©2014 The Institute for Functional Medicine
FunctionalNutrition:
“Seeing More” During the Functional Nutrition Physical ExamP. Michael Stone M.D., M.S P. Michael Stone M.D., M.S.
Sydney Australia
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Please note the videos included in this presentation have been
removed for copyright reasons.
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Nutritional defects, “like deer in the forest” do not announce their presence but must be looked for” (Sanstead 1969)
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Nutrition Evaluation
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Pattern Recognition
Undernourished
Reduce Exposures
Ensure a Safe Detox
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©2014 The Institute for Functional Medicine
Core Aspects of the Nutrition Physical Exam
1) Vitals and Body Composition2) Evaluate Smell and taste3) Look in the Mouth4) Look at and feel the Skin5) Look at the Nails6) Evaluate Peripheral Sensation
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Test Smell
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Altered Smell or Taste• Smell and Taste are Closely Linked• Evaluate the History: Trauma, Exposure,
Allergy, Obstruction• Other physical exam findings- peripheral
neuropathy• Evaluate Medications• Evaluate Nutritional Status:
Mineral Status: Zinc, Copper, Iron, IodineVitamin Status: A, E: B complex-B2, B3, Pantothenic Acid, Biotin, Folate, B12
©2014 The Institute for Functional Medicine
Causes of Abnormal Smell Test(*most common)
• Obstruction: Allergies, Nasal polyposis*, Deviated Septum*, Intranasal tumor
• Sensory: Viral infection*, Chronic sinusitis*, Allergic Rhinitis*, Cigarette Smoke*, Toxic Chemical exposure, heavy metals (Al, Si, Pb, As, Cd)Drugs-calcium channel blockers
• Neural: Head Injury*, Alzheimer's disease, Parkinson’s disease, Intracranial tumor, Schizophrenia
• Endocrine: Hypothyroidism, DM• Nutritional: Iron, Zinc, Copper, Vitamin A, B1,12
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Drugs That Alter SmellDrug Group Examples z Calcium Channel Blocker Nifedipine, amlodipine, diltiazemLipid Lowering Cholestyramine, clofibrate, pravastatinAntibiotic/Antifungal Streptomycin, doxycycline, terbinafineAntithyroid CarbimazoleOpiate Codeine, morphineAntidepressant AmityptylineSympathomimetic Dexamphetamine, phenmetrazineAntiepileptic PhenytoinNasal Decongestant Phenylephrine, pseudoephedrine,
oxymetazolineMiscellaneous Smoking, agyria (topical silver nitrate),
cadmium fumes, phenothiazines, pesticides, Betnesol-N, Cocaine
snorted
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SMELL TESTPocket Smell Test1) With the patient sitting, test nasal patency by having
them cover one nostril and breath in. Listen for the sound of abnormal air flow. If present do not test, investigate cause of obstruction.
2) Open the card. Use the tongue depressor and scratch the scratch and sniff odorant. Have the client cover one nostril and sniff. Inquire as to the smell. If they are not sure, then offer choices. Repeat with the other nostril.
3) Repeat this with all three odors. The total score should be 6. If 2 or more are missed, then further work up of disordered smell and taste should begin.
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• Smell (Quick Card), – Apple – Natural Gas– RoseOR– Lemon– Lilac– Smoke
UPSIT Test www.sensonics.com
POCKET SMELL TEST
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Bitter BitterBitterTest Taste
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Screening Questionnaire for Loss of Taste
How easily can you detect the tastes Easily Somewhat Not At All
1. Saltiness (chips, pretzels, salted nuts)
2. Sourness (vinegar, pickles, or lemons)
3. Sweetness (soda, cookies, ice cream)
4. Bitterness (coffee, beer, tonic water)
Negative Predictive value for easily: saltiness 95%, sourness 89%, Sweetness 98%, Bitterness 92%. Positive predictive values range from 5-26% (when a person can Easily taste each of the 4 senses then there is a high degree of confidence that they Can taste. Easily is negative for gustatory loss, and somewhat or not at all is positive For loss. Malaty J, IAC Malaty: Smell and Taste Disorders in Primary Care Am Fam Physician 88;12; 852-859, 2013.
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Taste (TAS2R)
Genetics of Taste
3
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Are you a supertaster?Bitter (phenylthiocarbamide-PTC)
Supertasters vs non tasters: Vegetable avoidance, increased fat and sweet intake, disinhibited eating behavior among women, More Alcohol dependence.
m.stone md
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Why Check Bitter-Taste?1) Taste perception affects food selection2) Supertasters have a tendency to eat less
vegetables, eat vegetables more with sauces, dislike coffee, moderate to little like for sweets, pepper/chili and alcohol are more irritating, and perceive feel not tast of fat.
3) Non bitter tasters more susceptible to eating spoilage, and poisonous alkaloids.
4) Can change your therapeutic interventions.
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Genetics and Taste
Reed DR, Knaapila A: Genetics of Taste and Smell: Poisons and Pleasures. Prog Mol Biol Trans Sci: 2010:94:213-40
Chemical Gene Allele Sucrose TAS1R3 -1572 C/T Glutamate TAS1R3 R757C Isothiocyanate TAS2R38 A49P, V262A, 1296V Isovaleric acid OR11H7P C/T at nt 679 Androstenone OR7D4 R88W
YUCK!
YUM!
Gene Quality Genotype Rating of Good Child 1 Child 2 Taste
TAS1R3 Sweet in Onion +/+ -/- TAS1R3 Umami in Tomato +/+ -/- TAS2R38 Bitter in Watercress -/- +/+ OR11H7P Sweat odor in Cheese -/- +/+ OR7D4 Boar Taint in Ham -/- +/+
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Taste LossInfection: Oral Candida, Periodontal disease, gingivitis oral abscess,
viral URI, HIVOral Appliances: Dentures, prostheticsPostsurgical: Middle ear surgery affecting corda tympany, oral or
dental surgery especially 3rd molar extractionRadiation: HEENT irradiation with oral mucositis, xerostomiaNutrition insufficiency: Protein malnutrition, zinc, copper deficiency, B12,
niacin deficiencyMedications: Intranasal zinc, chlorhexidine, chemotherapy,
ACE Inhibitors, ARBs, calcium channel blockers, diuretics, macrolides, terbinafine, fluoroquinolones, protease inhibitors, griseofulvin, PCN, tetracyclines, metronidazole, antiarrhythmics, antidepressants, anti convulsants, lipid lowering agents.
Head Trauma:Toxins: pepper gas, weed killer, ammonia, benzene,
cadmium, iron, leadMedical Conditions: Cancers, Type 2 DM, Hypothyroidism, Renal Failure
Malaty J, IAC Malaty: Smell and Taste Disorders in Primary Care Am Fam Physician 88;12; 852-859, 2013.
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Eight Step Mouth Exam
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8 Steps in Evaluation of the Mouth
1) Jaw Movement2) Lips3) Soft and Hard Palate4) Tongue5) Gums6) Buccal Mucosa7) Teeth8) Chew/swallow
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Nutrition-oriented Physical Exam;
8 Step Mouth Exam
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Oral Mucosal Lesions and Micronutrient Deficiency
Oral mucosal condition Associated micronutrient deficiency
Angular Cheilitis Cheilosis (dry cracking)
Riboflavin, Nicotinic acid, Folic Acid, Biotin Cobalamin, Vit C, Fe, Zn. /Riboflavin, Niacin, Pyridoxine
Burning Mouth Syndrome Pyridoxine
Candidiasis Folic acid , cobalamin, Iron
Glossitis Riboflavin, nicotinic acid, pyridoxine, folic acid, cobalamin, iron, protein energy malnutrition
Lip fissures Pyridoxine
Oral Sensitivity Thiamine, pyridoxine
Recurrent apthae Riboflavin, Folic acid, Cobalamin, Ascorbic Acid
Stomatitis Nicotinic acid, Folic acid, Cobalamin.
Periodontal disease Vitamin A, D, E, B-Carotene, Thiamin, Folate B12, E, C, Ca, Se
Poor mucocutaneous border
Riboflavin, Niacin, pyridoxine, Zinc
Moynihan P. : Nutrition and its effect on oral health and disease. Ch 5, pp 83-99. In M. Wilson: Food constituents and oral health. Current status and future prospects. CRC Press Boca Raton Fl 2009.
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©2014 The Institute for Functional Medicine
Herpes Labialis
Recurrent Aphthous Stomatitis
Perlèche-angular cheilitis
Which Nutrients are Associated
With Each Condition?
2-Lips Cracks, Lesions, Sores
Am Fam Physician 2007;75:501-7.
Zinc, Vitamin A, C
Lysine/Arginine BalanceLower levels of A,E,C
Riboflavin, B-6, B-12Folate, Minerals: Zinc, Fe
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©2014 The Institute for Functional Medicine
4-Tongue-What do I look for?
• Movement • Color • Coating • Fissuring • Scalloping • Piercing • Taste Bud
Distribution • Lesions
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Color
m.stone md
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Tongue CoatingTongue Coating Score
0= No tongue coating1= Thin tongue coating2= Thick tongue
coating difficult to see papillae
J Oral Rehabil 2007 Jun;34(6):442-7.
Significantly more anaerobic bacteria the thicker the coat,
No significant difference in candida
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B12, Thiamin, Riboflavin Niacin, Pellagra
4-TongueGlossitis with Taste Bud Atrophy
mstone
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Hairy tongue
Erythema Migrans
Median RhomboidGlossitis
Leukoplakia
Am Fam Physician 2007;75:501-7, Head Face Med. 2006 Oct 16;2:33.
Iron and Selenium
Candidiasis
Allergy-Intolerance
Oral Hygeine, Candida, AbxDysbiosis-oral
4-Tongue Additional Patterns
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Scalloping• Macroglossia- any cause• Hypothyroid, acromegaly,
amyloidosis, down syndrome
• Sleep apnea• Increased in autoimmune
conditions*• Increased in food allergy
and hypersensitivity*
*clinical experience
m.stone md
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mstone
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Taste Bud DistributionCircumvallateVallate (Inverted V)
FoliateFungiform (spots)
Filiform (coating)
mstone
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• Tendency toward Allergy• If painful and geographic: -Iron, folic acid, B2, B12, Niacin
• Associated with systemic inflammation
NEJM 361:20, 2009
4-TongueGeographic Tongue
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Tongue Coating, pH, Caries and Metabolomics
Evid Based Complement Alternat Med. 2013; 2013: 204908 BMC Complement Altern Med. 2013; 13: 227 Sci Rep. 2012; 2: 936
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Lichen Planus Tongue Cancer
•
Wikipedia images: Lichen Planus and Oral Cancers
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4 –TongueColor, Coverings, Buds, Size, Movement
• Glossitis (Red Tongue) Protein Undernutrition, Iron, Riboflavin, niacin, B6, folate, B12
• Decreased taste/smell Burning tongue: Zinc, Vitamin C
• Tongue fissuring Niacin, gut triggered immune issues
• Tongue –taste bud atrophy Iron, Riboflavin, niacin, B12
• Leukoplakia Vitamin A, B2, niacin, B6, Folate, B12
• Hairy black tongue Not Specific; associated with smoking, sulfur granule positive bacteria, antibiotics
PFC-MVP
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©2014 The Institute for Functional Medicine
Gingivitis Periodontitis
5-Gums and Gingiva
Atlas of Clinical Oral Pathology 2nd Edition. 2003. P. 100-101, Lane, M. Et al: Int J Dent. 2010; 2010: 324719
IL1, IL6, IL10, VDR, genes may be associated with Chronic Peritonitis
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Periodontal Disease
Treating Periodontal disease aggressively and early in pregnancy increases the chance of a full term vs preterm delivery by 6 fold.
M. Jeffcoat, S. Parry, M. Sammel, B. Clothier, A. Catlin, and G. MacOnes, “Periodontal infection and preterm birth: successful periodontal therapy reduces the risk of preterm birth,” British Journal of Obstetrics and Gynaecology, vol. 118, no. 2, pp. 250–256, 2011
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Periodontal Disease is Increased by Several Risk Factors
1) Cigarette smoking2) Systemic diseases autoimmune, diabetes, CVD... 3) Medications such as steroids, anti-epilepsy drugs
cancer therapy drugs4) Ill-fitting bridges 5) Crooked teeth and loose fillings 6) Pregnancy7) Oral contraceptive use8) Low Vitamin D, Vitamin A, Low Vit C, Low Fe, Zn
Jemin Kim-Periodontal disease and systemic conditions: a bidirectional relationship. Odontology. 2006 September ; 94(1): 10–21.
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Hemorrhages: Vitamin C Bleeding gums and...
5-Gums, Gingival findings can cause you to look elsewhere...
m.stone md
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5- Gums-Scurvy
Pretreatment Post-treatment
Weinstein, M. et al.: Pediatrics 2001;108(3). 108/3/e55
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Dark Lines: Lead (Burton’s Line)
5-Gums
Some discolorations from other heavy metals toxicity and therapeutics have been documented-cadmium, bismuth, mercury, cis-platinum
. J A Regezi, J L Sciubba and RCK Jordan: Oral Pathology Clinical Pathologic Correlations. 2008. 5th Edition
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60 y.o. male T2DM, Arrhythmia, Htn, worsening evening vision with mouth findings...What do you see and think?
• Low Vitamin D• Low ionized calcium• Low Vitamin A• Low Vitamin C• Low pH• Low salivary output
secondary to beta blocker for arrhythmia
• Occult infection
m.stone md
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©2014 The Institute for Functional Medicine
7- Teeth
Missing Teeth/Repairs Amalgam and Alloy Load
MStone MStone
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7- Tooth Enamel and Celiac Disease
• 1 in 5 Celiacs have Enamel DystophicChanges. Those without celiac 1/100
.El-Hodhod, MA et al: Screening for celiac disease in children with dental enamel defects. ISRN Pediatr.2012:763783. Epub2012 Jun7.
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• Methamphetamine
• Erosions of Recurrent Vomiting- Bulemia
©2014 The Institute for Functional MedicineDenBesten P. , Wu Li: Chronic Fluoride Toxicity: Dental Fluorosis. Monogr Oral Sci. 2011 ; 22: 81–96.
Consider Background Water or Food Levels of Fluoride
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Possible Antecedents and Triggers
A = AmalgamGC = Gold CrownPC = Porcelain CrownPD = Periodontal DzRC = Root CanalEX = Extraction
EX EX EX EX
A
A GC/RC
A A
A EX EX
EX EX
A A A A
A A
7-Teeth and the Dental Chart
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7- Teeth and Breath
Missing Teeth/Repairs Amalgam and Alloy Load
MStone MStone
RA Bernhoft: Mercury Toxicity and Treatment. J Env Public Health 2012Ucar, Y, WA Brantley: Biocompatibility of Dental Amalgams, Int J Dentistry 2011
2-28 mcg/facet/day80 % absorbed
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Marek, M. "Interactions Between Dental Amalgams and the Oral Environment." Advances in Dental Research Sept. 1992: 100-09. A.sagepup.com. Web. 19 Nov. 2011. <doi: 10.1177/08959374920060010101>. Courtesy of : Mary Ellen Chalmers
Illustrating Galvanic Currents
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If Amalgam Fillings might be a root cause of health problems…
For a Biologic Dentist near you!
International Academy of Oral Medicine & Toxicology www.iaomt.org
Mercuryexposure.info
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Why Check pH?1) The pH of the mouth helps determine and is
determined in part by the microflora- oral dysbiosis, infection, salivary flow, and buffering capacity of the saliva.
2) pH<6.8-7.4 is associated in increased endothelial dysfunction, inflammation, and oxidative stress.
3) pH<5.8 associated with enamel disruption and cariogenesis
4) Intervention with increased vegetable intake, alkalization of the diet, and treating causes of low salivary flow or poor buffering improves pH and oral dysbiosis
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7- Teeth and Salivary pH
• pH paper or sticks• Different Techniques- Touch, Spit, Collect• Compare to the pH guide• pH>6.8-7.4 “ideal”• pH <6.8 is acidic• pH<5.8 enamel erosion
“Alters environment”
.Oscillating pH Conditions in the Mouth
©2014 The Institute for Functional Medicine
©2014 The Institute for Functional Medicine
Core Aspects of the Nutrition Physical Exam
1) Vitals and Body Composition2) Evaluate Smell and taste3) Look in the Mouth4) Look at and feel the Skin5) Look at the Nails6) Evaluate Peripheral Sensation
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Look At and
Feel the Skin
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Touch the Skin on the Arm
Character:• Temperature• Texture• Color• Hydration• Lesions• Hair Distribution
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Skin and Nutrition
• Barrier Health• Membrane Health• Cellular Health• Requires Cofactors
– Elongases– Desaturases
Psoriasis
Atopic Dermatitis
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Xerosis
Hyperkeratosis pilari
P. , F:EFA, C, M:Zinc inadequacy, V:Vitamin A Vitamin C, B, P.
Xerosis
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Seborrhea, dry scaly skin Dry eczematous rash
Which nutrients are involved?
EFA, Zinc, Vit A, Biotin Zinc, food intolerances (atopia), vitamin A, probiotics, EFA
Skin Dry Rash
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Seborrheic Dermatitis
+Deficiency in EFAs, Vit A, zinc, biotin +Dysbiosis +Food allergy / sensitivity
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Beta carotene Retinol• Highly variable• BCMO1 – encodes enzyme converts beta carotene to
retinol• In summary, a range of SNPs can influence the
effectiveness of using plant-based carotenoids to increase vitamin A status in at-risk population groups and this effect may vary depending on ethnic origin.
• Other influences – food source, BMI (increased BMI = decreased conversion), hypothyroidism, zinc, copper and selenium
• Zinc deficiency limits bio availability of vitamin A• Often give vitamin A and zinc together
Beta carotene Retinol
Lietz, G. J Nutr. 2012;142:161S-165C
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Celiac Dermatitis Herpetiformis
Atopy:PermeabilityImmune BalanceProtein lossEFA/GLA,Zinc, Vit. A/DHoming, C
Gluten Sensitivity vs.Celiac;Innate vs.AdaptiveImmune Balance
Atopy/Eczema Infected Severe Atopy
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Acanthosis Nigricans
• Smooth, velvet-like, hyperkeratotic plaques in intertriginous areas (e.g., groin, axillae, neck).
• Will resolve when insulin resistance resolves.
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Acanthosis Nigricans• Type I is associated with malignancy. Sudden
onset. Extensive truncal distribution,including the face, palms, and trunk.
• Type II is the familial type, with autosomal dominant transmission. Rare and appears at birth or soon after.
• Type III: obesity and insulin resistance. Most Common
• Drugs: systemic corticosteroids, nicotinic acid, diethylstilbestrol, and isoniazid (INH).
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Acanthosis Nigricans
Type 2 DM, PCOS
Glucocorticoids, niacininsulin, oral contraceptivesprotease inhibitors
Severity is predicted byFasting Insulin levels
Higgins, SP et al Dermatology Online J 14(9):2
Skin Tags
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Follicular Hyperkeratosis: EFA, Zn, Vit. A, C, B complex
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©2014 The Institute for Functional Medicine
S Ragunatha,1 V Jagannath Kumar,2 and S B MurugeshA CLINICAL STUDY OF 125 PATIENTS WITH PHRYNODERMA
Indian J Dermatol. 2011 Jul-Aug; 56(4): 389–392.
Vitamin A, B complex, EFA, Vitamin C undernutrition
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Skin- Vitamin C Deficiency
Actas Dermosifiliogr. 2005 Jul-Aug;96(6):400-2.
Swan neck hairs
Léger D. Can Fam Physician 2008;54:1403-6
Follicular Purpura
Bruising
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ACNE
Deficiency in Zinc, Vit A, EFAs.
Dietary Allergens, High GL diet, Dairy.
Photos by James Heilman, MD
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Gut / Brain / Skin Connection• Hypochlorhydria results in increase risk of SIBO /
gut infections• SIBO leads to decreased absorption of protein,
fats, carbs and vitamins secondary to inflammation• Injury to enterocytes in small intestine = increased
intestinal permeability• SIBO associated with depression and anxiety and
eradication improves emotional symptoms• SIBO is associated with a 10X increase in acne
rosacea• LPS endotoxins are more common in people with
acneBowe + Logan. Gut Pathogens. 2011;3:1.
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Acne vulgaris, Probiotics, and the gut-brain-skin axis-back to the future?
Bowe and Logan. Gut Pathogens. 2011;3:1.
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Other Causes of AcneiformConditions
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Dioxin Poisoning Typical blood dioxin level: 15-45 units / gram of blood fat
Yushchenko: 100,000 units / gram AP Photo/Viktor Podedinsky/Efrem Lukatsky
March 28, 2002 Dec 6 2004
21 Months
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Chloracnegenic Chemicals• Chlorinated phenols• Chloronaphthalenes• Polychlorinated biphenols• Other polychlorinated compounds:
polyhalogenated dibenzofuranes,polychlorinated dibenzo-p-dioxins, chlorinated azo and azoxybenzenes.
• Location of the halogen on the benzene rings determines the acnegenicity.
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Dioxin• Chloracne is most consistent
manifestation of dioxin intoxication• Absorbed by direct contact, inhalation,
ingestion• Normally TCDD <10 ppt (parts per trillion)
in patients with chloracne levels in the several hundreds.
• Dioxin: highly lipophilic• Half life 7-11 years
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Chloracne Distribution• Early: face and neck• Later: trunk, extremities, genitalia• Comedone appearance more often on the face
and neck, below and to the outer side of the eye (malar crescent), Posterior auricular triangles.
• Ear lobes, suboccipital hairline and groin involved.• Nose, perioral skin and supraorbital regions
usually spaired.• Other skin lesions: xerosis from decreased sebum
secretion, pigmentation, porphyrinopathy,hirsutism, skin thickening , palmoplantar hydrosis,palmoplantar hyperkeratosis.
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ChloracneClinical Features Acne Vulgaris Chloracne Age group Adolescent and childhood Any age, children susceptible
Predilection site Localized, face, chest, back Generalized: retroauricular, malar, axillae, groin, extremities
Major Lesions Limited comedones, papules, pustules, cysts
Myriad comedones
Pathogenic factors
Inflammatory lesions common Very rare
Sebum production Increased Decrease
Microflora Propionibacterium acnes Propionibacterium granulosum
No bacteria
Androgen sensitivity Dependent Unknown
Therapy Effective under treatment of antibiotics, Resistant to therapy retinoids and other treatment
Calorie Restriction and Dietary fat substitute (Olestra) up to a 30 fold increase in excretion
Ju Q, CC Zouboulis, L Xia: Environmental pollution and acne: Chloracne Dermato-Endocrinology 1:3,125-128, 2009
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Drug Induced Acneiform EruptionsDu-Thouh A, N Kluger, H Bensalleh, B GuillitAm J Clin Derm 2011; 12(4)233-245
Categories Causitive Agents
Hormones Corticosteroids, Corticotropin(ACTH), Androgens/Anabolic steroids, Hormone contraceptives, TSH
Neuropsychotherapeutics Tricyclic antidepresents, Lithium, Antiepileptics, SSRI...
Vitamins Excess Vitamin A, Thiamine, Pyridoxine, B12
Cytostatic Drugs Azathioprine, thiourea, thiouracil, Dactinomycin (actinomycin D)
Immune Modulators Cyclosporin
Antituberculin Isoniazide, Rifampin, Ethionamide
Halogens Iodine, Bromine, Chlorine, Halothane, Lithium
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Iodine
• Cold dry skin• Sparse hair• Decreased
perspiration• Frank Myxedema
• Iododerma (multiple nodular, ulcerating, pustular, fungating lesions
• Kelp Acne
Low Iodine High Iodine
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Skin and Heavy Metals: Mercury
• Increased dermatographia• Acrodynia of the hands and feet• Xerosis and peeling palms and soles of
feet• Autonomic dysfunction with increased
flushing/sweating/hypersalivation (acute)• Methyl mercury, ethyl mercury, elemental
mercury with different findings dependent on exposure.
Weinstein M, S Bernstein CMAJ • JAN. 21, 2003; 168 (2) 201.
©2014 The Institute for Functional MedicineWeinstein M, S Bernstein CMAJ • JAN. 21, 2003; 168 (2) 201.
©2014 The Institute for Functional MedicineWeinstein M, S Bernstein CMAJ • JAN. 21, 2003; 168 (2) 201.
©2014 The Institute for Functional MedicineH
g+ D
ose
Burd
en
Curr Probl Pediatr Adolesc Health Care 2010 September; 40(8):186-215.
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Skin and Heavy Metals: What About…Arsenic?
©2014 The Institute for Functional Medicinepmstone, md,ms 2013 91
©2014 The Institute for Functional Medicinepmstone, md,ms 2013 92
Seborrheic keratosis: common benign epithelial tumors. Do not appear until age 30 and over the lifetime. Small to large barely elevated papules to “stuck on” Plaques Lesions do not require treatment except for cosmetic reasons. They can become irritated or traumatized with pain and bleeding, squamous cell cancer should be ruled out. Wolff, K, RA Johnson: Benign Tumors pp 215-218. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. 6th ed 2009
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Seborrheic Keratosis Key Question….. When Did They Appear? All at once, over a short period of time…? Patient…Why do you ask? Provider…I am wondering, what was the trigger?
pmstone, md,ms 2013 93
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Significant associations between low intakes of various nutrients (retinol, calcium, fiber, folate, iron, riboflavin, thiamin, vitamins A, C, and E) and Keratotic skin lesion incidence in people exposed to environmental arsenic. Greater intakes of methionine, Cysteine, protein and vitamins such as thiamin and niacin increased arsenic secretion Mekonian S et al: J Nutr 142:2126-2134,2012
What About Nutrition Imbalance in the setting of the toxic exposure?
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Further Considerations for this physical exam finding of Seborrheic Keratosis
Timing of Appearance Defense and Repair Exposures-toxins Structural Integrity -Repair-methylation status Nutrition Adequacy- Protein Fat Minerals Vitamins Phytonutrients
pmstone, md,ms 2013 95
©2014 The Institute for Functional Medicine
Seborrheic Keratosis: When Did They Appear?
pmstone, md,ms 2013 96
Physical Exam Finding of Seborrheic Keratosis Ask when they appeared- all at once or gradual Ask about water- well or city Ask about diet- adequate protein, essential fats Carbohydrates, Minerals, Vitamins, Phytonutrients Ask about cancer in family, consider MTHFR Status Ask about toxins (environmental, water, air, occupation) particularly heavy metals including arsenic Clinical Findings that may be associated: fatigue, peripheral neuropathy, digestive symptoms-nausea, vague tenderness Consider heavy metal testing (random serum), provoked urine collection of urine following oral chelator dose like DMSA at 20-30 mg/kg if creatinine is normal to harvest high levels of arsenic, lead, or mercury, cadmium, or tin Discuss Dietary and Lifestyle Changes which will aid in the repair of DNA, the excretion of arsenic and heavy metals and the adequacy of micronutrients in the setting of unique SNP patterns in the patient. Consider Evaluating other Abdominal Pathology.
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Seborrheic Keratosis
Nutrition Deficiency or Toxicity Sign?
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SK, SSC, Melanoma Skin Cancer MTHFR and VDR polymorphisms
• UVA breaks down plasma folate – Folate is involved in DNA
synthesis and repair• UVB can synthesize
vitamin D in the skin – Vit D has anti-proliferative
effects• Highest risk for SCC
(squamous cell carcinoma) with MTHFR 677TT polymorphism and low folate intake
Han J. Carcinogenesis. 2007;28:390-7mstone
VDR Receptor SNP’s Fokl T Increased risk of MM Bsml Decreased risk of MM, Increased Sq Cell CA Taq1 Increased risk of S.K.
Dermato-Endocrinology 3:1, 11-17, 2011
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Inspectthe NAILS“Rings of our physiology”
6 Months of your medical record
©2014 The Institute for Functional Medicine
Look at the Nails
• Shape• Color • Pattern of Color• Texture and
Strength• Growth Pattern• Surrounding Tissue
Lunula
Cuticle
Distal Edge
Eponychium
Lateral recess
©2014 The Institute for Functional Medicine
Nails• Koilonychia Fe, Cu, Zn, Protein• Transverse pigmentation Protein• White spots leukonychia Zinc, selenium, protein, niacin
(pellagra)• Psoriatic nails Vitamin D• Beau’s lines Zinc• Pale nail beds Iron• Muehrcke's lines (bands) Protein, stationary and paired• Mees’ lines Transverse white lines: arsenic• Splinter hemorrhages Vitamin C• Onycholysis Iron, niacin• Chronic paronychia Zinc• Red lunula (CHF) CoQ10, Ribose, Mg, Carnitine (if DD)• Terry nails (white) Liver Failure, Hep B, DM, CHF • Brittle nails (onychorrhexis) Malnutrition, protein, calcium, low HCl• Diffuse milky white nails Niacin (pellagra), zinc, malnutrition• Variable white Hypocalcemia• Diffuse brown/black bands Malnutrition• Blue nails Wilson’s disease
©2014 The Institute for Functional Medicine
Nails Leukonychia Punctata & Leukonychia Striate
Zinc Deficiency Selenium Deficiency
Shape, Color and Pattern of Color, Texture and Strength, Growth Pattern, Surrounding Tissue Differential:
©2014 The Institute for Functional Medicine
Onychorrhexis: Iron, Folic Acid, Protein
Median nail dystrophy: Malnutrition
Koilonychia: Iron, Protein, Zinc, Cu
Beau’s Lines: Hypocalcemia, Zinc Deficiency
Clubbing: Inflammatory Bowel, Sprue
Examining the Fingernails When Evaluating Presenting Symptoms in Elderly Patients Mark E. Williams, MD Medscape.com
Beau’s Lines: Hypocalcemia, Zinc DeficiencyBeau’s Lines: Hypocalcemia, Zinc DeficiencyBeau’s Lines: Hypocalcemia, Zinc Deficiency
Nail InspectionPutting Nutrition in the Differential
©2014 The Institute for Functional Medicine
• Deficiency: Zinc, Selenium• Toxicity: Arsenic, Selenium• Systemic disease: Renal
(hemodialysis), Liver Disease
• Medications: Chemotherapy
• Trauma, manicure, biting tapping.
Engle, K:Transverse Leukonychia NEJM July 13. P.100, 1995
©2014 The Institute for Functional Medicine
Shape, Growth Pattern: Beau’s Lines
• Zinc deficits
• Other causes-
• Severe illness
• Measles/mumps
• Syphilis
• Poorly controlled DM
• Myocarditis
Shape, Color and Pattern of Color, Texture and Strength, Growth Pattern, Surrounding Tissue
©2014 The Institute for Functional Medicine
Mees Lines, Arsenic Toxicity and More
Arsenic poisoning, Hodgkin’s disease, CHF, leprosy, malaria, chemotherapy, carbon monoxide poisoning, other systemic insults
©2014 The Institute for Functional Medicine
Core Aspects of the Nutrition Physical Exam
1) Vitals and Body Composition2) Evaluate Smell and taste3) Look in the Mouth4) Look at and feel the Skin5) Look at the Nails6) Evaluate Peripheral Sensation
©2014 The Institute for Functional Medicine
Peripheral Sensation
Light touchHot/ColdPosition SenseVibratory SenseReflexesMuscle StrengthBalanceWalking
©2014 The Institute for Functional Medicine
Vibratory Sense, Light Touch Testing
• 128 Hz tuning fork
• 5.07 Semmes-Weinstein Monofilament
• Normal Peripheral vibratory sense of the thumb and 5th distal finger, and the great toe and the 5th toe.
• Normal Monofilament sensation Feet and Hands
©2014 The Institute for Functional Medicine
Abnormal Vibratory Sense or Monofilament Testing consider:Monofilament Testing consider:
Routine-Tier One• Hbg A1C, hsCRP, CBC dif• Serum B12, Methylmalonic acid, Homocysteine• Serum Heavy metals: Arsenic, Lead, Mercury, • Celiac Panel-gluten induced autoantibodies.
Tier Two or Three• RBC Lipids,• RBC Minerals• Organic Acid Testing
– (metabolism of valine, leucine, and isolucine blocked by insufficiency of B1,B2,B3, Pantothenate, and Lipoate),
– Isoleucine catabolism (blocked by deficiency of Biotin)
• Serum Amino acids
Further w/u with Nerve Conduction Studies may be warranted.
©2014 The Institute for Functional MedicineVinik AL: Diabetic Neuropathy in Older Adults. Clin Geriatr Med 24(3)407-v, doi:10.1016/j.cger.2008.03.011, 2008.
©2014 The Institute for Functional MedicineVinik AL: Diabetic Neuropathy in Older Adults. Clin Geriatr Med 24(3)407-v, doi:10.1016/j.cger.2008.03.011, 2008.
©2014 The Institute for Functional Medicine
Peripheral Neuropathy: Presentation
1) Symmetry, sensory level dependent peripheral neuropathy
2) Proximal Weakness vs. Distal Weakness3) Muscle loss4) Periosteal Tenderness5) Multilevel neurologic change vs isolated
©2014 The Institute for Functional Medicine
Peripheral Neuropathy: Small Fiber
1) Prominent pain: burning, superficial and associated allodynia (painful touch)
2) Hypoalgesia late in the condition3) Defective autonomic function with decreased sweating,
dry skin, impaired vasomotion and blood flow and cold feet.
4) Intact reflexes, motor strength5) Silent electrophysiology6) Reduced sensitivity to monofilament and pricking
sensation using the Waardenberg (Wartenburg) wheel or similar instrument
7) Abnormal warm thermal perception, neurovascular function, pain, quantitative autonomic function tests.
Vinik AL: Diabetic Neuropathy in Older Adults. Clin Geriatr Med 24(3)407-v, doi:10.1016/j.cger.2008.03.011, 2008
©2014 The Institute for Functional Medicine
Peripheral Neuropathy: Large Fiber
1) Impaired vibration perception and position sense2) Depressed tendon reflexes3) Dull (like a toothache), crushing or cramp like pain in the
bones of the feet4) Sensory ataxia (waddling like a duck)5) Wasting of small muscles of the feet with hammertoes
and weakness of hands and feet6) Shortening of the Achilles tendon with equines7) Increased blood flow to the foot (hot foot) increased risk
of charcot neuroarthropathy)
Vinik AL: Diabetic Neuropathy in Older Adults. Clin Geriatr Med 24(3)407-v, doi:10.1016/j.cger.2008.03.011, 2008
©2014 The Institute for Functional Medicine
Peripheral Neuropathy: Presentationoften mixed large and small fiber
1) reduced vibration sense2) reduced position sense3) reduced light touch4) weakness5) muscle wasting6) depressed tendon reflexes
©2014 The Institute for Functional Medicine
Type 2 diabetic peripheral neuropathy and methylation factors for 6 months led to
improved neuropathy with nerve growth, decreased pain, increased function
Abstracts of the Diabetic Foot Global Conference. Oral Presentations 2009.
Metanx® is an orally administered medical food for use only under medical supervision for the dietary management of endothelial dysfunction in patients with diabetic peripheral neuropathy.
At the end of their treatment, 73% of patientsshowed an increase in calf Endothelial NerveFiber Density, 82% of patients experienced both reduced frequency and intensity of paresthesias and/or dysesthesias. Greater improvement after 1 year
Jacobs AM, Cheng D Rev Neurol Dis. 2011;8(1-2):39-47.Walker MJ, Morris LM, Cheng D Rev Neurol Dis. 2010;7(4):132-9
Methyl Folate: 3 mg, Methyl Cobalamin 2mg, Pyridoxine 5 Phosphate 35 mg twice a day
©2014 The Institute for Functional Medicine
Growing New Nerves in Diabetics with DPN
Nutrient Mechanism
Methyl Folate Enhances production of tetrahydrobiopterin, enhances endothelial nitric oxide synthase. Counteracting oxidative-nitrosamine stress through restoration of endothelial nitric oxide synthase coupling vasonervorum.
Methyl Cobalamin Neutralization of superoxide and peroxynitrite, promotes myelination and transport within the cytoskeleton of the peripheral nerves
Pyridoxine 5 Phosphate
Chelation of transition metals and traps 3 deoxygluosone to inhibit the formation of Advanced Glycosylation End products.
Abstracts of the Diabetic Foot Global Conference. Oral Presentations 2009.
Metanx® is an orally administered medical food for use only under medical supervision for the dietary management of endothelial dysfunction in patients with diabetic peripheral neuropathy.
Jacobs AM, Cheng D Rev Neurol Dis. 2011 8(1-2):39-47 .Miranda-Massari JR: Curr Clin Pharmacol 6 (4):260-273, 2011Shevalye, H, et al:. Diabetes 61:2126-2133, 2013 Walker MJ, Morris LM, Cheng D Rev Neurol Dis. 2010;7(4):132-9
©2014 The Institute for Functional Medicine
• Highly Prevalent amongst patents with DM type 1,2,3
• Impaired Memory
• Dementia
• Delirium
• Peripheral Neuropathy
• Sub acute combined degeneration of the spinal cord
• Megaloblastic anemia
• Pancytopenia
Kibirige, D, R Mwebaze: Vitamin B12 deficiency among patients with diabetes mellitus: is routine screening and supplementation justified. J Diabetes & Metabolic Disorders 12:17, 2013
©2014 The Institute for Functional Medicine
M
Biotransformation & Elimination
Energy
Communication
Defense & Repair
Structural Integrity
Assimilation Antecedents
Triggering Events
Personalized Lifestyle Factors
Nutrition & Hydration
Physiology and Function: Organizing the Patient’s Clinical Imbalances
Mediators/Perpetuators Spiritual
Sleep & Relaxation
Name:____________________________ Date:___________ CC:_____________________________________ © Copyright 2011 Institute for Functional Medicine
Stress & Resilience Relationships & Networks
Exercise & Movement
Nutrition & HydrationNutrition & Hydration
M
Communication Biotransformation Spiritual
• Renal Failure, many causes, VAT,
• Obesity, • Endothelial dysfunction
• Food Allergy• Celiac, IBD/Crohn's with
malabsorption. Postherpetic neuralgia
• RA, SLE, Intrinsic Factor Autoantibodies, low ADE
• CoQ10 /statin• B12
transcobalamin deficiency,
• Methylation factors
• Heavy metals, MSG, Gentamicin, Cisplatinum, Alcohol
• Salicylates, arsenic, gout,occupational
• Inflammatory bowel diseases leading to poor
absorption of nutrients.
• IR and DM• Low testosterone
Decreased Vibratory Sense
MTHFR, Methylation SNPs FHx DM
Retelling the Patient’s Story
3 Most common causes of Neuropathy in Adults 1) Insulin Resistance, DM 2) Alcohol 3) Occupational or Therapeutic Exposures
©2014 The Institute for Functional Medicine
Romberg, Balance, Get up and Go
©2014 The Institute for Functional Medicine
Workshop- Peripheral Sensation
Light touch- Monofilament Testing
©2014 The Institute for Functional Medicine
Why Check Light Touch with a Monofilament?
1) Helps determine adequacy of one of the protective senses.
2) Helps determine whether there is large or small fiber involvement.
3) If abnormal points to heavy metal burden, dysglycemia, drug associated causes for neuropathy, mitochondrial dysfunction, or nutritional underlying cause of system dysfunction.
©2014 The Institute for Functional Medicine
Reducing Oxidative Stress Reducing the Biologic Dysfunction Promoting Growth and Repair…
Acetyl L Carnitine
Thiamin
Pyridoxine 5 phosphate
L methyl folate
Methycobalamin
Protein Copper
Vitamin E
Niacin
Taurine
Magnesium
Low Glycemic Diet
Omega 3 Fatty Acids
Alpha Lipoic Acid
Nicotinamide
Rosemary
Green Tea
Grape seed extract
Curcumin
Resveratrol
Zinc
Selenium
Inositol
Choline
Riboflavin
Hyperbaric Oxygen
Glutathione
Manganese Vitamin C
Vitamin A
Asparagine
Biotin
Vitamin K
Glutamine
Spices
CoQ10
Propolis
Gamma Linoleic Acid Sodium
Microbiome Balance
Pantothenic Acid
©2014 The Institute for Functional Medicine
Core Aspects of the Nutrition Physical Exam
1) Vitals and Body Composition2) Evaluate Smell and taste3) Look in the Mouth4) Look at and feel the Skin5) Look at the Nails6) Evaluate Peripheral Sensation
©2014 The Institute for Functional Medicine
©2014 The Institute for Functional Medicine
Context History-Timeline Network Influences
Company Symptoms, Other Signs Current Biochemical Markers
Quality Diet, Food, Nutrient
Quantity Diet, Food, Nutrient
©2014 The Institute for Functional Medicine
Thank You
“Seeing More” During the Functional Nutrition Physical ExamP. Michael Stone M.D., M.S.
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