Tired and on Fire Assessing and Managing Chronic

Tired and on Fire! Assessing and Managing Chronic Inflammation Melanie Dorion AGNP Functional Forum November 6, 2017

Welcome to the November 2017 Functional Forum A collaborative meeting for healthcare providers Here’s to thriving! 2

The Functional Forum Team Melanie Dorion Sera Fiana 3

The Pentad Team Melanie Dorion Rob Abbott Trevor Shand CEO, Founder Content Director COO 4

Outline • Review chronic inflammation • Main areas to assess in chronic illness and inflammation • Food and gut issues • Nutritional deficiencies • Lab testing • Management options • Case Photo by Mohamed Nohassi on Unsplash 5

What is chronic inflammation? ? Acute Inflammation Chronic Inflammation Injury/damage = Injury/damage not resolved = • Dolor • Calor • Rubor • Tumor • trigger(s) is usually identifiable: infection, trauma, etc • T lymphocytes • Activation of innate immune system (mast cells for eg) • trigger(s) not always clear 6

Triggers to Chronic Inflammation Photo by Lukasz Szmigiel on Unsplash 7

Assessing Chronic Illness and Inflammation How to solve the puzzle? ? Photo by Hans-Peter Gauster on Unsplash 8

Five Facets. TM • 5 areas to cover with every patient • core focus is diet and lifestyle • fluid structure to help find obstacles to healing • critical foundational steps Intro and initial Assessment Neuropsychological Health Metabolism Diet and Lifestyle Immune and Inflammation Gut Health and Detox 9

Main Contributors to Chronic Inflammation 1. Digestive disturbances and food issues 2. Nutritional deficiencies 3. Stress – physical and emotional 4. Toxins 5. Infections 10

Digestive Disturbances and Food Issues 11

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Microbiome - Impact on Overall Health https: //bmcmedicine. biomedcentral. com/articles/10. 1186/1741 -7015 -9 -24 13

Gut Brain Axis 14

What Type of “Food Issues”? Allergy, intolerance or sensitivity? https: //www. slideshare. net/keithberndtson/gluten-sensitivity Intolerance • lacking the enzyme • think lactose intolerance 15

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Leaky What? ? Leaky gut is real • Is one of 3 factors leading to Celiac disease and possibly other autoimmune diseases • Environmental trigger • Genetic susceptibility • Leaky gut “Apparently [the microbiome] can also influence which genes in their hosts are active at any given time. Hence, a person whose immune system has managed to tolerate gluten for many years might suddenly lose tolerance if the microbiome changes in a way that causes formerly quiet susceptibility genes to become active. ” Dr. Fasano 17 http: //www. komar. org/faq/celiac_disease/Fasano-Scientific-American-8. 2009 -1. pdf

Gluten and Leaky Gut 18 http: //www. komar. org/faq/celiac_disease/Fasano-Scientific-American-8. 2009 -1. pdf

Nutritional Deficiencies 19 http: //skinnaturalmedicine. com/functional-lab/optimize-health/

Why is Nutritional Testing Useful? • Humans are not great at information recalls • There are low correlations between dietary questionnaires, and actual levels for most nutrients • Dietary assessment is best used in population studies • Nutritional deficiencies caused by many medications 20

Medications Associated with Nutrient Depletion folate La. Valle JB: Consequences of Cardiovascular Drug-Induced Nutrient Depletion. Pp. 369 -404. Sinatra ST, Houston MC: Nutritional and Integrative Strategies in Cardiovascular Medicine. CRC Press 2015 21

Nutritional Deficiencies in Obesity Nutrient Prevalence of the Deficiency Vitamin C 35 -45% Vitamin D 80 -90% B 12 9 -10% Folate 25% Iron 13 -19% 22

Testing “Argh! CRP, sed rate, CBC and chem panel are normal! Now what? ? !” 23

Standard Testing… with a twist • Blood sugars!! • • fasting glucose < 90 A 1 c ≤ 5. 5 fructosamine ≤ 235 Insulin < 8 • Homocysteine: <7 • A/G ratio: goal is >1. 5 -2 (this may vary but in general, this range seems optimal) • 1, 25 OH/25 OH ratio: goal is <1. 5, • higher ratio may indicate immune upregulation, especially infectious cause 24 Dr. Ben Lynch, SHEICON 2017, https: //mpkb. org/home/mp, https: //www. ncbi. nlm. nih. gov/pmc/articles/PMC 4160567/pdf/11_2014_Article_755. pdf

More on Homocysteine http: //www. lifeextension. com/Magazine/2006/6/report_doctors/Page-01 25

Functional Testing 26 http: //skinnaturalmedicine. com/functional-lab/optimize-health/

Functional Testing • Omega 6/omega 3 ratio: goal is 1: 1 or 2: 1 • Reverse. T 3 (r. T 3) • goal is <17 • elevated in stress and nutritional deficiencies: think inflammation r/t injury, infections/toxins, low iron • Stool testing: GI Effects • Nutritional testing: Nutr. Eval • Genetic testing - methylation genetics: Strategene 27 http: //www. redalyc. org/pdf/309226770013. pdf

GI Effects

Nutritional Testing 29

Looks at many markers for every nutrient evaluated 30

Oxidative Stress Markers 31

Genetics and Homocysteine – it all comes together! Folate pathway MTHFR B 12 pathway Strategene. org and mthfr. net 32

Management Treat the cause!! https: //www. cartoonstock. com/directory/i/inflammation. asp 33

Managing Inflammation – Back to Basics Plus Some What are the obstacles to healing? Gut and food issues? Nutritional deficiencies? Toxins? Infections? Stress? • Low carb, no processed foods and no added sugars! • Move and Exercise • R&R • Get some sunshine/daylight 34

Management – Digestive Support • Elimination diet • Gut Healing Support • Perma. Clear by Thorne: start 1 cap twice per day x 5 -6 days then increase to 2 cap twice a day x 5 -7 days then 3 caps twice a day for repairing. • Glutagenics by Metagenics (glutamine): total between 3, 000 -10, 000 mg/d in 2 -3 doses. Start with 3, 000 mg/d and increase every 3 -4 days as tolerated to reach 10, 000 mg/day if needed in divided doses. If benefits are reached at lower doses then the patient may not need to increase the dose. • Bone broth, 1 -2 cup daily if possible or Great Lakes gelatin (green container) daily 1 -2 cups/day. • Restore: Start with 1/2 tsp 3 x/day and increase to a full tsp 3 x/day over 5 -7 days, put in water and drink. 35

Management – Medical Diets Ketogenic diet • Very low carb, high fat diet – 70% fat, 25% protein, 5% carbs • must be done correctly for it to work • it IS safe and NOT like diabetic ketoacidosis • ketones are a very efficient fuel • resources: Keto Clarity by Jimmy Moore – keto “bible” or The Keto Diet The Complete Guide to a High Fat Diet by Leanne Vogel books 36

Medical Diets Autoimmune Protocol – AIP • specialized Paleo diet, • removes potential gut irritants • gluten, dairy, corn, soy, egg, nuts&seeds, legumes and nightshade free • https: //www. thepaleomom. com/start-here/the-autoimmune-protocol/ Vegan Alkaline Diet • ALL plant-based foods, no animal products of any sort • May help “reset” the digestive system • After about 4 -6 weeks I will transition patients back to vegetarian or start re-introducing meat 37

Management - Nutraceuticals The list is long so here are my favorites • Turmeric (remember, curcumin is an active ingredient in turmeric) • Get liposomal if possible to increase absorption • Entero. Mend by Thorne • Meriva by Thorne • Fish oils: EPA/DHA, goal dose 5 -10, 000 mg to reduce inflammation • Omega. Genics by Metagenics • in stores: Nordic Natural - Ultimate Omega • Metagenics • SPM Active (specialized pro-resolving mediators): 3 caps twice a day • Ultra. Inflam. X: 2 scoops/day 38

Best Forms of Folate 39

Homocysteine Management Key Nutrients • limit/avoid folic acid! • methyl folate • methyl B 12 • P 5 P (active B 6) • R 5 P (active B 2) • TMG • Zinc Mehtyl. Guard or Methyl. Guard. Plus – start low and go slow!!! 40

Others Low Dose Naltrexone • compounded • start low and go slow: 1 -2. 5 mg for two weeks then double the dose • take at bedtime High Dose vitamin A • 15, 000 -20, 000 IU 1 -4 x/day • upregulates Treg • used by dendritic cells • pulse like a steroid, high doses for 4 -5 days, stop then restart if needed • high in cod liver oil 41 Vit A: DOI: 10. 1079/PNS 2002172 ; https: //www. ncbi. nlm. nih. gov/pubmed/8354037; https: //www. ncbi. nlm. nih. gov/pubmed/20363594

Case 1 70 yo female presents for weight loss and fatigue

Case History 6+ years of debilitating fatigue and ongoing consistent slow weight gain Desperate about her fatigue, moving to assisted living in PA in case it gets worse Has seem many traditional and integrative providers w/o much relief Current symptoms: GI (bloating, cramping, diarrhea), fatigue, brain fog, memory issues, mm weakness, anxiety Past History: etoh abuse, Lyme disease, OSA, low Fe Retired, lives alone BMI 30, other vitals wnl Labs • Nutr. Eval and Complete Hormones – covered by Medicare! • Reactivated mono • ++ Celiac genetics • Elevated ANA • Lyme inconclusive • Normal G 6 PD • Other labs wnl

Management Treat the mono • Valtrex x 10 days, Supplements: Lomatium x 7 days, monolaurin and mushroom complex x 1 -3 mo • Start IVs: weekly high vitamin C IVs with magnesium and glutathione push

Management • Diet and Lifestyle: • gluten free and lower carb, discussed ketogenic • Daily gentle exercise • IM hydroxy B 12 and B complex twice a week • Continue weekly high C IVs with magnesium and glutathione push • Oral B complex and sublingual Bs (B 12, B 9 and B 6 [P 5 P]) • Daily Ultra. Inflam. X • Gut healing support At the two week follow-up, patient reports feeling more energy than has in years At the four week follow-up, continues to feel better and weight gain has stopped

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