The 2022 Functional Medicine Year in Review

Video

Podcast

Pathways to Well-Being · 2022 Year in Review

Guest Bio

Dan Lukaczer, ND, IFMCP, is the director of medical education at The Institute for Functional Medicine.
Robert Luby, MD, IFMCP, is the director of medical education initiatives at The Institute for Functional Medicine

Transcript:

Kalea Wattles, ND:
In 2022, functional medicine had its finger on the pulse of several prominent topics in the medical research and offers new ways to clinicians to enhance the health and healing of their patients. On this episode of Pathways to Well-Being, we’re recapping the functional medicine year in review. IFM’s Director of Medical Education Dan Lukaczer, ND, IFMCP, and the Director of Medical Education Initiatives Robert Luby, MD, IFMCP, are going to discuss the clinical advances and clinical pearls gleaned from this calendar year. Welcome, Drs. Lukaczer and Luby. We are all looking forward to your commentary today!

Robert Luby, MD:
Thank you, Kalea.

Dan Lukaczer, ND:
And thank you, Kalea.

Robert Luby:
Dan, let’s start with the microbiome. That’s always a big topic, it was a big topic in 2022. And there’s really two emerging trends that we’ve selected out of many that we possibly could have. One is the finding of polypharmacy having an adverse impact on the microbiome and new thoughts on therapeutics with regard to the microbiome, especially with regard to fecal transplant and the future of that intervention. I’ll start with the polypharmacy issue. What was found in the new, emerging research was that polypharmacy has an adverse impact on the richness of the gut microbiota. And this is something that, even beyond antibiotics, non-antibiotic pharmacy, so those individuals with more prescription drugs tended to have a less healthy, less diverse, less rich microbiome.

I guess the comment I would make here, Dan, would be that if we extrapolate this, let’s consider pharmaceuticals’ new-to-nature molecules, so to speak. If we extrapolate this to other new-to-nature molecules, what does it make us think of? I think it reinforces a lot of the principles of functional medicine, because we would think of food additives. We’re swallowing those; those could have a similar impact. As a pharmaceutical, we can think of what’s on the foods—herbicides, pesticide. And then in terms of policy, I think policy is a big theme here in this next half hour. There’s been a lot of pressure to get glyphosate and herbicides containing that substance out of the food chain, and that’s been a win. But we may want to look at what’s replacing that. What are the new-to-nature molecules in the herbicides and pesticides that farmers will be using? We know that two of those are paraquat and rotenone. Research needs to be done on those to make sure that they don’t have a similar effect. So, Dan, that starts it off with a bang. I’ll take it over to you now.

Dan Lukaczer:
Well thanks, Robert. And I would just add to that this doesn’t seem to be out of left field. I mean, as we have been talking about things like artificial sweeteners having an effect on the microbiome. We know this is just a larger study that I think is cementing the fact that first, there are many, many, as you say, new-to-nature molecules that clearly have an effect on the microbiome. And then the second part of what you brought up is that the microbiome, this is another flash, is important in all sorts of ways for the human organism. We are a multi-microbial organism. We are more than just our human selves. And I think we all know that. And every year, we learn more about the microbiome, and every year, we learn there’s even more complexity than we realized the year before. And so I think there’s a couple, from a couple of articles that have come out just over the past year, there’s a couple of things that maybe we would reinforce or bring forward.

And I think that first, the idea that diversity is good, and that is certainly one of the things that I try to instill or teach patients that I’m seeing when I’m talking about the microbiome or I’m looking at some sort of stool analysis and looking at their diversity index, or various ways to assess diversity. The more diverse the microbiome, I think, the better. And obviously, there are bad bugs and there are not so good bugs, but I think the things that we can do to diversify the microbiome are very important. I think another kind of big picture that I’ve come away with, with certainly some of the information this year but also kind of over the past few years, is that there are short-term solutions to changing that microbiome. I look at things like a low-FODMAP diet, a short-term solution, and can often be a very important short-term solution.

But I think long-term, we know, and there’s been recent studies that show that with a low-FODMAP diet, I should say, there are reductions in Bifidobacteria, for instance. And that can be good short-term, but we also know that long-term, probably not so good. And I think there are other short-term diets that are out there that I think certainly changing the microbiome can have a pronounced effect. Short-term, we all know about the carnivore diet. And I think short-term, while there’s not a whole lot of study, or not a whole lot of research, there can be some positive benefits.

But I think long-term is what I’m looking for. And I think, therefore, the long-term solutions that we’re looking at, at least that I look at consistently, are prebiotics, probiotics, synbiotics, and now this new term that has come into vogue in the past couple of years of postbiotics, those are metabolites. And I often think of, metabolites are the words of universal biological language. And so I think there are new ways to affect how the microbiome is and what it does. And I don’t know, we could both go quite a bit longer about those kinds of things. And I certainly have a few other things to say, but I’m curious about your take on the new research on probiotics and synbiotics and postbiotics. Any other things that you think that stick out for you in the past year?

Robert Luby:
Well, I think it reflects our ancestral diet to some degree, that some of those things that are so good with prebiotics are going to be beneficial for the microbiome. I think the other thing we’ll see trending in the future is that those postbiotics of which you spoke, the metabolites, will become part of the pharmaceutical regimen of the future. So I’d like to put a bow on this topic and say, there’s at least two opportunities here. One is that this is the kind of research showing that polypharmacy adversely affects the gut microbiome. This is going to make its way into the consciousness of the conventional practitioner. And then I would say for those functional medicine clinicians out there listening to this, think of the opportunity we’ve got here to reduce polypharmacy. We know that functional medicine so often can lead to de-prescribing of medications. And that, I think, is one of the great opportunities here that we can, as we de-prescribe, the other benefit, not just for detoxification enzymes and such, is we’re going to improve the microbiome. Now, this kind of research points in that direction. So, Dan, unless you have a final word, we could move on to the therapeutics and that, the emerging research on fecal transplant.

Dan Lukaczer:
Yeah. I think the emerging research there I think is really fascinating. I guess my final word on those things is, as I forgot who it was that I have quoted, but it’s instead of this warring idea that we have with the microbiome, it’s being a wildlife microbial manager, I think, is a better way to look at what we’re doing and how we’re living, hopefully in some kind of harmony with that microbiome.

Robert Luby:
Yeah. Dan, you’ve always been good with Yogi Berra. So I think before this podcast is over, why don’t you come up with what Yogi Berra would’ve said about the microbiome that would be…

Dan Lukaczer:
I’ll think of a Yogi Berra…

Robert Luby:
That would be a real pearl for our listeners, I think.

Dan Lukaczer:
Oh yeah. Absolutely. That’s important.

Robert Luby:
There was an article that came out this year speaking to the future of fecal transplanting and pointing out with this theme of new-to-nature molecules, perhaps, that autologous fecal transplant, where a person takes their own stool and that is what gets transplanted, is a real viable idea in the future. But the point was made that we have such a toxic society, really, that our fecal bank materials, shall we say, of adults who’ve lived in this world for decades is probably not the healthiest way to use fecal transplants. And the suggestion is made to use autologous transplants from feces that was banked when we were young children.

And I find this very intriguing. The logistics of it, and the infrastructure needed is pretty daunting. And I would also say that with regard to the new-to-nature molecules, and even the number of chemicals that we know a fetus is exposed to in utero, Dan, what do you think are the possibilities of doing that? Is that really going to be beneficial if we are banking our stool as infants, say, even though we’ve already been exposed to a lot of factors that affect the microbiome? I think this might be pie in the sky thinking, but what do you think? A lot of resources it would take to get this to happen.

Dan Lukaczer:
Yeah, I think when I read that article, and this will date us both, I was thinking of the Jetsons, that old cartoon of what’s happening in the future. And as you say, it’s interesting. I think we’re a long way from that. I think we’re decades from that. And how many individuals would really bank that? And I think we need to do things to clean up our environment now as opposed to focusing on that. It’s an interesting thought experiment at some level, but it’s not something that I’m really focused on that at this point. Now fecal microbial transplants, they’re here now, and they’re going to continue to, I think, expand not only from what they are currently FDA approved for, which is intractable C. Difficile, but I think there’s now some research on IBD, and that may be the next step. And then there are other places. Now there are things that one has to watch out for with FMT, but I think it’s a fascinating and really here to stay and expanding therapeutic intervention.

Robert Luby:
Okay. Well, let’s move on to mast cells. That is increasing on the awareness of the media and certainly coming out in the literature more. The way I’d like to think of the research on mast cells is, I think we don’t want to think of it as a silo. Like, “Oh, there’s, you have a mast cell condition or a mast cell disease.” But rather, it’s part of the inflammatory response or the hyperinflammatory response. Even with COVID, and I think this accelerated, it was identified as part of the inflammatory response of COVID.

So the way I think of it, Dan, and I’d love to hear your thoughts, is that this is one arm, or one aspect of the immune system that kicks into gear when the immune system gets activated. Either in a regulatory or a dysregulatory way, so that with our patients, anytime there is a dysregulatory response of the immune system, we need to think of mast cell activation as a part of that. And I think it’s a real advantage, because we want to always use multimodal regimens in functional medicine, and to address mast cell activation, there’s a set of different therapeutic interventions that we need. And this can just really expand our therapeutic arsenal in a very positive way if we maintain vigilance for it, and just consider that we’re going to need to pay attention to mast cells in many different diseases, but not so much think of it as a thing in and of itself. Your thoughts?

Dan Lukaczer:
Yeah. I agree with you, Robert. I think that in the functional medicine vernacular, mast cells are a mediator. And the question then is what is triggering those mast cells? And as you said, how there appears to be a variety of triggers. And that’s where I think it gets really complex and a bit murky. As I’ve seen it thus far, there are not great biomarkers that one can really use—well, one can use clinically, at least. And so it seems to be a diagnosis of somewhat of exclusion. But I think having said that, I think that if you suspect some sort of activation, I think there’s a lot of foundational things one can look at to decrease the potential triggering of mast cells. So, as you say, it’s all a part of the taking a good history and a timeline and looking at, what’s activating those mast cells? What are the triggering events?

Robert Luby:
Well said. And we should never let the absence of accurate laboratory markers deter us from making clinical judgments and saying, “Clinically, it appears that this person would have mast cell activation.” And if we can introduce a safe therapeutic as a therapeutic probe, really a therapeutic/diagnostic probe, I think that’s well justified. And to stick with your analogy of mast cells certainly are mediators and can be triggers as well.

The research that came out this year on mast cells being tied to circadian cycles, having a circadian rhythm was fascinating. And that in individuals whose circadian cycle was altered, mast cells were activated in a dysregulatory way. I find that fascinating, because here again, we have mast cells as a mediator, but a triggering event could be a change in a person’s circadian cycle. And sleep was called out here. And I think this is a real opportunity, again, for the lifestyle foundation of functional medicine, that regular sleep routines, and sleep hygiene, and all the things we talk about, the benefits of sleep, add another factor that it affects, and that’s the mast cell function. So, Dan, what do you think about that?

Dan Lukaczer:
I, again, agree, and I think there’s other research that we’re going to maybe get to—hot topics in 2022—in terms of looking at COVID and looking at anxiety. And we know that foundational lifestyle factors, which include sleep, obviously, are very much tied to or can be tied and can be a mediator in just about everything. But those two areas, there’s newer research that shows both of those issues have improvements when you improve your both quality and I think quantity of sleep. For some of us, quantity of sleep.

Robert Luby:
Very good. Let’s move on to one of your favorite topics, which is fasting and time-restricted eating. Let’s start with a tee it up, easy for us. There is some research that showed that fasting is beneficial immunologically and can have anti-inflammatory effects, et cetera. I’ll just start off by saying, well, we know that eating itself is a pro-inflammatory event, fasting should be the opposite. So do you see anything new here, any new opportunities clinically for our practitioners in the emerging literature that fasting has all these benefits for the immune system, but beyond what we already know?

Dan Lukaczer:
Well, I guess I’d say a couple of things. One is, I think the literature continues to support different aspects of what we call intermittent fasting, which under that rubric I put time-restricted eating, which is eating on a regular 24-hour schedule but restricting that eating window. And then greater than 24 hours, as what I refer to as longer term fasting. And then a fasting-mimicking diet, which apparently has some of the attributes of fasting, which are, as you know, autophagy and ketosis, or nutritional ketosis. And now, this newer area of research, I think of mitophagy, which is just the mitochondrial autophagy. And I think that there has been nothing that I’ve seen—so now there’s research on congestive heart failure that I saw there. And there continues to be supportive research for all of the things that I think we probably talked about last year.

And in terms of cardiovascular, blood sugar, adjunctive for cancer.

The one caveat that I would add that I’ve started to think about more is just remembering protein requirements when fasting. Either fasting with a time-restricted eating window or longer-term fasting. I think that particularly with that former, I think that there has been now at least newer research to me that really suggests that the amount of protein can often be insufficient as we age. And as we age, many of us, particularly the elderly, get less protein. So I think we have to think about that more when we’re counseling patients on fasting regimes. Not that I’m saying that fasting regimes aren’t important, useful, and can be therapeutic, but I think we need to put that into the mix. Anything you saw in the literature, Robert, that you want to comment on?

Robert Luby:
I would add that I noticed in a lot of the literature they talked about adherence as well. And clinically, what’s so important is the volunteers in these studies might not have been volunteers. They might have been paid to do this. And it’s often said that the best diet is the diet that the patient will adhere to. So with that in mind, I would offer, I think this idea of fasting offers a great opportunity for peer support, shared medical appointments. To get a group of individuals who their motivation might be questionable, or their willpower might be questionable, to get them together to do the time-restricted eating or the intermittent fasting and have them support each other I think just offers a great opportunity to magnify and amplify the potential clinical benefits of fasting and time-restricted eating. And it goes so well with just the whole lifestyle foundation that we emphasize. You know, a shared medical appointment becomes a form of relationships as well and can be stress reduction. So that’s how I like to think of fasting interventions as well. Dan, I’ll turn it back to you before we go on.

Dan Lukaczer:
Well, I absolutely agree with you on all points. And this is not a setup, I don’t think, but over the past 18 months, maybe a little longer, I’ve been doing virtual shared medical appointments. And one of the areas that I’ve focused on, surprise, surprise, is fasting. And I think you’re exactly right. I think doing that in particular—but of course, there’s other shared medical appointments, which I think are a great way to get people working together and sharing their both successes and challenges—but shared medical appointments and fasting really go together.

Robert Luby:
Amen to that. And I’ll add something to the protein that you said needs to be attended to with fasting and time-restricted eating. And let’s move on to our next topic. And that would be spices and herbs. If you’re going to be eating less food, let’s make it more nutritionally dense. And spices and herbs, this is my favorite topic, Dan. I want to throw this in here every year for our year in review. Because some of my meals are like, I’m having a little food with my spices, here, it’s the other way around. I’m heavy on the spices. We know they have antioxidant properties. We know they’re cardioprotective, they have detoxification capacity, et cetera, et cetera. They can mitigate the adverse effects of some forms of food preparation. The other thing is they can be very inexpensive, and they can be accessible in food deserts, because you can grow your own herbs at home no matter where you live, no matter how far you are from a source of good, nutritious food. So for all those reasons, I just love the idea of spices and herbs. I think it is a critical adjunct if you are going to be doing calorie restriction or time-restricted eating or fasting of any kind. So, Dan, I know you’re a gardener, so you’ve got to have a perspective on this.

Dan Lukaczer:
I am very much in agreement with you. I had heard Michael Stone, a colleague of ours, a number of years ago—I can’t, unfortunately, find the reference, I should ask him—but he talked about some epidemiological study in which there was improvements in various parameters in one tablespoon of herbs, of spices daily. And that’s not that much. Obviously, there are, as you said, a variety of herbs that have a variety of effects, from curcuminoids to thyme to black pepper to cinnamon. We all know about those. But I think to your point, just getting used to and encouraging increased culinary adventures with herbs.

I’m big into curries, as I know you are. And one of the reasons is that it’s so complex, you put so many things into a curry, or so many different herbs, or at least I do, at least six, generally, and they make such a flavorful addition or change in that particular dish that you’re cooking. So that’s a long-winded way to say, yes, more herbs, more spices into both your foods. But also, as I have fairly regularly and also try to fairly regularly encourage my patients to have some kind of smoothie, I am generally putting some kind of herb mixture, particularly ginger. I haven’t gotten to turmeric yet; I know that’s a great herb to put into a smoothie. But I like the ginger in there, ginger and lemon and basil, sometimes I put into a smoothie. What do you put into your smoothies, Dr. Luby?

Robert Luby:
Well, yeah. I was going to spare the audience the recipe for my dairy-free, sugar-free, turmeric, black pepper gelato that’s spiked with star anise and cardamom and fenugreek, so I won’t go there. But I would just say that when I remodel my kitchen, I’m going to have to go with an orange theme, because there are turmeric stains everywhere. And if you look at my wardrobe, man, if I had orange camouflage, you wouldn’t even be able to see me in the kitchen probably. But yeah, stains everywhere, Dan, it’s kind of embarrassing. But we better move on before we get too far down this road.

Let’s talk about long COVID and functional medicine. Long COVID is emerging as perhaps the biggest story of the year, and maybe 2023 too. Let’s hope not, but let’s hope that if it does, it’s because of good news about that. I think we’re preaching to the choir here when we say this is a multisystem disease, this is a chronic disease. It should fit very well into the systems biology approach of functional medicine. And we think it will, because we will not just try to treat symptoms. We will not just try to treat one organ. We will try to treat the whole body as it is affected. And I think different individuals will have different aspects of their physiology affected to different degrees. So an opportunity I see here, Dan, is to identify subtypes, and to the extent that we can do that, we can really personalize the therapy and pick our multimodal regimen with much more precision. And I will be shameless here and say at our annual conference this year, we’re certainly going to focus on long COVID, but I’ll turn it back to you, Dan. That’s my initial thought. Teeing it up for long COVID.

Dan Lukaczer:
Yeah. I think it’s an opportunity, as they say, and a challenge, because I think that functional medicine and the way we look at things can have a significant impact. And so, I mean, I think we all have experience and we’re all moving through this. I mean, I’ve seen now a few different headlines and studies about the estimated expenditures that are over $3 trillion, that there was some newscast recently similar to the Great Depression. There was an article, I believe, in Medscape that basically showed that conventional medicine working hard at it, there are no guidelines, and so that many conventional doctors are making it up as they go along. And it’s important that we try to move forward and put a stake in the ground, because I think functional medicine has something to offer there.

And so it’s something that I think, as you say, we’re going to be moving forward on. And as we should, you’re always going to start with the foundations of the modifiable lifestyle factors, as I mentioned before with sleep, but sleep and nutrition and hydration and stress reduction and movement as one can. But I think that there are a number of other areas around the functional medicine matrix model in terms of mitochondrial dysfunction and transport, et cetera, that I think we really need to be looking at. So it’s an opportunity and a challenge, as I say, Robert.

Robert Luby:
Right. And hopefully, the virulence of the COVID itself does not reemerge in a strong way. And if it does not, then long COVID is perhaps even a greater threat to the public health than COVID itself. So I think it’s also an opportunity to throw down the gauntlet to our field and say, in addition to identifying subtypes so that we can treat with more precision, let’s identify the antecedents and the triggers of long COVID. You know, which individuals will come down with this, and which ones will get it more severe? Is it related to lifestyle factors? Is it related to disruption of circadian function? Things like that. So that we can actually take people who don’t have long COVID, if COVID is going to stay with us forever, and get them adopting those factors that we have identified as antecedents and triggers and to avoid those so that they stay healthy, even if they do come down with the virus. So those are some aspirational research activities that I’d like to see going forward. But Dan, let’s turn to anxiety.

Dan Lukaczer:
Let me just add one other thing here, Robert, is that now the statistics are wide and staggering. So anywhere between 5-30% of individuals who get infected with SARS-CoV-2 appear to come down with long COVID. That’s somewhere between, I don’t know, 7 million and 30 million people we’re talking. In either case, we’re talking a lot of individuals on either end of that spectrum, there’s a lot of individuals who have some kind of long COVID symptomatology. And I just think that it’s important, they can’t all go to specialists. And that’s why it’s important for functional medicine, and for primary care in general, to be informed and to have answers, because it will overwhelm the system if we don’t put, as I said, a stake in the ground and really feel that we have something to offer there.

Robert Luby:
And on that note, one other thing I just thought of is another opportunity to emphasize our theme here of the power of shared medical appointments. Long COVID is really dispiriting to an individual, and to have that peer support, try to get through this with other individuals, I think, is going to be a very effective way, especially before we have real effective molecular agents, shall we say.

Speaking of molecular agents, it was found that mindfulness practices can have equal effects to pharmaceutical anxiolytics with regard to anxiety disorder and the positive benefits of exercise and lifestyle changes on anxiety. And I’ll start off with a couple comments here, Dan. It makes me think of policy, for one thing. If exercise is so good for anxiety, and we know what school children have been through with these past couple years of COVID and homeschooling and whatnot, it seems to me that school recess and physical education becomes ever more important as a policy issue, a public health issue, because exercise has now strong evidence that it can be mitigative of anxiety. And also policy for workplaces to add movement to the workplace and for employers to adopt that as a way of keeping their employees healthy. So I think those are really important aspects, and it also makes me think of, we think of anxiety mostly as a brain-related condition. Why are we so surprised that the brain is so amenable to exercise and lifestyle changes? I think we artificially isolate the brain and say, somehow it’s privileged, and it’s not. Or it’s immune or not affected by these dietary lifestyle changes. So I think we need to change that whole mindset, Dan, perhaps the brain is the most sensitive to lifestyle changes and dietary changes. Your thoughts?

Dan Lukaczer:
I loved recess when I was in school. It was great, and I think we should have more of it. So I thought you kind of described something that we have known, and again, it’s always good when new research comes out, but as I think we’ve said many times, if you could put exercise in a bottle, it would be the highest selling monetized therapy that there is.

I’d just add one other thing, I think, Robert, in terms of, you talked about exercise and mindfulness practices and diet—clearly important. And I would just wrap into this idea of getting in touch, or getting back to nature. And we know that evolutionarily as a species, we have gone through something on the order of 50,000 generations living in nature, and perhaps the last 50 or so where we’ve lived in a more agrarian society. So we are entrained to nature as a species. And there are studies, not this year that I saw, but there are studies on nature bathing and that sort of thing. And getting back into nature is, I think, an important way to get that exercise. So that would be my addition to what you’ve said.

Robert Luby:
I love it. And keeping with the nature theme and the exercise theme, the next topic that emerged in 2022, I absolutely love, because it’s about sleep. And I’ll start it off by saying, one way I get into nature is with moonlight bike rides. And I’m not talking in the evening, I’m talking in the morning. And the thing I love about this research was sleep, it showed that sleep has a positive effect on dysglycemia, and the factors are not even how long you sleep, but the median point of your sleep in the night, the earlier the median point is. In other words, the earlier you get to bed, the more of a positive impact it has on dysglycemia. So I love it, Dan. It gives credence to the old saying of, “Early to bed, early to rise makes a person healthy, wealthy, and wise.” I live by this. I love my early morning moonlight bike rides in the dark and one way I spend time in nature. So sleep, it’s great, it really has to be seriously considered as a major therapeutic intervention with significant physiological benefits. Over to you.

Dan Lukaczer:
Agreed. Yeah. No. Agreed. I don’t really have that much to add other than I think it’s good for everyone to be thinking about sleep. But in terms of just what you commented on, counseling patients, particularly who have metabolic syndrome and/or diabetes, because blood sugar is obviously such a critical factor for everyone, but for them, they’re more borderline around the edge. So that’s really the connection that I would add to that.

Robert Luby:
Yeah. One of the most interesting findings that came out in the dementia literature this year was about dementia prevention and fiber. It was found that the higher the fiber intake, the less likely you were to develop dementia later in life. One thing I’d be curious to know is how well they controlled for other factors. You could argue that a person who eats a lot of fiber might be engaging in other healthy lifestyle activities as well throughout their life. Regardless, I think what this literature points out, it’s one more reinforcement of the benefits of lifestyle in dementia prevention, in cognitive decline prevention. I think also we might say we know fiber as a prebiotic, and this might just be putting an exclamation point on the gut-brain connection. If you’re eating more fiber, you’re going to have a healthier microbiome; we know that can affect brain health.

And I would return back to my earlier question, my rhetorical question of, why do we consider the brain as privileged and not amenable to lifestyle and dietary changes? So this research really points out that, hey, if you’re eating fiber, you’re probably doing something neuroprotective. And we shouldn’t consider the brain as somehow separate from the body, despite the Cartesian split that occurred with good old René in his mind-body separation centuries ago. So let’s take that message to the field as well. The brain may be the most amenable organ to lifestyle changes. Dan, top that, would you?

Dan Lukaczer:
I can’t top that. I would add to your point that when we’re looking at fiber, we’re very likely looking at some indirect effect and/or direct effect of the gut microbiome. And then it often, I think, we’re looking at some effect of the gut microbiome on intestinal permeability. And then you get to all sorts of systemic issues. So I think that clearly that’s one of the areas that we talk about incessantly, or I do, at least, but for a good reason. I think they’re all connected. And I think that’s the, while it was dementia and fiber, I think there’s a lot of biologic plausibility that the microbiome and intestinal permeability are linked into that equation.

Robert Luby:
Well said. Turning to the literature on social determinants of health and discrimination. This, we know, is antecedent of chronic disease and poor health later in life. So there was an interesting article that came out showing that experiencing social determinants of health discrimination earlier in life leads to more rapid immunologic aging. You, leveraging that, the technology of measuring aging, that’s really coming to the fore now. A few thoughts on this, Dan, would be, boy, this sure speaks to the importance of clinicians. We as clinicians attending to our own implicit bias and really addressing that with every visit, with every patient in the way that we gather ourselves for that patient.

Identifying social determinants of health and the experience of discrimination is obviously much easier than ameliorating it. And especially when it’s something in the past that’s a past event as opposed to an ongoing mediator. I guess it also makes me wonder about, is there an opportunity here too for shared medical appointments? Will peer support help individuals somehow modulate their physiology in the way that it’s been affected by experiences of discrimination and social determinants of health? I don’t have the answers, Dan, but I’d love to hear your comment.

Dan Lukaczer:
Well, I think that we have been talking for many years about stress and the cortisol response, or cortisol and DHEA and various other hormones and neurotransmitters that are involved in the stress response. And it’s good that the literature, which has been there and has now been heightened as talking about other stresses on the system and social determinants of health are clearly one. Individuals, people of color and lower economic status, at least for me, it’s become much more into my sights of thinking about that when I see patients of asking about those kinds of issues or trying to decipher if that’s part of their stress, of doing an ACEs on all individuals that I see. So I think it’s another call to be looking at what are the stresses in a person’s life, and social determinants of health have to be right up on top of that list.

Robert Luby:
Well said. Of the topics that came to the fore in 2022, that just gave me a sense of gratitude and kind of saying “Finally” was the article that came out confirming that yes, diabetes can go into remission. And I struggled with this when I was working in the academic setting before working with IFM 20 years ago. I was letting my colleagues know, “Diabetes can be reversed. You can take this problem off the patient’s problem list.” And I got all kinds of pushback. But in practicing functional medicine in those years, it happens regularly. And our listeners know this, so I love the myth-busting aspect of this that this was published. I think it can really accelerate the field too and change the mindset of the medical community that we do not need to think of a disease or a diagnosis as a permanent tag, a permanent jersey, or with irreversibility.

These conditions are reversible mostly with the foundation of diet and lifestyle interventions. I think this can be a big opportunity for public health messaging, but also for practice market messaging for individual practitioners that we can now confidently say, “Hey, we can change diseases. We can really help you reverse diseases.” And obviously, again, another opportunity for shared medical appointments, individuals with diabetes getting together and reversing their disease together. We’ve already seen that in our functional medicine field. I’d love to see more of that. I’d love to see this kind of research accelerating that. Dan, what are your thoughts on that article?

Dan Lukaczer:
Well, I was not sure, what was the publication? But it was the American Diabetes Association. And I’m just as you are, I’m thankful, because now I don’t have to… I was for many years a little reticent to say, “Oh, we can reverse that,” because it put me at odds with mainstream medicine. Which I don’t mind being at odds, but I don’t want to be too at odds. And now, I think, as we’ve talked about before, what does it take, something like 17 years for an idea to get into, start in the literature and then to get into clinical practice? And I think, just as you’ve said, I think we’ve all seen a diabetes reversal, and it’s good that we’re on the same page, I think.

Robert Luby:
All right, so our last topic of 2022 that we chose as a hot topic is the review of systems becoming retired. This was really an opinion piece, not so much a research, but there was an opinion piece arguing whether or not the review of systems as it is taught and performed in the conventional medical history taking is valuable. Does it lead to actionable clinical insights? And the review of systems is an organ-based activity where you ask about symptoms related to certain organs, and that’s always been part of the traditional medical history. If you really do look at the value of it, would you be hard pressed to say how this translates to healthcare savings or health outcomes? What I think the opportunity here is IFM has developed a different kind of history taking, that that is adjunctive to this. We don’t do away with the review of systems, but in taking a history that involves personal antecedents, triggers, and mediators, we’re getting further upstream, and we’re getting much more specific to what might be affecting the health of that individual than just a list of symptoms, which we know are much more downstream.

So, Dan, I think this is an opportunity for the functional medicine field to step in and say, if we’re going to question the review of systems and its value, then we have something to offer you. We have antecedents, triggers, and mediators. Because these not only get at the root cause further upstream of the person’s health problems, it’s also a much more personalized intake than is a review of systems, because one antecedent discovered will lead you to ask very specific questions of that patient about other antecedents, triggers, or mediators, for example.

So I think we got a real opportunity here to change the medical paradigm, to really bring our “gather” step to the fore in the way that we incorporate antecedents, triggers, and mediators. And the “organize” step, how we organize those into a hypothesis about what is affecting this person’s health and what are the highest priorities to address therapeutically. So I’d love to hear your thoughts to close out this podcast, Dan.

Dan Lukaczer:
Well, Robert, I think you encapsulated it in a wonderful way. I think that what we’re doing, and I’m at least not ready, as you said, to throw out review of systems. I do have people fill that out, but I think infusing the timeline and antecedents, triggers, and mediators into a thorough intake is the way to go. So I just agree with you. I agree with this article, and I’m hopeful that there can be more infusing of those two, of conventional and functional medicine in this way.

Robert Luby:
Well, with that, we’re going to conclude this podcast. We really thank you for your attention. We thank you for the community we’ve had in this year, 2022. And we look forward to and hope for an even better 2023. Dan, any final words from you?

Dan Lukaczer:
Well, you wanted me to talk about Yogi Berra, I thought.

Robert Luby:
Yeah. I think we got to go there.

Dan Lukaczer:
Yeah, just to kind of say about what can you predict about 2023. And it reminds me of a Yogi Berra quote. I believe he said, “It’s tough to make predictions, especially about the future.” So I’ll leave you with that.

Robert Luby:
With that profundity, we will lead you to the new year. Thank you all for joining us.

Kalea Wattles:
Thank you, Dr. Lukaczer and Dr. Luby for wrapping up an eventful year and sharing your insights about the most exciting topics in the functional medicine ecosystem. And thank you to our audience for exploring so many important topics with us this year. We can’t wait to learn with you in 2023.

To join the conversation on this topic, visit IFM’s pages on Facebook and Instagram. For more information about functional medicine, visit ifm.org.

Show Notes

For more information on the topics mentioned in this podcast, see the following links:

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