian suggests that digestive enzymes may play a major role.  The job of a digestive enzyme is to breakdown proteins into their single amino acid components.  Impaired enzymatic function, which may be caused by food additives, such as dyes, results in improperly digested proteins which look “foreign” to the body.  If an individual suffers any loss of barrier function (gut permeability), there is a risk that the incompletely digested proteins will trigger the formation of antibodies which may later cross-react with their own tissues. Although this message is grim, perhaps the most inspiring part of this presentation was the suggestion of a possible solution for the repair of a dysfunctional gut barrier. Butyrate, a short chain fatty acid metabolite has been shown to modulate an overactive immune response and protect intestinal epithelial cells from breakdown as well as increase the synthesis of tight junction proteins. In essence, this small molecule may be able to directly heal a permeable gut.

Continuing upon this thread of effective and safe solutions for difficult to treat autoimmune disorders, William Parker, PhD and Sydney Baker, MD offered a most convincing presentation on “Helminth Therapy in Autoimmune Disease.”  There is an emerging body of research examining the relative proximity to the equator and the incidence of autoimmune disease.  Scientists are asking the questions of whether this pattern could be pure coincidence, related to a vitamin D deficiency, or explained by a disruption of an evolutionary symbiotic relationship between humans and helminths.  Dr. Sidney Baker, a Yale trained physician with over 50 years in clinical practice has successfully treated patients using the species Hymenolepis Diminuta Cysticercoids. The “little dudes,” as he affectionately refers to them have been effective in diminishing the over-reactive immune system, treating autoimmune related disorders from alopecia areata (hair loss) to thyroid disease. Although this solution may seem a bit non sequitur, the “little dudes” owe their effectiveness to the same immuno-modulatory role celebrated by the more commonly used steroid treatments, but without any of the nasty side-effects.

Attending this conference provided me with much needed inspiration at this point in my educational journey.  Too often, my studies in medicine are focused on asking the question “what?,” and not “why?” Knowing the name of the illness does not mean that we understand the cause.  Too often, I have had to memorize a disease based on what it looks like, and regurgitate the treatment–usually a single drug or surgery.  Even those disease those processes that have been widely accepted by the medical community to be mediated by lifestyle (think hypertension and diabetes) are ubiquitously treated with pharmaceutical intervention first.  Too often, I have been “reassured” as a medical student that the biochemistry we learned as first year medical students is just a hurdle to climb over and leave behind—that the molecular mechanisms and metabolic pathways are unimportant to providing care to patients.  This conference proved to me that those foundational concepts are not only important, but that understanding them is crucial to stay relevant in medicine. I can see that Functional Medicine is the medicine of the future

Coming Home:

On the heels of my return to Cleveland from the IFM conference, I toured the William G. Mather museum with my 6 year-old son.  An animal and nature lover, I have been somewhat surprised by his blossoming interest in the giant machine freighters of the Great Lakes.  The Mather is a 600+ foot long freighter that was at the heart of shipping and industry of the Great Lakes region from the 1920s-1970s.  We boarded the freighter museum just as the northwinds ushered in a spectacular thunderstorm.  We imagined what it must have been like to be aboard such a colossal vessel, weighted down with cargo and crew in the middle of its journey to deliver raw materials and commodities to the consumers at the other end of its shipping route.  As the rain poured down, we ducked into one of the cabins to find an elderly gentleman carefully polishing the steel light switch.  He had been one of the original crew members aboard the Mather, now working as a museum docent.  He was the cook.  He had been responsible for the logistics, planning, prepping and serving of meals for all the members of the crew and their guests—a formidable job for such a sizable crew.  He went on to describe his subsequent demotion to dishwasher, as convenience foods made their way onto the scene.  The once elaborate, three course homemade meals gave way to frozen dinners.  With the promise of a pension, he tried to hang on to his employment as long as he could—to get in the full 30 years before retirement but was unable to continue working after suffering a heart attack, and then a stroke.

His story felt tragic.  It is the story of a man who was, at once, robbed of his dignity and pride as well as his health and vitality.  I couldn’t help (given my recent course of study) but to think of how the sudden switch to packaged, processed foods contributed to his decline, and wonder just how many others suffered the same misfortune.  It was a poignant example of how economics and blind enthusiasm for convenience can lead us down a dangerous path.  We are facing a concerning reality in this country.  Despite astounding advances in health science, quality of life is declining, rather than increasing.  It is time to close that 17 year gap.  Functional Medicine offers me the inspiration and motivation to envision a new approach to medicine that embraces the foundational science I worked so hard to learn, and highlights the obvious potential of diet, nutrition and lifestyle in addressing health, wellness, and chronic disease.