2. Integrative Nutrition in an Holistic Family Practice Setting: Guiding Principles & Case Studies Ranan D. Cohen, MS, RD, LDN Clinical nutritionist in private practice Holistic Family Practice, Newbury MA March 11, 2011

3. Holism: four dimensions “ n. the view that an organic or integrated whole has a reality independent of and greater than the sum of its parts.” ( Webster’s dictionary ) This definition implies synergism, potentially applying to: the body/mind/spirit alternative therapies nutrients ecological systems

4. Nutrition Therapy as a “Recipe” ….Change several nutritional variables in combination, treating them as “ingredients” in a “recipe” designed to improve several categories of nutritional and health status together. Example: Dairy elimination diet + improving legume intake + increasing sources of ALA + an improved multi (with a better balance of B vitamins) + pro-biotics.

5. Nutritional challenges Suboptimal intake Malabsorption Depletional factors Food sensitivities Toxic/environmental exposure Iatrogenic Genetic Emotional-spiritual /Stress

6. FUNCTIONAL QUESTIONS PLAN Nutritional adequacy? Digestive efficiency? Absorptive efficiency? Microbiological balance? Detoxification improvement?

7. Suboptimal intake assessment Water/hydration Vitamin/mineral sources EFA/EPA/DHA sources Phytochemical sources Ancillary nutrient sources Fiber intake level

8. Fruit smoothie Spelt toast + butter Salad Bar (field greens, carrots, other vegetables, cottage cheese, kidney beans, EVOO + balsamic + rosemary + garlic) Chana masala over brown rice with mango lassi Yogurt + fruit + whole- grain graham crackers

10. Whole-grain pancakes (include wheat germ + flaxmeal) + berries Turkey sandwich (on whole grain with grass- fed turkey) + carrot sticks Yogurt + cashews + banana + kiwi Salmon + roasted red potatoes + broccoli salad+ Red Wine

13. Malabsorption factors Insufficient enzyme and/or HCl secretion Insufficient emulsification (lecithin) Insufficient nutrient provision (B vitamins) Food allergy/intolerance/sensitivity Impaired mucosal integrity (probiotics; SCFA; glutamine) Iatrogenic

14. Depletional factors Pregnancy/lactation Alcoholism Smoking Surgical-metabolic/disease/other stress Medications Pollution Intensive exercise

15. Symptom history (1) Angular stomatitis A, B2, B6, Fe, ?EFA Photophobia A, B2, B6 Eyes irritated/invadedB2 Bruise easily/gums bleedC, E, K, ?Fe Nose bleeds (frequent)K, C Poor wound healingA, C, Zn, Cu Exertional fatigue/staminaFe, B2 Coordination/ ataxiaB12, fol, B1, B6

16. Symptom history (2) Cold extremities/poor circulationFe, B3, E, C PallorFe, Cu Poor night visionZn, A Decreased taste/smell sensationZn, A Muscle crampingMg, Ca, K+, E “Burning feet”Panto Brittle nailsCa/Mg, Folate, ?Si Dry skin/hairEFA, Zn, A

17. PAST MEDICAL HISTORY HxETOH’ism Hx Smoking Diabetes/Hypoglycemia Hypertension Carpal Tunnel Syndrome Hx Anemia (Did Fe help?) Chronic Fatigue Cervical Dysplasia B1, Fol, B Complex, Zn, Mg E/Se, Beta-Carot, C, Fol Cr/B3, Zn, Cu, Mn Ca, Mg, K+/Na+ B6/Mg, B2 Fe, Fol/B12, Cu, E, B6 Fe, Mg, Fol/B12, Pro, EFA Fol, Beta-Carot, C

18. PAST MEDICAL HISTORY(2) Hyperemesis Gravidarum Fibrocystic Dx Pre-menstrual Syndrome “ Restless Legs ” Syndrome Psoriasis Acne Vulgaris Hx Kidney Stones Osteoporosis B6, B2 E/Se, I- Ca, Mg, GLA E/Se, Fol, Fe, Ca, Mg A, D, B6, B2, EFA A, Zn, Se/E Mg, B6 Ca/Mg, D, Cu, Mn, F-, B-

19. Available (& worthwhile) labs Ferritin/serum iron/TIBC Ionized calcium (& bone density) 24-hour urinary magnesium Serum B12 Serum & RBC-folate Serum pyridoxine/RBC-pyridoxine/pyridoxal PO4 Serum ascorbic acid

20. Available (& worthwhile) labs (2) Plasma retinol 25-hydroxy vitamin D Prothrombin time/INR RBC-EFA levels

21. Deborah - quick case history 36y.o --- s/p 3 pregnancies --- fatigue, anxiety, depression Pneumonia x 2; Anemia, including in preg.; Toxemia x 2 Palpitations, dry skin, nails peeling, inability to focus No supplements; on Welbutrin TFT’s WNL; B12 - 315; ferritin, folate, MCV, H&H all WNL. Diet low in fruits, veg., legumes, EFA X2 and H2O. Therapeutic suggestions??

22. Deborah - quick case history Suggestions: Balanced, diversified menu Multi with B complex, trace minerals, etc. (DMF) B12 -- 1mg X 2; L-tyrosine -- 500mg (after med. d/c’d) “I felt the effect of the tyrosine” Suggestions all well-implemented Energy, skin, MH (except focus), palpitations all improved Plan discontin./resumption  worsening/improvement

23. Food sensitivity: potential diagnostic connections Migraine Eczema; Acne Sinus; Asthma; Bronchitis Arthritis IBS; IBD ADD/ADHD Auto-immune disease

24. Allergy/sensitivity symptoms Throat irritation/closure Nausea/vomiting Hives/rash Headache Constipation/diarrhea/stomach ache/indigestion UR congestion/stuffiness Joint pain

25. Symptoms of Food Allergy Gastrointestinal Manifestations Abdominal pain Nausea Vomiting Diarrhea Gastrointestinal bleeding Protein-losing enteropathy Oral and pharyngeal pruritus Cutaneous Manifestations Urticaria (hives) Angiodema Eczema Erythema (skin inflammation) Itching Respiratory Manifestations Rhinitis Asthma Cough Laryngeal edema Milk-induced syndrome with respiratory disease (Heiner’s syndrome) Systemic Manifestations Anaphylaxis Hypotension Controversial or Unproven Manifestations Behavioral conditions Tension-fatigue syndrome Attention-deficit and hyperactivity disorder (ADHD) Otitis media Psychiatric disorders Neurologic disorders Musculoskeletal disorders Migraine headache

26. Common allergenic foods Cow’s milk dairy Peanuts/Soy Tree nuts Crustaceans/Mollusks Fish Eggs Wheat

27. Taking a sensitivity history Check pediatric sensitivity history Appropriate signs/Sx: GI, headache, skin,etc. Take history by symptom category “Any other food/meal that…” Review prominent allergenic foods list Foods consumed > 1X/week Chronological comparisons

28. Shawn - quick case history 7 y.o --- 40 lb.; 40 “ --- eczema; food sensitivities;  thirst Dry eyes, dry skin, with eruptions around flexure points Rash around anal area, exacerbated by antibiotic Rx Allergy testing (RAST) + for all tree nuts, peanuts, wheat, dairy, soy, shellfish, apple, egg white & beef. All eliminated without effect! FBS -- WNL. Reports reactions to: popsicles, skittles, gummy bears & gum balls, but still in diet! Diet low in vegetables, legumes; very low EFA X2 and H2O. Therapeutic suggestions??

29. Shawn - quick case history Dietary plan: 1) Hypo-allergenic, balanced, diversified menu with immediate reintroduction trial for wheat & beef; 2) inclusion of safflower oil and flax oil daily. Artificial additive sources excluded. Ensure adequate Ca/Mg. Pedi multi; GLA (100 mg.); Zn -7mg; Pro-biotic (5 bi. org’s) Results: Skin “about 90% resolved”, with minimal scratching of dry areas. Suggestions all well-implemented, except no pro-biotic and EFA introduced via flax only. Mother noticed regression of skin problems without this food.

35. Therapeutic goals Optimal digestive/absorptive capacity Optimal biotic balance Optimal, diversified intake without food sensitivities Optimal genetic potential Optimal detoxification Optimal exercise Optimal spiritual-emotional wellness

36. Dysbiosis profile (1) Poor fruit, vegetable and lean protein intakes Craves concentrated sugars, but ill-tolerates them Increasing pattern of food sensitivities over time IBS Hypoglycemic symptoms Chronic fatigue “Aching all over”

37. Dysbiosis profile (2) Poor quality of sleep PMS symptoms Antibiotics associated with yeast infection Antibiotics associated with GI symptoms Probiotic therapy/yogurt relieves GI and/or yeast challenges

38. Dysbiosis therapy No concentrated sugars; no alcohol Garlic L. acidophilus (DDS1; NCFM; GG) Bifidobacteria (infantis; longum; bifidum) Goldenseal; Oregon grape root; Barberry root Pau D’Arco Oregano; Grapefruit seed extract; Caprylic acid Prebiotic factors

39. Semi-volatile Organic Compounds in Adipose Tissue: Estimated Averages for the US Population and Selected Subpopulations (Am. J. Public Health 1996; 86: 1253-1259) Objectives. The fiscal year (FY) 1986 Environmental Protection Agency National Human Adipose Tissue Survey (NHATS) was conducted to estimate average concentrations of 111 semi-volatiles in human adipose tissue within US general population and selected subpopulations. Results. Among polychlorinated biphenyls (PCBs), average concentrations for the group aged 45 and older were 188% to 706% higher than for the 0- through 14-year-old age group. Similar increases with age were observed for pesticides.

40. Lipotropic profile Poor fruit and vegetable intakes Indeterminate food sensitivity pattern; MCS IBS Mono /hepatitis/alcoholism hx Chronic fatigue Detox. profile abnormalities Liver function tests elevated

41. Jen - Case history (1) 33y.o. --- Rhematoid arthritis; fatigue (intermittent) Envir. allergies; Raynaud’s; migraines; PMS (mastalgia, mood). “Burning” sens. on top/front of feet; “restless legs”; gas/bloat. Multiple Sx w/  stress: memory , constip., sleep/energy  ; “body ache” Family hx: mother allergic to wheat; migraine; rheum. arthritis ANA  ;  H&H; CDSA -- + for dysbiosis, but fine for digestion. Relafen; Tavist-D; oc’s; 1-a-day; Cr-picol. (150mcg); Tums (2) Diet needs  whole grains, legumes, fruit,  CS,  white flour,  ALA. IDEAS/SUGGESTIONS SO FAR??

42. Jen - Case history (2) IDEAS THUS FAR: Food group improvements (fruit, whole grain, ALA, etc.) Food sensitivity (fam. hx; migraine, fatigue, GI ) B complex (multi), pantothenic acid, vitamin C, Mg (Tums) MORE FINDINGS (initial visits): Sensitivity to CS, coffee, corn, citrus shrimp, crab, soy & ?bread Elim./ challenge diet + for corn, tomatoes (joints); wheat remains. Joints reported to “feel better after a fish meal” AM joint pain decreases from 2 hours down to 20’.

43. Jen - Case history (3) INITIAL STEPS TAKEN: Elimination/challenge trials: corn, tomato, dairy, pork, beef & coffee. Nutrient-dense diet with EFA X 2 & EPA/DHA. EPA/DHA, GLA, multi w/ B complex (TF2), Ca/Mg, Flush-free B3. MORE FINDINGS: Diet  in EPA/DHA   discomfort Change from TF2 to TheragranM  decrease in energy Ran out of B3  joints felt worse; same for GLA. Trial GF diet  more improvements (joints; GI)

44. Jen - Case history (4) RECENT UPDATE: Pantothenic acid tried vs. “burning feet”: trial was +; d/c  return of Sx, and dose related to degree of symptoms. Also has influence on how joints feel. “Emergen C” reported poorly tolerated (hives) Oatmeal “rips through me” (GI), but GF oats well-tolerated. Pro-biotic therapy used when on antibiotics, with success. Combination of med (Humera currently), nutrient-dense (elimination) diet & supplements has proven very effective.

45. Traditional vs. optimal Rx Caloric balance+ adjust CHO /Pro ratio Adequate protein + semi-vegetarian model 4 food groups + optimal whole grains, nuts,legumes, fish, etc. Low-fat/SFA optimal EFA’s + EPA + GLA DRI/RDA/DVoptimal vitamin/mineral intakes per individual’s history Food allergy mgt. + food sensitivity mgt.

46. IBS profile #1 Craving tomato /pasta dishes, corn chips, and feels they may not be well-tolerated Excellent dietary balance Adequate baseline supplementation IBS (approximately five days a week) Intermittent eczema Migraines (approximately three times a month)

47. IBS profile #2 Craves concentrated sugars, but ill-tolerates them Poor fruit, vegetable and lean protein intakes Increasing pattern of food sensitivities over time IBS Hypoglycemic symptoms Chronic fatigue “Aching all over”

48. IBS profile #3 Excellent dietary history/food group balance Adequate baseline supplementation Weight stable IBS Poor energy and sleep Recently divorced Peri-menopausal

49. IBS profile #4 Poor fruit and vegetable intakes Indeterminate food sensitivity pattern IBS Mono /hepatitis/alcoholism hx Chronic fatigue Detox profile abnormatlities Liver function tests elevated

50. Anti-inflammatory Nutrition Essential fatty acids (LA & ALA) Herbs & spices (licorice, ginger, turmeric, rosemary) Fish & fish oils (EPA/DHA) Gamma linolenic acid (GLA)  Saturated fat Weight management ? Mind-body

51. Toxic metal profile ?Metallic taste ?Headache ?Hypertension ?Bone/muscular/joint pain ?Fatigue/malaise Pediatric history Occupational history Hair, urine, blood analysis

52. Toxic/environmental exposure Lead, cadmium, mercury (Ca, Zn, Se; ?chelation) Chemical/occupational exposure (detoxification) Air/other pollution (E/Se, C, antioxidants) Environmental allergens (Nettle extract) Pesticides, etc. (Organic foods) Food additives/food poisoning Food allergens (Elimination/rotation) Iron (Ca, whole wheat & rye)