Defining functional medicine at the Cleveland Clinic

Show Notes

Daniel sits down with Dr. Mark Hyman, Head of Strategy & Innovation at the Cleveland Clinic Center for Functional Medicine – “a paradigm shift in our thinking about disease.” Dr. Hyman says, “We've now got 155,000 diseases in our diagnostic category book, but they're really all driven by a smaller number of common root causes.”

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Dr. Mark Hyman:
We really need to rethink health, we need to rethink disease. Because it's not just what we do that matters, it's how we do it. And some of the democratization and decentralization of healthcare is really what's going to change everything. It's healthcare without walls, right? It's hospitals, not walls. It's putting health in the hands of consumers because health doesn't happen in the hospital. I can't cure diabetes in the office, it's cured on the farm, in the grocery store, in the kitchen. That's where diabetes is cured.

Dr. Daniel Kraft:
I'm Dr. Daniel Kraft, and really pleased to be joined today by my friend and co-conspirator Dr. Mark Hyman. So you're a really amazing clinician. You've been a guiding light in the field of what's often called functional medicine, and we've had a lot of providers listening.

Dr. Mark Hyman:
I usually jokingly say it's the opposite of what we traditionally practice, which is dysfunctional medicine. But to be fair, it's a paradigm shift in our thinking about disease. We've now got 155,000 diseases in our diagnostic category book, but they're really all driven by a few number of common root causes.
Inflammation, for example, is one of those common themes that seems to be linked to everything from heart disease to cancer, to diabetes, to Alzheimer's, to autism, to obesity. I mean, it's just, how does it connect to all those things? And so functional medicine, I think is the first attempt to create a coherent theory of medicine that the body is a network, it's not a series of different parts.
The truth is that we are one ecosystem, one integrated biological network or a network of networks really. And that these biological systems are influenced by our environment and our fundamental lifestyle factors. And when you are healthy, these systems are in balance. And when you're not healthy, they're out of balance. There are really only about seven systems. We talk about, for example, these seven systems as our gut, our microbiome and our assimilation, our immune system, which is our defense and repair system, our energy system, how we produce energy in our mitochondria, our detoxification system, our transport system, how we transport and move things around our body through lymph and circulation. And our communication systems, which is hormones, neurotransmitter, cytokines.
And our structural system, which is what we're made of. Everything from our biomechanical structure to our subcellular structures of mitochondrial membranes and cell membranes, and look at it through these lenses and allows us to remove the things that are causing impediments to health for people, which can be diet, stress, bor toxins, allergens, whatever microbes, and add into things that the people need to create health. The right food, nutrients, the balance of hormones, light, air, water. So it's really that simple. It's taking out the best and putting in the good stuff and letting these systems get back to balance.

Dr. Daniel Kraft:
As you talked about the telescope, many of us who are clinicians are very much in a very narrow silo. We look at one little fragment of biology. I'm an oncologist, I'll look at some subset of labs and studies. The rheumatologist looks at another. And I always think of functional medicines really starting to connect all those dots.

Dr. Mark Hyman:
Absolutely. Because we really have understood this framework before, but we didn't really have as much of the science and data behind it. If I can, I'll just share one case study. So this is a woman who was about 48 years old, and she had psoriatic arthritis, which is an autoimmune disease that affects the skin and the joints. Quite debilitating. And on Stelara, very expensive immune modulating drug that costs about 50 grand a year. She was depressed. She had irritable bowel and reflux and had extra weight and migraines and insomnia. And most of these problems when I looked at them, were being treated by separate experts, all with the latest and best and greatest treatments for that particular disease. And still she was kind of miserable. And I said, "Why do you have all these problems?" And they're all linked by inflammation. Depression is an inflammatory disease of the brain. Irritable bowel and reflux are inflammatory disease for the gut.
Psoriatic arthritis clearly is an inflammatory disease. Insulin resistance and pre-diabetes is also an inflammatory disease, which she had. Well in her case, it seemed pretty likely that it was her gut. We know the gut is the center of 60% of your immune system. And so I said, "Why don't we try to clean up your gut and get rid of the inflammatory triggers that in your diet", and we just sort of guessed it was gluten and dairy and sugar processed food and put her on a whole foods anti-inflammatory diet. I gave her things to clear out the bacterial overgrowth in her gut. And then I gave her antifungal because she had tons of antibiotics and steroids. I gave her a multivitamin, fish oil, vitamin D. And I said, "Okay, I'll see you in six weeks." And she came back and she lost 20 pounds.
She wasn't depressed. Her reflux was gone. Her irritable bowel was gone. She was sleeping. Her mood was better, and her psoriatic arthritis was gone. And I hadn't told her to stop her medications, but she had her own and felt so good she stopped them. And so all these different conditions, which we see as separate siloed problems treated by different specialists with different medications are often linked by common underlying root causes. And so functional medicine in a sense is the medicine of why, not what disease do you have and what drug you do, but why is this going on? And how is this all connected?

Dr. Daniel Kraft:
And many folks, as this patient had basically poly chronic disease and you're finding a root cause. Can you give some examples of now how medicine is transitioning to food and food is medicine?

Dr. Mark Hyman:
Well, food as medicine is a general concept. But what we're learning about is the unbelievable influence of the molecules in our food on our biology. Food is the single biggest biological response modifier on the planet and we're intersecting with it every day. I'll just give you a couple of examples of how we're being doing anything differently about using food to regulate some of these systems. So one is the gut. We know that yes, if you want to have a healthy gut microbiome, eat more fiber and prebiotics. But what we're learning also is that polyphenols, which are these compounds in foods, the phytochemicals that are found in the plant kingdom, there's 25,000 of these, many of them are just beginning to understand. And it turns out that it's a very important bacteria called Akkerman eosinophilia, which coats the lining of the intestinal tract and helps prevent damage and prevents leaky gut and inflammation diseases, and can be involved in all sorts of different problems if it's low, such as heart disease, diabetes, autoimmune disease, and even cancer.
These particular bugs love to eat green tea, pomegranate and cranberry, and then they grow. It's like fertilizer for them. In order for them to function, your gut has to be healthy and the Akkermansia levels have to be high, otherwise they don't work. And William Lee, who I think as well as a friend, is a world renowned physician scientist whose mother had stage four uterine cancer and was not responding to these drugs. And he said, "Wow, I read about Akkermansia, so I'm going to check my mom." And she checked her poop. He gave her these polyphenols. Her Akkekrmansia came back and she was cured of stage four cancer simply by understanding how to use food as medicine. There's another kind of great example of a food that has been rediscovered called Himalayan Tartary buckwheat. And it was grown in conditions which were super arduous. Very little water, high altitude, cold temperatures, poor soils, just awful life for a plant.
But it forced the plant to bolster its own defenses. And the defenses of plants are these phytochemicals. Himalayan and Tartary buckwheat has over 132 phytochemicals, some of which are found nowhere else in the world and is probably the most powerful super food on the planet. The immunomodulatory effects of these phytochemicals from buckwheat are so profound. So right now, the aging process, we're understanding in more detail and one of the things we're learning is that we often are calling aging inflammaging because it's a disease, often have inflammation across the spectrum of our age.
The body in the bone marrow produces your white blood cells, which help regulate your immune system. Well, when your stem cells that make the white blood cells and your bone marrow get injured by poor diet, stress, toxins, the usual stuff, it produces these funky white blood cells and it produces out a million white blood cells every second. And they accelerate the aging process. Well, it turns out very hard to get rid of them except when you use a Himalayan Tartary buckwheat, the phytochemicals in there kill the zombie cells. So it's an example, for example, of how we can rejuvenate our immune system or rejuvenate our microbiome using food as medicine in a very specific particular way.

Dr. Daniel Kraft:
Yeah, I think it's a new mindset. So functional medicine I think is really super impactful, particularly for folks with multiple comorbidities and diseases. You've done a lot of work leading at the Cleveland Clinic. How have you integrated into a more traditional Cleveland Clinic element?

Dr. Mark Hyman:
When you are so far in your intellectual development and your scientific career, you understand there's a lot we don't know. You're humbled by the sort of enormous body of knowledge that we don't have in medicine and understand that our traditional models don't explain everything. And so there's been a real welcoming of this approach for the most part. And so we've created a group model where we've actually called functioning for life, where we've created outcomes that are three times as good as one-on-one visits at lower costs for delivering health care for chronic disease. One woman came in named Janice, she was 66 and she was the typical comorbid nightmare of any internist. Her BMI was 43, which is massively overweight. She had type-two diabetes for 10 years. She was on insulin. She had heart failure with an ejection fraction of like 30%. Her kidneys were starting to go.
She had a lower kidney function, fatty liver, high blood pressure. She had a number of stents put in. She was a mess. She was on tons of medications and her copay was 20 grand a year. And she grew up on junk food because that's all her family gave her. And she was on her way out. She was like on her way to a kidney transplant, heart transplant. In joining the program and changing her diet and doing some simple things we do in functional medicine, she was off her insulin in three days. She was off all her medications in three months and lost 43 pounds. And in a year she was off everything and her A1C in three months went from 11 to five and a half. That's almost a six point reduction. You don't see that. If you see a drug that causes a half a point or a one point or two point, that's like a miracle drug for diabetes. And so here's the potential in a place like Cleveland Clinic to start to really see these transformations in care, both in terms of what we do and how we do it.

Dr. Daniel Kraft:
Do you, or the functional medicine field in general, manage or treated Covid in any distinct ways?

Dr. Mark Hyman:
When we focus on getting the body to function better, which is functional medicine, then disease has a harder time showing up. So we've really been focusing at the Institute for Functional Medicine, which is a 501c3 nonprofit educational institute, on how do we train our clinicians to help people address Covid in a different way. For example, vitamin D plays a huge role in your risk of getting it and your outcomes. We know that Selenium plays a huge role. That zinc plays a huge role that there are a lot of different approaches that can be used to optimize your biological function. The goal of functional medicine is how do we optimize the body's own functioning to help it become disease resistant? And that's really the beautiful piece about it.

Dr. Daniel Kraft:
And certainly in the setting of Covid, a lot of the folks who had the comorbidities and mortality rates had social disparities. Sometimes something as simple as vitamin D level and optimization can play a big role, not just maybe for preventing Covid, but other elements from osteoporosis and beyond.

Dr. Mark Hyman:
I remember talking to Dariush Mozaffarian, who's the dean of Tufts School of Nutrition Science and Policy early on, and he said, "Mark, I think there's a lot of data on nutritional immunology. And we have a whole nutritional immunology department at Tufts and we've identified a number of compounds that seem to be high potential for Covid." And he said, "We're really struggling to get any funding to study this. So we'll spend billions and billions and billions and billions and billions of dollars on, for example, vaccine development or drug development. But we won't spend literally hundreds of thousands on doing studies to look at some of these other approaches." It's really unfortunate because again, there's no big pharma company pushing this. There's no one who's going to benefit at the end really, other than the patients. And the health care system, we have a financially driven health care system.
Unfortunately, it doesn't always elucidate the best treatments like we talked about with this patient Janice, who had type two diabetes. And we saved untold hundreds, maybe millions of dollars of healthcare costs for her. And yet what we had to do was concoct a way of treating her with a shared medical appointment that was hacking the system so we could actually bill, it is just kind of stupid. I mean, we should be able to deliver this care universally to everybody, and we should democratize health care. I think I learned from Paul Farmer about what he did to treat TB and Aids in Haiti was using the power of community and community health workers and going into people's homes and figuring out what the obstacles were for them to change. We need to do kitchen biopsies and fridge biopsies, and yet we don't really pay for those or we don't even study those that much.

Dr. Daniel Kraft:
Do you see the opportunity now to leverage these new digital connected tools, both social measurement, therapeutic, to really kind of almost not say digitized functional medicine, but to bring some of those elements to scale?

Dr. Mark Hyman:
Absolutely. I mean, we are unfortunately so backwards in our approach to treating patients. We see them in the office, we give them a prescription, we tell them to change their diet, they go home and we're like, "Good luck." And even when you look at the best data, only half of prescriptions are filled. And then once they're filled only, I think half of them are taken even for things like statins, which it's kind of scary. So for example, we've now developed virtual shared medical appointments at Cleveland Clinic where we are doing the same care. People in their homes are on a format like Zoom and they're able to interact with each other, share and support each other in ways that really drive behavior change. Because we know about the socio genomics. I sort of came back from Haiti and realize that chronic disease was also treatable in this way. That health is contagious, but so is chronic illness and if your friends are all drinking beer and eating McDonald's and having french fries and sitting around watching TV, you're probably going to be overweight and unhealthy.
But if all your friends are drinking green juices and going to yoga class, you'd probably be a little healthier. We got 15,000 people at Saddleback Church to lose a quarter million pounds in a year and get healthy by simply doing it in small groups together. So whether it's a virtual group, whether it's things in homes or churches, we've now got 30 churches in Cleveland doing the Daniel Plan, the faith-based wellness program. Even though place of Cleveland Clinic is so advanced, I said to the CFO when I first got there, "We should hire 10,000 community health workers. That's going to really fix our population health problem." He's like, he didn't quite get it. It's hard to tell people about it in the future that they can't actually see. Well, I think we'll get there, but it's these other disruptive tools that are coming outside of healthcare are really going to move healthcare in the right direction.

Dr. Daniel Kraft:
The future is coming faster than you think. Community health workers can now be upskilled with everything from a tablet, computer or a sensor. So we've talked somewhat unhealthy conversations about Covid as a catalyst. I'm wondering how you're seeing it shift functional medicine, whether you're seeing any sort of vaccine hesitancy.

Dr. Mark Hyman:
Yeah, I mean I think it definitely has affected us. And I think the Institute for Functional Medicine's position is that vaccines are important in a necessary part of our Covid strategy baseline. It's not an either or phenomena. And what really breaks my heart, Daniel, is the complete and almost utter disregard for the science of who gets Covid and who gets really sick from Covid and who dies from Covid. And what we can do about that, which is those patients with obesity and chronic disease primarily caused by food. But really it's quite a deafening silence in the scientific community talking about how we need to address Covid by getting our overall health as a population up. Cleaning up our diet, by dealing with our stress, by addressing our levels of activity and exercise and sleep, which all affect our immune system.
I think we have the potential to really transform things. I mean, even with the flu, we know that, for example, if your vitamin D levels is really optimal, you're 75% less likely to get the flu. Well, that's a simple intervention that costs pennies and we just really don't talk about that. Maybe this podcast will get people listening and thinking about refocusing on our pandemic resilience, not just by being ready from a political perspective by having enough gowns and masks or vaccines, but pandemic resilience from taking care of our own immune systems in a different way.

Dr. Daniel Kraft:
Well, Cleveland Clinic is an Ohio, arguably a purple-ish state. And have you seen some lessons that collaboration you see in a place like Cleveland Clinic help address those divides?

Dr. Mark Hyman:
Yeah, I think there's a real focus on social determinants on addressing these issues. We now have in our EMR a whole social determinants set of questionnaires. We also have a clinic called the Recover Clinic. Because the long hauler phenomena is a real phenomena. About a third to a half of people who get Covid may have some residual symptoms long after they've been acutely ill. And we're not sure why, but it's sort of striking when you see, we've had 32 million of the date of this recording, people in America diagnosed with Covid, half a million have died or 150 million worldwide have Covid. It's estimated that half to a third of those people will have long-term symptoms. That terrifies me. So we really have to collaborate and think differently about how do we treat these patients who have chronic critique like symptoms after Covid. And that's exciting to happen at Cleveland Clinic. We've got this multidisciplinary team and we're all working together to come up with strategies to work on all the ways of treating these patients in a different way.

Dr. Daniel Kraft:
I think that's super critical because it does seem like the long haul that is so complex and there's no one size an element to it. So last question I'd have is around, does your perspective and that a functional medicine play a role from preventing depression, grief, the PTSD in this integrated, more holistic way? Any kind of take home messages there?

Dr. Mark Hyman:
We really need to rethink health. We need to rethink disease. Because it's not just what we do that matters. It's how we do it. And some of the democratization and decentralization of healthcare is really what's going to change everything. It's healthcare without walls, it's hospitals without walls, it's putting health in the hands of consumers. Because health doesn't happen in the hospital. I can't cure diabetes in the office. It's cured on the farm, in the grocery store, in the kitchen. And so having us rethink all this in this moment, if Covid is forcing us to look at our vulnerabilities, at our risks, and sort of reimagine a new healthcare system based on how do we create health as opposed to simply just whack-a-mole with diseases and medications. I'm just sort of thrilled to be alive in this moment and I hope I live long enough to kind of see the fruition of what I'm seeing as the trends heading forward.

Dr. Daniel Kraft:
Well, you've certainly been a trendsetter and a catalyzer and done amazing work at Cleveland Clinic and beyond, so thanks for all you've been doing and thanks so much for joining us on Healthy Conversations today.

Dr. Mark Hyman:
Oh my God, thank you for having me. What a pleasure.