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From the Townsend Letter
February / March 2013

Advanced Metabolic Detoxification Strategies
Kristi Hughes, ND
Based on an interview with Nancy Faass
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Detox has become a buzzword in the media. Although detox is now a popular self-help concept, many patients could benefit from professional support for a safer, more effective detoxification experience. Those who are dieting and focused on weight loss, for example, may be unaware that the rapid breakdown of adipose tissue can result in a surge of toxins into the circulation.

Kristi Hughes, NDAs Associate Director of Medical Education for the Institute for Functional Medicine (IFM), a trainer for Metagenics' international lifestyle programs, and a clinician in private practice, I frequently present on the topic of detoxification for both health care providers and the public. In naturopathic medicine, we consider medically supervised detox a powerful method for removing key obstacles to health and healing. I find that the naturopaths I teach tend to be among the providers most knowledgeable in understanding and applying detox protocols effectively in clinical practice. In conjunction with my work as an instructor on advanced detox principles, I have had periodic discussions with naturopathic physicians regarding lifestyle modification programs. Most report that they had a level of familiarity with about 80% of the course content in FirstLine Therapy, but that the insight they gained from the remaining 20% has made a difference in their clinical management and offered usable clinical pearls.

Candidates for Detox
For many patients, effective, gentle detoxification is one of the first steps in healing. Applying the lens of functional medicine, a sequenced metabolic detox program can provide a systematic approach that lowers the patient's total body burden, allowing more optimal function. An extended personalized detoxification program that lasts weeks or months can offer greater therapeutic benefit, with the potential for deeper, more lasting impact.

One of the unique features of the functional medicine approach is that we begin the detox sequence by addressing energy dysregulation, targeting oxidative stress, and supporting mitochondrial function. Everyone, in any state of health, can benefit from an increase in their cellular energy processes, enhanced cell membrane integrity and fluidity, integrated nutrition and cleansing foods, improved assimilation and elimination, and a healthier lifestyle to improve their vitality and well-being.

Detox not only helps those with weight-loss goals, but also serves a therapeutic purpose for those at risk of metabolic syndrome, blood sugar and insulin dysregulation, and cardiovascular disease. Clinical management of fatigue and generalized pain using therapeutic detoxification strategies often results in improved energy and tissue repair. A personalized care approach, guided by a comprehensive biotransformation and elimination assessment, can support tissue regeneration and enhanced cellular function. In my own practice, the patients who have responded well to advanced clinical detox programs include those who have:

  • Insulin resistance or hypoglycemia
  • Need for healthy weight loss to reduce adipose tissue
  • Energy deficits
  • Chronic aches and pains
  • Persistent or recurrent irritability
  • Changeable emotional disposition
  • Multiple allergies or chemical sensitivities
  • Paradoxical reactions to appropriate medication or supplements
  • Women's health disorders such as polycystic ovary syndrome
  • Fertility issues or the desire to prepare for healthy pregnancy
  • Learning disorders, hyperactivity, or autism
  • Chronic illness

Rarely is enough forethought and talk time dedicated to the prep for a detoxification program. Yet adequate attention to detail in the setup phase is critical to the success of the entire metabolic cleansing process. In order to provide a patient with the most effective detoxification, an evaluation of their elimination capacity is critical. Care should be taken in noting relevant details collected through history, examination, and laboratory analysis and in organizing the information in a way that informs the therapeutic direction.

The first phase of this entire process involves assessing whether a particular patient is appropriate for a metabolic detoxification program and then preparing him or her for the cleansing process. Initially the goal is to bring patients through a series of lifestyle modifications that move them toward a cleaner lifestyle, making healthier choices. Once those changes begin to take root, patients will reach a stage at which they are able to sustain a three-day cleansing process using entirely liquid foods, nutraceuticals, and protein supplements.

As practitioners consider the various therapeutic interventions and dosing scales, guidance will come from understanding the patient's total toxic burden and the strength of his or her constitution. The focus of specific supplements, botanical medicines, dietary modification, and lifestyle depends on the patient's stage of the detoxification journey. Note that similar products are often used throughout all the stages, with the dosing schedule increasing in a more restrictive and therapeutic lifestyle program as patients prep for detox and systemic cleansing.

In the next phase of detox, patients engage in a process requiring additional nutraceutical support and specific dietary guidelines, often culminating in a liquid nutrition/medical food fast. The entire detoxification journey is usually based on the timing of those fasting days, making sure that the patient's life schedule around that time creates the proper space for rest and regeneration. A weekend fast with liquid nutrition is not the easiest time to go to a wedding or a major social event. Planning ahead is part of preparing for a successful detox.

Once the deeper detox and cleansing phase is complete, patients "break fast" and begin reducing the therapeutic dosages of their supplements and medical/functional foods. They are encouraged to pay close attention to their symptoms as they reintroduce foods or behaviors that were restricted or avoided in the elimination protocol. The post-fasting detox window is very informative. As patients begin to transition back into a more diverse diet, they are encouraged to observe how their body responds to food, stress, people, sleep, sleeplessness, activity, lack of activity, and more. It is not uncommon for patients to notice that particular foods create immunological or gastrointestinal reactions as they systematically add common foods back into their diet. Usually it is best to dedicate as much as two months for the complete process. This allows the patient the personal flexibility to accomplish a comprehensive detox program on a successful timeline.

Personalized Toxicity Assessment
In-depth assessment and pattern recognition are the first steps in preparing for the detoxification process. The practitioner must first determine whether the patient is a candidate for detox based on his or her clinical presentation. This is achieved through advanced history-taking skills and the use of key questionnaires to gain robust, well-rounded insight into what is unique about the patient's lifestyle and manifestation of toxicity. The history includes detail on any symptoms of toxicity, as well as potential risk factors or triggers in the patient's lifestyle and environment.

Review of symptoms. One of the most commonly used questionnaires in clinical practice is the MSQ (Medical Symptom Questionnaire). The MSQ is widely recognized as a useful, patient-friendly tool for the review of body systems, associated symptoms, and their intensity. This assessment also provides an opportunity to step back and observe how the patient is expressing the total toxic load. Any area of the questionnaire that scores greater than 10 directs the physician's attention to a particular system of the body for a more detailed intake or additional assessment. Scores greater than 50 overall indicate the need for a more thorough personalized assessment to determine if there is an excessive toxic load. The higher the score overall, the slower the detox program should be.

Assessing environmental exposures. When reviewing a patient's medical history, symptoms, and symptom progression, half the equation involves gathering the right data to identify potential toxic sources and exposures. This is by far the most difficult aspect of the intake, one which requires time and diligence. The more experience a practitioner has in managing complicated toxicity-based cases, the more robust the line of questioning. To evaluate the impact of the patient's environment, the provider must learn as much as possible about the patient's exposures, particularly any type of environmental exposure that could be compromising health.

One of the most efficient tools I've seen for these assessments is the TEQ (Toxin Exposure Questionnaire) developed for the IFM Advanced Practice Detox Module. The TEQ is an in-depth survey of the patient's background and history to identify exposures (past or present) in the home, workplace, or community. The questionnaire also explores hobbies and personal habits that may involve a toxicant. This type of analysis has the potential to open a direction of inquiry that could ultimately resolve the patient's condition. Identifying the primary causes of disease, while uncovering significant details related to exposures and personal detoxification capacity, are the challenges both the patient and doctor face as they move toward becoming more effective medical detectives.

A Personal Note
When my husband and I were ready to begin our family, we bought a plot of land in the country with the idea of settling in a clean environment to raise our kids. We chose a beautiful place with lakes and trees in a forested area of central Minnesota. When I did a search on my zip code at, a pollution information site, I identified the most common toxicant risks in our area, which led us to do a more robust assessment of our well water. Due to the increased agricultural activity in the area, our water source has the presence of lead, as well as an iron-loving fungus. Some of the abnormalities in the water sample were most likely linked to the presence of local pesticides and herbicides impacting the ecosystem of our well water. I've carried three pregnancies since we moved to this property, so I'm deeply concerned about the development of my little ones and have taken additional precautions to minimize their further exposures now that they are all in preschool and grade school. It was a significant disappointment to realize that there are so few places left that have low toxic exposure levels.

Lab Work
Testing for environmental toxins. In order to check for specific chemicals and toxins, Metametrix provides a series of panels in serum or whole blood that practitioners can use to effectively identify increased toxicant levels. One of their more common panels includes assessments for whole PCBs and volatile solvents; persistent organophosphates (which have been directly linked to diabetes); herbicides and pesticides, including chlorinated pesticides such as DDT, HCB (hexachlorobenzene), and other commonly used agricultural chemicals. Patients who grew up on a farm or who live near a farming community are good candidates for this type of testing if they are symptomatic. These panels are among the most up-to-date evaluations available for assessing risks and needs for personalized detox.

Metametrix also provides testing for phthalates, parabens, and BPA in urine. Most of us are exposed to these compounds in small amounts on a constant basis. As a result, we may be unaware of the body's tipping point – the level at which the overall body burden can begin to cause chronic irritation and oxidative stress, resulting in symptom expression. Few people are fully aware of the extent of these toxic exposures. Few realize, for example, that women on average apply more than 120 different chemicals on their skin before they leave the house in the morning (due to compounds contained in their personal care products) or that the number one source of BPA exposure occurs when we touch printed receipts.

Heavy metals can also be an important factor, and additional tests for the presence of heavy metals are an option, especially if the onset of symptoms includes neurologic issues such as mild tremors, paresthesias or mild numbness, intermittent or transient pain syndromes, or petit mal or grand mal seizures. Not all patients can be tested for heavy metals. Assessing for an immunologic reaction to metals through MELISA (Memory Lymphocyte Immunostimulation Assay) can inform the work of functional dentists and practitioners who want a more comprehensive dental assessment to determine if the oral cavity is contributing in any way to the toxic load. The test also provides information useful in deciding if existing amalgams can be safely removed, and whether oral or IV chelation therapy may be indicated to support personal detoxification.

Evaluating liver function. A hepatic panel is still considered relevant in identifying the status of principle liver enzymes. Even high normal values will be of concern to the practitioner. When assessing patients I often request testing for an additional biomarker for toxicity: the liver enzyme termed GGT (gamma-glutamyl transpeptidase). When elevated, this enzyme helps to identify a higher demand for glutathione due to excessive exposure to toxins or lifelong accumulation of toxicants. These can include over-the-counter and prescription drugs, alcohol and other habitual substances, environmental compounds, and xenobiotics. Research has shown that patients who are obese with high normal levels of GGT (between 40 and 60, depending on the reference range) may be experiencing an increased toxic burden, resulting in an elevated demand placed on glutathione production. Obese patients with elevated normal ranges of GGT levels have a higher association with diabetic risk. Laboratory testing for GGT is provided by mainstream labs such as LabCorp; however, the test is not included in a standard hepatic panel and needs to be specifically requested as a stand-alone evaluation.

Genetic testing. The detoxigenomic panel from Genova is one of the most comprehensive available to evaluate the impacts of genetic predispositions on detoxification functions and to support clinical guidance on lifestyle modifications. This panel reviews four of the six primary phase II conjugation pathways and identifies SNPs (single nucleotide polymorphisms) for the most common cytochrome P450 enzymes. The test report includes an extensive review of substrates that are processed or metabolized via each specific pathway. This provides insight for patient management, such as prescription medications the patient should avoid in order to reduce the risk of overdose or adverse side effects, and dietary modifications that could improve the functionality of specific detox-related metabolic pathways.

In some cases, patients may not produce adequate levels of phase I enzymes, compromising their ability to process certain chemicals or compounds. Other patients have an increase in the activity level of these enzymes, creating oxidative stress through an elevated burden of reactive oxygen intermediates. Inadequate support for phase II conjugation can also have an impact on the detox process. Metabolic byproducts of detox can place further demand on the body's endogenous systems. Genetic testing enables us to move beyond general recommendations to make more specific suggestions that address the patient's unique needs and support individualized healthy lifestyle choices.

Pulling together the details: benefits of the Functional Medicine Matrix. The Functional Medicine Matrix can assist the provider in organizing the medical case history, identifying repeated symptom triggers or triggering events, and ascertaining the primary underlying causes of the patient's health concerns. In my own work, before I began using the Matrix and applying a system's biology approach, I often struggled with detoxification because the topic is so vast, with so many variables. The Matrix provides indications of where to begin as we initiate care, and looks at a range of other considerations, including familial or genetic trends that are the most relevant. Using the FM Matrix, practitioners can identify patterns to more effectively guide them through the detox sequencing.

Stage 1. Preparation for Metabolic Detox and Adequate Support
In order to adequately prepare for a safe and healthy detox, patients must reduce daily toxic exposures due to food, personal products, and environmental chemicals. Major goals include an emphasis on specific healthy food choices and inclusion of adequate phytonutrients to support systemic detox. It is also important to improve hydration status while gently shifting the diet in preparation for a supported liquid fast. The fast can last for one to five days, and often includes the use of a medical food to provide balanced detoxification, macronutrients, and calories.

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