Putting nutrition to work in the doctor's officePutting nutrition to work in the doctor's office

nbj: When you talk about functional medicine and nutrition as treatment, how does that play out with a patient?

Michael Stone: I think that every child, every person, has a history and a story. Part of our job as physicians is to listen to that story and try to figure out if we can integrate that story into a timeline. Then we begin to understand some of the inter-relationships of seemingly unconnected portions of that story. You begin to see the
triggers that can lead to disease.

nbj: I still remember your case study around autism at the inaugural
gathering of the Personalized Lifestyle Medicine Institute. Can you share it again?

Stone: Autism is one of those situations where there are a whole series of multiple-level possibilities to change how nerves form and interact and communicate, changes that can lead to symptoms. It's multi-factorial. We know that food sensitivities can be a trigger. We know that if the intestine gets more permeable, you can see ‘leaky gut' and more triggers that affect the immune system and cause changes in the brain. We know that the alteration of bacteria and the biofilm that is influenced by probiotics and antibiotics can play a role. We know that if the child has an altered ability to get rid of toxins through their liver and kidneys, that can play a role. We know that not enough vitamins and minerals can play a role. We know that inflammation in the gut and in the brain can play a role. We know that the ability to make energy can play a role in your mitochondria, and we know that immune imbalance can play a role.

nbj:  How do you sort through all of that with a patient?

Stone: Here's that case study you mentioned. A mother came
to us after being told that her son had autism and,
because of insurance the way it is, they qualified for about 20 minutes of vocational rehab a month. The child was born seemingly normal. This was her oldest child. Between six months and a year-and-a-half of age, the child had multiple ear infections and multiple courses of antibiotics. Then, in the normal immunization sequence, the child had a really severe fever at around 18 months,  so high that the child was admitted to the hospital. After the fever,
that child that had been developmentally normal was no longer
making talking sounds. That continued until about two-and-a-half years of age, when the child started having seizures and
actually overdosed on seizure medication. Neurologically, he became more and more withdrawn. By the time the child was three-and-a-half years old, he had no words at all in a typical presentation of
autistic behavior. The mom heard that it may be dairy-related, so she stopped milk and, within about a week, the child got one word back and it was ‘eat.’ Then the child went for further evaluation and they found the lowest normal levels of folic acid or folate in the
cerebral spinal fluid.

In listening to the story, the timeline starts with the mom’s and
father’s genetics. The mom had a common genetic marker—MTHFR, methylenetetrahydrofolate reductase. Fifty percent of us have it, and it can cause a diminished ability to activate folic acid. I asked how the child was fed. He wasn’t breastfed. He was bottle-fed. Then we noted the multiple ear infections and antibiotics. Then there was the fever. We had multiple possible triggers for autism. Did the child’s immune system suddenly start reacting to folate-binding proteins in the cow’s milk formula? In 70% of
autistic children, they make antibodies that prevent or diminish the amount of folic acid that can enter the brain. They can’t make
neurotransmitters in balance, and the brain can’t function as well.  A lot of that work has come out of Drs. Frye and Rossignol’s work. They showed that by giving higher doses of this nutrient, the children actually had improvement in behavior, mood, attention and language. What you have to do if the child has developed those antibodies, you have to remove milk, which the mom already did. Once she took away the milk, the child developed a word. I asked her if she’d be willing to try a higher dose of these B vitamins, especially activated folium methylfolate with some other B vitamins. We saw a very significant change in this child’s behavior, including the development over three weeks and then six weeks of 50 words, and this child looking at his mom for the first time and saying ‘Mom, I love you.'  In a kind of simplified way, that outlines how you can take a phenomenally complex case that seems desperate, and you can chart a timeline that creates the ability to see patterns. And then you can begin to intervene. Our interventions are nutritional, lifestyle and then, we will layer the pharmaceuticals as needed.

nbj:  Where else do you use a nutritional approach?

Stone: I can say that in our practice, nearly 100% of the people with any chronic issue will see our nutritional professionals.

nbj: What do they typically learn?

Stone: We begin to see what patterns of eating and which nutrition decisions are pro-inflammatory, are immune-suppressing, are neurotransmitter-altering, are energy-inhibiting. You could summarize our approach as looking to see what we need to get in the diet and lifestyle, or what we need to get rid of in the diet or lifestyle. Every chronic disease has a significant and modifiable lifestyle intervention. Every single one of our chronic disease academies in their algorithms will say, before initiating treatment for hypertension, for heart disease, for cognitive changes of aging, for asthma, address lifestyle and diet. And we're not doing that as a profession. We too often skip that step and go right to the prescription pad.

nbj: In terms of nutritional therapies, food or supplement?

Stone: I think the answer of food versus supplement is often ‘yes.’ It really depends on the degree of imbalance. Let’s say you have an increased requirement for an enzyme or mineral or some other co-factor, and it has been imbalanced for a long time. Therapeutically, we sometimes see the bridge as a higher dose supplement and then we bring the food on and begin to back off the supplement. I just saw a person who was wheelchair-bound. We did some organic acid testing on her and she has a significant inability to move the carbohydrate breakdown product of glucose into her mitochondria to make energy. She wanted to use food, but I told her we first had to bridge this with a supplement while we bring more of those foods in. Now, another classic example is Terry Wahls of the Wahls Way. She was a wheelchair-bound physician with multiple sclerosis.
She started looking at her condition through a functional nutrition, functional medicine lens and she started using supplements as a bridge until she could work up to the 10 servings of kale a day that ultimately turned her whole condition around. She is back
riding horses and riding bikes and walking. Supplements may be used as a bridge, but food has all sorts of interactions that we can’t put in a pill.

nbj: Do you recommend supplements on an ongoing basis, as a maintenance tool?

Stone: If you follow the timeline of life, there are different peaks and valleys of nutrient needs. A classic example is pregnancy. In our clinic, we look at pregnancy and we know that if the mom doesn’t have enough B vitamins and choline and essential fatty acids three months prior to when she conceives and one month after, plus she has some really common genetic weaknesses—MTHFR, CBS, cystathionine  beta synthase—and the baby happens to have those common genetic weaknesses too, then the fetus might not metabolize adrenaline well. If the mom doesn’t have those adequate B vitamins and methyl factors, and the baby has that issue, three months prior to conception and one month after conception, there is a 720% increase in autsm. You get those methylation factors, those one carbon metabolism factors, from enough greens. We're talking six to ten servings of greens a day. Okay, how many Americans are doing that? We have developed this whole program for pre-natal nutrition that all the ODs go through in our clinic. So during pregnancy, if you are not taking in enough of these nutrients, you bet we should be supplementing. If you're an athlete with a marked increase in oxidative stress because of your workouts, you bet you should be using a supplement if your diet and nutrition is not adequate.

nbj: This sounds like a personalized nutrition plan?

Stone: You can determine that you have these combinations of gene SNPs and get a urine sample done and see how your mitochondria are dealing with your lifestyle. Maybe you need some extra oomph. If you can get that oomph with kale, broccoli, whole eggs and a pomegranate juice smoothie, you bet, do that. But if you can’t, then use a supplement as a bridge.

nbj: We have a Q&A in this issue with Dr. Paul Offit, who has been a loud critic of the supplement industry. We asked him if personalization could begin to make the case for supplement efficacy in a way that population studies don’t. What do you think?

Stone: Population studies are population studies, but what are the characteristics and what is the history and timeline of the person on the other side of the stethoscope? When you are looking at them and you see the family history and their uniqueness, when you see patterns and you think systemically versus single organs, then you begin to see the power of that personalization. In pregnancy, we see it with miraculous outcomes. Children who weren’t supposed to be able to walk could begin to function. Children begin to start talking. It's recognizing the uniqueness of that person's metabolism, as unique as a fingerprint. When you begin to have the tools to be able to see what the body is doing through the markers of lifestyle
washing over genetics, we begin to see this shift. That shift is
phenomenally inspiring to me.