What "functional medicine" really is

I’ve frequently written about a form of medicine often practiced by those who bill themselves as practicing “complementary and alternative medicine” (CAM) or “integrative medicine” (or, as I like to refer to it, “integrating” quackery with medicine). I’m referring to something called “functional medicine” or, sometimes, “functional wellness.” Over the years, I’ve tried to explain why the term “functional medicine” (FM) is really a misnomer, how in reality it is a form of “personalized medicine” gone haywire, or, as I like to refer to it, as “making it up as you go along.” Unfortunately, thanks largely to its greatest popularizer, Dr. Mark Hyman, FM is popular, so much so that Bill and Hillary Clinton count Hyman as one of their medical advisors and the Cleveland Clinic, not satisfied with embracing prescientific traditional Chinese medicine, has gone “all in” for FM by hiring Dr. Hyman two years ago to set up a functional medicine clinic. Unfortunately, it’s been “wildly successful” there.

Unfortunately its success is not deserved, at least from a scientific standpoint.

Functional medicine: A little bit right, a whole lot of wrong

FM, like so much of integrative medicine, sounds good in principle. Look at its seven principles and, knowing nothing more than what these principles are, you’ll find it hard to disagree:

• Acknowledging the biochemical individuality of each human being, based on concepts of genetic and environmental uniqueness
• Incorporating a patient-centered rather than a disease-centered approach to treatment
• Seeking a dynamic balance among the internal and external factors in a patient’s body, mind, and spirit
• Addressing the web-like interconnections of internal physiological factors
• Identifying health as a positive vitality—not merely the absence of disease—and emphasizing those factors that encourage a vigorous physiology
• Promoting organ reserve as a means of enhancing the health span, not just the life span, of each patient
• Functional Medicine is a science-using profession

In any post about FM, I feel compelled to remind our readers that the very first principle is, in essence, FM’s “get out of jail free” card for basically anything its practitioners want to do. They can always find ways to justify any form of treatment, be it science-based or quackery, simply by invoking the “biochemical individuality” of the human being whom they are treating. I also like to remind my readers of my retort to this: Yes, human beings are individuals, and each human being is unique. However, we’re not so unique that our bodies don’t all work pretty much the same way. In other words, in terms of biology, physiology, and yes, systems biology, human beings are far more alike than they are different. If that weren’t the case, modern medicine, developed before we had the tools to probe our genetic individuality, wouldn’t work as well as it does. FM fetishizes “biochemical individuality,” not so much because humans are so incredibly different that each one absolutely has to have a markedly different treatment. We’re not. FM fetishizes “individuality” because it distinguishes FM as a brand from science-based medicine and, I suspect, because it makes FM practitioners feel good, like “total” doctors never at a loss for an explanation for a patient’s symptoms or clinical condition, and makes patients feel like special snowflakes whose every bit of “individuality” is being catered to. As for the last bit about FM being a “science-using” profession, FM “uses” science more as a means of justifying whatever its practitioners do rather than guiding them to scientifically-proven treatments.

Here, it must be stated that are some things that FM gets right, although these things tend to be no different than the sorts of things every primary care doctor should be getting right anyway, such as emphasizing healthy lifestyles, good nutrition, enough exercise, adequate sleep, cessation of habits known to be deleterious to health (e.g., smoking). One advantage FM doctors have over primary care doctors practicing science-based medicine (SBM) is that, because insurance often won’t cover much of what they offer, FM doctors tend to spend more time with patients, which is something that primary care doctors have a harder time doing these days. They emphasize prevention, which is a good thing but again something that good primary care doctors do anyway. Unfortunately, the FM version of “prevention” isn’t always in line with the SBM version of prevention. Where FM doctors go so very wrong is in what Grant Ritchey described as a major unstated premise. That premise is that FM really does address the root causes of disease better than conventional medicine. FM also encompasses a lot of quackery, such as acupuncture, chiropractic adjustments, and especially “detoxification” programs. It’s little wonder that many naturopaths are very enthusiastic about FM.

Although I’ve discussed FM before and even shown how its use to treat a cancer patient led to enormous amounts of unnecessary treatments, what I haven’t really done is to show what typical FM clinics offer. Given that it’s only been a week since those of us in the US finished enjoying (I hope) the Thanksgiving weekend and FM is, in part, all about the diet, I thought it might be interesting to survey a couple FM clinics.

Lauren Grace

Although not a physician, Lauren Grace is a self-proclaimed functional medicine practitioner. She is a licensed acupuncturist and doctor of oriental medicine who did “additional study” in naturopathy, whatever that means. (Apparently it means that she uses mesotherapy, homeopathy, and something called the Maxim Life Health System, which purports to “take patients through a series of detoxes to eliminate any disease or disorder” and claims a 95% success rate.) I don’t remember where I first encountered Lauren Grace. I think it was on Twitter, but memory is foggy. I do remember, however, that she was laying down some really dubious medical advice and statements. Unfortunately, I can’t find them now. Fortunately, I don’t need to because there are plenty of other examples right on her very own website and YouTube channel.

For example:

As is frequently the case with such practitioners, Grace starts out with reasonable advice about diet and not stopping exercising. However, by the time you get to the 4:30 mark, she’s suggesting “mini-cleanses” and selling her two week digestive cleanse, which, according to her, pretty much all of her patients do every three months anyway. For the holidays, she suggests three-day “cleanses” to get rid of “all those toxins.” What does this cleanse involve?

This:

There’s some serious woo here. For instance, Grace claims that, because there is a component of the immune system in the gut, cleansing the gut to make it “healthy” will boost your immune system. She even invokes the untrue claim about there being pounds of “rotting food” in your colon. Basically, to Grace, cleansing can fix all sorts of medical conditions, such as eczema, autoimmune diseases, digestive ills of all sorts. Amusingly, her cleanse seems to consist only of special magic smoothies, plus some supplements, a recipe guide, and a two week meal plan. The cost? $175. Oh, and the site has a quack Miranda warning right here.

I ran down the services offered by Ms. Grace and her physician collaborator Dr. Carter (who, for some reason, is listed only as “Dr. Carter,” no first name). Maybe this is why:

Dr. Carter is a Board certified physician who has been in practice for 22 years and over the last several years has focused on providing excellent care in the preventive medicine and minimally invasive cosmetic world. He was the previous owner, Cosmetic Surgeon and Functional Medical Physician at Atlanta Liposuction. His focus has always been on treating the patient as a whole, not only from an outward cosmetic improvement but from a naturopathic, holistic view which paves the way for overall health of the patient. Addressing the hormonal, adrenal, immune, GI and endocrine systems are all critical to balance for a truly successful and optimal outcome.

As the Medical Director here at Sarasota Integrative Health, Dr. Carter consults with Dr. Lauren Grace regarding client cases. He assists with diagnosis and treatment plans and contributes to the latest research studies in the field of functional medicine.

In case you’re wondering how Lauren Grace can provide medical services even though she doesn’t have a degree in medicine or even naturopathy, Dr. Carter is how. Amusingly (to me, anyway), Google reveals his name to be Dr. Michael Carter, and it didn’t even take Google Image Search!

Be that as it may, the services offered by Ms. Grace are fairly typical for an “integrative medicine” clinic, including quackery such as acupuncture, thermography (which is not a screening modality for breast cancer more effective than mammography), life coaching, and the like. However, for purposes of functional medicine, the money is in the description of integrative medicine and the “advanced lab testing” on Grace’s website. As with many other services, Grace offers this helpful video:

Grace starts out by saying that these are “not typical lab tests,” like the CBC (complete blood count). No kidding! Of course, she also claims that her tests are “much more preventative” and “much more advanced.” Personally, the FM definition of “preventative” tends to mean preventing disease by diagnosing lab abnormalities that have little or no effect on health or disease and then “treating” them aggressively with vitamins and supplements. As for “much more advanced,” that’s a ludicrous claim. These lab tests don’t test anything that conventional lab tests can’t test. It’s just that FM doctors use them indiscriminately to test pretty much anyone with any symptom whatsoever, no matter how vague.

Let’s take a look at the sorts of tests offered:

• Genova or Spectracell Single Panel: $175
• Diagnostechs Female Hormone Panel: $150
• Diagnostechs Male Hormone Panel: $150
• Doctors Data Heavy Metal Test: $100
• Germany Stool Panel DNA: $175
• Diagnostechs ASI Panel: $150
• Genova Rhythm Plus: $175
• Genova Thyroid Panel: $150

There are even combo deals:

• Any 2 test reads: $250
• Any 3 test reads: $300
• Any 4 test reads: $350

You know right away that you’re dealing with highly dubious tests by one name that stands out: Doctors Data Heavy Metal Test. Doctors Data, as you might recall, specializes in dubious hair tests and “provoked heavy metal tests.” Basically, these are tests in which patients are given a chelating agent and then their urine is collected and various heavy metals, such as mercury, are measured in it. The results are then compared to “standard” levels in patients who have not received a chelating agent, an inherently deceptive way of measuring metal levels. Let’s just say that Doctors Data is well known among those of us who try to refute antivaccine and autism quackery, as it’s the go-to lab quacks use to justify chelation therapy. Quackwatch has documented this extensively, and as a result Doctors Data has sued Steve Barrett.

But what about the other lab tests?

Check out Spectracell Micronutrient Testing:

Are you taking too many supplements? Not enough? Nutritional status is a vital foundation of health and performance. SpectraCell’s micronutrient testing is an innovative assessment of nutritional status. Unlike traditional serum, hair and urine tests, SpectraCell’s tests evaluate how an individual’s white blood cells respond to varied environments of over 32 vitamins, minerals, amino acids and antioxidants. As a result, individual differences in metabolism, age, genetics, health, prescription drug usage, absorption rate or other factors are taken into consideration. Nutrient Functions & Deficiency Symptoms.

Ah, yes. Another test to pander to the patient’s need to feel special and unique. Not only is there no convincing evidence that this method of “micronutrient testing” provides actionable information more useful than other tests or that its use results in better outcomes, but it’s not cheap. It does, however, produce pretty reports:

Sure it's a pretty graphic, but does it actually mean anything?

Then there’s the Genova GI Comprehensive Stool Panel:

By evaluating targeted biomarkers, the GI Comprehensive Stool Profile can reveal hidden conditions that other stool tests may overlook. Balancing gut microbiota is key for improving core gastrointestinal functions, such as digestion and absorption of nutrients, as well as metabolic functions.

I looked at a sample report. It’s a mix of standard tests and tests that are basically meaningless. For instance, there is a test for ova and parasites, which is a standard stool test with specific indications. Ditto tests for fecal blood, C. difficile, Campylobacter, H. pylori, and certain strains of E. coli. Then there’s a nonstandard test of sensitivity of various fungi in the stool to various antifungals, both natural and pharmaceutical. This is a test that is rarely indicated, but quacks love it for diagnosing the catch-all made up disease of “systemic candidiasis.” Yes, I know that systemic candida infections exist, but generally if candida has infected the whole body the patient is usually immunosuppressed and becomes sick as snot (a real medical term) as a result. Naturopaths, however, like to blame “chronic candidiasis” or other yeast infections for all manners of vague complaints. Basically, it’s another version of chronic Lyme disease. In addition, by testing basically everybody who wants to be tested for all the conditions Grace tests for, the false positive diagnosis rate will be astronomical.

Then, of course, there is the Genova Full Spectrum Allergy Panel:

Testing aids the clinician in the specific dietary change that is needed, helping to achieve positive outcomes sooner, even when combined with elimination or provocation testing.

Because FM loves to blame all manner of symptoms on various “allergies,” whether the patient has such an allergy by standard criteria or not. Consistent with FM, Grace offers all sorts of tests for female and male hormone levels, thyroid function, and, of course MTHFR mutations, one of latest dubious lab tests beloved of FM practitioners and naturopath quacks (but I repeat myself) everywhere.

Basically, FM takes one of the worst aspects of conventional medicine (the “shotgun” lab tests) with speculation based on science not yet validated in humans, and uses it to order batteries of lab tests on patients, which, because of the sheer number of lab tests, will virtually always discover “abnormalities.” Then, FM doctors will state that these “abnormalities” demand treatment. Never mind that in the vast majority of cases it’s unknown or unclear whether these abnormalities have any health significance.

The Grand Poobah himself

You might be thinking that I picked too easy a target when I decided to “feature” someone like Lauren Grace as my first example, but she’s really not doing anything different than the Grand Poobah of Functional Medicine himself, Mark Hyman, who runs the Center for Functional Medicine at the Cleveland Clinic. Hyman is without a doubt the most famous and influential advocate for FM. Get a load of what is said about FM on the CCF website itself:

Cleveland Clinic Center for Functional Medicine physicians spend time with their patients, listening to their histories, mapping their personal timeline, and looking at the interactions among genetic, environmental, and lifestyle factors that can influence long-term health and complex chronic disease.

Perhaps you have experienced being examined by your doctor, having blood tests done, x-rays or other diagnostic tests taken, only for your doctor to report back that “all your tests are normal." Yet, both you and your doctor know that you are unwell.

Unfortunately, this experience is all too common. Our physicians at the Center for Functional Medicine aim to reduce this problem by applying a new model that focuses on treating your body as a whole system, that treats the causes not only the symptoms, that sees the body as a whole organism, rather than simply a collection of organs. This emerging model of diagnosis and treatment – called Functional Medicine better matches the need to improve the management and prevention of chronic diseases.

By changing the disease-centered focus of medical practice to this patient-centered approach, our physicians are able to support the healing process by viewing health and illness as part of a cycle in which all components of the human biological system interact dynamically with the environment. This process helps to seek and identify genetic, lifestyle, and environmental factors that may shift a person’s health from illness to well being.

Damn those regular doctors practicing SBM! They run the standard lab tests and don’t find anything. Don’t worry, though. FM has way, way more lab tests to run. Dr. Hyman and his acolytes will definitely find “abnormalities” to “treat,” no matter how hard they have to look or how many hundreds of individual nutrients, minerals, hormones, and chemicals they have to measure!

Now, again, I have to concede that not all of FM is bad. For instance:

A new patient consult will last approximately four hours, that consists of a medical consult with the physician, nutrition counseling, education on laboratory testing and health coaching. We are committed to addressing all of your concerns and will provide recommendations as well as construct a personal health plan.

If you are traveling from out of town, please arrange overnight accommodations and be sure to fast prior to your appointment for same-day laboratory testing. You need to bring insurance cards, current medications and vitamins. It’s very important to also bring your medical records if they were not already sent.

A four hour visit with a physician, dietician, and a “health coach” could well be beneficial for many people. However, the price of that the potentially good parts of that visit is the massive overtesting that FM mandates, which is, of course, baked into the visit. As is frequently the case with clinics like this, particularly ones affiliated with academic medical centers, the Cleveland Clinic is fairly vague about what actually happens at its Center for Functional Medicine. After all, I suspect that even the Cleveland Clinic at some level knows it’s peddling quackery and doesn’t want to advertise that too obviously. If you wander over to Dr. Hyman’s website, however, you’ll find “detox” (of course), “ultrametabolism,” and this gem about autism:

TODAY MOST PEOPLE BELIEVE that Autism is a genetic brain disorder. I’m here to tell you that this isn’t true. The real reason we are seeing increasing rates of autism is simply this: Autism is a systemic body disorder that affects the brain. A toxic environment triggers certain genes in people susceptible to this condition. And research supports this position.

Think about it. Rates of autism have skyrocketed over the years, from an estimated 1 child in 3,000 to just 1 in 150 kids today. Sure, wider criteria for diagnosis and better detection might explain some of it but not an increase of this magnitude.

He dances around the issue of whether he thinks vaccines cause autism by noting that he treated a 2 year old boy named Sam who “was born healthy but diagnosed with autism after his vaccination for measles, mumps and rubella at 22 months,” noting:

Every child with autism has unique genetics, causes or triggers. And it is not usually one thing but a collection of insults, toxins and deficiencies piled on susceptible genetics that leads to biochemical train wrecks we see in these children.

In other words, “I’m not sayin’ it was the vaccines, you know, but it was the vaccines plus other nasty stuff, you know, ‘toxins.’” No wonder Hyman was willing to be co-author of an antivaccine book by Robert F. Kennedy, Jr! In any case, Hyman subjected Sam to a huge battery of tests typical of the “autism biomed” movement and, as is usually the case, found all sorts of “abnormalities” in detoxification pathways (a favorite of autism biomed quacks), methylation (another favorite of autism biomed quacks), and oxidative stress (still another favorite). Of course, Dr. Hyman found elevated levels of aluminum and lead in Sam’s blood and antimony and arsenic in his hair. (Yikes! I thought Hyman, at least, would know not to use hair tests for metals. It sounds as though he probably used the typical quack tests for heavy metal “toxicity.”) Oh, and Sam was found to have multiple allergies and a “gluten sensitivity” as well, because, of course he did.

In any case, you can guess the rest. Sam improved, which is not unexpected, given that autism is a condition of developmental delay, not stasis. Sam “lost his autism diagnosis,” which, contrary to popular belief, happens in a significant proportion of children with an autism spectrum diagnosis. Most likely, Hyman’s nostrums had nothing to do with Sam’s loss of his autism diagnosis, but there’s no way of ever knowing for sure one way or another because there are no good clinical trials to tell us whether his nostrums do anything for the symptoms of autism or to affect the course of the developmental delay associated with autism.

Yes, this is the doctor in charge of a major clinic at a major academic medical center. Quackademic medicine rules in the form of functional medicine.

Functional medicine: Fake “individualization”

It’s been noted before many times how how CAM and “integrative medicine” fetishize “individualization” of treatment über alles and how, unfortunately, that individualization is more akin to making it up as you go along than it is to any sort of science-based individualization. This is an aspect of all of CAM, and it strikes me, more than anything else, as a means of catering to the normal human desire to feel special. It also caters to the physician’s desire to feel like a “real” and “complete” doctor who can take care of the “whole patient” and handle basically anything. None of this is to say that it’s not important to individualize treatments, but such tailoring of treatment to patient must be based on evidence and science, coupled with what the patient values. It must be shown to produce superior outcomes. Functional medicine has failed that test.

Basically, FM borrows from the worst tendencies of conventional medicine through its indiscriminate use of dubious lab tests, all in the name of “individualization.” Unfortunately, FM is “individualization” run amok based on more on a desire to individualize for the sake of individualization more than anything else.