Autoimmunity & Inflammation Case Study: Functional Medicine Series

Show Summary:

Welcome to a special series on the Capital Integrative Health Podcast! I am your host, Dr. Andrew Wong, and this is a podcast dedicated to exploring the root causes of both disease and wellness.

I am a co-founder of Capital Integrative Health, a clinic with a mission to create a revolution in healthcare by educating, leading and inspiring people towards optimal health and true wellbeing.

We’re excited to offer you this series as an insightful look into functional medicine and walk you through case studies that exemplify how we think about and approach care with our patients.

These cases are de-identified and names used are placeholders.

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Full Transcript:

Dr. Andrew Wong 

Welcome friends to a special series on the Capitol Integrative Health podcast. I'm your host, Dr. Andrew Huang. And this is a podcast that is dedicated to exploring the root causes of both disease and wellness. I am honored to be a co founder of Capitol Integrative Health Clinic in Washington DC area with a mission to create a global revolution in health care by educating, leading and inspiring people towards optimal health and true well being. One of the key modalities we utilize in our clinic to help patients and be of service is functional medicine. We're excited to offer you this series is an insightful look into functional medicine, otherwise known as root cause resolution medicine, and walk me through case studies that emphasize how we think about and approach holistic care with our patients. So let's get into our case study for today on immune health and how we take a functional medicine approach to immune health. So today, we have who will call Ari Ari is a 48 year old male. He has been experiencing health issues since childhood, including recurrent ear infections and was frequently on antibiotics. He was also even hospitalized for pneumonia when he was 10 years old. He does have psoriasis on his knees and elbows. And he's tried some conventional treatments like steroids and vitamin D cream for this. He was an active child and active young adult he played soccer and baseball through high school and then recreationally into his 20s. He has now married four kids, and he works as a project manager for a construction company. Our reports joint pain, stiffness and his hands, wrists, knees and ankles, particularly in the morning or after periods of inactivity. His job as a construction company manager is moderately active. He's on site about 50% At least at the time, and his joint pain has been affecting his ability though to work and to exercise. He has difficulty also staying asleep sleeping for four to seven hours per night. He reports significant fatigue in the afternoon. In addition, his skin condition psoriasis has been spreading and becoming more symptomatic, not responsive to the storage of the vitamin D cream. He occasionally has low grade fevers up to 100, without any obvious explanation. In terms of lifestyle factors, we asked him about his nutrition and diet. So recently, I restarted an anti inflammatory diet focused on eating the rainbow with colorful fruit, fruits and vegetables focusing on healthy fats and quality proteins. He does eat some animal proteins like chicken and fish tries to stay away from red meat in terms of stress between work family and his health. Overall, his stress level is reported at a seven out of 10 On average, which is pretty high. From a movement perspective, he does have a moderately active job, he's not really sitting as much because he's on the on the worksite. He does strength training at the gym one to two times a week. And he does have reduced ability to exercise overall because of his joint pain. So in terms of questions, I would ask Gary and why we would ask those questions. I think you know, when you take a medical history, again, we all need to know from school that really about 70% of what's going on with the patient, at least will be reviewed, revealed rather by by the patient histories are really taking time to deeply listen to Ari and try to understand what treatments have you tried before, you know, we know if he's tried some vitamin D cream, vitamin D analog cream, I should say and also topical steroids. He is trying to go on an anti inflammatory diet, which in theory would help with his his psoriasis. I'm wondering what he has also tried for the joint pain as well. I'd also want to ask because we take a team based approach here, but part of that is who's on on his team overall, whether it's say in our clinic or outside specialists, so yeah, have you seen a rheumatologist for instance would be a good, good, good question. I think. So what what is he tried, what's worked, what's not worked, that kind of thing. I'd also want to ask him a little bit more about a sleeping which we can talk about in terms of lifestyle, but why is he not sleeping? Well, you know, four to seven hours a night, it's really important to get proper sleep for healthy immune system rejuvenation recovery. Because we know in functional medicine, these skin conditions is intimately or intimately connected to gut health. I want to ask him about his his gut health overall. How are his bowel movements? You know, we know that one primary function of the gut besides absorbing nutrients is also to eliminate toxins. So the frequency and the consistency of the bowel movements is extremely important. And his situation we know that a lot of times it's rice is and we'll talk about more of that in terms of the root cause section but a lot of times toxins are involved with with the pathogenesis of psoriasis. So having healthy and regular bowel movements can be really helpful. There's actually an interesting stool scale I think from the UK called the Bristol stool scale, which is spelled b r i s t o l and you can Google that you can go online and look at that. It looks at the consistency of the school and stool and it's based on I think types one through seven so you want it to be you know, kind of in the middle There were it's not too hard, not too soft. And this can be very, very helpful in terms of health of the gut overall, when you just look at your stool and compare that to the chart. So that would be an interesting thing to do for our ear. Does he have any bloating? Does he have any undigested food in his stool? Does he have any diarrhea or constipation? Those type of things are really helpful for gut issues, questions. And then I'm also wondering, does he have any gut issues or skin issues that are related to his nutrition, so if he's eating, say, fried food or unhealthy food, overall processed foods, maybe sugar, maybe, maybe gluten or dairy, these are some of the things that can be really triggering for the immune system, especially with a patient with an autoimmune condition like psoriasis. So trying to figure out the time course of what he's doing in terms of his lifestyle. And if his symptoms get better, or worse, can be really, really helpful to connect the dots there the biology. Besides that, I'm really concerned about his combination of the skin condition with psoriasis, but also his joint pain and stiffness in the hands, wrists, knees and ankles. So one of the things that can happen with psoriasis is that it can get complicated and become not only psoriasis, but it can progress to something called psoriatic arthritis, where the autoimmune condition not only affects the skin is starting to affect the joints as well. So that will be a question there is, you know, did the pain and the joints start happening after the skin condition? Because we know that the skin condition is getting worse? So so that that will be a question. And then what has he tried for the joint pain? What is he tried in terms of diet, lifestyle, or nutraceuticals, or medications? It would be interesting from a family and social history perspective, a couple of factors for First of all, from a social history perspective, we know that certain very basic lifestyle factors can be really, really helpful. And just you know, mitigating someone's symptoms or improving their health is certainly alcohol and smoking, we would try to eliminate that if he's, if he's, you know, taking any of those substances. And then family history, we do think about something where psoriasis is often very genetic. And so we would ask him about his family history, as well there. And then I would also think about something called the there's there's kind of a T cell axis and the immune system. So I think just to be basic about it, there's kind of, we can consider a pretend there's like a, a weather vane, where you have like maybe a horizontal axis and the vertical axis on the horizontal axis, you're gonna have T helper cell one, and then you'll have T helper cell two on the other side of the horizontal axis, and then the vertical axis, you might have th 17 at the top and then th T regulatory cells or T regs on the bottom of the vertical axis. So that's what I would think about in terms of the immune system. And the balance of that immune system between th one and th two and also between th 17 and T regulatory cells are very helpful in terms of someone with autoimmune disease to try to understand that a bit. And I think suffice it to say that we want someone to have not have a th two dominant situation in which case, we would ask this patient already about asthma and allergies and eczema. So these are more of to eight th two or T helper cell two kind of conditions. And that kind of spectrum may predispose to autoimmune conditions, like psoriasis, and addition. And we know that for psoriasis, there is a upregulation of the T helper cells 17 class, which does promote inflammation and autoimmunity. One of the things is th 17 can be mitigated by various lifestyle and dietary factors. So, T 17 would be something I would I would think about from an immune perspective. And we would ask him about inflammation. Because basically, when you look at the immune system, there's a bidirectional and vicious circle interface between inflammation and autoimmunity. There's different molecules that are involved that if someone has inflammation, it's going to generate more autoimmunity. If someone has more autoimmunity, it's going to generate more inflammation. So inflammation is really the name of the game here for Ari and we know that there's some inflammation going on, the inflammation is interacting with its genetics and causing psoriasis or psoriatic arthritis.

Dr. Andrew Wong 

In terms of his lifestyle, we use a smart approach here often or we think about a lifestyle kind of approach to to care because when we focus on lifestyle, wellness, a lot of time, disease can go away or get mitigated as a side benefit of focusing on lifestyle. So in our clinic, one thing we use is something called a smart mnemonic, which is S M AR T RT. So living smartly, living a smart lifestyle. The S stands for sleep. M stands for mindfulness. A stands for activity, R stands for real food, I eat real nutrition, and then T stands for ties or relationships. So we kind of go through that and our history and we're going to ask Ari about his lifestyle. Is it smart? Is it something where he's focusing on the lifestyle factors that are fundamentally underpinning His immune health and you know, this is going to basically as we increase his life as he increases his lifestyle I'll balance then that's going to help his immune system overall. So for sleep, I'm wondering really about, you know, why is he not sleeping Is it because of the stress from work and family and his health? Is it because he has a medical condition A lot of times asleep. And I've reviewed this on a couple of these other podcast episodes, but we look at sleep apnea as a potential root cause. I'm wondering what his body mass index is, a lot of times, people that are overweight tend to have more risk of sleep apnea, although you can have a person that's quote unquote, skinny, but still have an obstructed airway. And so just because someone is not just because someone is overweight doesn't mean that that they can't have sleep apnea. So if he's having anything like He's snoring, or and in this case, he's having fatigue in the afternoon, and I'm wondering, even if he gets, you know, eight hours, he's still tired. But I would say for someone like this with insomnia and immune issues, I would, I would rule out sleep apnea with a home sleep study or in lab sleep study. If it's not a sleep apnea issue, then if the stress issue, there could be other things that could be helpful, calming herbs, for instance, adaptogens, we think about, we think about Ashwagandha is one, we can name a couple of things, but things that are coming as well, things like lavender, things like passionflower, so there's a bunch of things that can be done even CBD, which is cannabidiol. So a lot of things can be done for sleep, meditation, acupuncture can be really helpful. So mind body practices, yoga, yoga, Nidra, that can be really helpful. So sleep is gonna be one of the big factors that are going to be really helpful to augment his lifestyle to start with, really. So I think prioritizing things, because we are talking about a lot of things with Ari. And one of the things that we want to not do is overwhelm someone and really try to focus on what's the priority for him to start with mindfulness, I think, you know, taking deep breaths, making sure that he is stopping and pausing during the day. So he's not just like running around the whole day, which is going to activate that fight or flight system and not allow his immune system to rest. So I think that's a big thing is always tying the lifestyle back to what Ari is concerned about, which is his immune health. So sleep affects immune health, mindfulness will affect immune health activity is also very anti inflammatory exercise is very anti inflammatory, as long as he's not overdoing it. So I think as he gets, you know, better, hopefully, with his joint pain, then then he can do more activity, and that reduces inflammation. And then certainly real food or real nutrition, he's starting an anti inflammatory diet, definitely the healthy fats. And again, just to review that, that would be things like, Omega nine rich fatty acids, like olive oil, and omega, three rich things like like fish, for instance, certain nuts, you know, in theory, certainly, healthy greens. We did have a recent podcast on on oxalates. And it would be interesting to see if oxalates affect his health as well. That's from Sally Norton. So you can listen to that quality proteins is very helpful as well to help detox the system. Overall, it could be plant or animal proteins. And I think also things that are to be avoided. You know, often with people with psoriasis, you have to think about, you know, are there any food sensitivities which could be, that could be where a food diary or food journal could be really helpful. Gluten is definitely associated with psoriasis. And many patients, a lot of people strive to have gluten, or dairy sensitivity. So these are things that can be really affected. And then like I said before, with alcohol, alcohol is a type of sugar, so any sort of sugar, that's going to cause more immune system activation, whether it's alcohol, whether it's too many processed carbohydrates, things like grains, things like potatoes, or even things like obvious things like pastries, could be really, really inflammatory. So gluten, dairy sugar might be where we start in terms of trying to reduce that for Ferrari there. And then from a Ty's perspective, you kind of always think about holistically Mind, Body Spirit, how, how are his relationships at work and his family and his relationships with himself and how he thinks about his health, how he feels about his health, how's that affecting his overall overall health, he, he has a stress level that seven out of 10, which is pretty high, if that's chronic, and we know that chronic stress will make it really hard for him to recover and rejuvenate. So I think doing some mind body techniques, things like meditation, HeartMath, yoga, Nidra working on integrative treatments, things like my official release, or cranial sacral therapy, or massage or acupuncture, I think could be really, really helpful for Ferrari, just probably choosing one of those, you know, just to try to get his autonomic nervous system more in balance. And then I think that I think I skipped over that. Yeah, so lifestyle. We talked about the test that we would consider ordering for this patient. So so from a bloodwork perspective, we think about a triad of three micronutrients that we definitely want to order for someone like ra so we think about vitamin A, we think about vitamin D, and we think about zinc and all these are really, really important for immune health, and they work synergistically with each other. So ad and zinc are very important for gut health and immune health. In addition, we think about an Omega check and Omega check as a lab test that looks at omega three index, which is basically the percentage of omega three fatty acids that are found in the red blood cell membrane, we think about the ratio between omega six and Omega three, which can be really, really elevated in someone that's on a quote unquote, standard American diet. Sad, which has now been exported to the world, as well. Unfortunately, so I think that one of the one of the key factors is you know, what is is omega three level, which is omega six, and six to three ratio EBV, which is Epstein Barr Virus, which we're going to have a podcast on. And our podcast here talking about chronic EBV. Epstein Barr is also associated with with with psoriasis as well. So I would check his Epstein Barr test. Another thing that is affected, that can be affecting psoriasis is heavy metal toxicity. So things like Latin, mercury, cadmium, arsenic, things like that. So we'd want to check that as well. On the blood test and potentially urine testing, I would test a few other things on the bloodwork I would test immunoglobulins, like IGA and IgG, because those are antibody levels that if they're if they're low, it might cause someone not to be able to clear infections, it might be leading to gut permeability issues if especially if the IGA is low. Because Secretary IGA is found in the stool on a stool test, which we can measure as well, but it's found in the gut lining, and if you have an IGA level that's low in the gut lining, you're gonna probably have leaky gut, or impaired intestinal permeability is another way to say that. So we would think about celiac disease because often if someone has one autoimmune condition, it's not like it's just going to stay in one part of the body just like a fire is not going to stay in one one location, it's going to spread so there's different other you know, immune system factors that can be affected if someone has one condition like psoriasis. So often we're going to look at may look at celiac markers to make sure that our he doesn't have celiac disease, we're going to definitely look at thyroid to make sure that he doesn't have Hashimotos, which is autoimmune hypothyroidism, or low thyroid, in which case that can cause things like joint pain and fatigue as well and even sleeping issues. So I think that those are really, really important. We check some basic bloodwork, like blood counts, complete blood count, comprehensive metabolic panel, which is looking at liver and kidney tests and electrolytes and blood sugar, certainly would want to check his blood sugar, we check his blood glucose, but also fasting insulin levels. Insulin is associated with inflammation when it's too high. So we typically want that insulin level fasting insulin level, below five, I would say. And then from a functional end, we definitely want to look at I think we will look at stool testing. There is a thought in functional medicine that really the the gut is really intimately tied to to skin health, and vice versa. So if someone has a skin condition, whether it's whether it's something like psoriasis, like we're talking about this case, or whether it's eczema, whether it's acne, it's whether it's alopecia areata, which is head of hair loss, these are all things that can be really intimately connected to gut health, specifically to gut dysbiosis, which is an imbalance in the micro micro micro biome on the gut. So we're going to look at at gut health, using functional stool testing, the one we typically like uses proprietary DNA technology to look at at different aspects like bacteria and viruses that are in there, parasites that are in there, that could be in there that are affecting the immune system.

Dr. Andrew Wong 

Also, it's important to review that most of your immune system actually ends up in your gut. So your digestive tract or your gut has about 70 to 80% of all immune cells in your body. So that's important to know that if you have any immune condition, you're listening out there you have some sort of, you know, whether it's whether it's psoriasis, whether it's rheumatoid arthritis or lupus, or Hashimotos, these are all autoimmune conditions, autoimmune conditions, likely there's something going on in the gut. So definitely take a look at that. Talk to your practitioner about that. And I think from a practitioner perspective, you know, we know that it takes a village to work with, with, with people with autoimmune conditions and just in general having a whole body approach with it regardless of what's going on with with a patient. I think a functional medicine practitioner functional nutritionist make a lot of sense. Someone on the wellness side that a practitioner that's involved with mind body work, I like acupuncture myofascial release for this could be other practitioners as well. And then from a conventional perspective, because I'm suspecting that that this patient already has rheumatoid arthritis I'm sorry, not room for arthritis, psoriatic arthritis, could have rheumatoid arthritis. You can have two two conditions at one time and we could do bloodwork to look at that to to differentiate between psoriatic arthritis and RA, but definitely referring referring ra to rheumatologist as well, just to do more testing and see if that diagnosis Is there so top three most important steps that are he needs to take, I would evaluate his sleep to rule out sleep apnea. I would check some lab work including vitamin A vitamin D, zinc and Omega check and some of the other tests there to see if there's any root micronutrient contributions there. And I would do a gut test, I would really look at his gut to look to see if there's any microbiome imbalances that can be addressed that could really impact and help his immune system. Thank you so much for joining us today for this episode of the capital Integrative Health podcast. A quick reminder that the information we share on this podcast is meant for educational and informational purposes only. It's not a substitute for professional medical advice, diagnosis or treatment. We highly recommend that you speak to a qualified health care provider before making any medical or healthcare decisions. This episode, please take a few moments to subscribe and leave us a review. Your reviews help us reach more people and continue to offer innovative insights and information to better optimize your health and wellness.