How Can Functional Medicine Help Me?

As many of my patients know, I run a busy chiropractic office in Austin, Texas… but I also have a thriving Functional Medicine practice that allows me to consult with and help people all over the US and abroad.

Still, many of my you have been asking me questions surrounding Functional Medicine and what it entails.

My philosophy to health is pretty simple: Move Well, Eat Healthy and Cultivate Happiness.

As a chiropractor, my goal is to make sure that your spine is healthy, your joints are mobile and you have no physical limitations in movement. Functional Medicine allows me to address the other 2 components: eating well and cultivating happiness.

In this article, I’d like to discuss my approach and how it works.

Conventional medicine has a doctor for every part of your body. There are cardiologists for your heart, gastroenterologists for the digestive system, neurologists for the brain and nervous system, podiatrists for your feet, and ophthalmologists for your eyes.

Due to specialization, conventional medicine often focuses on individual body systems, rather than trying to understand the whole person and ultimately that individuals underlying causes of disease and chronic illness.

In light of this, symptoms are used to name a disease and find a corresponding drug. That’s typically your treatment.

  • High blood pressure gets you blood pressure lowering pills.
  • High cholesterol, gets you cholesterol lowering pills.
  • Infections of any kind almost always get you antiobiotics
  • Imbalanced hormones, gets you hormone replacement therapy.
  • Etc. Etc. Etc.

Basically, your symptoms are treated with no regard for the “cause”.

In functional medicine, the goal is to view your body as an interconnected whole, within a larger environment.

In other words, your health is the sum of all nongenetic (your external environment) and genetic (internal environment) exposures in your lifetime, starting from the moment of conception to death. It encompasses the food we eat, the air we breathe, social interactions, lifestyle choices and inherent metabolic and cellular activity.

Functional Medicine doctors recognize that in order to treat one part of the body, all other parts must also be considered. This breaks apart artificial divisions of the body.

What Functional Medicine Addresses

I have a hierarchy of importance for which factors to address when starting with a patient:

  1. Diet, Lifestyle and Environment.
  2. Nutrient imbalance, gut and HPA-axis
  3. Cellular Dysfunction, Toxic Burden, Hormone Imbalance
  4. Chronic Infections and Immune Dysregulation
  5. Treating symptoms for diseases that cannot be fixed

Diet, Lifestyle and Environment 

As a good rule, any doctor interested in improving health should begin with diet, lifestyle and environment. It is what it is and there’s no way to self-medicate, supplement or artificially create what life requires.

Nutrient Imbalances, Gut Infections or Dysbiosis and HPA-axis

There are two reasons why we address this next:

First, these factors are often at the root of, or at least strong contributors, of other pathologies such as hormone imbalances (Low T, Thyroid problems, PCOS, etc), cellular dysfunction (Energy balance, Diabetes, Heart Disease, Weight) and immune dysregulation (autoimmune disease, cancer, arthritis, tissue repair).

Second, even if there are other problems occurring, this will lead to a significant clinical improvement towards helping any other condition.

I believe that up to 80% of health problems can be addressed by simply getting #1 (Diet, Lifestyle, Environment) and #2 (Nutrient imbalances, gut infections or dysbiosis and HPA-axis) in check.

Cellular Dysfunction, Toxic Burden, and Hormone Imbalance

In some cases we have to dig deeper. This involves assessing methylation, heavy metals, mold/biotoxins, impaired detoxification, thyroid, sex and metabolic hormones. Again, most of these problems can be addressed by improving diet, lifestyle, nutrient imbalances, gut health and stress.

Chronic Infection and Immune Dysregulation

Some patients have infections (Lyme, co-infections, parasites) that are pretty nasty and almost always require a more specialized and even integrated (Medical Prescription) approach.

How can you get started?

If you’re interested in a functional medicine consult, here’s my flow:

The consult has 2 parts: A 20 minute case review and an hour to 2 hour case review

STEP ONE: INITIAL 20 MINUTE CONSULT

After purchasing an initial consult, we will setup a time for us to meet over the phone or in person. During this 20-minute appointment, I will interview you to determine which lab tests to order for your Case Review, based on your chief complaints and your history.

This appointment has two purposes: to make sure that I have all of the information needed to gain a comprehensive understanding of the factors affecting your health and to give you a head start on your treatment before you meet with me.

The exact lab testing ordered after the Initial Consult depends on your individual circumstances, but may include:

  • A comprehensive blood chemistry panel. This is the single most efficient, effective and affordable tool for quickly evaluating your health. It screens for a wide range of conditions, including several types of anemia; gut, viral and bacterial infections; insulin resistance and hypoglycemia; liver and kidney issues; and thyroid and adrenal problems. It offers important clues for how to structure and focus your treatment to get the best results. It also provides a baseline of biomarkers that can be used to objectively track the progress of your treatment over time.
  • Additional blood tests for specific conditions, such as high cholesterol, hypothyroidism, autoimmune disease and gluten sensitivity.
  • Advanced stool testing to screen for parasites, fungal overgrowth, bacterial infections, intestinal inflammation, dysbiosis and a deficiency of beneficial gut bacteria.
  • Urine organic acids testing to screen for small intestinal bacterial overgrowth, fungal overgrowth, problems metabolizing fat or carbohydrates, B-vitamin status, methylation issues, detoxification capacity, oxidative stress and neurotransmitter metabolism.
  • Urine hormone testing for adrenal and sex hormone status.

You will also be provided the Case Review health history paperwork to complete.

This paperwork includes:

  • A detailed health and medical history questionnaire
  • A survey of your chief complaints and most important health goals
  • An assessment of your most troubling and frequently experienced symptoms
  • A diet survey and questionnaire
  • A survey of your current supplements and medications

Once we’ve received your lab results and completed the Case Review paperwork, I will give you specific protocols to start working on before moving on to part 2: the case review consultation.

This typically occurs between 60 and 90 days after the Initial Consultation, because some of the labs we use take up to 8 weeks to deliver the results to us after receiving your sample.

STEP TWO: THE CASE REVIEW CONSULTATION

The Case Review Consultation is a 60-minute to 120-minute in-person, phone or video appointment.

Prior to the consultation, I will have reviewed the results from the labs that were ordered along with your Case Review paperwork, medical history, diet and supplement survey, assessment forms and relevant prior lab work. I will also create a Report of Findings, which is broken into three parts:

  • A summary of the underlying patterns that are contributing to your symptoms.
  • An outline of the suggested treatment plan, including dietary, supplement and lifestyle recommendations.
  • Recommendations for further testing (this will typically be minimal, if necessary at all, because of the completeness of the Case Review process)

During this visit, I will present the Report of Findings as well as your treatment plan. I will also review all of your test results with you and answer any questions you have about the findings or the treatment plan.

Why Your Saliva or Blood Hormone Test Results Mean Sh!t

Physicians have three options for hormone testing – serum, saliva or urine. Each of these testing methods is a viable option, but by themselves they are nearly useless for clinical recommendations.

As a long time chiropractic physician, I have spent the vast majority of my life studying human physiology and performance. Certified in Functional Medicine, I’m always looking for reliable tests to confirm or deny my clinical suspicions and help patients achieve a higher level of function and performance. Nothing irritates me more than someone who comes to me with a set of test results that quite literally mean shit in the realm of function and performance. So here’s my attempt to clear things up with respect to salivary, serum (blood) and urine hormone testing.

In my world, body fluids remain the most valuable source of information along with a thorough history. As I always say, let’s test, not guess. As a health provider, the most common fluids I’m interested in are blood, urine, saliva and sh!t (stool). Each one has its particular strengths and weaknesses, but they do not provide enough information by themselves. Therein lies the problem. Performing and analyzing just 1 of these panels is not comprehensive enough to make any sort of recommendation.

Serum (Blood) Testing

Advantages: Ideal for measuring hormone concentrations in the blood or plasma. Accurate for circulating hormones (not bioavailable hormones)

 

Disadavtanges: Does not measure Bioavailable Hormone or How those hormones are being metabolized in your body. It’s also just a “snapshot” of what’s happening.

Drawing blood or pricking your finger for hormones has long been accepted by the conventional medical community as the standard for measuring hormones.  There’s something “legit” about drawing blood and it’s also a pretty simple process that doesn’t take much time to do at all. Serum is ideal for testing peptide hormones such as FSH, LH, prolactin, fasting insulin, and thyroid hormones including Reverse T3, as well as thyroid antibodies.  It is also used to measure Sex Hormone Binding Globulin (SHBG) and, less commonly, Cortisol Binding Globulin (CBG).

For sex hormones, serum testing is accurate but limited. Why? For most sex hormones, no distinction is made in serum between bound and free hormone. This means you have no way of knowing the difference between a hormone that’s circulating in your blood versus actual uptake or utilization of that hormone in your tissue. Estradiol, estrone, estriol and progesterone are reported as total hormone and free hormones assays are not commonly available.  This may lead to misleading results in which hormone levels appear to be normal or even high normal because of an abundance of bound hormone.

However, if your free hormone level is low, you can be functionally deficient even with a normal total hormone level.  Serum testosterone is an exception in that it is commonly available as both total and free, and therefore can be useful in assessing hormone balance. But not so fast…

Another limitation of serum hormones testing is the “snapshot” nature of single point testing.   Because hormones are secreted in a pulsatile manner over the course of the day (and night), it is difficult to know whether the levels in serum represent a peak, a valley, or something in between (1, 2). This also presents a difficulty in monitoring treatment, as it is not possible to know whether today’s test was drawn at a similar point of hormone secretion as a previous test.

Finally, serum hormone testing does not typically allow for the measurement of estrogen, androgen, and adrenal metabolites, which can provide a wealth of information to assist in understanding of your condition and help to guide and fine-tune treatment options.

Saliva Testing

Advanatages: First, it’s non-invasive and can be done easily in your home. This also allows for multiple data points throughout the day. It’s a great way to measure Free Hormone or Bioavailable hormone.

Disadvantages: Accuracy starts to head south because of many factors including saliva production,

Over the last 10 years it appears that everyone is now doing salivary testing. Saliva has the advantage of being non-invasive as well as being accessible to practitioners such as naturopathic physicians, acupuncturists, health coaches and other practitioners who may be practicing in states where they are not licensed to order blood tests or draw blood themselves.  Saliva collection also allows for multiple collections over a period of a day or month which can help elucidate abnormal hormonal patterns, such as a shortened luteal phase or cortisol drift.  While this can theoretically be done with a serum test, it would be logistically cumbersome and you’d be walking around looking like a heroin addict.

Saliva is best used to evaluate the balance and flow of the estrogens and progesterone in women who are still having menstrual cycles.  It can also be used to evaluate cortisol secretion patterns by taking multiple samples over the course of a day and evening. While the free cortisol pattern in saliva has clinical value, there is a significant piece of the puzzle missing – metabolized cortisol. To properly assess your “adrenals” you need to know your free and metabolized cortisol.  A saliva test measures free hormone and its multi-point versatility makes it a better measure than serum for evaluating un-supplemented hormone status.

Saliva production is difficult for some patients, and there are multiple restrictions regarding eating, drinking, gum-chewing, make-up use, topical application, and tooth-brushing that must be observed to get a useable specimen.  Micro-damage from tooth brushing can result in elevated salivary testosterone levels for up to an hour after brushing, even in the absence of visible signs of bleeding, such as “pink toobrush”. Saliva can only be used to evaluate steroid hormones.  Peptide hormones, such as growth hormone and thyroid are not available.  While estradiol, estrone, and estriol, progesterone, testosterone, DHEA and cortisol are all available, depending on the lab, steroid hormone metabolites are not measured in saliva, limiting its utility in assessing metabolism of hormones or how they are actually impacting your body.

If your doctor or practitioner is using Saliva to monitor actual hormone therapy, stop! It’s not a great way to measure success because measurements are greatly affected by the use of exogenous hormones (3,4). Transdermal progesterone and testosterone, in particular, can result in supra-physiological levels (very high) in saliva testing, but all exogenous hormone use seems to distort results to some extent.

Because of this, you should be instructed to discontinue hormone use for between 12-36 hours prior to collection, depending on the hormone preparation. This of course can pose problems for practitioners who want to monitor hormone therapy.  Estrogen, for example, washes out of the system almost entirely in 20 hours and drops significantly within 12 hours.

Saliva collection, like blood, is a single point collection.  Although cortisol can be collected at multiple points, sex hormones are measured from a single morning collection.  Just as with serum tests, a single point of collection does not account for individual variation and may catch a peak or a valley in hormonal secretion – or perhaps a peak for one hormone and a valley for another.

Urinary Testing

Advantages: Non-invasive, as long as you don’t “piss” yourself. Good for monitoring available circulating hormone levels as well as their metabolites.

Disadvantages: You’re working with pee. Not able to accurately assess Free Cortisol to get an accurate depiction of Adrenal fatigue and Hormone balance. Accuracy is highly dependent on the lab and their equipment.

Measuring hormones in urine is less common in clinical practice than either serum or saliva, yet it is quite common in research. So Boom… guess which one Dr. Daniel prefers.  A 24-hour urine collection is the preferred method for testing hormones that are secreted at night and during deep sleep, such as Growth Hormone (5) Melatonin (6), and is the most economical and reliable way to evaluate steroid hormone metabolites.

But don’t start pissing in a cup just yet. Not all urine hormone testing methods are equal.  Serial single-point urine collection does not account for individual differences in hormone secretion, especially for patients with non-traditional schedules, such as shift workers.  Twenty-four hour urine collection accounts for the full day and night of hormonal secretion.  This eliminates the possibility of falsely elevated or depressed levels that may be obtained when a single point collection occurs at a peak or valley of an individual’s secretory cycle.

Just as single-point and 24-hour collection are different, not all technical methods of urine assay are equally accurate. Highly sophisticated Gas Chromatography(GC) run in tandem with Mass Spectrometry(MS) is emerging as the method against which all other methods are measured (7). So the methods matter. Some methods of urine testing are not optimal and quality may differ significantly from lab to lab.

Urine assays measure unbound hormone, reflecting that which is bioavailable.  The use of 24-hour urine hormone profiles in clinical practice has found these profiles to correlate well with symptoms reported by patients on hormone symptom questionnaires. Similarly, supplementation with exogenous hormones or other treatments and improvement in symptoms is reflected in values seen on follow-up tests.

What Form of Hormone Testing Do I Think is Best?

All of them. But in my opinion and for sakes of saving money, The DUTCH test is the best all in one.

The DUTCH test is a urine test, but it’s dried urine. DUTCH stands for Dried Urine Test for Comprehensive Hormones and is currently the most comprehensive lab test available in the market for measuring hormone balance and their metabolites.

This advanced hormone test was developed to improve on the available hormone testing options currently available. DUTCH offers the most extensive profile of sex and adrenal hormones along with their metabolites. Additionally, the daily (diurnal) pattern of free cortisol is included along with melatonin. This unique combination of clinical information is not available by any other method.

Effective HRT Monitoring: DUTCH testing was specifically made to be optimally effective for most forms of hormone replacement therapy. Unique methods are used for improved monitoring of oral progesterone and vaginal hormones.

Easy Collection: Patients collect just four or five dried urine samples over a 24-hour period. Dried specimen shipments are convenient worldwide. Dried samples are stable for several weeks.

Analytical and Clinical Validation: Precision Analytical testing methods go through a rigorous validation process to verify accuracy, precision, recovery, linearity, etc.

This single test gives you the same information that you would get from a blood, saliva and 24 hour urine test but oh so much more!

Now you know.

 

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