COMMENTARY

The New, Old World of Functional Medicine With Dr Hyman: Part 2

Hansa Bhargava, MD

Disclosures

October 12, 2016

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

Hansa Bhargava, MD: Hi. I'm Dr Hansa Bhargava, a medical editor for Medscape and WebMD. I am joined again today by Dr Mark Hyman to continue our conversation on functional medicine.

A lot of physicians may feel that you might miss something big with functional medicine. Let me be the devil's advocate. If you go through a review of systems with your patients, will that ensure that we don't miss anything like an occult fracture, an occult bacteremia, or an occult cancer? How do you make sure that you encompass traditional medicine as well?

Mark Hyman, MD: Functional medicine is not throwing out what we all learned in medical school. We still go through a traditional history, physical assessment, and traditional diagnostics, whether they are imaging or laboratory tests. They are all part of it. But in conventional thinking, the end stop is the differential diagnosis, which we all learned in medical school. That's usually the end of our thinking. Once we've made the differential diagnosis and we have the diagnosis, we know what to do. We pick up the Washington Manual of Medical Therapeutics for residents. We have the standard of care. It's not that complicated. Once you make the diagnosis, you know what the treatment is, right?

In functional medicine, the diagnosis is the place where we start to think. It's not the end of our thinking. In traditional medicine, it's the naming and blaming game. We name the disease and blame the name for the problem, and then we tame it with a drug. Let's take depression, for example. Someone comes in, and they're hopeless and helpless. They're sad. They have no interest in life. They have no appetite. They're not sleeping. They have thoughts of suicide. You say, "I know what's wrong with you. You have depression." Depression isn't the cause of those symptoms. It's the name of those symptoms. Then, we ask, "What's the cause of those symptoms?"

Well, there may be dozens of causes of depression, right? It could be psychosocial trauma, early life experiences, or Hashimoto thyroiditis, an autoimmune disease that leads to low thyroid function and is caused by eating gluten, which creates an autoimmune thyroid disease. The depression could be because you have been taking a proton-pump inhibitor for 10 years and you have vitamin B12 deficiency, or because you live in the Northeast and you have vitamin D deficiency, or because you have taken antibiotics that altered your gut flora, or because you love sushi and you're eating sushi all the time and you have mercury poisoning, or maybe you hate fish and have omega-3 fatty acid deficiency, or maybe you're insulin resistant and love cinnamon buns and have prediabetes. All of those can cause depression. So it's a methodology for sorting through the root causes and the things that are driving it and then addressing those.

Dr Bhargava: You're saying that you take the traditional approach, but you're adding on a whole number of other diagnostics as well to find the underlying causes for the diagnosis.

Dr Hyman: Absolutely. I'm a trained family doctor, and I do all of the traditional diagnostics. I can make the regular diagnoses, but I don't stop there. I don't say, "Okay, you've got psoriatic arthritis. The treatment is a biologic drug or methotrexate." I ask what's going on. I had a patient the other day who had rheumatoid arthritis for a year. She was on intensive immunosuppressive therapy. It turned out that she had babesiosis and Lyme disease that nobody had ever thought of. I just go through an algorithm of what the root causes are. And then I ask what the missing ingredients are. It's not just asking what the triggers for disease are, but also: What is the biological terrain? Louis Pasteur came up with the germ theory. The germ was seen as the cause of disease. And then at the same time, Claude Bernard had a competing theory, which was that it's the biological terrain.

We know that if you inject rhinoviruses into people's noses, not everybody is going to get a cold. It's going to be stratified based on their level of stress, which suppresses the immune system. We know this in medicine. So the question is: What is your biological terrain and how do you enhance it? In a way, functional medicine is the science of creating health. It removes the impediments to health and provides the ingredients to health. The body has a natural healing capacity. It's very powerful. We think of food, nutrients, the right balance of hormones, light, air, water, sleep, exercise, restoration, and even meaning, purpose, connection, and love as ingredients for a healthy human. We try to support the removal of the impediments to health and provide the ingredients for health.

Dr Bhargava: So, you're adding areas to the history and physical that we don't normally do as physicians. You're not ignoring traditional medicine but actually adding other areas that are just as important. How does that compare with integrative medicine?

Dr Hyman: Integrative medicine is an advance that happened a couple of decades ago. It grew out of a holistic health movement during which we discovered alternative therapies such as acupuncture, homeopathy, energy medicine, chiropractic care, and osteopathic care. There were various modalities in mind-body medicine that were being ignored but that had the capacity to support health. So, Andy Weil and a group of innovative doctors decided to integrate these modalities into conventional medicine and began to develop integrative medicine centers. However, the doctors were just learning about these alternative therapies and then recommending them. It became more of a triage and referral system. I'm not trained as an acupuncturist, and I'm not a homeopath. I don't know anything about many of these modalities, but I'm a Western biomedically trained doctor. What I wanted to know was how to actually work with my patients and help them.

I would say that functional medicine is the map. It's the map of what the root causes are. Which biological systems are out of balance? How do we work with those? And then, with the modalities, if someone needs surgery, they get surgery. I use medications all the time. I will use lifestyle change when it's most appropriate. If someone comes in with diabetes, the treatment isn't metformin or glipizide or insulin. The treatment is changing what they eat. You can eat cinnamon buns all day and take more and more insulin, but we know from the ACCORD study[1] that there's a higher risk for mortality and heart attacks in those who had more rigorous insulin therapy and more aggressive control of their blood sugar. It matters how you get there. We put people on aggressive dietary interventions, and we see people getting off 30, 40, or 50 U of insulin in a week. It's unheard of because most physicians don't know how to apply food as medicine.

It's as if you have a headache and I give you 2 mg of aspirin. Is it going to work? No, it's not going to work. You need two 325-mg aspirins to get rid of your headache because it's dose-dependent. It's the intensity of the intervention that matters.

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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