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Learning from Stumbling: Advanced FM Practitioner Pearls

Unlike many other light-and-fluffy, fly-by-night, or I-went-to-a-weekend-class “certifications”, our program was designed from the beginning to be highly credible, rigorous, and to truly certify that a practitioner has deep and demonstrated knowledge of functional medicine principles.  Skills that potential clients and medical practice hiring managers both value.  Our students are setting themselves apart from their rapidly growing competition with the AFMC certification!

I want to share with you a list of advanced pearls that cropped up last week from the certification case study reviews.  I chose just a few; I could go on and on. Fair warning: some of these are pretty advanced.  Would you stumble over them too?  These are potential, detailed gotchas that I want to give you the opportunity to learn from – and avoid in your own practice.

No matter how much you know, never stop learning.

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  •  People who eat “low carb” diets can and do sometimes develop insulin resistance (i.e. they aren’t necessarily lying and eating bags of chips in their closets.)  Insulin resistance is indeed rampant.  Identifying and addressing this common root cause of diabetes before it creates downstream issues (e.g. T2 diabetes) is a HUGE benefit for your clients.  The standard American diet – with its overload of refined carbohydrates – can indeed be a further upstream driver.  But we need to keep in mind that insulin resistance at its root is a result of progressive oxidative stress.  And chronic inflammation from a huge array of sources can contribute to this oxidative stress.  Poor fatty acid metabolism can create oxidative stress.  As can smoking, chronic exposure to toxins, insufficient exercise, antioxidant deficiency (think people with low glutathione), insufficient omega-3 fatty acid intake,  hepatitis, chronic infections, and so on…  The pearl here is not to make assumptions based on “typical” root causes.  Keep Beginner’s Mind – perhaps the best practitioner wisdom I have ever been given.
  • Picky eaters, especially those with long-standing issues regarding flavor and texture, may have an issue with insufficient zinc.  Certainly there are other possible contributors (including other nutrient issues), but this is a common connection to consider which can perhaps be affirmed with other data.  Looking at conventional labwork, a suppressed Alkaline Phosphatase or ALP (even within reference range, if <55 U/L) is likely indicative of insufficient zinc (especially if other liver enzymes e.g. ALT and AST are not suppressed).
  • An elevated MCV (mean corpuscular volume) – indicating suboptimally large red blood cells – is typically a reflection of a need for more Vitamin B12 and/or Vitamin B9 (folate) at the cellular level (especially if MCH and MCHC are also high).  Intake, digestion, absorption, etc. might be at play.  However, serum levels of these nutrients may still be optimal – or even high.  MCV is a cellular marker for a unique’s person’s body, and cellular markers are much more useful.  A logical follow-on lab for high MCV would be methylmalonic acid (MMA) to confirm whether Vitamin B12 is involved.  Serum and cellular markers may often appear inconsistent in their implications.  Sure, it could be a lab error, but more likely, it just means you have to think more deeply about what might be at play.
  • Every cell in the body needs optimal ATP production in the mitochondria in order to thrive.  This includes brain cells, immune cells, and cells lining the GI tract.  Always remember to consider the possibility of mitochondrial dysfunction  (e.g. toxins, low B vitamins) or simply a low metabolic rate being the reason why *any* body system isn’t working optimally.  When someone has IBS-like symptoms with constipation, yes, it might be SIBO with a dramatic bacterial overgrowth.  However, the true root cause of gut dysfunction could also simply be low thyroid and/or adrenal hormones working together to slow *everything* down.   Low energy production in gut cells = poor motility and glandular secretions = poor digestion = excessive food fodder for microbes = overgrowths = gas build up = downstream symptoms like IBS.
  • Insomnia might be caused by food sensitivities.  We know that immune system reactions to food typically cause an elevation of cortisol as a stress response to a perceived “foreign invader”.  Persistent, unaddressed food sensitivities can cause enough dysregulation in the HPATG axis (especially when combined with leaky gut and/or chronic emotional stress) to lead to inappropriately high cortisol at night.  We eliminate the typical causes (e.g. poor sleep hygiene, caffeine, PM chocolate, alcohol, late dinner, noise) and someone still struggles.  Sure, one might have issues with low serotonin or glutamate overload or poor melatonin synthesis (needs B6!), but the hormonal culprit might be cortisol.  And the true root cause might be food sensitivities.  Gluten-y cookie, anyone!?!   Again, the pearl is Beginner’s Mind.  Don’t jump to conclusions.  Be comprehensive in your thinking.
  • Drugs are toxins.  Absolutely medications can be life-saving or therapeutic, but especially when they are prescribed “for life”, we need to remember that all drugs are exogenous toxins that the liver is rapidly trying to clear.  Sometimes the reason for poor liver function is the combination of multiple daily drugs putting a constant burden on related detoxification pathways in the body.  The liver can be so busy processing drugs each day that it struggles to process other daily toxic exposure like pesticides or personal hygiene products.  Daily drugs can also promote intestinal permeability (especially hormones, antidepressants, NSAIDs) which becomes the root cause of inflammation elsewhere in the body.  Sometimes the advent of inflammatory symptoms might be as a result of a person starting a cocktail of drugs for a totally different purpose.  The pearl is to remember that everything is Systemic.  Every lifestyle choice can affect every body system.  Think broadly.
  • Digestive enzymes require an optimal pH in the intestinal chyme in order to be effective.  A person might have plenty of digestive enzymes yet struggle with symptoms that make you think otherwise (e.g. bloating, distension, flatulence).  If the chyme is too alkaline, the enzymes won’t work as well.  The upstream cause might be insufficient stomach acid (hypochlorhydria) or an imbalance of intestinal microbes that favors  more alkaline secretions (e.g. insufficient Lactobacillus – a notable producer of acidic secretions).  (As an aside, it’s also the acidic secretions of Lactobacillus that can create an environment that is inhospitable to many pathogens.)  The pearl here is to think thoroughly about upstream drivers and avoid knee-jerk conclusions.  Using more enzymes in an environment that is  fundamentally weakening their activation won’t help your patient much.

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Jacqueline Gang

Although, digestive enzymes may not help in a fundamentally weakened environment, can they actually cause things to be worse? Increased gas, bloating flatulence?

Star D.
Star D.

Wow…being able to connect a clients food sensitivities to their insomnia is quite an amazing discovery!

Anthony Llabres
Anthony Llabres

This article in particular exposes the difference between blood sugar increase when in response to very low carb or ketogenics diets vs non-low-carb: http://ketopia.com/high-blood-sugar-in-ketogenic-dieters-plus-a-special-surprise-hint-genotypes-and-metabolism/

Anthony Llabres
Anthony Llabres

Regarding the Low Car and Physiological Insulin Resistance….It is my understanding that the body will induce this state for those folks when they get lean in order to spare glucose in the liver for transport to the brain. In the end, insulin resistance on *very* low carb appears to be a physiological adaptation to spare glucose for the brain and prevent your muscles from gobbling it up. I see no reason to think it’s a pathological problem.