Unconventional Medicine: Join the Revolution to Reinvent Healthcare, Reverse Chronic Disease, and Create a Practice You Love by Chris Kresser
Functional Medicine is a comprehensive theoretical framework for medicine that incorporates a modern understanding of the body as a complex adaptive system, an integrated biological ecosystem, an interdependent, web-like network of biological functions.
A review in the New England Journal of Medicine (Farrell 2002) cataloged the myriad diseases that can be caused by celiac disease, from anemia to osteoporosis, from autoimmune diseases to thyroid dysfunction, from schizophrenia to psoriasis. Because each of these conditions may be triggered by multiple factors, not just eating gluten, consideration of him as a unique individual was critical.
Clinical medicine can shift to applied systems medicine—personalized, predictive, preventative, and participatory (Snyderman and Langheier 2006). Most chronic disease is preventable, and much of it is reversible, if a comprehensive, individualized approach addressing genetics, diet, nutrition, environmental exposures, stress, exercise, and psycho-spiritual needs is implemented through integrated clinical teams based on emerging research (ACPM 2009).
Part One Part One: The Promise
one day, while browsing in a bookstore, I came across a book called Nourishing Traditions by Sally Fallon.
One in two Americans now has a chronic disease, and one in four has multiple chronic diseases. Chronic disease causes seven of ten deaths in the U.S. and accounts for 86 percent of healthcare expenditures (and 99 percent of Medicare dollars!), 91 percent of prescriptions, and 76 percent of physician visits (NCCDPHP 2016; NIEHS 2015, 295; Johns Hopkins University Partnership for Solutions 2000).
Three Reasons U.S. Healthcare Is Destined to Fail
Big Pharma influence. Like insurance companies, pharmaceutical companies wield enormous influence in the medical industry and are usually motivated by factors other than optimizing care.
Bias in medical research. Two-thirds of medical research is sponsored by pharmaceutical companies, and conflicts of interest, groupthink, and a failure to replicate many findings undermine the credibility of the studies that form the edifice of our current medical paradigm.
Broken payment models. Because we rely on insurance companies to pay for care, the treatments offered are not necessarily the most effective or those supported by the most current evidence—they’re simply the treatments that insurance companies have agreed to reimburse. This is not evidence-based medicine, it’s reimbursement-based medicine.
Our modern diet and lifestyle are out of alignment with our genes and biology. Our medical paradigm is not well-suited to tackle chronic disease. Our model for delivering care doesn’t support the interventions that would have the biggest impact on preventing and reversing chronic disease.
#1: Mismatch Between Our Genes and Environment
Contrast that with today. The top six foods in the American diet are grain-based desserts, bread, sugar-sweetened beverages, pizza, alcohol, and chicken—primarily fried dishes like chicken nuggets
If you think about the evolution of humans—indeed, all organisms—you’ll see that life evolved in the natural twenty-four-hour light-dark cycle on this planet. We’ve long used candles and fire to light up the night, but only in the past 100 years have we had the capacity to be exposed to bright, artificial light at times when the sun wasn’t shining.
Every cell in our body is regulated by the natural light-dark cycle. When we change that cycle, our bodies suffer.
People who walk or are active doing gardening, chores, or manual labor in addition to exercise have a much brighter outlook than those who just exercise. If someone is inactive, it’s more important for them to reduce the amount of time they’re sitting than it is for them to start a workout routine. The important change for them is to move from being completely sedentary to increasing their non-exercise physical activity.
#2: The Wrong Medical Paradigm for Chronic Disease Our current medical paradigm is based more on managing disease and suppressing symptoms than it is on preventing and reversing disease, or promoting health.
Today’s patient has multiple problems, sees multiple doctors, and requires multiple treatments that go on for years if not decades.
Another reason that conventional medicine hasn’t been successful is that it focuses on suppressing symptoms rather than addressing the underlying cause of disease.
#3: A Healthcare Model That Doesn’t Support Preventing and Reversing Disease
Recent studies, however, have found that 84 percent of the risk of chronic disease is not genetic, but environmental and behavioral (Rappaport 2016). Our genes do play a role in determining which diseases we’re predisposed to developing, but the choices we make about diet, physical activity, sleep, stress management, and other lifestyle factors are far more important determinants of our health.
The average visit with a primary care provider (PCP) in the U.S. lasts for just ten to twelve minutes (Yawn et al. 2003), with newer doctors spending as little as eight minutes with patients (Chen 2013).
The Toll: How Conventional Medicine Affects Healthcare Providers
A New Model: The ADAPT Framework
the ADAPT Framework. It consists of three elements: A Functional Medicine approach, which is focused on preventing and reversing, rather than simply managing, chronic disease. An ancestral diet and lifestyle, which reflects the recognition that we are evolutionarily mismatched to our environment and that this mismatch is the primary driver of chronic disease. A collaborative practice model, which offers clinicians a structure that better supports delivering Functional Medicine and ancestral diet, lifestyle, and behavioral interventions to patients.
The Exposome, Genome & Epigenome At the core of the model is the relationship between the Exposome, our genes themselves, and the way our genes express themselves over time. The Exposome is the sum of all non-genetic exposures an individual encounters from the moment of their conception to the moment of their death.
Inside, out (Functional Medicine) vs. outside, in (conventional medicine)
Note: Gdt graphics
Comparison of Functional Medicine and conventional medicine
Within conventional medicine, pharmaceuticals are the primary treatment for almost 90 percent of all chronic conditions. At any given moment, roughly 50 percent of American adults, including nine of ten adults older than sixty, are taking at least one prescription drug. Almost a third of adults take two or more drugs. Almost 30 percent of all teens are now on a prescription drug, as are 20 percent of young children in the United States. America spent just under $310 billion on pharmaceutical drugs during 2015 (IMS Health 2016).
If we examine the actual cost of care—without the insurance subsidies—we’ll see that Functional Medicine is often much more affordable than conventional medicine, largely because it seeks to prevent and reverse disease, rather than just manage it.
proton pumps aren’t limited to the stomach; they’re present in just about every cell in the body, and they’re involved in the process of cellular energy production. This explains why PPIs are associated with numerous adverse effects, from altering the gut microbiota, to impairing nutrient absorption, to increasing the risk of cardiovascular events, to damaging the kidneys, to decreasing cognitive function (Kresser 2016).
PPIs have been shown to increase the risk of cardiovascular events because they reduce the production of nitric oxide, a substance that promotes the dilation of blood vessels and improves blood flow.
The Functional Medicine Pyramid
Realignment: Matching Our Environment With Our Genes
The industrialized diet is low in many of these micronutrients, which explains why nearly one-third of the U.S. population is deficient in at least one essential vitamin or mineral (Bird et al. 2017).
Mice raised by stressed mothers are more likely to be stressed themselves. Stress causes changes in DNA methylation that affect receptors for cortisol, a major stress hormone. So, the offspring of these mothers have a biological susceptibility to stress that was “pre-programmed” by exposure to a stressful environment early in their life.
We went from eating nutrient-dense, naturally low-calorie, anti-inflammatory food, to eating nutrient-depleted, calorie-dense, pro-inflammatory food.
The 21st Century Practice: A Collaborative Model
call this a collaborative practice model. It consists of several elements. First, it embraces a more streamlined operation, which reduces overhead and bureaucracy and provides a higher level of care for patients and a better work environment for clinicians. Second, it refers to a practice that offers both in-person and virtual (via telephone and video conference) appointments, which gives both patients and practitioners more flexibility and allows practitioners to expand their practice beyond their immediate geographical area. Third, as the name implies, it suggests a model that incorporates both licensed providers, like medical doctors and nurse practitioners, and non-licensed allied providers like nutritionists and health coaches, to provide additional layers of support for patients beyond what they typically receive in today’s episodic care model.
MDHQ One area of dissatisfaction and pushback among doctors is with electronic health records (EHRs). Initially, there was a lot of enthusiasm for EHRs, but the way they’ve been implemented in conventional medical settings has been horrific. There’s a steep learning curve, and some software has increased error rates. A lot of doctors don’t like having to look at a screen the whole time they’re with a patient. But those problems are solvable. We use an electronic health record called MDHQ, which is specifically designed for Functional Medicine and for this type of practice. It’s streamlined. It doesn’t contain a whole bunch of features and things that you don’t need in a Functional Medicine practice. It’s also got a patient portal, where the patient can access their record. It has a lot of features that make it easier to get things done without having to stare at the computer the whole time you’re with a patient.
Is Conventional Medicine Evidence-Based? “It is simply no longer possible to believe much of the clinical research that is published,” says Marcia Angell, a former editor of the New England Journal of Medicine (Full Measure Staff 2017). She should know! John Ioannidis, an influential researcher from Stanford, published the 2005 paper, “Why Most Published Research Is False,” to illuminate this problem (Ioannidis 2005). Ioannidis explains that in many research papers, “Claimed findings may be accurate measures of the prevailing bias.” Clearly, Dr. Ioannidis struck a nerve; this paper is now the most widely cited paper ever published in the journal PLoS Medicine.
Conflicts of interest abound: two-thirds of medical research is funded by pharmaceutical companies (Smith et al. 2014). Such financial ties don’t guarantee bias, but they do make it more likely.
called “Out of Sight, Out of Mind, and Out of the Peer-Reviewed Literature,” published in JAMA Internal Medicine (Seife 2015). The study notes that the FDA’s findings of fraud in medical research rarely end up being reported. The studies are still published. In this investigation, a researcher falsified a lab test to hide a patient’s impaired kidney and liver function in a trial comparing two chemotherapy regimens.
UpToDate Some databases are better than others, but even the best databases serving most conventional doctors maintain a symptom-driven lens. UpToDate is a more balanced, subscription-based information product for clinicians. If you look up IBS here, you see an entry describing the treatment of IBS in adults, along with an introduction to the condition, definitions, and indications for referral. UpToDate is unusual in that it does sometimes talk about dietary therapy, though it moves quickly on to pharmacological therapy, laxatives, how to treat diarrhea, how to treat constipation, and how to treat many other symptoms.
That’s where allied providers like health coaches come in. Coaches are trained in several disciplines that support people in making lasting change. These include (but aren’t limited to): Positive psychology, which leverages people’s strengths (rather than focusing on their weaknesses) to make changes. Motivational interviewing, which helps people link behavior changes to their deepest needs and goals (e.g., “I will change my diet because I want to live to see my grandchildren graduate from college.”). Habit formation and reversal, which supports patients in making positive habits, or breaking negative ones.
“Effects of Positive Psychology Interventions on Risk Biomarkers in Coronary Patients” found that a positive psychology intervention lowered levels of C-reactive protein, an inflammatory marker, in patients with heart disease (Nikrahan et al. 2016). Another paper found that motivational interviewing increased the efficacy of a weight loss program in a group of overweight and obese women (Mirkarimi et al. 2015).
To use an analogy, the doctor gives the patient a fish so she can eat for a day, whereas the coach teaches the client to fish so she can eat for a lifetime.
We might also look at exposure to heavy metals like lead and mercury and infections like Helicobacter pylori. These problems can all lead to high cholesterol and a high LDL particle number (Kresser 2013b; Asgary et al. 2017). After testing, we would do specific treatments to address those issues.
One such theory is known as the “Three Hit Paradigm,” in which three key influences—or “hits”—combine and contribute to not only ADHD but other behavioral conditions in both children and adults (Slattery et al. 2016). The three hits are: Biome depletion: this refers to the depletion of the microbiome due to poor diet, overuse of antibiotics, and other aspects of the modern lifestyle. Environmental stimulus at critical times in development: e.g. acetaminophen exposure, vitamin D deficiency, antibiotic exposure, and other diet and lifestyle influences. Genetic and/or epigenetic predisposition.
The primary relationship is between the patient and the coach, not the patient and the doctor—which, as I’ve argued throughout the book, is likely the best approach in cases where diet, behavior, and lifestyle change are the most important interventions.
Perhaps the best sign of Iora’s success is how enthusiastic their patients are. The Net Promoter Score (NPS) is an index ranging from -100 to 100 that measures the willingness of customers to recommend a company’s products or services to others. The national average NPS in primary care is four. The highest NPS in the traditional healthcare world is Kaiser Permanente, at 35. Apple, with its raving fans, has a NPS of 72. Iora’s NPS is an impressive 90. They also boast a patient engagement score of 80 percent, versus
ADAPT Academy is offered through a monthly online membership platform. It features:
ADAPT Practitioner Training Program We also offer the ADAPT Practitioner Training Program, which is designed to provide practitioners with everything they need to start a successful Functional Medicine practice, incorporating an ancestral diet and lifestyle and a collaborative practice model.
Masterclass with Masterjohn Pro These series of “masterclasses” with Dr. Chris Masterjohn, a nutritional scientist, go into great depth on topics like energy metabolism—topics we all learned while studying medicine but may need a refresher on.
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StephanGuyenet.com Dr. Stephan Guyenet is a scientist who formerly studied the neurobiology of weight regulation at the University of Washington.
SaraGottfried.com Dr. Sara Gottfried, a Harvard-trained MD, has turned her focus to educating the public on health and wellness, with a focus on women’s health and using genetics and epigenetics to improve well-being and extend lifespan.