Forgotten Roots: Causes of Disease Left Unaddressed by the Current Functional Medicine Paradigm
What is Functional Medicine?
Functional medicine seeks to understand the interconnections between symptoms and disease processes. It recognizes that one condition may have many underlying causes (e.g., hypertension may be caused by inflammation from emotional stress and food intolerance or an elevated body burden of toxic metals). One cause, such as an undiagnosed parasitic infection, may also drive several health conditions, e.g., autoimmune thyroid disease, chronic joint pain, and IBS. The Functional Medicine approach involves conducting a detailed history and exam and may employ a variety of advanced testing (such as genetic variations, hormonal, micronutrients, digestive function, and toxin exposures). Diagnoses and initial plans of care are developed from a synthesis of these different streams of information.
Advantages of Functional Medicine - why is it so darn popular?
There are many reasons why functional medicine has been an increasingly popular approach. One of these is the time and attention that practitioners are able to provide the people with whom they work. An initial visit with a functional medicine practitioner often lasts at least an hour, if not longer. In addition, the individualized attention and the significant investment of time and financial resources by the patient may strengthen their commitment to the care process. Care in a functional medicine clinic has been associated with increases in measures of health-related quality of life1.
So, what’s the problem? Some disadvantages (aka challenges) of Functional Medicine
There are several potential disadvantages to the functional medicine model. One is that it is cost-prohibitive for many. One survey of functional medicine physicians found that their average hourly price is $460 (ranging from $125 - $1250/hour). Most practices are cash pay and provide services not covered by insurance. Additional concerns and challenges of the functional medicine approach include its upholding of a narrative that reifies the individual - individual actions and responsibilities as the main levers that drive health transformation.
I am also increasingly concerned with the ways that many of the recommendations of very well-known practitioners in the functional medicine arena advocate for nutritional and lifestyle interventions that are beyond the economic reach of so many and are ecologically unsustainable. We cannot all eat wild-caught salmon 2-3x/week, for instance.
Why do I care?
I became a physician out of a deep desire to be able to support others in their healing process. After several years of practicing, I began to see how increasingly protocol-driven and insurance-based care imposed more and more limitations on what was possible within the scope of clinic visits. The expectation to see more and more patients in shorter and shorter visits and to check off more and more ‘elements of care’ within the algorithm-based frameworks felt unsustainable and demoralizing.
My own health suffered, and in my journey to regain my health, I discovered functional medicine. In time I recovered and gained an appreciation for this approach. I appreciated the functional lens that allows one to see the interconnections between seemingly disparate diagnoses. In time I learned there are benefits to the model. Still, there are shortcomings - including its lack of focus on the non-physical aspects of healing and its centering on a narrative of the individual as the primary actor in health transformation.
Functional medicine, often branded as ‘root cause medicine’ has forgotten a few key roots in its attempts to radically and comprehensively address disease. These forgotten roots are in the domains of ecology, culture, and the social-political.
“The soil is the great connector of lives, the source and destination of all. It is the healer and restorer and resurrector, by which disease passes into health, age into youth, death into life. Without proper care for it we can have no community, because without proper care for it we can have no life.”
Ecological Roots
#1 Topsoil Erosion and Loss of Soil Nutrients
Many regions of the US have lost a significant proportion of their topsoil due to a history of unsustainable and short-sighted farming practices and policies2,3. If there is no soil, there are no crops. The loss is happening at an accelerating rate. Soil contains the nutrients that support crop growth. Minerals from nutrient-rich soils get absorbed into plants and are a source of the nutrients we then need to support our own biological processes.
Studies have shown that today's food contains less nutrition than a generation ago4,5. Plant breeding practices have prioritized larger sizes, higher yields, and pest resistance are part of the explanation. While these larger plants are less capable of extracting nutrients from the soil, modern farming practices have also led to the depletion of minerals from the soil.6 Conventionally grown (non-organic) crops also contain lower amounts of certain key nutrient compounds such as antioxidants and higher levels of pesticide residues.7
In the modern United States, it is uncommon to see frank nutrient deficiencies of the type we learned about in history class and medical schools, such as scurvy8 and pellagra9. But, there is increasing recognition of the role that chronic sub-clinical micronutrient deficiencies may play as a driver of chronic diseases, including diabetes10 and hypertension 11. Studies of the effectiveness of single nutrient supplementation to treat these conditions are not always effective, likely due in part to a growing number of multiple and interacting micronutrient deficiencies in the population. It is also much more difficult to reverse the course of a condition once it has progressed from a functional disturbance to frank organ pathology and disease.
Functional medicine practitioners regularly assess patients for vitamin and mineral deficiencies and recommend dietary and nutritional supplements to address nutrient deficiencies. But how much effort do we make to tell the larger story of why this is happening and to advocate where we are able for changes? There are certainly examples of practitioners doing this work. Dr. Zach Bush and his efforts with regenerative agriculture12 come to mind, and there are doubtless others. But how can we do more in our respective communities to advocate for healthier soil practices and to support those growers who are using these practices?
Some (but not all) patients that work with functional medicine practitioners have considerable financial means. What would it look like to encourage them to support small local farms, with an explicit emphasis on BIPOC growers and growers from historically marginalized groups? Could you offer your clinic as a distribution site for a CSA? Or offer discounted services to farmers in your community? What else?
#2 Climate Crisis - Rising Atmospheric Carbon Dioxide Levels and Plant Nutrition
In addition to soil depletion and its effects on food nutrient quality is the recognition that elevated atmospheric carbon dioxide (CO2) levels also drive decreased levels of key nutrients, including zinc, iron, and protein in foods. At first pass, this may seem counterintuitive - plants thrive on CO2, don’t they? They use CO2 and sunlight for photosynthesis and produce oxygen for us to breathe. In this sense, they are our biosynthetic complement 🙂
But as the saying goes, too much of a good thing is a not-so-good thing. An overabundance of CO2 is like junk food to the plant. They grow larger, not because they possess more nutrition, but because they have a higher water content that dilutes the nutrients they do possess.
So we have less nutritious watery plants, coupled with other factors such as worsening soil quality (we just spoke of that) and the selected breeding of larger but less nutrient-dense varieties. All of these factors can contribute to what is known as hidden hunger - where one appears to be consuming a diet that is sufficient in calories but is profoundly lacking in nutrition. Individuals and populations who derive a significant proportion of their diet from staple plant foods (maize, rice, etc.) are particularly susceptible as they are often less able to supplement their diet with additional proteins and vitamins that might stave off malnutrition13. This is a concern globally and increasingly in this country as rising food prices, less nutrient-dense plant foods, and the perverse incentives that make processed foods the most affordable option make the reality of homegrown malnutrition an increasingly present reality.
Supporting local agriculture and regenerative farming are, again, ways to lessen the carbon footprint and sustainability of the food we eat. We also need to increase our awareness of the ecological impacts of our recommendations to patients regarding foods (I speak more about this below), and I wrote a blog about sustainability in supplements here.
Cultural Roots
source: Unsplash - julian mora
Root #3 - Loss of Traditional Food Ways
Throughout most of human history, people have been in deep relationships with the land where they lived and the animals and plants that inhabited it. Through countless generations of observation, indigenous people (on whatever land mass they lived) cultivated the wisdom to live sustainably and often abundantly on the lands they called home. Nutritional and anthropological lines of inquiry have supported that the diets of hunter-gatherer populations were often more nutritionally abundant in micronutrients than modern Western diets, where a large proportion of calories are derived from processed oils and grains14,15.
Throughout human history, people have found ways across various habitats to live sustainably with the food sources available to them.
This traditional knowledge included:
Which plants were safe and good to eat?
Which plants could be used as medicine?
How to maximize the variety in the diet? - often with dozens of different plants being eaten over the course of a year
The appropriate techniques to maximize the nutrition and safety of foods eaten through various forms of preservation, cooking, etc.
Traditional foodways keepers had deep wisdom about what foods to eat and how they should be eaten. In a culture that reifies innovation and information gained by dispassionate scientific manipulation, it can, or at least should be humbling to recognize this ‘grandmother’ wisdom gleaned from generations of experience and observation has pointed to what we are only now beginning to understand through scientific inquiry.
I humbly admit that my knowledge in this subject is limited, but here are a few examples of the harm of not following indigenous foodways. [Dear reader - if you have more examples, please share them with me so that we can all learn more]
Soaking and slow-cooking beans - traditional cultures that have eaten beans have known the benefits of soaking and slow cooking them to increase their digestibility.
The consumption of raw tomatoes, with their skin and seeds, contains high amounts of lectins, compounds made by plants as a means of protecting their seeds that irritate the intestinal linings of animals and people that may try to eat them. Peeling, removing the seeds, and cooking in oil generally make tomatoes easier to digest and their antioxidant compounds, including lycopene more bioavailable.
We have already noted the history of pellagra (in Root Cause #1) but did not mention that part of the reason this came about was the loss/disregard of the knowledge from traditional cultures who ate corn of preparing corn in an alkaline solution, a process called nixtamlization16, to increase its digestibility and remove mold toxins.
So what do these historical examples have to do with Functional Medicine? There are a couple. Functional medicine often works by helping patients identify and address (often through dietary elimination) what are deemed problematic foods. These foods are often deemed problematic because they are being consumed in ways that are not rooted in traditional foodways, e.g., poorly prepared beans, lots of raw greens in smoothies, almonds, and almond flour in everything. While Functional Medicine practitioners may do the work of supporting patients in their individual identification and repair work, there is also the work of messaging around having a more grounded approach to how we nourish ourselves. This conversation and what it engenders could look different ways, including asking those we work with to look to their own cultural backgrounds and find ways to rekindle dietary practices that feel aligned and rooted in their own culture in preference to one-size-fits-all food plans.
Social Political Roots
Root #4 - Inequality
Inequality and living under systems of oppression impact our health17,18. The unequal access to the opportunities, conditions, and material goods that support individuals and communities in sustaining health and well-being are hallmarks of the American Project. It is increasingly recognized that the medical system has historically been19 and continues to be a site of harm for marginalized groups20.
A comprehensive discussion of the impacts of inequality on health is beyond the scope of this article. But I will touch on some points related to what we’ve been discussing.
Functional Medicine, which is borne of the same biomedical system which has produced and continues to produce some of the harms noted above, is not immune from unconscious and conscious biases, ableism, and racism. In addition, the delusion of healthism and the wellness industrial complex, when taken to the nth degree, would have us believe that if we can afford to purchase the right foods, supplements, water filters, etc., we can escape the impacts of the climate crisis and environmental degradation. Some of the above discussions on the global impacts of soil degradation and rising CO2 levels should start to disabuse us of these notions.
The notion that health is an individually held quality or resource is rooted in individualistic modern Western culture. But this is one perspective, and one might argue that in this time of increasing global interconnectedness and rising inequality, it is not serving most of us. Many indigenous cultures have believed something quite different, that health is rooted in relationship and community - relationship to one another, to the environment, spirit, and purpose.
How does one step away from toxic individualism and the notion that all of the levers that can impact one’s health can be controlled by adding more financial resources and time to the issue?
In Conclusion
The anti-inflammatory effects of belonging and next steps
There is an epidemic of loneliness. The effects of loneliness are equivalent (in terms of disease risk elevation) to smoking half a pack of cigarettes per day - elevating the risk of premature death from all causes and increasing the risk of developing everything from dementia to depression to heart disease. Isolation is inflaming. It drives our stress response because it feels fundamentally unsafe. We are, by nature, social beings, and isolation is an existential threat. While we are capable of surviving alone for some period of time, it does not provide the conditions for thriving and healing. How can you heal when you have to watch your back constantly?
For a beautiful essay on this topic, I recommend you read this.
In functional medicine, we spend a lot of time talking about inflammation - as a common factor in many disease processes. Chronic inflammation tends to generalize, to move beyond the bounds of a cell, a tissue, an organ, or an individual body to travel amongst families, groups of people, and communities. The remedy to isolation is belonging. How do we, as practitioners and proponents of Functional Medicine, support more belonging and connection across the boundaries of individually defined health concerns? What is the benefit for all of us when we do this?
Yours in healing and solidarity,
Nicole Winbush, M.D.
Dr. Winbush founded Sankofa Healing Arts & Functional Medicine, an interdisciplinary healing practice based in North Carolina. Through this practice and aligned partnerships, Dr. Winbush seeks to support others in their goals for their health and well-being and doing so in ways that are easeful, ecological, and enduring. You can follow her at @sankofahealing on Instagram and learn more about the practice at sankofahealingarts.com.
References
1. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2753520
2. https://e360.yale.edu/features/how-the-loss-of-soil-is-sacrificing-americas-natural-heritage
3. https://www.ucsusa.org/sites/default/files/2019-12/safeguarding-soil-policy-brief-2019-web-final.pdf
4. https://journals.ashs.org/hortsci/view/journals/hortsci/44/1/article-p15.xml
5. https://www.tandfonline.com/doi/full/10.1080/09637486.2021.1981831
6. https://www.scientificamerican.com/article/soil-depletion-and-nutrition-loss/
7. https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/organic-food/art-20043880
8. https://en.wikipedia.org/wiki/Scurvy
9. https://en.wikipedia.org/wiki/Pellagra
10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3313629/
11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916651/
12. https://farmersfootprint.us/
13. https://blogs.scientificamerican.com/observations/vanishing-nutrients/
14. https://onlinelibrary.wiley.com/doi/epdf/10.1111/obr.12785
15. https://pubmed.ncbi.nlm.nih.gov/15699220/
16. https://en.wikipedia.org/wiki/Nixtamalization
17. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/
18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2747726/
19. https://healinghistoriesproject.com/what-is-hhp/
20. https://www.michiganmedicine.org/health-lab/anti-racism-and-dr-susan-moores-legacy
