Practicing Functional Medicine (the clinical application of Systems Medicine) entails casting a wide net with regard to an individual’s history and physical exam to look for the underlying causes of their present complaints. Likewise, careful laboratory investigations may be needed to corroborate the clinical findings. Mapping all pertinent findings to a tool developed by Institute for Functional Medicine, the Matrix, is a powerful & effective way to “data sort”, identifying not only areas needing to be addressed, but in the order in which they should be addressed.
In my practice, I start by mapping history and physical exam findings into the Matrix, and documenting all antecedents, triggers (if apparent) and mediators. This step also helps to prioritize needed laboratory testing. After laboratory data are back, I often return to the Matrix and populate it with those key findings. I like to “lean on” the Matrix: Once it’s sufficiently populated, not only do I have a good understanding of the patient’s key issues over time; I’ve created a solid direction for treatment where all of the major areas are clearly represented.
I know! It seems these early steps are time demanding and difficult! But fear not, I ASSURE you that if you put the time into doing this early data sorting, not only does it get much easier after you’ve attempted it a few times (and there are tools such as Living Matrix to assist you), you’ll also have an amazing document you can truly “lean on” to guide you through the most complex of cases. The value of this process will become eminently clear to you.
Here’s an example:
Joe was 65 when he first came to our clinic. He was highly motivated and aware with regard to his health. He farmed many of his own vegetables organically and consumed a clean, mostly gluten-free diet. He engaged in high-intensity exercise for years, he maintained a daily meditation practice. He reported having a supportive relationship with his wife and good friends. Despite his admirable lifestyle habits however, Joe felt tired and moody most of the time.
Since his 20’s, he had multiple loose BMs daily, accompanied by much gas and bloating. Colonoscopy findings were reported as normal/negative. Clostridia difficile was tested for and ruled out. Diagnosed with hypertension at 50 years old, he was maintained on 30mg Lisinopril per day. His sleep was very poor–disrupted by hourly nocturia; he also experienced chronic post nasal drip and occasional hives.
Joe was prescribed multiple courses of antibiotics in his teens for pneumonia and in his 50’s for Lyme disease. He stated that Lyme presented with fever and myalgia, and that Doxycycline was effective in eradicating the infection. He reported no lasting symptoms.
Until recent dietary changes noted above, he described his diet as standard American. He regularly experienced (and gave into) very strong sugar cravings, and loved Fritos.
Joe grew up with an alcoholic father, and described his childhood as highly stressful. He later developed alcoholism himself, but had stopped drinking over 30 years ago. Joe’s father died at 68 from lung cancer, he was a life-long smoker and drinker. His mother died at 89 from heart failure. His sisters have arthritis.
Joe’s goals for our work together were:
1. Recover energy & motivation
2. Repair bowel function
3. Resolve hypertension, stop Lisinopril
Pertinent physical exam findings:
Blood pressure 130/80 LAS (with 30mg Lisinopril); mild rosacea (suggestive of small intestinal bacterial overgrowth and/or hypochlorhydria); scalloped tongue (suggestive of poor digestion/hypochlorhydria, possible B12 deficiency) fingernails: thin, brittle, with multiple leukonychia (suggestive of mineral, protein-especially sulfur amino acids- and/or B vitamin deficiencies).
Read more about tongue and nail physical exam diagnosis
Figure 1: Matrix Findings
Select laboratory findings:
• Serum chemistry, CBC, thyroid panel with antibodies, celiac serology, ANA, anti-CCP and RF, testosterone panel with SHBG, free and total PSA, IgG and IgM Lyme western blot: All negative or within acceptable limits
• Lipid particles were within optimal range.
• A1C was 5.4, fasting insulin was 7, fasting glucose 97.
• Low levels of nutrients included: B12 (elevated methylmalonate), RBC magnesium, RBC potassium, vitamins E & D; CoQ10, Omega 3 fatty acids. Folate levels (RBC folate and FIGLU) were within normal limits.
• Whole blood toxic metals within acceptable limits
• Homocysteine was high at 11 mmol/L
• Total IgE was 70. Inhalant and food IgE allergy panel was negative
• Elevated IgG gluten antibodies
• Stool test identified a high level of Klebsiella pneumoniae; with very low level of Lactobacillus species.
• Hydrogen breath test was highly positive at 53 ppm (>33 ppm indicates severe small intestinal bacterial overgrowth/SIBO)
Treatment plan as guided by the Matrix and laboratory data
Assimilation
Lab findings demonstrated SIBO, dysbiosis and IgG gluten sensitivity.
Plan: Low FODMAP/lower carbohydrate/elimination diet, including total removal of gluten and other common antigenic foods such as dairy and soy. Avoid simple carbohydrates
Supplements for GI support included:
1. Betaine HCL: Follow titration sheet
2. S. Boulardii: 2 caps po bid
3. Enteric coated oil of oregano: 2 caps po bid x 4 weeks
4. Berberine 500mg: 3 caps po bid x 4 weeks
Defense and Repair
Lab findings demonstrated no IgE allergies, low vitamin D and omega 3 fatty acids.
Plan: We expected the low antigenic diet to address the chronic post nasal drip and occasional hives.
1. EPA/DHA: 3 grams po qd
2. Vitamin D3: 5000IU po qd
Energy (mitochondrial support)
Lab findings demonstrated a need for B12, magnesium and CoQ10.
Plan:
1. CoQ10 300mg po qd
2. Magnesium aspartate, 600mg po qhs
3. Methylcobalamin 5,000ug, po qd
4. A coffee taper was prescribed
Transport
Lab findings demonstrated elevated homocysteine and low RBC potassium. Fasting blood sugar and insulin levels were slightly higher than optimal
1. Blood pressure:
a. Sustained release arginine, 2 caps po bid
b. Potassium, 500mg po qhs
2. B12 (prescribed in Energy) and B6 (prescribed in Communication) were used to lower homocysteine.
3. A lower carbohydrate diet (prescribed in Assimilation) was used to lower insulin and blood sugar
Communication: A combination product with saw palmetto, nettle, zinc, vitamin D, B-6, diindoylmethane and pumpkin seed extract, 2 caps po bid, was prescribed for BPH/nocturia.
Structural Integrity: (brittle nails, leukonychia) Minerals, B vitamins as prescribed above. HCL for digestion (prescribed in Assimilation) will aide in further nutrient assimilation, including protein
*Note that Joe’s physical exam findings were consistent with laboratory data: The mild rosacea and scalloped tongue corroborated the finding of SIBO and dysbiosis, which probably contributed to the B12 deficiency and food sensitivities, PND and hives. Joe’s thin, brittle nails with leukonychia were indicative of mineral deficiency (and possibly protein malabsorption), again likely related to his gut issues. Blood pressure can be negatively influenced by food sensitivities and micronutrient insufficiencies including both potassium and magnesium, which were identified as being low on laboratory data.
Follow-up (2 months into treatment): Joe enjoyed the therapeutic diet. He lost weight, and his energy and mood began to improve. Joe’s gas, bloating and diarrhea lessened and then resolved over the course of a month. HCL titration demonstrated a high need for support (he stopped at 6 caps per large meal). Nocturia was reduced to twice nightly. Blood pressure normalized, Lisinopril was tapered and stopped. A sustained-release arginine taper was started. There were no reports of hives, and post nasal drip lessened.
Joe was pleased with his progress and felt his health goals were being realized. Food challenges were initiated, after which a lactobacillus spp probiotic would be introduced and supplements would be reduced or stopped as indicated.
A final note: Assimilation was clearly the priority starting area. While I chose to address multiple nodes concurrently in this case given Joe’s health goals, an argument could be made for starting with Assimilation only and moving to the other nodes once GI function was normalized.
