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Clinical Protocols

Find out how expert integrative health practitioners are assessing and treating clinical conditions. Each clinical protocol is presented through a robust collection of practical insight including one-on-one interviews with the experts, Q&A forum, research updates, patient resources, and more - all produced by condition experts. New clinical protocols are added monthly so you can develop new and effective strategies for helping your patients across a variety of conditions.


TAP Clinical Protocols

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Attention-Deficit/Hyperactivity Disorder (ADHD): An Integrative Approach

The National Survey of Children’s Health reports that 1 out of 11 school-aged children have a current diagnosis of ADHD and that the prevalence of ADHD has been steadily increasing by an average of 5% each year between the years of 2003-2011.
ADHD is characterized by symptoms of inattention, hyperactivity, or impulsivity that affect academic or social functioning. Conditions that may coexist with ADHD include anxiety, depression, behavior disorders, learning disorders, sleep disorders, or tics. Although ADHD is most often diagnosed in children, it is now recognized that symptoms of ADHD extend into adulthood in as many as 60% of cases. Conventional treatments rely on behavior therapy and medications to achieve long-term symptom management.
Dr. Todd Roach, DC, views ADHD as an expression of underlying genetic, biochemical, and neurological dysfunction. In this discussion, Dr. Roach explains how to identify and treat the underlying causes ADHD and how to empower patients for lifelong change.

Autism Spectrum Disorder

The prevalence of Autism Spectrum Disorder (ASD) has increased dramatically in recent years, from 1 in 5000 (1975) to 1 in 2500 (1985) to 1 in 500 (1995) to 1 in 250 (~2001) to a current rate of about 1 in 50 children in the United States. A diagnosis of ASD is given to individuals who meet the criteria for autism disorder, Asperger syndrome, or pervasive developmental disorder not otherwise specified (PDD-NOS). Diagnosis relies on the presence of persistent deficits in social communication and social interaction with restricted or repetitive patterns of behavior. ASD can occur with or without intellectual impairment, language impairment, a known genetic condition, or other medical or developmental disorders.

Whereas ASD has conventionally been viewed as a neurological disorder, a new medical paradigm is emerging to help understand and treat this disorder. Here we interview Elizabeth Mumper, MD, about her approach to patients with ASD. She views ASD not as a brain disorder, but rather as a multisystem disorder associated with numerous medical problems that, when resolved, can improve patient outcomes dramatically. Some of these medical problems include gastrointestinal disease, immune dysregulation, oxidative stress, metabolic impairment, and mitochondrial dysfunction. In this interview we focus on metabolic patterns observed in ASD, including problems with methylation, transsulfuration, and mitochondrial function.

Autoimmune Disease

We have not made progress in our battle to ease suffering caused by autoimmune disorders. The National Institutes of Health estimates that between 14 and 22 million people in the United States have an autoimmune disease with the most common being systemic lupus erythematosus (SLE), multiple sclerosis (MS), type 1 diabetes, thyroid (Graves and Hashimoto), myasthenia gravis, scleroderma, and rheumatoid arthritis (RA). These disorders affect more women than men and are among the 10 leading causes of death for women in all age groups up to the age of 64. The physical, emotional, social, and financial burden of these diseases cannot be overstated.

Autoimmune disorders can be some of the most challenging illnesses to treat because etiology can be difficult to determine and disease progression can be complex and dangerous. With more than 80 different types of autoimmune disorders presently identified, the complexity begins with diagnosis. The wrong or delayed diagnosis can not only be frustrating for the patient but can also reduce the chance of successful treatment and possible remission.
Once a proper diagnosis is in place, conventional medicine looks to steroid and other drugs to help the patient manage symptoms. According to clinician, Kara Fitzgerald, ND, this is where an integrative approach can shine. We asked to her describe her clinical strategy. 

Bipolar Disorder: Integrative Management

In any given year, the Brain & Behavior Research Foundation reports that nearly six million American adults have bipolar disorder. This brain and behavioral illness is characterized by a spectrum of severe shifts in the patient’s energy and mood. Mood swings are described as episodes and can be expressed as either being manic (typically very high) or depressive (typically very low). Normal mood is present between episodes.
There is no specific blood test or brain scan that can detect bipolar disorder. It is diagnosed by evaluating symptoms and family history and ruling out other medical conditions.

While this can be a challenging patient population to treat, these patients are in desperate need for efficacious treatment. An integrative approach lends itself well to this type of challenge and can certainly help many individuals with bipolar disorder.

Breast Cancer: An Integrative Consultation

It is estimated that 1 in 8 women in the United States will develop invasive (infiltrating) breast cancer at some point in her lifetime. Ductal carcinoma, which begins in the milk ducts, accounts for 80% of all invasive breast cancers, and lobular carcinoma, which begins in the lobules, accounts for 10%. Invasive breast cancers are further categorized into several molecular and genomic subtypes.
Local treatment options for breast cancer depend on the tumor size, nodes, metastasis (TNM), and molecular subtype. Systemic treatment options depend on a patient’s overall health status and lifestyle. Breast cancer surgeon, Dr. Beth DuPree, urges clinicians to address both local and systemic factors in a holistic approach to the evaluation and treatment of breast cancer. In this discussion, she explains the diagnostic flow, surgical options, factors influencing treatment, and the role that integrative practitioners can play in the evaluation and early phases of breast cancer treatment.

Cancer: Biomarker Guided Risk Reduction

Three adults out of every 1,000 will experience a diagnosis of cancer each year in the United States. There are 14 million cancer survivors in the United States today and 18 million predicted by 2022. Practitioners are routinely faced with patients at risk of cancer occurrence or recurrence, yet many have limited knowledge of how to approach risk reduction in these patients. In the following discussion, Dr. Nalini Chilkov educates practitioners on value of using biomarkers to both assess and manage cancer risk in the general practice setting. Selected biomarkers can guide the use of interventions aimed at altering the bioterrain in order to reduce the risk of cancer incidence and recurrence.

Celiac and Non-Celiac Gluten Sensitivity

Celiac disease is an autoimmune reaction to gluten that causes destruction to enterocytes in genetically susceptible individuals. Celiac disease is estimated to affect approximately one in 133 people, or less than 1% of the population. Non-celiac gluten sensitivity (NCGS) is a non–immune-mediated reaction to gluten without enterocyte destruction. Estimates on the prevalence of NCGS vary greatly, ranging from 0.6% to 6% of the population in the United States.

Most experts agree that NCGS is as common or more common than celiac disease and that both conditions are on the rise. Because the symptoms of both celiac disease and NCGS improve when a patient adheres to a gluten-free diet, a definitive diagnosis is not always confirmed. In this discussion, Dr. Andrea Purcell explains the importance of differentiating between celiac disease and NCGS for appropriate risk stratification and case management.

Clinical Testing Through Applied Biochemistry

Applied biochemistry refers to the concept that metabolic reactions throughout the body determine health and disease and that those metabolic reactions respond to both genetic and lifestyle factors. The concept of biochemical individuality—that each person has unique nutrient and metabolic needs—is foundational to the practice of applied biochemistry.
The concept of applied biochemistry began more than 100 years ago, when Archibold Garrod, MD, described the idea of biochemical individuality in the Lancet in 1902. Roger Williams, PhD, popularized the idea in his 1956 publication, Biochemical Individuality: The Basis for the Genotrophic Concept. Bruce Ames then demonstrated this concept in his lab in Berkeley, CA, by showing that single nucleotide polymorphisms (SNPs) alter enzymatic activity, requiring different levels of cofactors.

Clinical testing of vitamins, minerals, amino acids, fatty acids, hormones, and intermediary compounds of metabolic pathways can help clinicians tailor targeted and individualized treatment plans for their patients. In this discussion, Dr. John Neustadt, ND, shares his insights on the practical applications of clinical testing through applied biochemistry.

Colon Cancer Prevention

Colorectal cancer (CRC) is the 3rd most common cancer in men and women in the United States. The lifetime risk of developing colorectal cancer is 1 in 5. Although family history and age are strong predictors of CRC risk, it has been estimated that modifiable risk factors may account for a substantial number of all CRC cases.

Despite the strong association between some of the non-modifiable risk factors and CRC, it has been estimated that as many as 70% of CRC cases might be prevented by lifestyle modification. Modifiable risk factors are influenced by diet, lifestyle, and evidence-based nutritional interventions, and these interventions can have a profound effect on CRC risk. An integrative approach can address modifiable risk factors that contribute to both increased CRC risk and to the disease process itself.In this discussion, Tina Kaczor, ND, FABNO, explains the importance of identifying and addressing modifiable risk factors of CRC.

Contemplative Cancer Care

According to estimates from the American Cancer Society, there will be more than 1.6 million new cases of cancer diagnosed in the United States in 2015. In addition, almost 15 million Americans alive today are cancer survivors. Cancer is a diagnosis that can create distress, depression, anxiety, and other psychological challenges for patients, family members, caregivers, and the community. Standard therapies focus on eradicating the physical disease through surgery, chemotherapy, and radiation, but there are no definitive guidelines to address the emotional and psychosocial aspects of this disease. Evidence-based psychosocial interventions and mindfulness-based therapies show promise in their potential to improve the quality of life for cancer patients and cancer survivors. In this discussion, Dr. Matt Mumber shares his unique perspective on the importance of what he calls “contemplative care” in cancer. 

Culinary Strategies for Appetite Stimulation

Medical interventions, cancer, chronic diseases, and even aging can create changes in taste perception and appetite. Appetite loss can lead to cachexia, which worsens the prognosis of any chronic illness. Clinicians encourage their patients to eat more, and caregivers struggle to find ways to make this happen. In this discussion, Rebecca Katz describes culinary strategies to successfully stimulate appetite and provide nutrient-dense foods to patients who are compromised and under duress.  


The Centers for Disease Control and Prevention estimates that 1 in 10 American adults meet the criteria for a diagnosis of depression. Most of these people are prescribed  antidepressant medications, which are now the third most commonly prescribed drugs in America.
Adverse effects and poor clinical outcomes have caused innovative integrative physicians to evaluate and treat depression differently and to move away from the model of care dependent on selective serotonin reuptake inhibitors (SSRIs). Kelly Brogan, MD, is one of those physicians. Here Dr. Brogan discusses the rationale, strategy, and outcomes associated with her integrative treatment plan, which addresses the underlying causes of depression.

Depression and Cardiovascular Disease

Cardiovascular disease is the number 1 cause of death in the United States and in the world.   According to the 2015 update by the American Heart Association (AHA), cardiovascular disease claims more lives than all forms of cancer combined, with 1 in every 3 deaths in the United States resulting from heart disease, stroke, or other cardiovascular disease. The AHA promotes 7 key behaviors that this organization hopes will reduce the risk of cardiovascular disease by 20% by the year 2020: not smoking, increasing physical activity, following a healthy diet, maintaining a healthy body weight, controlling cholesterol, controlling blood pressure, and controlling blood sugar.

Depression as a risk factor for cardiovascular disease has also attracted increasing attention, with the AHA listing depression as a risk factor for adverse events after acute coronary syndrome (ACS) in 2014. Here Dr. Decker Weiss discusses how the functional pathophysiology of depression and cardiovascular disease overlap, how to assess these conditions with functional labs, and how to approach their treatment. This information is critical for any clinician who treats patients with either depression or cardiovascular disease.     

Diabetes: Integrative Management of Type 2 Diabetes

Characterized by insulin-resistance and loss of glycemic control, type 2 diabetes accounts for more than 90% of all adult diabetes cases. In the United States, more than 1 in every 10 adults is affected by diabetes, and for older adults (aged 65 and older), that figure rises to 1 in every 4. Obesity, sedentary lifestyle, and poor diet are strong predictors of type 2 diabetes, making lifestyle interventions critical tools for the management and reversal of this disease. In the following discussion, Dr. Mona Morstein, ND, DHANP, emphasizes the need for strict glycemic control achieved through structured and monitored diet, lifestyle interventions, supplements and medications, in order to attain excellent glucose control, establish weight loss, and prevent complications of type 2 diabetes.

Dietary Management of the Microbiome

The human microbiome refers to all of the microorganisms that live synergistically on and in the human body. The Human Microbiome Project, funded by the National Institutes of Health (NIH) is currently underway. Among the goals of this project are to identify 3000 microbial gene sequences, differentiate between the microbiomes of different parts of the human body, and identify relationships between the microbiome and health and disease.

Dr. Liz Lipski, PhD, educates consumers and professionals on the effects of diet on the microbiome. She teaches that the diets of healthy individuals should be different than the therapeutic diets needed for those with an imbalance in their microbiota. In this discussion, Dr. Lipski describes the dietary management of the microbiome in both health and disease.

Emotional Eating

Emotional eating is defined as either eating instead of feeling, or as experiencing negative feelings about eating. In its most severe form, emotional eating manifests as pathological eating disorders, such as anorexia nervosa or bulimia nervosa. In milder forms, emotional eating manifests as binge eating, overeating, under-eating, or choosing unhealthy foods as a way to avoid or self-medicate emotional distress.
Deanna Minich educates practitioners on approaches to help patients overcome emotional eating patterns. In the following discussion, she provides streamlined techniques, tips, and tools that clinicians can incorporate seamlessly into routine patient care.

Endocrine Disruptors

You’ve probably heard the term diabesity in recent years, which refers to the spectrum of blood sugar dysfunction ranging from moderate abdominal fat gain to obesity and type 2 diabetes.
Despite efforts to control diabetes and obesity, these conditions have escalated to epidemic proportions. The Centers for Disease Control and Prevention (CDC) report that one third of all Americans are considered obese (BMI >30) and nearly 26 million Americans have diabetes. Based on current trends, the CDC reports that by 2050, 1 in 3 American adults will have diabetes. Millions more are prediabetic and aren’t even aware of it.
When the root causes of diabesity are identified and addressed, patients are more likely to lose weight, get lean, and reverse diabesity.  For those patients struggling with weight loss, an integrative approach that emphasizes effective detoxification and reduction of endocrine disruptors, known to act as obesogens, could benefit them greatly. By focusing on the obesogen pathways and supporting liver detoxification, these patients can successfully lose weight and in the process regain their health.

Fecal Microbiota Transplantation

Fecal Microbiota Transplantation (FMT), also known as fecal transplant, is defined as the therapeutic use of human stool or active stool extracts. It involves introduction of fecal flora from a healthy donor into the gastrointestinal tract of a patient for a therapeutic purpose. FMT has been used since the 4th century to treat severe diarrhea, and its first reported use in the United States was in 1958. US clinicians have administered FMT for a variety of conditions since the 1970s, but FDA regulations put an abrupt halt to physician-administered FMT in 2013. Dr. Mark Davis, ND, has extensive clinical experience administering FMT. Here he reviews the evidence for the efficacy of FMT in multiple disorders, explains how its use is now limited by policy, and gives practical information for clinicians who want to provide FMT as an option for their patients.    


Fibromyalgia is a condition characterized by chronic widespread pain and fatigue that can be accompanied by additional symptoms, such as sleep disturbance, depression, anxiety, and/or irritable bowel. Fibromyalgia affects predominantly women, with a female to male ratio of 7:1. Diagnostic criteria for fibromyalgia were first developed in 1990 and have evolved over time.

David M. Brady, ND, proposes that the current diagnostic criteria lead to inappropriate diagnosis in a large number of patients whose symptoms are better explained by other causes. For example, musculoskeletal disorders, organic diseases, and functional metabolic disorders can all create chronic pain and fatigue. He suggests that the fibromyalgia diagnosis should be reserved for those who truly experience a global hypersensitivity to pain with underlying central nervous system dysfunction. He uses the term “classic fibromyalgia” to describe this subset of patients. In the following discussion, Dr. Brady explains his approach to the accurate diagnosis and treatment of classic fibromyalgia.

Generalized Anxiety Disorder

Generalized anxiety disorder affects approximately one third of all adults. It is associated with several different mental, emotional, and physical symptoms. Because of the diverse and individualized symptom profile, it can be challenging to diagnose and treat. An integrative approach focusing on scientifically validated nutrients and herbs can provide healthcare providers with safe and efficacious options to prescription pharmaceutical drugs.
The foundation of the integrative treatment protocol for GAD is addressing underlying causal factors with a focus on correcting neurotransmitter imbalance in the limbic system. Hypothalamic-pituitary-adrenal (HPA) axis dysfunction should also be addressed.

Heavy Metal Testing and Interpretation

Heavy metals, including arsenic, cadmium, lead, and mercury, are ubiquitous in modern environments. Food, water, air, soil, and dust provide low levels of heavy metal exposure on a daily basis. Heavy metals can adversely affect the body, they can disrupt neurological, endocrine, and immune functions. Determining if a patient has been exposed to heavy metals is an important part of patient care.
The phrase ‘heavy metal toxicity’ typically refers elevated levels of metals in the body due to high dose occupational exposure or acute poisoning.  The phrase’ body burden’ of metals is commonly used to describe the presence of metals in the body due to low dose current exposure and/or long-term chronic exposure. Adipose tissue testing for metals is what truly measures stored levels or body burden. In the literature, blood, urine and stool test results are also used to describe body burden of metals.
Clinicians rely on a variety of lab tests to determine the presence of heavy metals that may be affecting a person’s health. Dr. Marianne Marchese, ND, proposes that we take a fresh look at the current practice of heavy metal testing and interpretation. She provides resources to identify heavy metal exposure and evidence to guide an updated approach to the interpretation of heavy metal test results.

Hidden Faces of Post-Traumatic Stress Disorder

The American Psychological Association defines post-traumatic stress disorder (PTSD) as anxiety associated with a traumatic event. The memories, flashbacks, nightmares, or other anxiety issues can be so disruptive it can significantly impede quality of life.

This type of trauma is typically associated with combat, crime, accident, or natural disaster. However, many experts feel PTSD can occur with many other traumatic events. Expert Nancy Gahles, DC, CCH, calls this expanded population the “hidden faces” of PTSD because they are often marginalized, overlooked, or under treated. Her innovative collaborative treatment strategy brings together key disciplines to ensure the best outcomes possible for this patient population.

While the National Institutes of Mental Health estimates that PTSD affects nearly 8 million American adults, Gahles and other experts argue that the number is much higher. In this interview Gahles defines the hidden faces of PTSD and outlines the collaborative, non-pharmaceutical approach she uses to successfully address this issue in clinical practice.

Hydrotherapy in Health Restoration

Hydrotherapy refers to the therapeutic use of water. It is sometimes referred to as balneotherapy, water therapy, or aquatic therapy. The applications of hydrotherapy are numerous and include baths, showers, pools, Jacuzzis, saunas, stream treatments, moist compresses, and internal hydrotherapy (colonics). Constitutional hydrotherapy is a specific form of hydrotherapy that is used extensively in the naturopathic medical tradition. In this discussion, Dr. Jared Zeff, ND, discusses the role that constitutional hydrotherapy plays in stimulating self-healing mechanisms and restoring patients to health. The origins, applications, mechanisms of action, efficacy, and contraindications of constitutional and other forms of hydrotherapy are described.      


Statin medications (e.g., Zocor, Mevacor, Lipitor, Crestor) have become the gold standard of conventional treatment of hypercholesterolemia despite their poor side effect profile and lack of efficacy in certain populations. Furthermore, the increased use of these prescription drugs has not had an impact on heart disease mortality and reduction of corresponding risk factors.

According to the Center for Disease Control and Prevention, nearly 34% or approximately 71 million Americans have high LDL cholesterol (>130 mg/dL). Conventional medicine focuses on lowering cholesterol, and LDL cholesterol in particular. The integrative approach, on the other hand, focuses on reducing glycation and inflammation, which causes oxidized cholesterol to inflame arteries, ultimately causing plaque formation. While all healthcare practitioners agree that it is important to lower risk factors for cardiovascular disease, there is significant debate as to the most effective way to do this. An integrative approach focuses on alternatives to statin drugs, while addressing diet and lifestyle factors in order to provide more broad spectrum cardiovascular disease risk reduction.


Hypertension is the most common form of cardiovascular disease (CVD) in America and a strong risk factor for other CVD, including coronary artery disease, peripheral artery disease, stroke, myocardial infarction, and congestive heart failure. Approximately 1 in 3 adults in the United States have hypertension, meaning that they either have documented high blood pressure or are taking antihypertensive medications. Blood pressure is controlled in only half of these adults, partly due to a lack of awareness and partly due to the challenges and side effects of drug therapy. In the context of our growing understanding of its functional pathophysiology, Dr. Kathleen Padgitt discusses the importance of dietary and lifestyle interventions as part of an integrative approach to the management of hypertension.


An estimated 20 million Americans have some form of thyroid disease, and many cases remain undiagnosed. In diagnosed cases of thyroid disease, we still lack a clear understanding of causes and the accuracy of laboratory testing. Because an underactive thyroid can be so hard to diagnose, and lab tests aren’t a reliable measure of optimal thyroid function, integrative practitioners need to be aware of the diverse symptoms and contributing factors.


Primary infertility is defined as a couple’s inability to conceive after trying for one year. It is estimated that about 10 to 15 percent of couples in the United States are infertile. Infertility affects men and women equally and in most cases, evaluation of both partners is necessary to determine the reasons for a couple’s infertility. The National Institutes of Health defines secondary infertility as a couple’s inability to get pregnant after having a live birth. With this definition, infertility can also be used to describe a woman’s inability to carry a pregnancy to full term, as is the case with multiple pregnancy losses. If standard infertility evaluation results are normal, the couple is diagnosed as having unexplained infertility. A 2008 paper revealed that 15 to 30 percent of couples have unexplained infertility. According to integrative fertility expert Jaclyn Chasse, ND, this is an area where an integrative practitioner can play a key role. Not only do the expanded integrative treatment tools lend themselves to enhancing fertility, but the integrative practitioner can likely uncover underlying causes that are contributing to unexplained fertility using functional diagnostic testing.

Inflammatory Bowel Disease

Inflammatory Bowel Disease (IBD), including ulcerative colitis and Crohn’s disease, affects 1.6 million people in the United States, with a higher prevalence in those who have a family history of IBD, who live in an urban area, or who live in a northern climate. Most patients are diagnosed with IBD before age 30, with onset most typically between ages 15 and 35 years. IBD is characterized by chronic inflammation of all or part of the gastrointestinal tract. Crohn’s disease can affect any part of the alimentary canal, ulcerative colitis tends to begin in the distal rectum and proceed to involve the rest of colon. Symptoms of IBD include diarrhea, abdominal pain, fatigue, and weight loss. Life-threatening complications can include bowel obstruction, perforated colon, or cancer. The conventional management of IBD emphasizes anti-inflammatory medications as well as immune-modulating and biologic medications as a means to modify disease progression. In this discussion, Dr. Ronald Hoffman shares insights from his decades of experience in treating patients with IBD using diet, lifestyle, and other integrative therapies to manage symptoms and control disease activity.

Injection Therapy for Chronic Joint Pain

Musculoskeletal pain can result from chronic overuse injuries or acute injuries that fail to completely heal. Incompletely healed injuries become chronic, creating such conditions, as carpal tunnel syndrome, epicondylitis, Achilles tendonitis, patellar tendinopathy, or osteoarthritis to name just a few. Standard therapies are typically palliative, such as non-steroidal anti-inflammatory medications, corticosteroid injections, or physical therapy; surgery is considered when conservative treatments fail.       
Regenerative injection therapies (RITs), including dextrose prolotherapy and autologous platelet-rich plasma (PRP), offer an alternative to standard therapies or surgery for chronic traumatic injuries. The goal of these therapies is to stimulate repair of injured tendons, ligaments, joints and other tissue. Prolotherapy has been in use for about 100 years, with modern protocols beginning in the 1950s. PRP injections are a more recent therapy, first used in the late 1980s. In this discussion, Dr. JoAnna Forwell shares insight from her clinical experience with RITs.   

Insulin Dysregulation

Insulin regulation has become a foundational health issue. Healthy cells naturally have sensitivity to insulin. A combination of dietary factors, sedentary lifestyle, and stress, however, can result in chronically elevated blood glucose and insulin. Cells that are constantly exposed to high levels of insulin adapt by reducing the number and sensitivity of receptors on their surfaces. The result is insulin resistance, a prediabetic condition that creates metabolic dysfunction and accumulation of visceral adipose tissue. Visceral adipose tissue acts like an endocrine organ, releasing disrupted levels of adipokines (e.g., decreased adiponectin and increased leptin, TNF-α, and IL-6). This pattern of dysregulation not only further promotes insulin resistance but also creates systemic inflammation.

Decades ago diabetes was considered to be the only clinical ramification of insulin resistance. Since then the scientific literature has highlighted prediabetes and metabolic syndrome. In this interview, nutritionist Corinne Bush expands the continuum even further with a discussion of early insulin dysregulation that can occur before the clinical manifestation of other metabolic syndrome components.

Intestinal Permeability

Increased intestinal permeability is a condition in which intestinal lining is damaged or changed in such a way that allows relatively large particles to leak through the intestinal mucosa into the bloodstream. These particles can include toxins, undigested food, and waste. This can result in an inflammatory response, as the immune system responds to the perceived threats.
A weakened endothelial lining in the gastrointestinal tract can lead to a wide variety of health issues. Because of this, repairing the intestinal lining can be a key strategy creating significant positive clinical outcomes. An integrative approach employs natural alternatives to H2 receptor antagonists, as well as supplements to help strengthen the intestinal lining and reverse permeability.

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) has a population prevalence of 10%-15% in the United States, with the majority of diagnoses made between the ages of 20 and 39 years. IBS is diagnosed when there are characteristic gastrointestinal symptoms in the absence of organic disease. Features of IBS include disordered bowel habits, bloating, abdominal pain, and aggravation of symptoms after eating. Symptoms are often intermittent or changing over time. Concerning symptoms that require specific diagnostic testing to rule out organic disease include onset after age 50, severe or progressively worsening symptoms, unexplained weight loss, nocturnal diarrhea, rectal bleeding, or unexplained iron-deficient anemia. Conventional treatments for IBS are aimed at symptom control. An integrative approach addresses the whole patient, including the hypothalamic-pituitary-adrenal (HPA) axis, immune factors, dysbiosis, and function of the migratory motor complex (MMC). In this discussion, Dr. Adam Rinde, ND, details emerging tests and protocols for the integrative management of IBS.

Lyme Disease

Lyme disease is the most common vectorborne illness in the United States, with more than 25,000 new cases reported to the Centers for Disease Control and Prevention (CDC) in 2013. More precisely called Lyme borreliosis, it is caused by 1 of at least 300 different strains of the spirochete, Borrelia burgdorferi. The most well recognized vector of transmission is the Ixodes tick, but research suggests that fleas, flies, gnats, mites, and mosquitos might also transmit this disease to humans. Prompt recognition and treatment of early infection can lead to complete resolution, and medical authorities disagree about whether or not Lyme disease can become chronic.

Dr. Ron Grisanti has observed that untreated or ineffectively treated Lyme disease can progress to chronic disease that can affect the skin, joints, immune system, nervous system, or other vital organs. In the following discussion, he explains his approach to the identification and management of chronic Lyme disease.

Metabolic Syndrome

Metabolic syndrome, initially described in 1988 as syndrome X, is a condition that involves multiple cardiovascular risk factors: obesity, hypertension, hyperlipidemia, and blood sugar dysregulation. Central to the metabolic abnormalities of this condition are insulin resistance and hyperinsulinemia. Patients with metabolic syndrome have an increased risk of type 2 diabetes, atherosclerosis, and death from cardiovascular disease. According to National Health and Nutrition Examination Survey (NHANES) data through 2012, the overall prevalence of metabolic syndrome in US adults is 33%, with higher rates in women than in men and higher rates in Hispanics than in other ethnic groups. Among US adults over the age of 60, the prevalence of metabolic syndrome is as high as 50%.

Methylation and Pregnancy

Methylation is defined as the addition of 1 carbon and 3 hydrogen atoms to a compound. This biochemical reaction influences innumerable functions in the body, including genetic expression, neurotransmitter synthesis, and detoxification.

During pregnancy, with the increased production of maternal hormones and rapid multiplication of cells in the developing baby, the demand for methylation increases dramatically. Impaired methylation during pregnancy can result in spontaneous abortion, pregnancy complications, or birth defects.

Ben Lynch, ND has a unique perspective on methylation during pregnancy. Not only does he emphasize the importance of methylation assessment during prenatal screenings, but also emphasizes the need to address any impairments with a whole-body approach. The following discussion provides Dr. Lynch’s perspective on the assessment and treatment of methylation defects during pregnancy.

Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in the United States, with an estimated prevalence of 1 in 3 adults and 1 in 10 children. Strongly associated with obesity, diabetes, and dyslipidemia, NAFLD is defined as accumulation of fat in the liver with no secondary cause, such as alcohol consumption, steatogenic medication, or a genetic disorder.

NAFLD begins as clinically benign fatty liver and can progress to nonalcoholic steatohepatitis (NASH), which is characterized by inflammation of hepatocytes with or without fibrosis. It is estimated that 3% to 5% of the general population has NASH, a serious liver disease that increases a patient’s risk for liver cirrhosis and hepatocellular carcinoma. In this discussion, Dr. Lyn Patrick offers unique insights into the etiology and treatments of NAFLD and NASH.

Nutritional Management of Diabetes

Diabetes includes type I diabetes, a condition where the pancreas produces insufficient insulin, and type 2 diabetes, a condition of insulin resistance or of insufficient insulin production. According to the Centers for Disease Control and Prevention (CDC), diabetes affects more than 29 million individuals in the United States (9.3% of the population). The incidence of diabetes increases with age, with an estimated prevalence of more than 25% in Americans aged 65 or older. Moreover, for every American with diabetes, there are at least 2 more with pre-diabetes. Complications from diabetes include cardiovascular disease, myocardial infarction, stroke, retinopathy, renal failure, neuropathy, and amputation.
One of the most challenging aspects of managing cases of type 2 diabetes is patient compliance with foundational lifestyle changes. Restricted diets and lifestyle changes can be daunting; patients might initially comply and then slip back into their old habits. In this discussion, Dr. Daemon Jones, ND, shares specific approaches to optimize compliance in this patient population.

Osteoporosis: Integrative Management

The World Health Organization defines osteoporosis as a disease of low bone mineral density (BMD), diagnosed by a T-score of −2.5 or less. In the United States, more than 10 million people are living with osteoporosis, and that number is expected to increase to 14 million by the year 2020. Osteoporosis is a serious health concern because it increases the risk for fractures, leading to disabilities, chronic pain, or even death. Hip fractures are particularly debilitating, putting patients at a 20% risk of death within 1 year. It is estimated that the annual number of hip fractures in the United States will rise to 289,000 by the year 2030, making fracture prevention a priority in the treatment and management of osteoporosis. In this discussion, Dr. John Neustadt, ND, explains the importance of treating not only bone density but also bone flexibility to achieve the most important clinical endpoint in osteoporosis: fracture risk reduction.

Perimenopausal Insomnia

Insomnia is associated with quality of life, productivity, depression, anxiety, cognition, and even safety.

Individuals with insomnia have significantly greater impairment in their living than people without insomnia.  Psychomotor and cognitive performance, attention, response time, unstable work performance, errors and accidents are all disrupted and altered in patients with sleep disorders.  Insomnia may also be associated with an increased risk of developing cardiovascular disease.  The good news is that the impairments and risk associated with insomnia are reversible with effective treatment. Patients may need in-office testing, or may need to be referred for specific evaluations.  Given the prevalence of insomnia, the impact on quality of life of insomnia, and the unique aspects in women, and in perimenopausal/menopausal women in particular, a practitioner who has a comprehensive understanding of sleep problems, and of midlife women, will enhance their ability to provide effective solutions.

Polycystic Ovary Syndrome

Polycystic ovarian syndrome (PCOS) was originally described in 1935 by Stein and Leventhal, who reported several cases of women with polycystic ovaries, amenorrhea, and accompanying obesity, hirsutism, or acne. PCOS is now recognized as a metabolic and endocrine disorder that affects between 1 in 10 and 1 in 20 women of childbearing age. The condition is diagnosed when 2 of the following 3 characteristics are present: androgen excess, ovulatory dysfunction, and polycystic ovaries. Clinical features can include amenorrhea, oligomenorrhea, acne, hirsutism, male-pattern baldness, mood disorders, or obesity. PCOS is an important cause of infertility, is strongly associated with insulin resistance, and increases the risks for diabetes mellitus, cardiovascular disease, and endometrial cancer. In the following discussion, Jane Guiltinan, ND, reviews evidence-based integrative therapies for PCOS.

Prenatal Through Postnatal Nutrition Optimization

The prenatal and postnatal periods are critical times in a woman’s life, accompanied by dramatic increases in energy and nutrient demands. A woman who is normal weight before pregnancy will gain between 25 and 35 pounds, and her blood volume will increase by 50% (or 1.25L). At the same time, she will nourish the growth of a baby from a single-celled zygote to a 6-8 pound human being. Caloric needs increase to 300-500 calories above preconception needs beginning in the 2nd trimester of pregnancy and continuing through lactation. Conventional guidance for pregnant women advises them to follow a healthy diet, take a prenatal vitamin, and avoid foods like raw fish that might cause Listeriosis or food poisoning. In addition, research conducted within the last decade has revealed information about common nutrient deficiencies during pregnancy and lactation. Tieraona Low Dog, MD, suggests that nutritional guidelines should be refined and updated to more accurately reflect current scientific knowledge related to nutrient demands and deficiencies during pregnancy and lactation.       

Prostate Cancer: Integrative Management of Early Stage Prostate Cancer

It is estimated that 3 million men are living in the United States with prostate cancer today. More than 180,000 new diagnoses are expected in the United States in 2016, and 1 in 7 men will develop prostate cancer in their lifetime. The risk for prostate cancer increases with advanced age, family history of prostate cancer, or African American descent. Fortunately, survival rates are good, with less than 15% of men with prostate cancer dying from the disease. The majority of cases of prostate cancer are slow-growing and diagnosed at a localized stage. Patients who are considered to be at low-risk for developing more aggressive cancer can opt for active surveillance rather than surgery or radiation. Active surveillance is defined as a monitoring program in patients with localized prostate cancer, intended to detect cancer growth as early as possible and intervene if there is evidence of more aggressive growth. In the following discussion, Dr. Geo Espinosa, ND, explains how to determine when active surveillance is appropriate, how to monitor patients, when to refer for conventional care, and what integrative therapies can be implemented during active surveillance of localized prostate cancer.

Research Interpretation and Analysis

The practice of medicine once relied on the passing down of information from authority figures and the clinical experience of practitioners. The evidence-based medicine (EBM) movement shifted the focus of medical practice to more heavily valued randomized trials and meta-analyses. Clinicians are now expected to be critical evaluators of scientific evidence. The problem is that the evidence base is growing rapidly—there are currently 26 million citations indexed in PubMed alone. In this context, it is no longer practical to expect clinicians to identify, read, and evaluate all of the research related to their field and their patient population. Practice guidelines, meta-analyses, and systematic reviews can be invaluable resources for busy clinicians, but even these publications run the risk of bias. In this discussion, Dr. Joshua Goldenberg, ND, empowers clinicians with skills and tools to critically evaluate current medical evidence. 

Skin Cancer: An Integrative Approach

There are more new cases of skin cancer each year than new cases of breast, prostate, lung, and colon cancers combined. Basal cell carcinoma (BCC) is the least aggressive and the most common form of skin cancer, with 4 million cases per year in the United States. Squamous cell carcinoma (SCC) is the second most common, with 1 million cases per year. Melanoma is the most deadly of all skin cancers, has a lifetime risk of 1 in 39 for men and 1 in 58 for women in the United States. Michael Traub, ND, discusses integrative options for risk reduction and adjunctive care for both nonmelanoma and melanoma skin cancers.  

Small Intestinal Bacterial Overgrowth

Small intestinal bacterial overgrowth (SIBO) is a condition in which an excessive number and altered composition of bacteria exist in the small bowel. SIBO is thought to result from a loss of homeostatic mechanisms that control bacterial growth in the upper gastrointestinal tract. It is conventionally treated with antibiotic therapy. Dr. Cindy Howard views SIBO as a condition that is influenced by diet, lifestyle, comorbid diseases, and overall health status. Dr. Howard’s unique clinical approach includes individualized protocols paired with calculated follow-up to ensure long-term treatment success. 

The Therapeutic Relationship

As we face an epidemic of chronic illnesses and lifestyle diseases, many medical professions are coming to realize that a shift is needed in the way we deliver care. The Pew Fetzer Task Force proposed the concept of “relationship-centered care” in 1994, referring to a clinical approach that relies on partnership and shared decision-making. Then in a 2004 report, the US Institutes of Medicine (IOM) emphasized the importance of teaching communications skills related to patient-physician interactions in medical schools. In the following discussion, Dr. Paul Epstein, ND, shares his insights on the value of the therapeutic relationship and offers guidance on how clinicians can cultivate their abilities to be more mindful, compassionate, and present in clinical interactions.

Traumatic Brain Injury

Traumatic brain injury (TBI) is defined as any damage to the brain resulting from external trauma such as an impact injury or penetration of the skull. Of the many forms of TBI, concussion, or mild traumatic brain injury (mTBI) is one of the most common. Causes of TBI include falls, vehicular accidents, violence, sports injuries, or combat injuries. Physical manifestations of TBI can include skull fractures, hematomas, subarachnoid hemorrhage, contusions, or diffuse axonal injury. Symptoms of TBI range in severity from disorientation or headache to loss of consciousness or coma.

Long-term consequences of TBIs can include cognitive deficits, seizures, and neurodegenerative disease. Because the brain has an effect on all body systems, and all body systems have an effect on the brain, Dr. Brandon Brock views TBI as the “pinnacle of all metabolic disease.” In this discussion, he explains his comprehensive approach to the assessment and treatment of patients with TBI.

Vestibular System Dysfunction

The vestibular system processes sensory information related to motion, equilibrium, and spatial orientation to create a sense of balance and proprioception. One important anatomical part of the vestibular system is the vestibular apparatus, located within the inner ear. The vestibular apparatus is the collection of structures in the inner ear that include the utricle, saccule, and 3 semicircular canals. Sensory information from this vestibular apparatus as well as other inputs is processed in the vestibular nuclei within the brain stem. Whereas the vestibular system has historically been thought of as a balance apparatus, emerging research suggests that its effects are much more far-reaching. In the following discussion, Dr. Monika Buerger, DC explains the relationship between stress, vestibular function, and other body systems. She explains practical ways for clinicians to identify and address vestibular dysfunction.