Nutritional Medicine Dr Fatiha Arhbal The Wellness Oasis 49 Portrush Road Payneham, Adelaide MBBS, FRACGP, DCH, DRANZCOG Board Certified Anti Ageing Physician
Nutritional Medicine The conventional medical approach aims for a quick diagnosis and treatment of acute symptoms. ď‚— The Nutritional Medicine approach aims to get to the source of the symptoms as well as promoting health, wellbeing and longevity. ď‚—
Nutritional Medicine Over 60% of deaths in Australia result from nutrition related disorders. Australia has overtaken America as the most obese country. “Good nutrition leads to health and resistance to disease; poor nutrition leads to ill- health and susceptibility to many diseases.”
Nutrition- Chapter 10.3 Oxford Textbook of Medicine, Third Edition
30-40% of all cancers can be prevented by diet. Donaldson MS.
Nutrition and cancer: a review of the evidence for an anticancer diet. Nutr J. 2004 Oct 20;3:19.
Nutritional Medicine
“Let food be thy medicine and medicine be thy food” – Hippocrates. “When the diet is incorrect, medicine does not work, when the diet is correct, medicine is not necessary”- Ayurvedic wisdom. “No human ever filled a vessel worse than the stomach. Sufficient for any son of Adam are some morsels to keep his back straight. But if it must be, then one third for his food, one third for his drink and one third for his breath”- Prophet Mohammed pbuh.
Nutritional Medicine Diet Nutritional Deficiency Inflammation Gastrointestinal dysfunction Detoxification Oxidative stress Neurotransmitters Hormones
Diet
Diet and Wellness
Diet is the major determinant of wellness or illness, cardiovascular, cancer, diabetes are >50% preventable through diet Food needs to be good tasting and enjoyable Part of an active lifestyle Should not be prepared and consumed quickly on the way to more pressing activities Enjoyment assists in savouring the tastes and textures and may reduce overeating and snacking Just choosing food to decrease chronic disease makes eating prescriptive and joyless Diet controls inflammation Williams MT et al. The role of dietary factors in cancer prevention: beyond fruits and vegetables. Nutr Clin Pract. 2005 Aug;20(4):451-9.
Calorie Restriction (CR) Decreases Inflammation CR is the most documented method of extending lifespan and health span in all species studied CR decreases inflammatory cytokines Chung, H et al. Molecular Inflammation Hypothesis of Aging Based on the Antiaging mechanism of Calorie Restriction. Microscopy research and techniques 59:264-272 (2002)
Calorie Restriction 10-25% less calories than the Western Diet BMI of 19.6 Intermittent fasting may be as effective Studies in animals, human studies take a long time Resveratrol has been shown to mimic the effects of CR in some animal species
Diet and Wellness Macronutrients- Protein, Carbs, Fat How to combine them? Zone-type diet 40-30-30 Optimises Fasting Insulin, Lipids, Inflammation, Fat storage, Body Composition Avoid Carbs without phytonutrients
Insulin Studied insulin resistance to predict a variety of age-related diseases. Baseline measurements of insulin resistance and related variables were made between 1988-1995 in 208 apparently healthy, non obese Evaluated 4-11 yr later for the appearance of the following age-related diseases: hypertension, coronary heart disease, stroke, cancer, and type 2 diabetes. The effect of insulin resistance on the development of clinical events was evaluated by dividing the study group into tertiles of insulin resistance at baseline and comparing the events in these 3 groups.
Clinical endpoints (n = 40) were identified in 37individuals (18%) of those evaluated, including 12 with hypertension, 3 with hypertension + type 2 diabetes, 9 with cancer, 7 with coronary heart disease, 4 with stroke, and 2 with type 2 diabetes. Twenty-eight out of the total 40 clinical events were seen in 25 individuals (36%) in the most insulin-resistant tertile, The other 12 occurring in the group with an intermediate degree of insulin resistance. Insulin resistance was an independent predictor of all clinical events, An age-related clinical event developed in approximately 1 out of 3 healthy individuals in the upper tertile of insulin resistance at baseline, followed for an average of 6 yr No clinical events were observed in the most insulin sensitive tertile Facchini FS, Hua N, Abbasi F, Reaven GM.
Slow Foods vs. Fast Foods Increased consumption of high density low quality foods Refined starches, sugars Unhealthy lipids Poor in natural antioxidants and fibre Activates immune system Produces pro-inflammatory cytokines and decreased production of antiinflammatory cytokines
Slow Foods vs. Fast Foods Inflammatory cytokines produce insulin resistance and endothelial dysfunction Leads to metabolic syndrome and Type 2 diabetes Fast foods are fast in preparation and are fast in producing health damage Nutrition vs. drugs to control inflammatory effects Fast foods speed up inflammation and slow foods slow it down.
How much do you need? Diet: As best as you can do it Omega 3: 8 gm per day of EPA + DHA Phytonutrients: 8 x 100 g servings vegetables per day Calories- not too many Don’t eat more than you need Don’t drink calories Pure Water, Green Tea
Polymeal 150 mL of red wine (about half a glass) 100 g of dark chocolate 400 g of fruits and vegetables 2.7 g of garlic 68 g of almonds 118 g of fish per day four times each week.
Polymeal Reduce cardiovascular disease events by 76% Increase life expectancy Men 6.6 years Women 4.8 years The Polymeal promises to be an effective, non pharmacological, safe, cheap, and tasty alternative to reduce cardiovascular morbidity and increase life expectancy in the general population. Franco OH et al. The Polymeal: a more natural, safer, and probably tastier (than the Polypill) strategy to reduce cardiovascular disease by more than 75%.BMJ. 2004 Dec 18;329(7480):1447
Nutritional Deficiency
Overfed and undernourished Surveys show that Australian nutrient intakes fall below the RDI Average calcium intake less than the RDI in most women Average folate intake in women aged 19-44 years was only 50% of that required to prevent birth defects Iron intake below the RDI in 25% of adolescent girls and young women Zinc well below the RDI in 50% of women and 10% of men more than 19 y Magnesium intake below the RDI in 25% of women aged over 19
Fruits and vegetables Fruit and vegetable intake was below recommended levels in 35% of adults and 65% of adolescents ď‚— 65% adults consumed less that the recommended levels of seafood oils ď‚— In adults, beverages accounted for over 60% of food and beverage energy intake- ie alcohol and sugar accounted for over 50% of dietary energy ď‚—
RDI We are taught to believe that the vitamin and mineral intake at the level of the Recommended Daily Intake as set by the NHMRC of Australia is perfectly adequate for the continued health of all ď‚— We are taught to believe that greater intakes than this are useless at best and harmful at worst ď‚—
RDI RDIs are the amounts of essential nutrients that are considered adequate to meet the nutritional requirements of healthy people The RDIs are designed to prevent the classical nutritional deficiency diseases They do not address the extra nutrient needs of persons with certain chronic aliments, who smoke, or are on
RDI New research suggests a role for vitamins and minerals in the prevention or slowing down of many diseases such as heart disease, cancer, cataracts, osteoporosis, and birth defects ď‚— The total effects of vitamins on the body are still not fully understood ď‚— Further, there is increasing scientific evidence to suggest that higher levels of certain vitamins may be necessary for optimal health and may provide extra protection against disease ď‚—
RDI In time, the concept of RDI may well be broadened to include a second set of much higher vitamin levels that optimise their disease preventing properties It is particularly important to remember that RDI’s are for healthy people In illness the requirements for nutrients are altered. For example, with stress, trauma or surgery, the requirement for vitamin C may be more than 8 times the RDI for healthy adults and zinc requirements increase for wound healing Nutrition Unit, Faculty of Medicine, Monash University, 1998
Biochemical Individuality “Our analysis of metabolic disease that affects cofactor binding, particularly as a result of polymorphic mutations, may present a novel rationale for high-dose vitamin therapy, perhaps hundreds of times the normal dietary reference intake (DRI) in some cases . . . Feeding high doses of the vitamin raises the tissue cofactor concentrations and thereby increases the activity of the defective enzyme.� Ames, BN et al. Am J Clin Nutr. 2002;75:616-
Homocysteine A cardiovascular risk marker Linked with a variety of chronic health problems- osteoporosis, migraine, obesity, arthritis, depression Metabolised by B vitamins-B6, B12 and folate The most common issue is a problem with an enzyme that causes folate activation within the cell. This is a genetic polymorphism and up to 40% of people have it. Need high dose B vitamins, large doses of folate or folinic acid
Vitamin and Mineral Deficiency Vit A- bumpy skin, night blindness, achy, tired, burning itching eyes, eyeball pain, inflamed eyelids, frequent colds, sinus trouble, dull hair, ridged nails that peel easily, birth defects, fatigue, depression, insomnia ď‚— Vit D- aching bones, joints, exhaustion, night sweats, aching muscles, rickets, anxiety, increased cell proliferation ď‚—
Vit C- fatigue, easy bruising, joint pains, loss of appetite, depression, poor wound healing, immune depression, periodontal disease Vit E- fatigue, restlessness, insomnia, increased destruction of red blood cells, oxidative damage, ageing, calf tenderness Vit K- Bleeding disorders, easy bruising,
Vit B group B1- anorexia and weight loss, moody and irritable, palpitations, memory loss, impaired co-ordination, CCF, peripheral neuropathy B2- angular stomatitis, red tongue, photophobia, migraine, hair loss
B3- dermatitis, diarrhoea, depression, low stomach acid, nausea, diarrhoea, constipation, glossitis, headache, dementia B6- low blood sugar, depression, dandruff, dermatitis, morning nausea, poor dream recall, PMS, carpal tunnel, microcytic anaemia B12- neurologic degeneration, poor memory, depression, fatigue, paraesthaesiae, dementia, palpitations
Folate-fatigue, weakness, anorexia, impaired memory, headaches, large red cells, vascular disease ď‚— EFA- dry flaky skin, dry brittle hair and nails, acne, alopecia, inflammation, immune system dysfunction, impaired wound healing, hormone dysfunction, vascular disease ď‚—
Iron- anaemia, learning problems, poor memory, depression, flat or spoon shaped nails, hyperactivity, fatigue, low BP Calcium- anxiety, irritability, depression, cramping in calves, palpitations, HT, period problems Selenium- cancer, muscle fatigue, immune depression
Zinc- short stature, tiredness, delayed would healing, loss of taste and smell, poor appetite, hyperactivity, stretch marks, acne, growing pains, white spots on fingernails, frequent infections, hair loss, infertility ď‚— Manganese- poor bone growth, knee pain ď‚—
Magnesium- sensitivity to sounds, irritability, insomnia, hyperactivity, cramps, anxiety, HT, palpitations ď‚— Chromium and Vanadium- essential for insulin receptor activity and deficiency results in insulin resistance, high cholesterol, fat gain ď‚—
Vitamin D Pandemic Balanced diet or living near equator not sufficient Everyone who does not get lots of sun or ingests at least 2000-10,000 IU per day is at high risk for skeletal and nonskeletal consequences High rates of Vitamin D Deficiency: USA, Europe, Middle East, India, Asia, Australia and New Zealand
Low Vitamin D Production Clothing Sunscreen Latitude > 37 in winter, Early and late hours Skin pigmentation Body fat Age: 70 yo produces 4 x less than 20 yo Drugs-Anticonvulsants, corticosteroids
Vitamin D
Few foods contain vitamin D Fish liver oils, such as cod liver oil, 1 Tbs. (15 mL) provides 1,360 IU Fatty fish species, such as: Herring, 85g (3 oz) provides 1383 IU Catfish, 85g (3 oz) provides 425 IU Salmon, cooked, 3.5 oz provides 360 IU Mackerel, cooked, 3.5 oz, 345 IU Sardines, canned in oil, drained, 1.75 oz, 250 IU Tuna, canned in oil, 3 oz, 200 IU Eel, cooked, 3.5 oz, 200 IU One whole egg, 20 IU Fortified Milk 100 IU/cup For every 100 IU ingested, 25(OH) D3 increases 1 ng/ml
25(OH) D and post-menopausal Breast Cancer 70% reduction in higher level >75 nmol/L compared to lowest 10 nmol/L ď‚— Abbas S et al. Serum 25hydroxyvitamin D and risk of postmenopausal breast cancer--results of a large case-control study. Carcinogenesis. 2008 Jan;29(1):939 ď‚—
25(OH) D and pre-menopausal Breast Cancer Compared with the lowest category (<30nmol/L), the ORs (95% CI) for the upper categories (30-45, 45-60, >/=60 nmol/L)were 0.68 (0.43-1.07), 0.59 (0.37-0.94) and 0.45 (0.29-0.70), (p = 0.0006) ď&#x201A;&#x2014; Abbas S et al. Plasma 25hydroxyvitamin D and premenopausal breast cancer risk in a German case control study. Int J Cancer. 2008 Oct 6 ď&#x201A;&#x2014;
Vitamin D Deficiency At least 17 varieties of cancer Heart disease, stroke, hypertension Autoimmune diseases, MS Diabetes, type 1 and 2 Depression Chronic pain Osteoarthritis
Vitamin D Deficiency Osteoporosis Muscle weakness Periodontal disease Childhood bone health Infectious disease www.vitamindcouncil.org
Vitamin D physiology Technically not a "vitamin" Vitamin D is in a class by itself. Its metabolic product, 1,25 dihydroxyvitamin D= calcitriol, is a steroid hormone that targets over 1000 genes Every cell has a vitamin D receptor that responds to 1,25 dihydroxyvitamin D
Cell Junction effects Apoptosis Anti-Metastasis Primary molecular action of Calcitriol is binding to Vitamin D Receptor (VDR) , a member of steroid hormone receptor superfamily Initiates gene transcription
VDR needed for growth arrest of cancer VDR turns on genes for increase in production of IGFBP-3 Cancer can turn off CYP27b1 inhibiting D3 production
Vitamin D and CVD Men with low Vitamin D suffer 2.42 x more heart attacks 157,000 Americans die every year If Vit D status was optimised, deaths prevented 92,500 Statin reduces heart attack 37%, men with higher Vit D levels reduction is 142% Cost effective
Why Deficient? ď&#x201A;&#x2014;
The really significant reductions in sunlight exposure have occurred since the industrial revolution, just the time the "diseases of civilization," like cardiovascular disease, diabetes and cancer became prominent
Common Causes of EFA Imbalances 1. Diet high in Ω -6 fats & low in Ω -3 fats 2. Biochemical individuality-altered delta-6 desaturase activity, micronutrient deficiencies(B3, B6, biotin, C, Zn, Mg) 3. Insulin dysregulation high carbohydrate/ low protein /low fibre diet Insufficient dietary chromium,
Dietary Intake of Ω-6 and Ω-3 Fats From 1909 to 1985 Omega-6 fat intake has increased from 1 kg per year to 12 kg per year The ratio of dietary Ω -6: Ω -3 fats has also increased from ~4:1 to ~25:1 Reasons for increased omega-6 fat intake: – Vegetable oil (grain-extracted) – Grain-fed livestock (no longer freerange) – Decreased wild game consumption
EFA Treatment All chronic inflammatory conditions, cardiovascular disease, auto-immune disease, arthritis, Crohn’s disease, colitis, allergies Foetal and neonatal neurological development Mother’s health during pregnancy & lactation Senile neurological degeneration Depression and behaviour disorders (ADHD)
Gastrointestinal dysfunction Low stomach acid- inability of stomach to digest adequately Pancreatic dysfunction- low digestive enzymes Dysbiosis- leading to absorption of toxins Leaky Gut- leading to absorption of large molecules Activation of GALT leading to immune system activation Production of neurologically active chemicals such as amines
Common signs and symptoms of low gastric acidity Bloating, belching and flatulence immediately after meals A sense of “fullness” after eating Indigestion, diarrhoea, or constipation Multiple food allergies Nausea after taking supplements Itching around the anus Weak, peeling, and cracked fingernails Dilated blood vessels in the cheeks and nose Acne Chronic intestinal parasites or abnormal flora Undigested food in stool Chronic candida infections Upper digestive tract gassiness/bloating
Diseases associated with low gastric acidity
Addison’s Disease Asthma Coeliac disease Dermatitis herpetiformis Diabetes mellitus Eczema Gallbladder disease Hepatitis Chronic hives Lupus
Myasthenia gravis Osteoporosis Pernicious anaemia Psoriasis Rheumatoid arthritis Rosacea Sjogren’s syndrome Thyrotoxicosis Hypothyroidism Vitiligo
Protocol for HCL Acid supplementation Begin by taking one tablet or capsule containing 600 mg of HCL at
your next large meal. If this does not aggravate your symptoms (ie there is no burning within half an hour of taking the tablet), at every meal after that of the same size, take one more tablet or capsule. (One at the next meal, two at the meal after that, then three at the next meal.) If you have no burning within half an hour of taking the tablets, this means you need more acid. Continue to increase the dose until you reach seven tablets or when you feel a warmth in your stomach, whichever occurs first. A feeling of warmth in the stomach means that you have taken too many tablets for that meal, and you need to take one less tablet for that meal size. It is a good idea to try the larger dose again at another meal to make sure that it was the HCL that caused the warmth and not something else. After you have found the largest dose that you can take without feeling any warmth, maintain that dose at all meals of similar size. You will need to take less at smaller meals. When taking a number of tablets or capsules it is best to take them throughout the meal. As your stomach begins to regain the ability to produce the amount of HCL needed to properly digest your food, you will notice the warm feeling again and will have to cut down the dosage. HCL may be
Pancreatic insufficiency Pancreatin Bromelain Papain
Dysbiosis We inherit our intestinal flora from our mother during birth Around 2kg of organisms in the gut Communicate with the immune system, maintain correct pH, produce beneficial short chain fatty acids, vitamins Poor diet, antibiotics, the OCP, chemicals can all impact on this
Anti-bacterials : Standard antibiotics Garlic Goldenseal Artemesia/ChineseWormwood Anti-fungals : Standard antifungal agents Oregano Thyme Garlic Goldenseal
Anti-protozoals: Standard anti-protozoal agents Oregano Thyme Goldenseal Artemesia/ChineseWormwood Endotoxic Binders: Charcoal Fibre Bentonite Clay
Leaky Gut Leaky gut occurs when the intestinal lining is damaged and the junctions between the cells are open Occurs with food allergy, dysbiosis, toxins, deficiencies, stress Large molecules able to cross into blood stream causing immune activation and symptoms elsewhere in the body
Food intolerance Mediated via IgG not IgE Intolerance vs Allergy Causes immune activation, leaky gut, malabsorption IBS, fatigue, sinusitis, joint pains, eczema, learning disorders, depression
Gluten Allergies: The Tip of The Iceberg Up to 30% of all Australians may be sensitive to gluten not to mention that 1 in 100-200 have the severe form called Coeliac Disease. ď&#x201A;&#x2014; Whatâ&#x20AC;&#x2122;s the big deal? The big deal is that gluten sensitivity appears to be associated and may be a contributing factor with a large number of severe illnesses ď&#x201A;&#x2014;
Risks and complications of Coeliac disease Osteoporosis Anaemia Gastrointestinal and liver cancers Non-Hodgkin’s lymphoma, risk of lymphoma is reduced on gluten free diet All cause mortality is doubled Risk of adenocarcinoma is high in patients with a long period of untreated disease
Who should be tested? If you have a history of any of the following, it would be
advisable to be tested for gluten sensitivity: Any autoimmune disease Osteoarthritis Any abdominal complaints (chronic diarrhea, constipation, IBS, heartburn) Asthma, psoriasis or eczema, other unexplained rashes Mouth ulcers Hair loss Neurological disease Autism, ADHD/ADD Chronic fatigue, fibromyalgia, depression, any psychiatric disorder Infertility, recurrent miscarriage Osteoporosis Liver disease of any type Type 1 DM
Testing Blood Coeliac screen Gene tests DQ2/DQ8 Small Intestinal Biopsy Other food intolerance can be detected with IgG testing
Immune System GI Immune Enhancers: Whey protein Saccharomyces boulardii Glutamine Arabinogalactans
Probiotics: Lactobacillus Saccharomyces boulardii Bifidobacteria Prebiotics : usually unnecessary to supplement if good diet
Inflammation Inflammation is behind much chronic illness Inflammation / Inflam-ageing Poor diet and insulin resistance increase inflammation
C-Reactive Protein CRP Risk factor for illness- Coronary events, cancer, depression, diabetes Produced in liver in response to inflammatory cytokines Can rise 1000 x with acute inflammation IL-6 TNF alpha IL- 1 beta What is your CRP?
Detoxification Liver detoxification occurs in two phases The process changes fat soluble toxins into water soluble ones so that they can be excreted into bile or via the kidneys Phase 1 creates intermediary metabolites that are more toxic and cause more damage, so many anti oxidants are required in this process
Detoxification Phase 2 requires amino acids from proteins so that the metabolites can be conjugated and excreted If any of these are missing, the process will not occur correctly Phase 1 can be increased with drugs and toxins There is great individuality in the ability of detoxification enzymes
Alternate Detoxification Programme Don’t eat the food Don’t drink the water Don’t breathe the air
Heavy Metals Heavy metals occur in the environment, some vaccines, amalgams, fish, old paint, clothing. Exposure is common, hard to detox, get hidden away There is individuality in the ability to detox Children are especially vulnerable as many heavy metals are neurotoxins and can cross the placenta in utero Heavy metals act as anti nutrients, blocking or using beneficial nutrients
Heavy Metals Detoxification of heavy metals can be with the appropriate mineral supplementation DMSA- Dimercaptosuccinic acid DMPS- 2,3-Dimercapto-1propanesulfonic acid EDTA- Ethylenediaminetetraacetic acid
Heavy Metal Testing Hair analysis Urine challenge – collect urine after IV DMPS
Oxidative stress Uses of Oxygen in the Body: 1. Energy Production: Oxygen is used to split carbon-carbon bonds, thereby releasing the stored covalent energy to make ATP 2. Detoxification: Oxygen species are added to toxins to make them more polar for elimination 3. Immune Function & Inflammation: Oxidative bursts are the major weapon of the immune system for defense and repair 4. Hormone Production: Oxygen is used for the biotransformation of steroid hormones ď&#x201A;&#x2014;
Oxygen and Free Radicals Unfortunately, the body cannot completely control its use of oxygen ď&#x201A;&#x2014; Whenever oxygen is used some of it is transformed into free radicals ď&#x201A;&#x2014;
Free Radical Theory of Ageing Increased oxidant generation Declining defenses and repair Accumulation of the end products of oxidative damage Advanced Glycosylated End Products Protein Oxidation Oxidized LDL, Isoprostane F2, Lipid Peroxides DNA damage
Effective Treatment Nutritional Anti-Oxidants (Vit A, C, E) Glutathione, alpha-Lipoic Acid Plant-based Anti-Oxidants Resveratrol EpiGalloCatechinGallate (EGCG) Many, many, many others Mineral Co-Factors Amino Acid Balance and Protein Digestion Proper Methylation Function (BVitamins)
Neurotransmitter Balance They affect many processes of the body including mood, pain, hormone regulation, digestion, and metabolism. ď&#x201A;&#x2014; The balance of NTs can facilitate or hamper well being and impact the efficacy of treatments. ď&#x201A;&#x2014;
Common Neurotransmitterrelated Conditions
Depression Migraine Anxiety Obesity/Overweight Insomnia PMS Irritable Bowel Syndrome ADD/ADHD Hypertension Fibromyalgia
Kryptopyrroles An abnormal production of a group of chemicals called 'pyrroles', this is called pyroluria, associated with depression and other mental health disorders. The pyrroles rob the body of B6 and Zinc causing them to be excreted in the urine. Results in a deficiency of B6 and zinc, which supplementation can correct. It is most often seen in females. It is thought that about 10% of a normal population has pyroluria, which may cause symptoms when the patient is stressed.
Symptoms Frequent ear infections, colds, fevers and chills. Fatigue Nervous exhaustion Insomnia Poor memory or inability to think clearly Hyperactivity Seizures Mood swings
Lack of regular periods in girls Stretch marks in the skin Impotence in males Unusual smelling breath and body odour Inability to tolerate drugs and alcohol Cold hands and feet Abdominal pain Intolerance to some protein foods Morning nausea and constipation Difficulty remembering dreams Frequent head colds and infections Addictions
Symptoms Pyrolurics can often be identified by their appearance: Pale skin. (A dark skinned pyroluric will have the lightest skin in the family). A lack of hair on the head, eye brows and eye lashes. Teeth in the upper jaw will often be overcrowded and poor appearance of tooth enamel. White marks on fingernails, opaque and paper thin. Acne, eczema, and herpes may also be
Pyroluria Pyroluria can occur at any age but appears to be brought on by stress. It is familial and may be a factor in the development of mental retardation, epilepsy, hyper activity and particularly depression. A family history of mental illness and all-girl families especially if there is also a history of miscarried boys.
Hormones Hormones are anti inflammatory Enhance quality of life May not be necessary after other areas addressed
Diet
Leaky Gut
Dysbiosis
Food Allergy
Nutritional Deficiency
Inflammatio n
Nutritional Medicine
Detoxification
Heavy Metals Insulin Dysregulatio n
Hormones Immune Dysfunction Neurotransmitters
Oxidation
Nutritional Medicine www.acnem.org www.a5m.net