functional medicine and nutritional genomics - American Association ...

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AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: USING PRINCIPLES OF FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS � Insulin Response (glucose tolerance with insulin) and hemoglobin A1C � Cardiovascular risk: lipids and particle size, triglyceride/HDL ratio, fibrinogen, Lipoprotein (a) � Thyroid: TSH, free T3, free T4, thyroid peroxidase antibodies, anti-thyroglobulin antibodies � Hormone analysis: male, female, IGF-1 (insulin like growth factor-1), adrenal (DHEA-S) � 24 hour urinary cortisol � Osteoporosis assessment- PTH (parathyroid hormone), ionized Ca, serum protein electrophoresis Inflammation/Immune Function � High sensitivity-C-reactive protein � Fibrinogen � Complete blood count (CBC) – differential � Celiac panel: IgG, IgA anti-gliadin antibodies, IgA tissue transglutaminase, total IgA � HLA DQ2/8 (celiac genes) � Autoimmunity: anti-nuclear antibodies, sedimentation rate, rheumatoid factor, anticyclic citrullinated Peptide (anti-CCP) antibodies, etc. � Infection screening (serology, PCR – polymerase chain reaction) � Natural killer cell function � Immunoglobulins � Lymphocyte Analysis Digestive Function � Helicobacter pylori serum antibody or stool antigen � Helicobacter Pylori breath test � Small bowel bacterial overgrowth breath test � Stool for ova and parasites � CBC – differential (neutrophil/lymphocyte ratio) Detoxification Function 28 � Hepatic function (NASH, drug reactions) � Whole blood or RBC metals (Hg, Pb, Ar, etc.) � Genomics: GSTM1 (glutathione), ApoE (apolipoprotein E polymorphisms) Emerging Functional Diagnostics Nutritional Analysis � Vitamin and mineral assessment � Essential fatty acid analysis � Amino acid analysis (blood, urine) � Organic acids (B vitamin status, etc) Hormonal Assessment � Adrenal stress index (saliva cortisol) � Estrogen metabolism and detoxification - urine, blood, saliva � Salivary sex hormone assessment � Bone resorption assays � RMR (resting metabolic testing) � DEXA body composition and bone density � Heart rate variability – autonomic function Inflammation/Immune Function � Allergy Testing - IgG and IgE antibodies to foods, and environmental allergens � Gut immunology: EPX (eosinophil protein X), calprotectin in stool � Microbial analysis (virus, bacteria, ticks, parasites, worms, etc.) Digestive Function � Digestive stool analysis o Digestive enzyme function, microbiology, absorption, immune function, metabolic function and microbial analysis with culture or PCR � Intestinal permeability � Lactulose:mannitol challenge � Urinary polypeptides (gluteo/caseomorphins) � Urinary dysbiosis markers (Clostridia, yeast, 2012
AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: USING PRINCIPLES OF FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS small bowel bacterial overgrowth) Detoxification Assessment � Hair analysis: methylmercury (fish) � Provocation/chelation challenge: heavy metals � Detoxigenomics: Phase 1 and Phase 2 � Blood and urine testing for pesticides, PCB’s, solvents, parabens and phthlates � Mycotoxin antibody assessment � Visual contrast sensitivity � Gamma glutamyl transferase Mitochondrial Function/REDOX � Organic acids (fat, carbohydrate and Kreb cycle metabolites) � V02 max – Cardiometabolic Testing � Lipid peroxides � 8 0H-2DG (DNA adducts) Depression or Imbalance? A Clinical Case History Abstractions are rarely helpful in clinical medicine when faced with a suffering patient. I present here complex medical case illustrating this model of functional diagnostics and therapy based on a new clinical compass. J.P. was an 18 year old young man who presented with fatigue, depression, anxiety, a 27 pound weight gain and acne worsening over the 4 years prior to his visit. His symptoms included cold intolerance, early morning fatigue, and canker sores, cracking at the corners of his mouth, acne on face, chest, back and shoulders, and seasonal allergies. He also complained of trouble falling asleep, increasing anxiety and depression worsening during the winter, for which he has been on Paxil for 4 years when he gained 27 pounds and had increased refined carbohydrate and sugar cravings. Other symptoms noted included itchy ears, and white spots on his nails. His past history included full term pregnancy by cesarean section. He was bottle fed with soy formula. He had transient synovitis of the hip at 5 29 years old, intermittent otitis media treated with antibiotics, and acne treated with Bactrim for 2 years. He also had gynecomastia treated surgically and hyperlipidemia. His medications were Paxil 15 mg daily, Bactrim daily, Claritin as needed and a multivitamin. Family history was significant for depression in father and paternal grandfather, allergies in his mother and sister, and myocardial infarction in maternal grandfather at 54. He was a non-smoker, used no alcohol or substances of abuse or caffeine. His diet consisted of no breakfast, fast food for lunch and dinner, and diet and regular sodas. He avoided seafood. He exercised 25 min a day on the treadmill and 1-2 times a week with a trainer. He slept 10 hours a night. His exam revealed a moderately overweight teenager. His blood pressure was 110/68, body mass index 26.5 (weight 201 pounds); his temperature was 95.5 degrees F. Other than severe acne vulgaris, chelosis, his physical exam was normal. Nutritional laboratory assessment revealed vitamin D deficiency (25 OH vitamin D 17 ng/ml – nl 30-100), severe omega 3 fatty acid deficiency with low ALA (alpha linolenic acid), EPA (eicosapentanoic acid), and DHA (docosahexaenoic acid), and an omega 6 fatty acid deficiency of GLA (gamma linolenic acid). Organic acids revealed deficiency of B6 (xanthurenate, kynurenate elevation), B12 (methylmalonic acid) and deficiency markers for CoQ10, biotin and B vitamins. Hormonal evaluation revealed ‚sub-clinical‛ hypothyroidism with elevated thyroid peroxidase antibodies, thyroid stimulating hormone 2.55 mIU/L (nl 0.5-3.5), normal free thyroxine (T4) of 1.1 ng/dL, and low free triiodothyronine (T3) of 281 pg/dL (nl 287-455). He also had hyperlipidemia with total cholesterol of 232 mg/DL, and LDL of 164 mg/dL, an HDL of 42 mg/dL and triglycerides of 130 mg/dL and an elevated lipoprotein (a) of 209 nmol/L (nl < 2012
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