COMMENTARY

The New, Old World of Functional Medicine: Part 1

An Interview With Mark Hyman, MD

Hansa Bhargava, MD

Disclosures

October 12, 2016

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Editor's note: This is the first part of a three-part interview with Mark Hyman, MD, director of the Center for Functional Medicine at Cleveland Clinic. It has been edited for clarity.

Hansa Bhargava, MD: I am Dr Hansa Bhargava, medical editor for Medscape and WebMD. Today we are privileged to have Dr Mark Hyman joining us. In addition to his role at Cleveland Clinic, Dr Hyman is a renowned author of several books and a New York Times best-selling author. Dr Hyman, thank you for being here.

Mark Hyman, MD: Thanks for having me.

Dr Bhargava: Can you tell us a little bit about yourself? Our readers will want to know what led you to your current path.

Dr Hyman: It's pretty exciting here at Cleveland Clinic, being at the center of one of the best healthcare institutions in the world, bringing functional medicine to scale, doing the research, and addressing the science in a rigorous way. I came to it through a very different path.

I was a family doctor. I worked in a small town in Idaho doing rural medicine, C-sections, and running the emergency room (ER). I was the old-time country family doctor for many years. Then I became an ER doctor in Massachusetts in the inner city for a couple of years. Afterwards, I got a job at Canyon Ranch in Lenox as the medical director, focused on lifestyle and wellness, which is where my heart has always been.

Right after I started at Canyon Ranch, I became quite ill. I had chronic fatigue syndrome. My whole system broke down: My muscle enzymes were elevated with creatine phosphokinase levels over 600. I had a positive anti-nuclear antibody, a low white blood cell count, elevated liver function tests, and severe cognitive dysfunction. I had myalgia, weakness, rashes, sores on my tongue, and severe diarrhea for years. My whole system just collapsed. I went from physician to physician, to Harvard and Columbia, and more. But I got no answers other than to take antidepressants or sleeping pills.

I began to search for other ways to understand what was happening. I knew it wasn't in my head. I finally discovered that after living in China for a year I had gotten mercury poisoning.

I learned through this process that there was a whole new field of thinking that had a systems-biology view of medicine. It addressed the root causes of disease—not just symptoms but also etiology. It's medicine by cause, not just symptoms. It's medicine by understanding mechanisms, not just geography, or where the symptom or pathology exists. It was a whole new operating system for understanding how to diagnose and treat chronic disease.

So I started practicing functional medicine at Canyon Ranch and healing myself. I started seeing extraordinary results with patients and myself. I joined the faculty and eventually became the chairman of the board of the Institute for Functional Medicine, which trains physicians and other healthcare providers in functional medicine, a powerful systems-based model that takes our observations of the root causes of disease and our biological networks, and integrates them into a framework for clinical application.

One example is the microbiome. All of a sudden, the microbiome is big medical news. We have been addressing the gut, the gut flora, and the microbiome for decades in functional medicine. It is a central focus of functional medicine—how to restore normal gut function and balance the microbiome. How can we explain, given our current reductionist diagnostic framework, that depression, autism, autoimmune diseases, heart disease, obesity, type 2 diabetes, cancer, and many other illnesses are all connected to your gut flora? It doesn't make sense given our current paradigm. At Cleveland Clinic, Stanley Hazen, MD, PhD, is doing research examining how the microbiome plays a role in regulating certain metabolites that may lead to heart disease.

These observations force us to rethink our diagnostic paradigm and question our current view. When you go to the rheumatologist, they do not ask about your gut flora; and when you go to the cardiologist, they do not ask about your gut flora. In functional medicine, it's exactly what we do. We look at the root causes. It's a new view of the body as a system, a biological network.

Functional and Western Medicine: A Case Study Comparison

Dr Bhargava: That is very interesting. The Institute for Functional Medicine defines this model as a systems-oriented approach that encompasses genetics, environment, and lifestyle. Can you explain that a little bit more to the traditional doctor?

Dr Hyman: I went to medical school like everybody else. In the second year of medical school, we had a course on systems. The cardiovascular system, gastrointestinal system, neurologic system, and so on. We separated and organized the body into these discrete systems. But that is not actually how the body is organized.

 
Why is it that all of a sudden we're learning that cardiac disease is not a plumbing problem but an immune or an endocrine problem?
 

Rather, the body is organized through biological networks that are all dynamically interacting. For example, how is inflammation linked to dementia, cancer, heart disease, and obesity, as well as autoimmune, inflammatory, and allergic disorders? How does that work? Why is it that all of a sudden we're learning that cardiac disease is not a plumbing problem but an immune or an endocrine problem? How do we explain that?

We have to begin to think upstream. As medicine evolves, we're now realizing that the body isn't actually what we thought it was. It's a dynamic, complex, adaptive ecosystem that responds to inputs from the environment. These influence gene expression and create your phenotype.

Most of us are still stuck in the siloed version of medicine. Nobody's communicating with each other across specialties to see these connections and understand how to work the dynamic complex adaptive system that is the human body.

I'll give you an example of how we would approach a patient with psoriatic arthritis differently. It's an autoimmune disease. With conventional medicine, these patients would need an immune suppressant, right? A woman who I saw was on ustekinumab (Stelara®), which costs approximately $30,000-$70,000 a year.[1] She also had a host of comorbidities, including migraines, depression, prediabetes, reflux, and irritable bowel syndrome (IBS). She had itching everywhere: anal itching, vaginal itching, dandruff. We would say that these are all comorbidities. She needs to see the psychiatrist for depression, the gastroenterologist for her reflux and IBS, the neurologist for migraines, the rheumatologist for her autoimmune disease, and the dermatologist for her skin conditions. And she was. She was getting the best possible care, the best standard of care. But no one asked, "How are these connected?"

 
In functional medicine, we don't believe in comorbidities. We believe that there are fundamental root causes that can explain a lot of discrete phenomena.
 

In functional medicine, we don't believe in comorbidities. We believe that there are fundamental root causes that can explain a lot of discrete phenomena that aren't necessarily immediately obvious but are linked together. John Muir [is alleged to have] said that when you pull on something in the universe, you can see that it's connected to everything else. Understanding those networks and connections is what functional medicine is about.

This woman had an autoimmune disease. We know that there are multiple causes. It could be a disturbance of the microbiome. It could be changes in intestinal permeability that lead to uptake of inflammatory peptides such as lipopolysaccharides (LPS) from the gut flora. She might have developed food sensitivities. She might have had an infection like Lyme disease, or she could have had toxic exposure. We look at the root causes, which are typically toxins, allergens, microbes, stress, or poor diet. I did that analysis on her. She was having postprandial bloating, a lot of yeast infections, and terrible digestive issues. All of those things could be linked to a disturbed gut microbiome. So I started there. She had psoriatic arthritis, but I started in her gut.

I put her on an elimination diet and got her off of common triggers such as gluten and dairy to reduce inflammation. I put her on a low-sugar and -starch or –glycemic load diet to prevent small bowel intestinal overgrowth and yeast overgrowth. I gave her the antibiotic rifaximin (Xifaxan®), which is used for small intestine bacterial overgrowth. I gave her an antifungal, fluconazole (Diflucan®), for yeast infections. I gave her digestive enzymes, probiotics, fish oil, and vitamin D.

She came back 2 months later and all of her symptoms were gone. Her psoriatic arthritis was gone and she was off the Stelara and all of her other medications. She had no more reflux, IBS, migraines, or depression. She lost 20 pounds. She had no more itching. All of her symptoms got better, not by treating each disease separately but by treating the system. That is an example of how functional medicine would work. It's not siloed in all of these specialties, with all of these doctors for different illnesses. We ask, "How is everything connected?"

We use a methodology that allows you to assess the patient and then filter the data into buckets of these biological networks. We call it the matrix, which is the system of thinking through and sorting the data that you see through history and physical examination. We look at all of the predisposing factors, genetics, and triggering factors. We look at lifestyle factors and how they influence the biological networks that drive disease.

Dr Bhargava: That was very interesting. I look forward to continuing our conversation. Thank you for being here, Dr Hyman.

Dr Hyman: Thank you.

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