KEYWORDS: Integrative medicine, Metabolic Medical Institute, George Washington University, A4M Education Fellowship, Metabolic code triads, Personalized medicine, Information management, Systems biology

Expanding Curriculum to Meet the Challenges of Integrative and Anti-Aging Medicine

by Andrew Heyman MD and James B. LaValle RPh, CCN, MT

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slightly small font size) Academic Co-Chairpersons MMI/A4M Education Fellowship

The field of medical wellness is maturing rapidly, and the marketplace is consolidating around personalization and optimizing health outcomes. Greater emphasis is also being placed on a model of medical care that is more predictive and preventive, which requires a growing reliance on technology and informatics to change the way practitioners understand and manage their patients. While it is difficult enough to continually improve one’s clinical decision making, these broader changes in health care demand an expansion of professional skills overall. How do practitioners keep up in this regard, and how do educational organizations meet practitioners’ diverse needs in order to remain relevant?

The answer is complicated. There is no single learning resource, practice management tool, or health services environment for integrative medicine practitioners to access in order to become successful. While the marketplace is replete with competing terminology such as ‘integrative,’ ‘functional,’ and ‘anti-aging,’ the lines have started to blur in surprising ways as strategic partnerships have been established between private educational organizations, academic institutions, commercial entities, and advocacy groups that attempt to service all of these specialties.

The annual A4M World Congress is in Las Vegas this year, and the organization is committed to meeting the challenges of the changing terrain of integrative care. One example within the world of A4M is the Metabolic Medical Institute (www.mmimedicine.com), which offers graduate level education in the clinical sciences in partnership with George Washington University. MMI has assembled a Fellowship curriculum taught by world experts that covers disciplines such as advanced cardiology, endocrinology, gastroenterology, nutrition and more to ensure practitioners remain up to date on the most progressive research and its clinical application in health and wellness.

George Washington University offers assistance to MMI with curriculum development, faculty participation, and academic support. In turn, MMI attendees have the option to enter the GW Integrative Medicine program to obtain a Master of Science in Health Sciences and are provided tuition discounts by completing specific MMI modules.

The GW graduate curriculum fully prepares practitioners to function at the highest levels in the field of integrative medicine, while drawing from specific MMI content to ensure educational coordination and a unified curricular experience. This partnership is a good example of how both entities leverage resources and expertise to offer high quality education collectively, which would have been difficult to impossible for either to have architected alone. To think that a major medical center would partner with a private entity on topics related to integrative, functional, and anti-aging medicine shows an important maturation in the industry.

The curriculum also represents a collaboration that takes advantage of another recent innovation—the new Board of Integrative Medicine approved by the American Board of Physician Specialties. For the first time, the medical profession offers an accredited board exam, and integrative medicine (IM) now exists as its own legitimized medical specialty. The GW graduate program is approved as one of the few accredited routes that physicians can take to qualify to sit for the IM Board exam.

The Board also reflects a broader acceptance of integrative medicine by the conventional medical community but creates a challenge to academic programs to raise the bar on how practitioners are educated and prepared for this opportunity. It also poses questions: Should a physician become board certified if they practice in the field, now that the Board has been established? What risk does it pose if one is not board certified, if any? Does it offer additional protections (or merely peace of mind)? Does it matter if one self-identifies more as ‘functional’ or ‘anti-aging’? It is too soon to answer these questions, but it is surprising that we are even asking these types of questions given the struggle for acceptance and legitimization over so many years.

While it is exciting to witness partnerships emerge such as the one between GW and MMI, they have been established out of necessity to offer the best possible educational experience and to produce highly competent professionals. This is not easy since the scope of possible skills and knowledge in our field continues to expand.

To make matters more complex, two new forces are further influencing the ever-expanding identity of the wellness practitioner, which include the advent of Personalized Medicine and the Quantified Self Movement: the tracking of a person’s activities and lifestyle with the goal of optimizing an individual’s health and vitality through every stage of their life. The intersection of these two fields represents an opportunity to tailor treatment regimens to the uniqueness of the person and support them on their path toward wellness.

Medicine is now at a tipping point where, for the first time, technology, big data, and personalized care are beginning to converge in practical ways to address the many challenges and failures in the health care system. Successful solutions will bridge the gap between information and understanding; and the solutions will be sophisticated enough to collect large amounts of information yet elegant and simple enough to individualize and clarify the results to the consumer in an actionable way. In addition, the process has to integrate the best scientific evidence and also take into account the person’s quality of life and how they are currently feeling. As these new disciplines emerge to reshape the medical wellness landscape, they also pose a challenge to current educational organizations to adequately prepare practitioners for this expanded reality.

A new commercial solution that offers a technology platform to deliver personalized medicine is the Metabolic Code. The Code is a cloud-based system that offers a powerful point-of-care tool to manage patients effectively. The platform aggregates biologic and self-report data from each patient and generates an individualized care plan utilizing evidence-based algorithms. This information is conveyed to the patient by the provider in a comprehensive report, which includes suggestions for nutrition, exercise, and strategic dietary supplementation to correct metabolic imbalances and restore vitality. Providers are able to track patients longitudinally, assess interim outcomes, and make adjustments between office visits. The Metabolic Code represents the nexus between lifestyle medicine, technology, and personalized care and is an evolution in the medical wellness space. Full CME education weekends are taught through MMI/A4M, training practitioners on systems biology relationships that make up the analytics of the cloud-based system.

Metabolic Code Triads: Systems Biology Made Simple

The Metabolic Code offers a way for IM practitioners to leverage technology by automating the collection of biometric data, subjective symptoms, and blood, urine, and salivary lab tests to determine where the greatest metabolic challenges exist for an individual. The Metabolic Code algorithms assign values for these data inputs into five key domains called Triads.

The Triads organize information using a systems biology framework. Each Triad is composed of three interdependent processes that form a collective subunit of important biochemical interactivity. The resulting Metabolic Code Report arranges information based upon which Triad is the most imbalanced. It produces a simple and clear set of recommendations to improve the function of each Triad.

Adrenal glands	GUT (gastrointestinal system or digestive tract)	Cardiovascular	Liver	Testosterone
Thyroid gland	Immune system	Pulmonary	Lymph	Estrogen
Pancreas	Brain (Central Nervous System)	Neurovascular	Kidneys	Progesterone

Triad 1 (Adrenals- Thyroid -Pancreas)

encompasses the relationship between three important hormones that reflect the state of stress, glucose balance, and metabolism: cortisol, insulin, and thyroid. In their most basic function, each is responsible for energy production and circulation. When Triad 1 is balanced, a person feels vital and healthy; but when unbalanced, a person feels fatigued and has a higher propensity for being overweight or obese.

Triad 2 (Gut – Immune – Brain)

is comprised of the digestive tract, immune system, and the central nervous system. Together, these intelligent body systems make moment-to-moment decisions with regard to absorption and assimilation and set key boundaries physically, immunologically, and mentally. When Triad 2 is normal, the person feels organized and secure within themselves and their environment; and when out of balance, this physiologic network becomes disordered and unpredictable.

Triad 3 (Cardiopulmonary – Neuro – Vascular)

includes the cardiopulmonary unit, autonomic nervous system, and the vascular tree. This triad reflects the relationship of the mind and heart and is mediated by the respiratory cycle. When Triad 3 is in balance, the individual has plenty of metabolic resiliency and strength to meet the challenges of life.

Triad 4 (Liver – Lymph – Kidneys)

contains the drainage organs of the liver, lymph, and kidneys. These organs form a functional unit for detoxification and elimination, metabolic processing and removal of toxins, and enzymatic activities. They allow us to thrive in a toxic world. When Triad 4 is in harmony, there is a smooth flow of substrates and emotions; and when out of balance, inflammation, stagnation, and retention ensue.

Triad 5 (Estrogen – Progesterone – Testosterone)

includes the reproductive hormones estrogen, progesterone, and testosterone playing a central role in the reproductive lifecycle. They confer a sense of potency, power, and self-esteem for both men and women.

In addition to system or organ-based intra-relationships within each Triad, all of the Triads can also influence one another. This is known as Triad stacking and explains how different metabolic networks affect each other.

Although the Triads are conceptual in nature, they reflect and express a practical framework of clinical systems biology. Their power is in their ability to focus the practitioner and patient on important aspects or domains of health and take corrective measures to restore harmony and vitality in measurable ways.

The Report: Wellness in Action

Data from the questionnaire, biometrics, and blood work are analyzed to produce a report, essentially a snapshot, of the patient’s current health status. The report also acts as a roadmap back to vitality by offering specific therapeutic recommendations, further testing suggestions, and lifestyle support.

The report is comprehensive, individualized and practical. It contains several components:

• Scoring system, displayed in numerical and graphical representation (low risk, moderate risk, high risk), to identify greatest to least Triad imbalances;

• Individualized lab and questionnaire ranking;

• Explanation of every lab abnormality;

• Data stacking between Triads;

• Specific dietary supplement recommendations;

• Description of Triad organ systems.

Outcomes, Efficiency, and Revenues

The practice of integrative medicine has become more complex in recent years with the availability of new testing methods and advancements in understanding chronic illnesses. Practitioners must develop new competency in information management, which poses time and intellectual challenges in the process of medical care. Technology ensures efficiencies in this regard, simplifies aggregation and analysis of data, and offers reporting to patients of their health status in meaningful ways. The role of technology reduces the barriers to entry in integrative medicine and supports evidence-based clinical decision-making.

Point-of-care systems, such as the Metabolic Code, also create a common language between practitioner and patient, and bridge the gap between information and understanding on both sides of the therapeutic relationship. Patients need to understand their current health status and mounting risks for future disease. Yet, most patients forget 80% or more of the details after office visits and need ongoing support to reinforce their self-understanding and plan of care. By offering a comprehensive, patient-centric report, patient follow-through with healthier behaviors and choices and improved adherence to suggested regimens becomes more likely.

While cloud-based technology supports practitioners in the process of care, equally important is the opportunity it affords to collect outcomes data across large populations. This is the very sort of data missing from integrative medicine, which is usually the major criticism by conventional practitioners. Unfortunately, it is costly and cumbersome to conduct large randomized controlled trials that do not reflect how integrative medicine practitioners actually care for patients.

Many challenges exist in the collection of medical outcomes data, even more so in the field of health and wellness. IM practices generally function independently of the conventional health care system, little industry oversight occurs, and dietary supplements are unregulated. By definition, this style of practice is multi-modal, interdisciplinary, and usually combines lifestyle recommendations with dietary supplements, traditional healing methods and, sometimes, conventional therapy. Point-of-care platforms link the process of care to patient outcomes and reduce barriers to conducting high-quality research.

Clinical Research and Education: The Life Cycle of Evidence-Based Education

Technology such as the Metabolic Code platform can be used to establish a practice-based research network. Clinical outcomes will be tracked and analyzed, and the analytical process will inform the algorithms and decision trees to refine patient reports and further improve the reliability and validity of clinical recommendations. Comparative analyses will be conducted on treatment approaches, specific dietary supplements, and lifestyle recommendations.

In review of the underlying science, practical clinical application, and market place innovation, George Washington University has agreed to include the Metabolic Code system in the master’s program in integrative medicine for all students. The MC offers an information-rich teaching environment for students that accelerates their understanding of fundamental concepts in lifestyle medicine and ensures exposure to real world tools for future integrative practitioners. Additionally, MMI offers weekend courses on the Triads, which teach the clinical implementation of systems biology in the context of health and wellness.

George Washington University also views the deployment of the MC platform as an enormous research opportunity as practices adopt the system. GWU will provide research support and analytics to assess clinical outcomes, improve the algorithms, and produce clinical care guidelines and research papers that will change the medical industry. The partnership between the Metabolic Code and GWU will ensure that a leap forward occurs in lifestyle medicine by establishing a health services infrastructure and research agenda to produce best practices in medical wellness.

As a result of these partnerships, IM practitioners now have the opportunity to receive graduate level education under the auspices of MMI and GWU, receive a Master of Science from a major university and Board certification from the American Board of Physician Specialties, adopt health services tools and technology to create practice efficiencies, and implement evidence-based IM care while participating in a practice-based research network to generate outcomes data and contribute to the betterment of medicine overall.

Conclusion

It is a new day for practitioners in the field of medical wellness as the marketplace consolidates to provide high quality education, offer effective health services support, and produce validated outcomes studies. Certainly the relationship between MMI, GWU, and the Code represents only one set of innovative partnerships. Several others currently exist, and more are entering the market as the whole field matures. This is an important time for integrative, functional, and anti-aging medicine. Time will tell how beneficial these changes will be to the field and to medicine as a whole.