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Integrative Nutrition in an Holistic
Family Practice Setting: Guiding
Principles & Case Studies
Ranan D. Cohen, MS, RD, LDN
Clinical nutritionist in private practice
Holistic Family Practice, Newbury MA
March 11, 2011
Holism: four dimensions
“ n. the view that an organic or integrated
whole has a reality independent of and
greater than the sum of its parts.”
(Webster’s dictionary)
This definition implies synergism, potentially
applying to:
• the body/mind/spirit
• alternative therapies
•nutrients
•ecological systems
Nutrition Therapy as a “Recipe”
….Change several nutritional variables in combination,
treating them as “ingredients” in a “recipe” designed to
improve several categories of nutritional and health status
together.
Example: Dairy elimination diet + improving legume
intake + increasing sources of ALA + an improved multi
(with a better balance of B vitamins) +
pro-biotics.
Nutritional challenges
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Suboptimal intake
Malabsorption
Depletional factors
Food sensitivities
Toxic/environmental exposure
Iatrogenic
Genetic
Emotional-spiritual /Stress
PLAN
Nutritional adequacy?
Absorptive efficiency?
Digestive efficiency?
Microbiological
balance?
Detoxification
improvement?
FUNCTIONAL QUESTIONS
Suboptimal intake assessment
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Water/hydration
Vitamin/mineral sources
EFA/EPA/DHA sources
Phytochemical sources
Ancillary nutrient sources
Fiber intake level
Fruit smoothie
Spelt toast + butter
Salad Bar (field greens,
carrots, other
vegetables, cottage
cheese, kidney beans,
EVOO + balsamic +
rosemary + garlic)
Chana masala over
brown rice with mango
lassi
Yogurt + fruit + wholegrain graham crackers
Whole-grain pancakes
(include wheat germ +
flaxmeal) + berries
Turkey sandwich (on
whole grain with grassfed turkey) + carrot
sticks
Yogurt + cashews +
banana + kiwi
Salmon + roasted red
potatoes + broccoli
salad+ Red Wine
Malabsorption factors
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Insufficient enzyme and/or HCl secretion
Insufficient emulsification (lecithin)
Insufficient nutrient provision (B vitamins)
Food allergy/intolerance/sensitivity
Impaired mucosal integrity (probiotics; SCFA;
glutamine)
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Iatrogenic
Depletional factors
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Pregnancy/lactation
Alcoholism
Smoking
Surgical-metabolic/disease/other stress
Medications
Pollution
Intensive exercise
Symptom history (1)
• Angular stomatitis
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Photophobia
A, B2, B6, Fe, ?EFA
A, B2, B6
Eyes irritated/invaded
B2
Bruise easily/gums bleed
C, E, K, ?Fe
Nose bleeds (frequent)
K, C
Poor wound healing
A, C, Zn, Cu
Exertional fatigue/stamina
Fe, B2
Coordination/ ataxia
B12, fol, B1, B6
Symptom history (2)
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Cold extremities/poor circulation Fe, B3, E, C
Pallor
Fe, Cu
Poor night vision
Zn, A
Decreased taste/smell sensation Zn, A
Muscle cramping
“Burning feet”
Brittle nails
Dry skin/hair
Mg, Ca, K+, E
Panto
Ca/Mg, Folate, ?Si
EFA, Zn, A
PAST MEDICAL HISTORY
HxETOH’ism
B1, Fol, B Complex, Zn, Mg
Hx Smoking
E/Se, Beta-Carot, C, Fol
Diabetes/Hypoglycemia
Cr/B3, Zn, Cu, Mn
Hypertension
Ca, Mg, K+/Na+
Carpal Tunnel Syndrome
B6/Mg, B2
Hx Anemia (Did Fe help?)
Fe, Fol/B12, Cu, E, B6
Chronic Fatigue
Fe, Mg, Fol/B12, Pro, EFA
Cervical Dysplasia
Fol, Beta-Carot, C
PAST MEDICAL HISTORY(2)
Hyperemesis Gravidarum
B6, B2
Fibrocystic Dx
E/Se, I-
Pre-menstrual Syndrome
Ca, Mg, GLA
“Restless Legs” Syndrome
E/Se, Fol, Fe, Ca, Mg
Psoriasis
A, D, B6, B2, EFA
Acne Vulgaris
A, Zn, Se/E
Hx Kidney Stones
Mg, B6
Osteoporosis
Ca/Mg, D, Cu, Mn, F-, B-
Available (& worthwhile) labs
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Ferritin/serum iron/TIBC
Ionized calcium (& bone density)
24-hour urinary magnesium
Serum B12
Serum & RBC-folate
Serum pyridoxine/RBC-pyridoxine/pyridoxal
PO4
Serum ascorbic acid
Available (& worthwhile) labs (2)
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Plasma retinol
25-hydroxy vitamin D
Prothrombin time/INR
RBC-EFA levels
Deborah - quick case history
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36y.o --- s/p 3 pregnancies --- fatigue, anxiety, depression
Pneumonia x 2; Anemia, including in preg.; Toxemia x 2
Palpitations, dry skin, nails peeling, inability to focus
No supplements; on Welbutrin
TFT’s WNL; B12 - 315; ferritin, folate, MCV, H&H all WNL.
Diet low in fruits, veg., legumes, EFA X2 and H2O.
Therapeutic suggestions??
Deborah - quick case history
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Suggestions: Balanced, diversified menu
Multi with B complex, trace minerals, etc. (DMF)
B12 -- 1mg X 2; L-tyrosine -- 500mg (after med. d/c’d)
“I felt the effect of the tyrosine”
Suggestions all well-implemented
Energy, skin, MH (except focus), palpitations all improved
Plan discontin./resumption  worsening/improvement
Food sensitivity: potential
diagnostic connections
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Migraine
Eczema; Acne
Sinus; Asthma; Bronchitis
Arthritis
IBS; IBD
ADD/ADHD
Auto-immune disease
Allergy/sensitivity symptoms
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Throat irritation/closure
Nausea/vomiting
Hives/rash
Headache
Constipation/diarrhea/stomach ache/indigestion
UR congestion/stuffiness
Joint pain
Symptoms of Food Allergy
Gastrointestinal
Manifestations
Abdominal pain
Nausea
Vomiting
Diarrhea
Gastrointestinal bleeding
Protein-losing enteropathy
Oral and pharyngeal pruritus
Respiratory
Manifestations
Rhinitis
Asthma
Cough
Laryngeal edema
Milk-induced syndrome
with respiratory disease
(Heiner’s syndrome)
Cutaneous Manifestations
Urticaria (hives)
Angiodema
Eczema
Erythema (skin
inflammation)
Itching
Systemic Manifestations
Anaphylaxis
Hypotension
Controversial or
Unproven
Manifestations
Behavioral conditions
Tension-fatigue syndrome
Attention-deficit and
hyperactivity disorder
(ADHD)
Otitis media
Psychiatric disorders
Neurologic disorders
Musculoskeletal disorders
Migraine headache
Common allergenic foods
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Cow’s milk dairy
Peanuts/Soy
Tree nuts
Crustaceans/Mollusks
Fish
Eggs
Wheat
Taking a sensitivity history
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Check pediatric sensitivity history
Appropriate signs/Sx: GI, headache,
skin,etc.
Take history by symptom category
“Any other food/meal that…”
Review prominent allergenic foods list
Foods consumed > 1X/week
Chronological comparisons
Shawn - quick case history
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Dry eyes, dry skin, with eruptions around flexure points
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Rash around anal area, exacerbated by antibiotic Rx
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7 y.o --- 40 lb.; 40 “ --- eczema; food sensitivities;  thirst
Allergy testing (RAST) + for all tree nuts, peanuts, wheat,
dairy, soy, shellfish, apple, egg white & beef.
All eliminated without effect! FBS -- WNL.
Reports reactions to: popsicles, skittles, gummy bears & gum
balls, but still in diet!
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Diet low in vegetables, legumes; very low EFA X2 and H2O.
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Therapeutic suggestions??
Shawn - quick case history
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Dietary plan: 1) Hypo-allergenic, balanced, diversified
menu with immediate reintroduction trial for wheat &
beef; 2) inclusion of safflower oil and flax oil daily.
Artificial additive sources excluded. Ensure adequate Ca/Mg.
Pedi multi; GLA (100 mg.); Zn -7mg; Pro-biotic (5 bi. org’s)
Results: Skin “about 90% resolved”, with minimal
scratching of dry areas.
Suggestions all well-implemented, except no pro-biotic and
EFA introduced via flax only. Mother noticed regression of
skin problems without this food.
Therapeutic goals
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Optimal digestive/absorptive capacity
Optimal biotic balance
Optimal, diversified intake without
food sensitivities
Optimal genetic potential
Optimal detoxification
Optimal exercise
Optimal spiritual-emotional wellness
Dysbiosis profile (1)
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Poor fruit, vegetable and lean protein intakes
Craves concentrated sugars, but ill-tolerates
them
Increasing pattern of food sensitivities over time
IBS
Hypoglycemic symptoms
Chronic fatigue
“Aching all over”
Dysbiosis profile (2)
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Poor quality of sleep
PMS symptoms
Antibiotics associated with yeast infection
Antibiotics associated with GI symptoms
Probiotic therapy/yogurt relieves GI and/or
yeast challenges
Dysbiosis therapy
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No concentrated sugars; no alcohol
Garlic
L. acidophilus (DDS1; NCFM; GG)
Bifidobacteria (infantis; longum; bifidum)
Goldenseal; Oregon grape root; Barberry root
Pau D’Arco
Oregano; Grapefruit seed extract; Caprylic acid
Prebiotic factors
Semi-volatile Organic Compounds in Adipose
Tissue: Estimated Averages for the US
Population and Selected Subpopulations (Am. J.
Public Health 1996; 86: 1253-1259)
• Objectives. The fiscal year (FY) 1986 Environmental Protection
Agency National Human Adipose Tissue Survey (NHATS) was
conducted to estimate average concentrations of 111 semi-volatiles in
human adipose tissue within US general population and selected
subpopulations.
• Results. Among polychlorinated biphenyls (PCBs), average
concentrations for the group aged 45 and older were 188% to 706%
higher than for the 0- through 14-year-old age group. Similar increases
with age were observed for pesticides.
Lipotropic profile
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Poor fruit and vegetable intakes
Indeterminate food sensitivity pattern; MCS
IBS
Mono /hepatitis/alcoholism hx
Chronic fatigue
Detox. profile abnormalities
Liver function tests elevated
Jen - Case history (1)
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33y.o. --- Rhematoid arthritis; fatigue (intermittent)
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Envir. allergies; Raynaud’s; migraines; PMS (mastalgia, mood).
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“Burning” sens. on top/front of feet; “restless legs”; gas/bloat.
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Relafen; Tavist-D; oc’s; 1-a-day; Cr-picol. (150mcg); Tums (2)
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Multiple Sx w/  stress: memory, constip., sleep/energy ; “body ache”
Family hx: mother allergic to wheat; migraine; rheum. arthritis
ANA; H&H; CDSA -- + for dysbiosis, but fine for digestion.
Diet needs  whole grains, legumes, fruit, CS, white flour, ALA.
IDEAS/SUGGESTIONS SO FAR??
Jen - Case history (2)
IDEAS THUS FAR:
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Food group improvements (fruit, whole grain, ALA, etc.)
Food sensitivity (fam. hx; migraine, fatigue, GI )
B complex (multi), pantothenic acid, vitamin C, Mg (Tums)
MORE FINDINGS (initial visits):
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Sensitivity to CS, coffee, corn, citrus shrimp, crab, soy & ?bread
Elim./ challenge diet + for corn, tomatoes (joints); wheat remains.
Joints reported to “feel better after a fish meal”
AM joint pain decreases from 2 hours down to 20’.
Jen - Case history (3)
INITIAL STEPS TAKEN:
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Elimination/challenge trials: corn, tomato, dairy, pork, beef & coffee.
Nutrient-dense diet with EFA X 2 & EPA/DHA.
EPA/DHA, GLA, multi w/ B complex (TF2), Ca/Mg, Flush-free B3.
MORE FINDINGS:
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Diet  in EPA/DHA  discomfort
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Change from TF2 to TheragranM  decrease in energy
Ran out of B3  joints felt worse; same for GLA.
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Trial GF diet  more improvements (joints; GI)
Jen - Case history (4)
RECENT UPDATE:
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Pantothenic acid tried vs. “burning feet”: trial was +; d/c 
return of Sx, and dose related to degree of symptoms. Also
has influence on how joints feel.
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“Emergen C” reported poorly tolerated (hives)
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Oatmeal “rips through me” (GI), but GF oats well-tolerated.
Pro-biotic therapy used when on antibiotics, with success.
Combination of med (Humera currently), nutrient-dense
(elimination) diet & supplements has proven very effective.
Traditional vs. optimal Rx
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Caloric balance
+ adjust CHO /Pro ratio
Adequate protein
+ semi-vegetarian model
4 food groups
Low-fat/SFA
DRI/RDA/DV
Food allergy mgt.
+ optimal whole grains,
nuts,legumes, fish, etc.
optimal EFA’s + EPA + GLA
optimal vitamin/mineral
intakes per individual’s
history
+ food sensitivity mgt.
IBS profile #1
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Craving tomato /pasta dishes, corn chips,
and feels they may not be well-tolerated
Excellent dietary balance
Adequate baseline supplementation
IBS (approximately five days a week)
Intermittent eczema
Migraines (approximately three times a month)
IBS profile #2
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Craves concentrated sugars, but ill-tolerates them
Poor fruit, vegetable and lean protein intakes
Increasing pattern of food sensitivities over time
IBS
Hypoglycemic symptoms
Chronic fatigue
“Aching all over”
IBS profile #3
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Excellent dietary history/food group balance
Adequate baseline supplementation
Weight stable
IBS
Poor energy and sleep
Recently divorced
Peri-menopausal
IBS profile #4
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Poor fruit and vegetable intakes
Indeterminate food sensitivity pattern
IBS
Mono /hepatitis/alcoholism hx
Chronic fatigue
Detox profile abnormatlities
Liver function tests elevated
Anti-inflammatory Nutrition
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Essential fatty acids (LA & ALA)
Herbs & spices (licorice, ginger, turmeric, rosemary)
Fish & fish oils (EPA/DHA)
Gamma linolenic acid (GLA)
 Saturated fat
Weight management
? Mind-body
Toxic metal profile
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?Metallic taste
?Headache
?Hypertension
?Bone/muscular/joint pain
?Fatigue/malaise
Pediatric history
Occupational history
Hair, urine, blood analysis
Toxic/environmental exposure
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Lead, cadmium, mercury
Chemical/occupational exposure
Air/other pollution
Environmental allergens
Pesticides, etc.
(Ca, Zn, Se; ?chelation)
(detoxification)
(E/Se, C, antioxidants)
(Nettle extract)
(Organic foods)
Food additives/food poisoning
Food allergens
Iron
(Elimination/rotation)
(Ca, whole wheat & rye)