5th Annual MMH CONFERENCE – San Antonio , TXFriday, September 19, 2014

THE PHYSICIAN IN SPITE OF HIMSELF II: The Pathway Toward Enlightened, Integrated & Holistic Practice

(The Adventure Continues!)

Louis B. Cady, MD – CEO & Founder – Cady Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Wellness Institute

Continuing Medical Education Commercial Disclosure Requirement

I, Louis B. Cady, M.D., have the following commercial relationships to disclose:

• Speaker faculties: Forest Pharmaceuticals, Sunovion, Shionogi, Takeda-Lundbeck

•Testing laboratories: Immunolaboratories, Great Plains Diagnostic Labs, LABRIX•Commercial endeavors: Pharmanex distributor•Historical honoraria, speaking: Bristol-Myers Squibb, Celltech, Cephalon, Eli Lilly, Glaxo Smith Kline, Janssen, McNeil, Pfizer-Roerig, Sanofi~aventis, Searle, Sepracor, Shire, Takeda, WorldLink Medical, Wyeth-Ayerst

WHERE TO “GET THE SLIDES”

Syllabus

www.slideshare.net/lcadymd

Cady Wellness Institute app.

THIS IN IN YOUR SYLLABUS ON THE LAST SLIDE OF EACH TALK.

www.slideshare.net/lcadymd

Le medicin malgre lui – Moliere, 1666

Microsynopsis: Sgnarelle – an alcoholic woodcutter forced into posing as a doctor who becomes rich and respected.

Going from “Drunken Woodcutter” status to the present….. With a little

help from my friends• My colleagues & peers at this conference:

Dr. William Shaw Ph.D., Dr. Kurt Woeller DO, Dr. Bill Code MD & many new friends!

• My mentors: especially Dr. John Graf, MD, Mayo Clinic

• My patients:– “You should be able to treat your clients as dear

and valued friends.” – Jay Abraham

“If you can only read one article in your entire career at Mayo on psychotherapy, read this one.”

- John Graf, MD

“If you can only read one article in your entire career at Mayo on psychotherapy, read this one.”

- John Graf, MD

Greben, S. Can Psychiatr. Assoc Journ. Vol 22 (1977): 371-380

“On Being Therapeutic”“On Being

Therapeutic”

Psychodynamics and functional medicine

• Some therapists stand out as uniquely effective.

• Academics are no better.

• “Every potential therapist must have a floor and a ceiling to his therapeutic capacity.”

• Some gifted therapists are able to say why they succeed; others can’t explain it. “A great deal of what they do ‘right’ is intuitive.”

“On Being Therapeutic” - Stanley Greben, MD [Canadian Psychiatric Association Journal. Vol. 22(1977) 371-380].

Greben’s “Seven Habits”• Empathy & concern

• Warmth

• Interaction

• Ability to arouse hope

• Expectation of improvement

• “Not to despair”

• Reliability & Friendliness

*Requires clinical depth and breadth of knowledge

*

Psychodynamics 101

• Patients can be vexing.• Diagnostic impasses provoke narcissistic angst.• Frustrated clinicians do not relate well with

patients.• The more tools and capabilities one has, the

greater the freedom, the options, and the ability to positively impact the patient.

• The greater the success, the better the patient feels, the doctor feels, and the doctor-patient relationship feels.

• The converse, worrisomely, also exists.

Animal, Vegetable, or Mineral?

The Case of the Phrustrated Pharmacist

North America 85%

South America 76%

Asia 76%

Africa 74%

Europe 72%

Australia 55%

% Mineral depletion from the soil during the past 100 years, by continent

Source: UN Earth Summit Report 1992

Huge reduction in Vit D & Iodine in last 40 years (source: www.vitamindwiki.com)

2X to 3X less Vitamin D 4X less IodineAir conditioning, sunscreen, multi-media Less Iodine in milk (no longer used

on cows)indoor jobs, less cholesterol, more obesity Less Iodine in bread (no longer

used in processing)live in cities - which have less UVB Increased use of Iodine blockers:

Fluoride Chlorine and Bromide (used in flour)

also perchlorate in some fertilizersincreased used of farmed fish (1/4 the Vit D) Less iodine in salt:

1) Use table salt much less 2)No Iodine in salt used in processed foods

3) half of iodized salt does not meet requirements

Swiss have increased iodine in ALL of their salt – from 3.75 mg/kg in 1975 to 20 mg/kg in 1998. Their intake > 2X US.

Magnesium mementos• One of the first minerals to disappear with:

– Processed food– Stress

• Decreased by EtOH, caffeine, sodas, meds

• Considered “anti-stress” mineral– Decreases cortisol (rel to sleep disruption)– Relaxes muscles, prevents cramps (sleep

disruption)– Decreases anxiety; improves sleep

Symptoms of Magnesium Deficiency

PSYCHIATRIC ISSUES:•Difficulty with memory and concentration•Depression, apathy•Emotional lability•Irritability, nervousness, anxiety•InsomniaAutismADHD

Migraine headaches PMS Dysmenorrhea Fibromyalgia Fatigue CONSTIPATION

Health Conditions Associated with Magnesium Deficiency

http://epiphanyasd.blogspot.com/2013/11/magnesium-in-autism-and-other.html

SELENIUM DEFICIENCY in FASEB:

• “Adaptive dysfunction of selenoproteins from the perspective of the ‘triage’

theory: why modest selenium deficiency may increase risk of diseases of aging.”

Foundation of American Societies for Experimental Biology

McCann, J, Ames BM. FASEB J. 2011 Jun;25(6):1793-814.

“the foot soldier”

LifePak Nano has 200% of RDA of selenium.

Se+

THYROID HORMONE

& 76% the RDA for iodine

“The concomitant evolution between plasma Se decrease over a 9-year period and cognitive decline suggested that optimal Se status is potentially important to maintain neuropsychological functions in aging people.”

“The concomitant evolution between plasma Se decrease over a 9-year period and cognitive decline suggested that optimal Se status is potentially important to maintain neuropsychological functions in aging people.”

Negative downstream effects from selenium deficiency:

“…cancer, heart disease, and immune dysfunction are prospectively associated with modest selenium deficiency…. suggesting that Se deficiency could be a CAUSATIVE factor”

McCann, J, Ames BM. FASEB J. 2011 Jun;25(6):1793-814.

November 2009 “Alpha Male” issue

Observational study of randomly selected men – Boston3 cohorts of men: 1987-1989; 1995-1997; 2002 -2004.1374, 906, and 489 men, respectively. “Age independent decline in T that does not appear to be attributable to observed changes in explanatory factors, including lifestyle characteristics such as smoking and obesity.”“Recent years have seen a SUBSTANTIAL, and as yet UNRECOGNIZED age-independent population-level decrease in T in American men.” Travison, Araujo, et al. Jrnl of Clin. Endocrinol & Metabol 92:1; 196-202.

Fast food (low Zn) is bad for you.

• Fast food = high energy density = low essential micronutrient density, ESPECIALLY ZINC

• Antioxidant processes are dependent on Zinc• Fast food = severe decrease in antioxidant

vitamins and zinc, correlating with inflammation in testicular tissue – with underdevelopment of testicular tissue and decreased testosterone levels

Special needs - Zinc

• Low Zinc- associated with low testosterone– Per USDA, 60% of US men between 20 – 49

years of age do not get enough.– N.B.: Do not supplement with > 50 mg daily (can

interfere with Cu+ metabolism)• Tsai, E.C., Boyko, E.J., Leonetti, D.L., & Fujimoto,

W.Y. (2000). Low serum testosterone level as a predictor of increased visceral fat in Japanese-American men. International Journal of Obesity and Related Metabolic Disorders, 24, 485-491

Special needs - Zinc• Low Zinc- associated with low testosterone

– Found in meat, seafood, oysters & dairy– Vegetarians at highest risk for zinc deficiency– Per USDA, 60% of US men between 20 – 49 years

of age do not get enough.– (N.B.: Do not supplement with > 50 mg daily -can

interfere with Cu+ metabolism)• Tsai, E.C., Boyko, E.J., Leonetti, D.L., & Fujimoto, W.Y. (2000). Low serum

testosterone level as a predictor of increased visceral fat in Japanese-American men. International Journal of Obesity and Related Metabolic Disorders, 24, 485-491

Balanced presentation inclusive of women…

• Oral zinc raises testosterone levels in women.– Vecchio M, et. Al. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD007747. doi:

10.1002/14651858.CD007747.pub2.

• Transdermal testosterone improves:– Sexual desire, arousal, orgasm frequency, and sexual

satisfaction in premenopausal and post-menopausal women.– Also associated with favorable effects on body composition,

bone, cardiovascular fxn, and COGNITION• Davis SR. Androgen therapy in women, beyond libido. Climacteric.

2013 Aug;16 Suppl 1:18-24. doi: 10.3109/13697137.2013.801736. Epub 2013 May 27.

Louis B. Cady, MD – CEO & Founder – Cady Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Wellness Institute Adjunct Asst. Prof of Psychiatry – Indiana University School of Medicine Department of

PsychiatryChild, Adolescent, Adult, Functional Neuropsychiatry –

Evansville, Indiana

Hormones, Cognitive Dysfunction & Depression in Older Adults

AMMG Fall Conference – Nov. 2, 2012 – General Session Curriculum 2:00 – 2:45 pm Las Vegas, NV - USA

T vs Cognitive Function

Rosario ER. Age-related testosterone depletion and the development of Alzhiemer disease. JAMA. 292(2004):1431-2

T vs. Cognitive Function• 400 independently living men, 40-80yo

– 100 in each age decade– MMSE 21-30, average 28– TT: 208-1141ng/dL; Bio-avail T 78-470ng/dL

• HIGHER T = better cognitive performance in OLDEST AGE category

• Men with lowest 1/5 T = worse than men with highest 1/5 T

• Highest Bio-available T more significant than TT, age, intelligence level, mood, smoking, and alcohol.

Muller M, et al. Neurology. 2005 Mar;64(5): 866-71

T vs. Mood in men

• Study: 278 men, >45yo, followed 2 years

• Compared to eugonadal patients, hypogonadal men w/TT <200ng/dL had – 4-fold increase risk of depression– Significantly shorter time to depression

diagnosis

• Depression risk inversely related to TT w/statistical significance <280ng/dL

Shores MM, Arch Gen Psychiatry. 61(2004):162-7

T vs. Heart Disease

• Men with CAD have significantly LOWER levels of androgens than normal controls.– English, KM et al. Men with coronary artery disease have lower

levels of androgens than men with normal coronary angiograms. Eur Heart J. 2000 June; 21(11):890-4.

• “There is early evidence from non-randomized studies that physiological testosterone replacement is extremely safe and may reduce cardiovascular mortality.”– Hackett G. Testosterone and the heart. Int J Clin Pract. 2012

July;66(7):648-55.

Low T’s (thyroid/testosterone) & presumptive nutrient deficiencies in the aging male:

The Phrustrated Pharmacist (8/3/2014)

• 73 yo MWM retired (2009) R.Ph. “burned out.” Essentially sitting home depressed. Not going anywhere.

• Presenting Rx:– Fluoxetine – 40 mg – Seroquel 50 mg XR for sleep (bipolar)– Hydralazine, amlodipine, Zocor, Metformin, ASA

• ROS: decrease in libido. Profound fatigue.

Mental Status Examination: • Depression:

– Sad/depressed/down in the dumps

– Lack of/loss of interest in things.

– Trouble concentrating

– Insomnia/trouble sleeping at times.

– Decreased energy

– Guilty/worthless – which wasirrational – he had nothing to feel guilty about it. (6 total symptoms; 5 = required)

• Other sxs:– Weakness, hopeless, feeling life is not worth living, sleeping too

much, loss of libido, and full diagnostic criteria met for generalized anxiety disorder

Relevant markers• Thyroid functions

– TSH 0.43 {0.34 – 5.61}– Free T4 1.34 {0.587-1.64}– Free T3 2.8 {2.0 – 4.4}– Reverse T3 32.1 (H) {9.2 - 24.1}

• Sex hormone– LH 8.7 (H) {1.24 – 8.62}

– Total testosterone 199 (L) {348 – 1197}

– Free Testosterone 3.6 (L) {6.6 – 18.1}

– PSA 0.24 {0.0 – 4.0]– Estradiol 13.6 {7.6 – 42.6}

• Coenzyme Q10 0.75 {0.37-2.20}

• Raman score 24,000 {>50,000}– ( =1.44 MICROgrams carotenoids/ml serum)

Interventions – 8/14/2013• Testosterone IM

– 200 mg ASAP, then 100 mg every 4 days until levels better.

• DHEA – 25 mg timed release• Liothyronine, timed release• Excellent MVI/multi-mineral/fish oil

supplement/phytonutrient/antioxidant supplement (with 200% Selenium; 100% Zinc RDA, 600 mg EPA, 400 mg DHA)

• continued fluoxetine

The Phrustrated Pharmacist: What happened?

• 11/26/2013 – (3 ½ months later)– Going to all grandchildren’s soccer games

– Out mowing his yard and mulching leaves

– Depressive symptoms ELIMINATED.

– Appetite has gone up; but clothes fitting better.

– Plenty of energy.

• 1/16/2014– “I’ve been doing good – I’m doing everything. I walk the dog

every day. I go to the soccer games.”

– Has gone to get OSA checked.

– Has lost so much weight (60 lbs) he’s using clothes pins on pajamas.

What happened to labs (1/6/2014)?

• Thyroid functions– TSH 0.47 {0.34 – 5.61}– Free T4 0.67 {0.587-1.64}– Free T3 3.8 {2.0 – 4.4}– Reverse T3 14.5 {9.2 - 24.1}

• Hormones (Rx of 80 mg T twice weekly)– Total testosterone 582 {348 – 1197}– Free Testosterone 12.0 {6.6 – 18.1}– DHEA-Sulfate 378 (“H”) {30.9 – 295.6”; OPTIMAL

RANGE – per Cenegenics is about 500}

Frustrated Fpharmacist Follow-up – 4/15/2014

• Animated and alert. • Got hired to tutor pharmacology at local

community college. • Playing in handbell choir again.

– “I’m not very good – they let me play the half notes and whole notes with the great big bells.”

• Quipped about a customer he recalled who came in ask (in past) and asked for “methyl-testosteroney.”

• On CPAP for six weeks. Doing well.

Raman spectroscopic carotenoid scans:

• 1.44 ugrams carotenoid/ml - 8/27/2013• 2.4 ugrams carotenoid/ml - 9/27/2013• 2.58 ugrams carotenoid/ml - 11/26/2013 (this is

without a lot of supplementation and none in the last two weeks. He is eating more fruits and vegetables.)

• 2.52 ugrams carotenoid/ml- 1/16/2014 on one pack of MVI/multi-minerals and fish oil (7 capsules)

• 2.82 ugrams carotenoid/ml - 7/15/2014

Antioxidant assessment

Reference:www.cadywellness.com/cadywhitepaper2008.pdf

Reference:www.cadywellness.com/cadywhitepaper2008.pdf

(c) 2013 Louis B. Cady, M.D. - all rights reserved

“The findings support studies that state that major depression is associated with mitochondrial dysfunction and OXIDATIVE STRESS, and that omega-3 supplementation could reverse some of these changes, probably due to its antioxidant properties.”

“The findings support studies that state that major depression is associated with mitochondrial dysfunction and OXIDATIVE STRESS, and that omega-3 supplementation could reverse some of these changes, probably due to its antioxidant properties.”

Raman spectroscopic carotenoid scans:

• 1.44 ugrams carotenoid/ml - 8/27/2013• 2.4 ugrams carotenoid/ml - 9/27/2013• 2.58 ugrams carotenoid/ml - 11/26/2013 (this is

without a lot of supplementation and none in the last two weeks. He is eating more fruits and vegetables.)

• 2.52 ugrams carotenoid/ml- 1/16/2014 on one pack of MVI/multi-minerals and fish oil (7 capsules)

• 2.82 ugrams carotenoid/ml - 7/15/2014

Final Follow-up – 7/15/2014

• Animated and alert. • Has lost more weight – now down to 209 lbs.• Played 18 holes of golf two weeks previous.

– “It was 46 – 47 years ago when I did that last time.”

• Local doc has told him he can drop one metformin when his weight gets down to <200 lbs.

• Still on CPAP. Doing well.

Teaching points• No change in antidepressants required to

ELIMINATE depression.• MVI/multimineral/fish oil used to support the

structure & function of the body.• Appropriate allopathic care given.• Predictable results occurred. • BUT WHAT ABOUT THE LAST 20 YEARS?• This way of thinking works in ALL specialties.

“Pending strong evidence …from randomized trials, it appears prudent for all adults to take vitamin supplements.” Fletcher & Fairfield, JAMA 2002

Bruce Ames, Ph.D.395 citations in PubMed, May 1952-June 2014.

Most recent is “Enough is Enough” Ann Intern Med 2014 Jun 3, with Frei, Blumberg and Willett

November 2, 2012

Ames & Micronutrient Triage - deconstructed

1. Inadequate dietary intakes of vitamins/minerals are widespread.

– Excessive consumption of energy-rich, micronutrient-poor, refined food

2. Deficiencies in many micronutrients cause DNA damage in cultured or living human cells.

3. Proposal: DNA damage and late onset disease are consequences of a triage allocation based on micronutrient scarcity.

– Natural selection favors short-term survival at expense of long-term health.

Ames B. Proc Natl Acad Sci U S A. 2006 Nov 21;103(47):17589-94. Epub 2006 Nov 13.

Ames & Micronutrient Triage - deconstructed

4. If proposal is correct, “micronutrient deficiencies that trigger the triage response would accelerate cancer, aging, and neural decay but would leave critical metabolic functions, such as ATP production, intact.”

5. “A multivitamin-mineral supplement is one low-cost way to ensure intake of the Recommended Dietary Allowance of micronutrients throughout life.”

Ames B. Proc Natl Acad Sci U S A. 2006 Nov 21;103(47):17589-94. Epub 2006 Nov 13.

44 million inpatients, 460 sites, 2000-2010 = 20% of all US inpatient episodes (1.6% were on ONS during the inpatient episode.)

44 million inpatients, 460 sites, 2000-2010 = 20% of all US inpatient episodes (1.6% were on ONS during the inpatient episode.)

>/= 18 years. No terminal patients, tube feedings.>/= 18 years. No terminal patients, tube feedings.

RESULTS for “ONS”:•2.3 day shorter length of stay•Decreased cost of $4,734 / episode•2.3% reduced probability of early readmission.

RESULTS for “ONS”:•2.3 day shorter length of stay•Decreased cost of $4,734 / episode•2.3% reduced probability of early readmission.

CONCLUSIONS: “Use of ONS decreases length of stay, episode cost, and 30 day readmission risk in the inpatient population.”

CONCLUSIONS: “Use of ONS decreases length of stay, episode cost, and 30 day readmission risk in the inpatient population.”

Tomas J, et al. Am J Manag Care. 2013;19(2):121-128

• Irritability• Apathy• Personality changes• Depression • Memory loss• Dementia• Hallucinations• Violent behavior• Anxiety

Symptoms of B12 Deficiency

• Diminished sense of touch and pain

• Clumsiness• Weakness• Pernicious anemia• Chronic fatigue• Tremors• GI problems

Mental Physical

The Effects of high dose B vitamins on stress at work

• “Occupational stress is increasing in Western societies.”

• 3 month, double blind, placebo control, randomized study

• Measured: Personality, work demands, mood, anxiety, and strain

• After variances in personality and work demands were

controlled, the vitamin B complex treated group reported significantly lower personal strain and a reduction in confusion and depressed/dejected mood after 12 weeks.

Strough C et al. The effect of 90 day administration of a high dose vitamin B-coplex on work stress. Hum Psychopharmacol. 2011 Sept 8. doi 10.1002/hup.1229 (Swinburne University of Technology – Hawhorn, Victoria, Australia.)

Vitamin/mineral supplementation & cancer, cardiovascular, and all-cause mortality (EPIC-Heidelberg) Li K, Kaaks R., et al. Eur J Nutri July 2011

• Purpose: evaluate vitamin/mineral supplementation with CA, CV dz, and mortality

• Methods:– 23,943 healthy participants, followed x 11 years– Baseline and “new-use” supplementation noted

• Results: 513 CA deaths, 264 CV deaths– “No MVI supplement had any significant effect”

– Baseline users of antioxidant supplements had significantly reduced risk of cancer [HR 0.52] and all cause mortality [0.58]

• “sick user” phenomenon discussed.

“Homocysteine lowering by B-Vitamins slows the rate of accelerated brain atrophy in MCI”…

Smith AD, Smith SM, de Jager CA, Whitbread P, et al. (2010) Homocysteine-Lowering by B Vitamins Slows the Rate of Accelerated Brain Atrophy in Mild Cognitive Impairment: A Randomized Controlled Trial. PLoS ONE 5(9): e12244. doi:10.1371/journal.pone.0012244http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012244

CONCLUSIONS: “The accelerated rate of brain atrophy in elderly with MCI can be slowed by treatment with homocysteine-lowering B-vitamins.”

Regional loss of grey matter volume reduced with B-vitamins

Douad G, et al. preventing Alzheimer’s disease-related gray matter atrophy by B-vitamin treatment. Proc Natl Acad Sci U S A. Jun 4, 2013; 110(23): 9523–9528.

OK. It slows shrinkage. But are they sharper? [deJager CA et al. Int J Geriatr Psychiatry. 2012 June;27(6):592-600]

“B-vitamins appear to slow cognitive and clinical decline in people with MCI.”

The Glamorous Grandmother• 4/8/11 – 80 yo returned to practice. No real

complaints. History of depression. On des-methylvenlafaxine.– Daughter “handling her finances”

• 5/2/11 – “doing terrible.” – TSH 3.84, Free T3 2.8 – on 50 MICROgrams T4– Fasting BS 120; HgBA1C 6.5%– Fasting insulin 36 (!!!) {3 – 25}– Progesterone – 0.2 {0.2 – 1.4 follicular}– Total testosterone 11– DHEA-S = 25 MICROgrams/dL (!!)

• Age adjusted {10 – 90} . Optimal = {c. 350-500}• Rouzier = {300 –females, 600 males}

G.G. - interventions 5/2/11 & Follow-up • Interventions:

– RAISE T4 from 50 to 75 MICROgrams – DHEA – 25 mg SR q a.m.– Progesterone 50 mg then 100 mg HS, transdermal. – Testosterone – 2 mg for one week, then 4 mg

transdermal– Referred to better MD for intervention with AODM.

• 6/13/2011 – improvement in fatigue. Labs rechecked.

• 7/11/2011 – “feeling wonderful” • Started on MVI/multimineral/fish oil supplement

G.G. – labs before and after

` 4/11/11 interventions 7/11/11 changes

TSH 3.84 Raise T4 from 50 – 75 ug

0.01 (L) none

FT4 1.16 “ 1.24 “

FT3 2.8 “ 3.3 “

Progesterone <0.2 100mg topical HS

0.9 None

Testosterone 11 4mg topical 15 4 mg LABIAL

DHEA-S 25 25 mg SR n/a continue

The glamorous grandmother – post tune-up: DHEA, thyroid, testosterone, progesterone

9/28/2011 (permission granted to use photos & data) 01/26/2012

Photo(s) removed for presentation posted on internet

October 12, 2012 – used with permission

July 29, 2014 – used with permission

• 85 years old – living independently

• Reading books• Driving car• Dating nice man from

church

• Thyroid RX:– T4 – 75 ug– T3 – 5 ug 2x/d

• Hormones:– DHEA 50 SR, Biest,

Progesterone, Testosterone

• Supplements: MVI/Multi-mineral/fish oil

G.G. – interventions & labs` 4/11/11 Interventions,

current6/9/2014 Ref range

TSH 3.84 Raise T4 from 50 – 75 MICROgrams, add 10 MICROgrams T3

0.02 (L) {0.45-4.5}

FT4 1.16 “ 1.07 {0.80-1.76}

FT3 2.8 “ 4.0 {2.3 – 4.2}

Estradiol 0.4 mg E2 SL 20 {27-122}

Progesterone <0.2 10 mg SL HS 1.5 {0.2 – 1.4 = follicular}

Testosterone 11 2 mg topical (wrists) 235(H) {5-32}

DHEA-S 25 50 mg SR 463 (“H”) {“10 – 90”}

NTX 19!! {17 – 94 –premenopausal}

ADHD as an exemplar of a precision & functional approach

“Trying as hard as I can”• ID: 20 year old biracial male.• CC:

– “People seem to think I have ADHD for some reason.”

– “I’m trying to go to this DII school – and I know I won’t be able to get through it if I don’t find out what’s wrong with me.”

• Academic failure impacting his athletic eligibility

• HPI:– Classic symptoms of ADHD since childhood.

– Parents were told that he wasn’t focused or doing his best, but that he was a “good boy.”

– Worked up at 8 years of age. But dx’ed with “anxiety disorder” and “learning disorder.”

BADNESS

GOODNESS

STATS:

•ATTENTIVE 12.5% (!!!) of the time

•Impulsive 72.5% (!!!)of the time

•Distracted 12.5% of the time

•Disengaged 2.5% of the time

BADNESS

GOODNESS

STATS:

•ATTENTIVE 60% (!!!) of the time

•Impulsive 32.5% of the time

•Distracted 7.5% of the time

•Disengaged 0% of the time

7/23/2013 – post treatment – 60 my Vyvanse (lis-dexamfetamine) per day

7/08/2013 – post treatment

Most recent follow-up – 6/27/2014

• Pitching for DII school as a walk-on trial.

• Concentration excellent.

• May audition for major league baseball team.

• No trace of ADHD.

• Only Rx is 70 mg of Vyvanse per day.

The Story of Alan• 2/24/2010 – “ADHD hampers his ability to focus and

comprehend information. He becomes overwhelmed. Lacks confidence in reading. Teacher believes he is capable.”

• Past history: “a busy child. “Couldn’t keep him in a chair.” • ADHD dx in kindergarten. Multiple Rx since, incl. Abilify• At presentation:

– 20 mg Adderall XR in a.m., 3 mg Intuniv in a.m., 5 mg Abilify at 4 pm.

– “Heart is racing” for two months. – Hx of stimulant rebound and having to push the dose– Stools like tar since starting on Abilify.

• Rating scales:– DSM-IV 9/8 before meds; DSM-IV 9/4 ON meds

Treatment summary and new developments

• Medications adjusted. Stimulant lowered and L-tyrosine started with it (inc. to 1 gram twice daily ).– Changed to Concerta + Ritalin (a.m.), Intuniv, Risperdal, and

Depakote (250 mg 3x/day)

• 11/9/10 and 12/6/10 – “meltdowns” at school. States “I am going to KILL you,” when he is upset. Kicking the table at school and not looking at the teacher.

• “Favorite food is pizza.”• 12/6/2010 – not totally coherent on MSE. c/o “head hurting.”

Seems generally tired and ill-appearing.– PE – grossly neurologically intact. (Examined).

• OAT test and IgG Food Allergy panel ordered.

“His favorite food is pizza.” – Mom(reviewed December 7, 2010 when these labs were

ordered)

“His favorite food is pizza.” – Mom(reviewed December 7, 2010 when these labs were

ordered)

Organic acid testing – 12/23/2010

Pertains to energy production, Kreb cycle, B vitamins, CoQ10, Mg

Interventions

• 1/5/2011:– School insisting he is “autistic” (meltdowns)– At appt. told to remove wheat, peanuts, and milk from diet– Started on CoQ10, B-50, ALA, Vit C & E

• 2/8/2011:– Alan - “for the first time I think the medicine is getting

right.” – “We need to tell Dr. Cady that that Kroger store in ____

has a lot of gluten free stuff he needs to know about.”

• Liquid fish oil added.

School work 6 weeks later…School work 6 weeks later…

School continuing to insist he is “autistic.”NOTE: doesn’t spin, doesn’t flap, doesn’t engage in stereotypical behaviors. Just had a history of “fits.”

School continuing to insist he is “autistic.”NOTE: doesn’t spin, doesn’t flap, doesn’t engage in stereotypical behaviors. Just had a history of “fits.”

Beginning of resolution….• 4/1/2011 – five weeks of “awesome behavior” at school

with “no blow-ups whatsoever.” – “The school authorities are amazed.” – Won STUDENT OF THE WEEK (!!)

• 5/31/2011 – concluded school year; no blow-ups. • 8/30/11 – some blowups, but not the “explosive kind like he

had last year.” • 12/21/11- scored “distinguished” in math and “proficient” in

reading. (continues supplements and diet)• 2/17/2012 – “Tired.” RX: lower Concerta from 54 to 36 mg• Having more meltdowns at school. New labs ordered.

IgG results – 3/29/2012

- Started on Nystatin, compounded, liquid – up to 500,000 IU three times daily. Also Probiotic. - ELIMINATE MILK & WHEAT

Progress!

Repeat IgG testing 06/28/2012

Original IgG 3 7 2012

Organic acid test – 6 26 2012

• Arabinose c/w candida (prev started on NYSTATIN)• All B-vitamin markers improved• Coenzyme Q10 high normal • HVA, VMA, 5HIAA – all increased.• Vit C low but c/w water solubility and a.m. spec.

Alan –7/31/2012• On Nystatin for candida, plus all Rx.• Concluded school year well. • “Was more interactive and playing on the

playground.”• Went up on state testing 17 points in reading. At

grade level in math. • Playing outside more, riding his bicycle. • Vitamin C increased 500 mg twice daily • Start on Curcumin/turmeric for inflammation• STABLE.

Alan –12/30/2013• In 6th grade. Working at grade level.• Going to retreats with church youth group.• Continues with strict DF/GF diet• RX:

– Allopathic: MPH-OROS decreased from 54 to 36mg; MPH 20 mg in a.m.; Intuniv 3 mg HS. Risperidone 0.25 mg 1 ½ a.m. and 1 pm. Valproate 250 mg ER three times daily. Nystatin dosing completed.

– HOLISTIC: L-tyrosine 1000 mg twice daily. Riboceine containing supplement; MVI, Coenzyme Q10, B50 twice daily , ALA, Vitamin E, Curcumin/turmeric 500 mg twice daily

How I got a patient’s wife pregnant and achieved fame in my time…

A “straight psych” workup?• 26 yo MWM ref by therapist –

5/14/2012.• Presenting issues:

– “obsessive unrealistic uncontrollable thoughts”– “anxiety and constant worry”– “I have strange thoughts that aren’t my thoughts” – “I can’t get rid of some disturbing thoughts.” – “have a low self-esteem & sense of

inadequacy” – “my whole life.”

A “straight psych” workup?• HPI: 2 months ago, acute onset [ego-

dystonic] of images of his wife with her throat cut.

• No previous formal psych history

• Med History: “dx with infertility and inadequate sperm count.” – “not feeling like having sex with wife.”

Eject button?

Labs 5/22/2012TFT’s

TSH 1.4 {0.3 – 5.6}Free T4 0.9 {0.6 – 1.1}|T3 Uptake 37% {24 – 39 – this is NOTE THE LAB I ORDERED.}Reverse T3 31.9 {13.5 – 34.2} 

TESTOSTERONE LEVELS:Total testosterone 227 (L) {348 – 1197; it probably should be in the 900 – 1000 range}Free Testosterone 6.6 (L) 9.3 – 26.5}

LH 5.3 {1.7 – 8.6}

DHEA-Sulfate 301.3 {160-449}

Rx:

• Continue Vilazodone titration for psych symptoms.

• Armour thyroid – ¼ grain x 7d, then ½ grain

• CLOMIPHENE CITRATE – 50 mg tabs – ½ daily x 3 – 5, then one daily

• HCG [human chorionic gonadotropin] injections = 1500 IU twice weekly SQ

• DHEA – 25 mg timed release daily

• Repeat labs ordered.

Labs & sperm count compared:• Previous:

– 400,000 {50 – 150 MILLION}– 35% motility– Low amount ejaculate

• New results - 6/21/2012 – one month later • Testosterone 956!! {348-1197}– 125 million (!!!!!) {50 – 150 MILLION}

– 85% motility– 4 cc ejaculate

• Patient & wife told to go PARTY DOWN!!• Patient & wife told to go PARTY DOWN!!

E-mail Oct. 19, 2012 –Subject: “Our first baby pic”(nine weeks gestation)

June 11, 2013

Interesting follow-up

• January 24, 2014 – happy with one child. Feeding the baby at appt. Wife with him. OK to go off clomiphene and HCG. Started on Axiron.

15 ½ months – Aug 27 2014Surprise! New sister! (EDC – 10/21/2014

Teachable points for this case• It’s not about the “age management” ideas.• It’s about LISTENING to the patient.• OPTIMIZE the biological platform• Refer or consult if you don’t know, but don’t

“wimp out” and push the “delete” or “eject” button on patient concerns. – Don’t say, “it’s not my department; I don’t know

about that.”

• If the patient expresses it, it’s a problem. • The body affects the mind and the thoughts.

How are you feeling?

Integrating functional medicine techniques

• Don’t blame the child, the parents, or the adult patient.• If you do not KNOW it’s not a biological, physical problem,

then you simply don’t know. PERIOD.• It’s most likely not a “Risperdal deficiency.” • It’s not an “Axis II” issue unless you have DEFINITIVELY

RULED OUT a biological problem.• Test test test test test. You can’t tell by “looking.”

– FUNCTIONAL MEDICINE TESTING in difficult cases.

• Recognize the importance of DIET.• Appropriate – not excessive – use of supplements and

interventions.– Be able to explain each one. (“The Peter Lynch rule.”)

Things to consider / action items:

• You must adapt; medicine is changing.– Internet and wide information distribution– Health care expenditures out of control– New paradigms of nutrient insufficiency and

environmental toxins– There are no new “magic bullets.”

• You don’t have to know it all and do it all... But you must be willing to ACKNOWLEDGE and REFER.

Things to consider / action items:

• Do not consider outside diagnoses as indisputable. EVERYTHING is “up for grabs” until proven.

• Integration of functional medicine is like learning to walk – “You do it UNTIL.”

• Humble your ego, admit your ignorance, and ask questions.

• Remain intellectually open and playful.

But what about the healers??

Or – “How do you want to spend the rest of your professional

lives?”

“Today, almost 50% of doctors report symptoms of burnout – emotional exhaustion, low sense of accomplishment, detachment.”

“Today, almost 50% of doctors report symptoms of burnout – emotional exhaustion, low sense of accomplishment, detachment.”

40% OF DOCTORS ARE BURNED OUT

• Too many bureaucratic tasks

• TOO MUCH PAPERWORK– ¼ of time is spent

in non-clinical paperwork.

– Dealing with “checkbox medicine”

Source: Medscape’s 2013 Physician Lifestyle Report cited in “Staying Sane as Medicine Goes Crazy” – July 25, 2014

How do YOU Want to Practice?

Doctors quitting medicine

• Suicide* (2004):• 1.41 X for male physicians vs. general pop.• Schernhammer ES, Coldit GZ. Am J

Psychiatry. 2004 Dec; 161 (12):2295-302

• "Half of primary care physicians in survey would leave medicine ... if they had an alternative." -- CNN, November 2008*

“Why I Left Medicine: A Burnt-Out Doctor’s Decision to Quit”*

• “It may be dramatic and self-serving to frame my career change as a way to avoid suicide, but I can attest that medicine was not conducive to my health.”

http://commonhealth.wbur.org/2013/10/why-i-left-medicine-a-burnt-out-doctors-decision-to-quit 10/18/2013 – accessed 01/07/2014

Are the Best and Brightest Staying in Medicine?

“60% of physicians would not recommend medicine as a career to their children.”

• – The Physicians’ Foundationhttp://www.mayorswellnesscampaign.org/wp-content/

uploads/2009/05/merritt-hawkins-survey.pdf. Accessed April 3, 2010.

Slide courtesy of John Adams, MBA – CEO, Cenegenics

THE ANTIDOTE (and Wellness for Docs)

ACHIEVE PERSONAL MISSION:

Change people’s lives – don’t push pills/drugs/ (or even supplements)

Healers: Take care of yourselves.

Seen for intake in my office – 9/5/2012• Alert. Serious. Intent on toys.

Played with them loudly. Not speaking in complete sentences. Phonated repetitively.

• Huddled down and pulled his lunch box in front of him when I asked him a question.

• Obsessive play with toys. “Push push push.”

Extensive laboratory testing ordered. Armour restarted.

December 5, 2012 follow-up• RX:

– Armour thyroid 1 ½ grains; Nystatin; high dose MVI with B-complex; GSH precursors, Cod liver oil, B6, Vit C, probiotics, 1 mg ionic Lithium.

– On food antigen diet.

• Family now able to go to church and sit in pew. Went to MGM’s 95th birthday party.

• Mental Status Examination:– Alert, pleasant, happy, engaging.

Talking more. Gait improved. Speech much more intelligible. Played happily and cooperatively with Dad.

The REST of the Story - Joey

9/15/20139/5/2012

Summer – 2014 – with Dad in their organic garden

Apple Store – Chicago, Michigan Avenue © 2008 Louis B. Cady, MD.

“It’s not the customer’s job to

know what he wants.” - Steve Jobs

SUCCESS: Apple Store, Michigan Avenue, September 20, 2013 – 8:20 PM

TODAY: September 19, 20141:16 a.m.

Start sipping your drinks at PUBMed.gov

Determining how patients (& healers) age

2000

What you can do with an integrated approach in 15 months:

RX: dairy free diet (+IgG test); D3 5000 IU/d; Armour thyroid, Testosterone cypionate 100 mg IM q wk, MVI, Zinc, DHEA 50 mg SR, CoQ10 400mg

(photo shot 15 months after tx)

(permission granted to use photos & data)

Cady Wellness Institute Synergy: The Five Point Plan for Patients AND Docs

1) GET ALL THE LABS YOU

NEED.

2) Rx: Hormones, if needed.

3) MONITOR ANTIOXIDANT &

vitamins/minerals.

SUPPLEMENT AS NEEDED.

4) RATIONAL EATING

5) RATIONAL EXERCISING.

Mind

Body

Actions

Wrapping Up: The “Survival Curve” – Where Are You?

“For me, the practice of medicine has opened the door to the greatest adventure in life. Medicine is like a hallway lined with doors, each door opening into a different room, and each room openinginto another hallway, again lined with doors. Medicine is always wonderful and never will be finished.”- Charles H. Mayo, M.D.