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Functional Nutrition Functional Nutrition: “Seeing More” During the Functional Nutrition Physical Exam P. Michael Stone M.D., M.S P. Michael Stone M.D., M.S. Sydney Australia ©2014 The Institute for Functional Medicine Please note the videos included in this presentation have been removed for copyright reasons. ©2014 The Institute for Functional Medicine Nutritional defects, “like deer in the forest” do not announce their presence but must be looked for” (Sanstead 1969) ©2014 The Institute for Functional Medicine Nutrition Evaluation ©2014 The Institute for Functional Medicine Pattern Recognition Undernourished Reduce Exposures Ensure a Safe Detox ©2014 The Institute for Functional Medicine ©2014 The Institute for Functional Medicine Core Aspects of the Nutrition Physical Exam 1) Vitals and Body Composition 2) Evaluate Smell and taste 3) Look in the Mouth 4) Look at and feel the Skin 5) Look at the Nails 6) Evaluate Peripheral Sensation ©2014 The Institute for Functional Medicine Test Smell ©2014 The Institute for Functional Medicine Altered Smell or Taste • Smell and Taste are Closely Linked • Evaluate the History: Trauma, Exposure, Allergy, Obstruction • Other physical exam findings- peripheral neuropathy • Evaluate Medications • Evaluate Nutritional Status: Mineral Status: Zinc, Copper, Iron, Iodine Vitamin Status: A, E: B complex-B2, B3, Pantothenic Acid, Biotin, Folate, B12 ©2014 The Institute for Functional Medicine Causes of Abnormal Smell Test (*most common) • Obstruction: Allergies, Nasal polyposis*, Deviated Septum*, Intranasal tumor • Sensory: Viral infection*, Chronic sinusitis*, Allergic Rhinitis*, Cigarette Smoke*, Toxic Chemical exposure, heavy metals (Al, Si, Pb, As, Cd) Drugs-calcium channel blockers • Neural: Head Injury*, Alzheimer's disease, Parkinson’s disease, Intracranial tumor, Schizophrenia • Endocrine: Hypothyroidism, DM • Nutritional: Iron, Zinc, Copper, Vitamin A, B1,12 ©2014 The Institute for Functional Medicine Drugs That Alter Smell Drug Group Examples z Calcium Channel Blocker Nifedipine, amlodipine, diltiazem Lipid Lowering Cholestyramine, clofibrate, pravastatin Antibiotic/Antifungal Streptomycin, doxycycline, terbinafine Antithyroid Carbimazole Opiate Codeine, morphine Antidepressant Amityptyline Sympathomimetic Dexamphetamine, phenmetrazine Antiepileptic Phenytoin Nasal Decongestant Phenylephrine, pseudoephedrine, oxymetazoline Miscellaneous Smoking, agyria (topical silver nitrate), cadmium fumes, phenothiazines, pesticides, Betnesol-N, Cocaine snorted ©2014 The Institute for Functional Medicine SMELL TEST Pocket Smell Test 1) With the patient sitting, test nasal patency by having them cover one nostril and breath in. Listen for the sound of abnormal air flow. If present do not test, investigate cause of obstruction. 2) Open the card. Use the tongue depressor and scratch the scratch and sniff odorant. Have the client cover one nostril and sniff. Inquire as to the smell. If they are not sure, then offer choices. Repeat with the other nostril. 3) Repeat this with all three odors. The total score should be 6. If 2 or more are missed, then further work up of disordered smell and taste should begin. ©2014 The Institute for Functional Medicine POCKET SMELL TEST • Smell (Quick Card), – Apple – Natural Gas – Rose OR – Lemon – Lilac – Smoke UPSIT Test www.sensonics.com ©2014 The Institute for Functional Medicine Test Taste Bitter ©2014 The Institute for Functional Medicine Screening Questionnaire for Loss of Taste How easily can you detect the tastes Easily Somewhat Not At All 1. Saltiness (chips, pretzels, salted nuts) 2. Sourness (vinegar, pickles, or lemons) 3. Sweetness (soda, cookies, ice cream) 4. Bitterness (coffee, beer, tonic water) Negative Predictive value for easily: saltiness 95%, sourness 89%, Sweetness 98%, Bitterness 92%. Positive predictive values range from 5-26% (when a person can Easily taste each of the 4 senses then there is a high degree of confidence that they Can taste. Easily is negative for gustatory loss, and somewhat or not at all is positive For loss. Malaty J, IAC Malaty: Smell and Taste Disorders in Primary Care Am Fam Physician 88;12; 852-859, 2013. ©2014 The Institute for Functional Medicine Taste (TAS2R) 3 Genetics of Taste ©2014 The Institute for Functional Medicine Are you a supertaster? Bitter (phenylthiocarbamide-PTC) m.stone md Supertasters vs non tasters: Vegetable avoidance, increased fat and sweet intake, disinhibited eating behavior among women, More Alcohol dependence. ©2014 The Institute for Functional Medicine Why Check Bitter-Taste? 1) Taste perception affects food selection 2) Supertasters have a tendency to eat less vegetables, eat vegetables more with sauces, dislike coffee, moderate to little like for sweets, pepper/chili and alcohol are more irritating, and perceive feel not tast of fat. 3) Non bitter tasters more susceptible to eating spoilage, and poisonous alkaloids. 4) Can change your therapeutic interventions. ©2014 The Institute for Functional Medicine Genetics and Taste Chemical Gene Allele Sucrose TAS1R3 -1572 C/T Glutamate TAS1R3 R757C Isothiocyanate TAS2R38 A49P, V262A, 1296V Isovaleric acid OR11H7P C/T at nt 679 Androstenone OR7D4 R88W Gene Quality Genotype Rating of Good Child 1 Child 2 Taste TAS1R3 Sweet in Onion +/+ -/- YUM! TAS1R3 Umami in Tomato +/+ -/- TAS2R38 Bitter in Watercress -/- +/+ OR11H7P Sweat odor in Cheese -/- +/+ OR7D4 Boar Taint in Ham -/- +/+ YUCK! Reed DR, Knaapila A: Genetics of Taste and Smell: Poisons and Pleasures. Prog Mol Biol Trans Sci: 2010:94:213-40 ©2014 The Institute for Functional Medicine Taste Loss Infection: Oral Candida, Periodontal disease, gingivitis oral abscess, viral URI, HIV Oral Appliances: Dentures, prosthetics Postsurgical: Middle ear surgery affecting corda tympany, oral or dental surgery especially 3rd molar extraction Radiation: HEENT irradiation with oral mucositis, xerostomia Nutrition insufficiency: Protein malnutrition, zinc, copper deficiency, B12, niacin deficiency Medications: Intranasal zinc, chlorhexidine, chemotherapy, ACE Inhibitors, ARBs, calcium channel blockers, diuretics, macrolides, terbinafine, fluoroquinolones, protease inhibitors, griseofulvin, PCN, tetracyclines, metronidazole, antiarrhythmics, antidepressants, anti convulsants, lipid lowering agents. Head Trauma: Toxins: pepper gas, weed killer, ammonia, benzene, cadmium, iron, lead Medical Conditions: Cancers, Type 2 DM, Hypothyroidism, Renal Failure Malaty J, IAC Malaty: Smell and Taste Disorders in Primary Care Am Fam Physician 88;12; 852-859, 2013. ©2014 The Institute for Functional Medicine Eight Step Mouth Exam ©2014 The Institute for Functional Medicine 8 Steps in Evaluation of the Mouth 1) Jaw Movement 2) Lips 3) Soft and Hard Palate 4) Tongue 5) Gums 6) Buccal Mucosa 7) Teeth 8) Chew/swallow ©2014 The Institute for Functional Medicine Nutrition-oriented Physical Exam; 8 Step Mouth Exam ©2014 The Institute for Functional Medicine Oral Mucosal Lesions and Micronutrient Deficiency Oral mucosal condition Associated micronutrient deficiency Angular Cheilitis Riboflavin, Nicotinic acid, Folic Acid, Biotin Cobalamin, Vit C, Cheilosis (dry cracking) Fe, Zn. /Riboflavin, Niacin, Pyridoxine Burning Mouth Syndrome Pyridoxine Candidiasis Folic acid , cobalamin, Iron Glossitis Riboflavin, nicotinic acid, pyridoxine, folic acid, cobalamin, iron, protein energy malnutrition Lip fissures Pyridoxine Oral Sensitivity Thiamine, pyridoxine Recurrent apthae Riboflavin, Folic acid, Cobalamin, Ascorbic Acid Stomatitis Nicotinic acid, Folic acid, Cobalamin. Periodontal disease Vitamin A, D, E, B-Carotene, Thiamin, Folate B12, E, C, Ca, Se Poor mucocutaneous Riboflavin, Niacin, pyridoxine, Zinc border Moynihan P. : Nutrition and its effect on oral health and disease. Ch 5, pp 83-99. In M. Wilson: Food constituents and oral health. Current status and future prospects. CRC Press Boca Raton Fl 2009. ©2014 The Institute for Functional Medicine ©2014 The Institute for Functional Medicine 2-Lips Cracks, Lesions, Sores Which Nutrients are Associated With Each Condition? Zinc, Vitamin A, C Riboflavin, B-6, B-12 Folate, Minerals: Zinc, Fe Perlèche-angular cheilitis Herpes Labialis Lysine/Arginine Balance Lower levels of A,E,C Recurrent Aphthous Stomatitis Am Fam Physician 2007;75:501-7. ©2014 The Institute for Functional Medicine ©2014 The Institute for Functional Medicine 4-Tongue-What do I look for? • Movement • Color • Coating • Fissuring • Scalloping • Piercing • Taste Bud Distribution • Lesions ©2014 The Institute for Functional Medicine Color m.stone md ©2014 The Institute for Functional Medicine Tongue Coating Tongue Coating Score 0= No tongue coating 1= Thin tongue coating 2= Thick tongue coating difficult to see papillae Significantly more anaerobic bacteria the thicker the coat, No significant difference in candida J Oral Rehabil 2007 Jun;34(6):442-7. ©2014 The Institute for Functional Medicine 4-Tongue Glossitis with Taste Bud Atrophy B12, Thiamin, Riboflavin Niacin, Pellagra mstone ©2014 The Institute for Functional Medicine 4-Tongue Additional Patterns Median Rhomboid Glossitis Erythema Migrans Oral Hygeine, Candidiasis Candida, Abx Leukoplakia Dysbiosis-oral Iron and Selenium Hairy tongue Allergy-Intolerance Am Fam Physician 2007;75:501-7, Head Face Med. 2006 Oct 16;2:33. ©2014 The Institute for Functional Medicine Scalloping • Macroglossia- any cause • Hypothyroid, acromegaly, amyloidosis, down syndrome • Sleep apnea • Increased in autoimmune conditions* • Increased in food allergy and hypersensitivity* m.stone md *clinical experience ©2014
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