Functional Medicine—the new orthodoxy?

| By Dr. Ronald Hoffman

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Functional Medicine—the new orthodoxy?

Time was, when I was an aspiring medical student in the 70s, that “holistic” practitioners were few and far between. I had a few role models in Dr. Robert Atkins, Dr. Michael Schachter, and Dr. Rudolph Ballentine, but there weren’t many doctors who took that career path.

In fact, when I began practicing in the 80s, we were so beleaguered that we banded together for mutual support because the mere practice of “alternative” medicine was considered illicit, and you could lose your license by deviating from “straight” medicine.

Fast-forward to the present and the movement has thrived. There are now thousands of integrative doctors, and certifications for non-physician practitioners—nutritionists, health coaches, personal trainers, etc.—have proliferated.

One of the most popular “brands” of alternative and complementary medicine is Functional Medicine. It rightly seeks to establish “root causes” for the many health problems our patients and clients face in contrast to the conventional medicine approach of merely palliating them with drugs. Functional Medicine has rapidly gained adherents.

But are we in danger of establishing a new orthodoxy? Sometimes, as a long-time practitioner of Functional Medicine—before the term was even coined—I fear we’re creating a new dogma that narrows rather than expands our scope of possibilities when evaluating health challenges.

It’s almost as if a few courses and seminars—admittedly rigorous—offer neophytes a “turn-key” entree to take on complex diagnostic challenges.

Some of the following queries to a popular community forum may give you the flavor of what prompts my concern:

|| 90 y.o. female w/ shingles, recent UTI [urinary tract infection], hx CHF/HTN [history of congestive heart failure/hypertension]. She is very weak. Blood work results show a high TSH [thyroid stimulating hormone]. Thyroid/iodine suggestions? ||

The practitioner is seeking advice on whether thyroid medication or thyroid support with iodine would “perk up” this very sick nonagenarian. We doctors are trained to recognize that shingles, frequent urinary tract infections, and congestive heart failure are often signs that a patient is failing and at high risk of succumbing to old age. They may show low levels of thyroid hormones and sometimes a high TSH, but not because hypothyroidism is causing or compounding their problems, but rather as a result of something called euthyroid sick syndrome:

“Euthyroid sick syndrome is a condition in which serum levels of thyroid hormones are low in clinically euthyroid patients with nonthyroidal systemic illness. Diagnosis is based on excluding hypothyroidism. Treatment is directed toward the underlying illness; thyroid hormone replacement is not indicated.”

Treating the patient with thyroid medication, or even natural iodine, likely wouldn’t help, and may in fact lead to dangerous arrhythmias which could complicate an already compromised cardiac output.

|| Happy 4th!!! Question if anyone knows of a supplement(s) that are more geared towards the elderly. ||

What troubles me the most about this question is that it completely sidesteps the issue of personalized medicine, and ignores individual circumstances and requirements. Age is a factor in recommending supplements, and there are “anti-aging” nutraceuticals, but nothing can supplant a detailed analysis based on a comprehensive history, physical exam, and lab test results.

|| Is anyone using hair tissue mineral analysis testing (HTMA) to help guide protocols for hormone balancing? Which test do you use? ||

Hair analysis has a checkered history, with some studies questioning its accuracy, and discrepancies observed when a hair sample is split and sent to multiple laboratories. Besides, mineral levels in hair have at best a speculative relationship with hormone levels. Why not measure hormones directly via more reliable methods—blood, urine or saliva? Or is it because this practitioner is not licensed to order conventional lab tests (laws vary state-by-state)?

|| Any thoughts on severe edema in the ankles of a young healthy woman? ||

This one alarms me. Is it because certain young people casually resort to superlatives like “severe” to describe “cankles” that are merely slightly aesthetically flawed? I hope so, for the sake of the client, because truly severe ankle edema should urgently trigger a search for a medical cause: Kidney failure? A blood clot in the calf? Heart failure?

Parasites, heavy metals, mold, Lyme and tick-borne diseases, microbiome disturbances, vitamin/mineral deficiencies, environmental toxicity, EMFs, food allergies, hormone imbalances, and hypoglycemia are all important considerations.

But are they the “root cause” of every health problem?

If we as practitioners go into every patient encounter armed only with these concepts, we may fall prey to our own confirmation bias. Overconfidence may lead us to diagnostic errors.

Here are a couple of examples from my own practice:

A 38-year-old male comes to see me about new-onset fatigue. He looks like a bodybuilder, but lately, he’s not getting his usual “pump”. He also notes some mild GI problems. I asked him if he’s had any foreign travel, but he said no, and denies ever having had food poisoning. He uses no drugs and minimal alcohol. It’s noteworthy that he works two demanding jobs and sleeps less than 6 hours a night.

My initial impression was that this was a simple case of burnout, remediable with more rest and some supplementation, but I ordered comprehensive blood and stool tests.

To my amazement, the blood tests indicated he was anemic with a very low iron. In the setting of a diet rich in heme sources of iron from meat, this is a sign of GI blood loss. I called the patient and arranged for him to have a colonoscopy. It turned out he had colon cancer, highly atypical in 30-somethings, but as the tragic case of Chadwick Boseman illustrates, it can happen in young people and is on the rise in that age group.

Simply treating his iron deficiency as a nutritional problem would have been catastrophic.

A 20-year-old college sophomore is brought in by her parents to see me for unexplained fatigue. She notes low-grade fevers and night sweats and has had tests for infectious diseases by her primary care physician, which have turned up negative. She also notes nagging lower back pain.

I suspect she may have an undiagnosed chronic viral infection, and prepare to offer her immune support; I also refer her to a chiropractor for treatment of her back pain.

A few days later her parents call to inform me that her astute chiropractor didn’t like what he was seeing, and ordered an MRI. The detailed study revealed something very unusual: tuberculosis of the spine, a condition almost unheard of in modern countries. Immediately she was put on a powerful antibiotic cocktail. TB explained the fatigue, malaise, and night sweats as well as the pain.

Don’t get me wrong, I’m not a foe of Functional Medicine—I embrace it. But it’s one thing to teach clinicians a lot of theories; the harder part is teaching them how to think!

And thinking “out-of-the-box” involves avoiding getting boxed in by any paradigm, notwithstanding how “holistic” or “natural” it might be.


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