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Reducing toxic exposures. The first step involves reducing and removing primary toxins to which the patient has been exposed. Detox could focus on clearing alcohol, caffeine, artificial sweeteners, or unhealthy fats and sugars in the diet. It might mean identifying and eliminating highly allergenic foods or environmental toxins. Stress is also a toxin, and the patient may have toxic emotional relationships – people in his or her life who feel toxic from an energetic perspective.
Hydration. In a healthy weight-loss program, it is helpful to determine hydration status and to assure that the patient is consuming adequate clean water. This may involve the use of bioimpedance technology to evaluate the patient's total body water and fluid distribution both within and outside the cells. We can certainly ask patients how much water they are consuming and encourage them to drink about half their weight (in pounds) in ounces of water. For example, a 200-pound person should drink 100 ounces of water, which is about 12 cups (8 oz. servings) a day.
Fiber. During this step in sequencing it is important to provide adequate dietary fiber in conjunction with high volumes of water while encouraging the body to flush using a purified food approach. Healthy bowel elimination will be essential once we start to increase the liver and kidney detoxification pathways through nutrition. Healthy bowel excretion is necessary to avoid auto-toxicity.
Juice fasts. Fasting and liquid nutrition are appropriate; however, it is always wise to use these approaches in conjunction with supportive medical foods or emulsified or juiced fruits and vegetables. Water fasts are no longer recommended from a nutrition perspective because they do not provide adequate protein intake for the patient to fuel phase II detoxification enzymes.
Protein. Balanced amino acids and quality protein sources are key requirements frequently overlooked in detoxification. Protein is now recognized as necessary for a sustained state of fasting. Fad diets that emphasize low fat have a tendency to lower protein intake as well. Naturopathic protocol incorporates adequate protein levels to support the physiology of the detox organs. This approach is in contrast to radical fasts and rapid weight-loss diets, which carry the risk of caloric deficiencies, macronutrient deficiencies, and hydro-nutrient deficiencies.
Health care providers need to be aware of potential side effects that can occur with fasting or detox, particularly an excessive release of toxins if the body burns fat deposits too rapidly. It is important to prescribe adequate calories and nutrients to support ATP (adenosine triphosphate) production given the high energy requirements and dependence on ATP during phase II detox in which compounds are packaged and removed. This is particularly important in patients with exhaustion or chronic fatigue and those with genetic risks or polymorphisms involving the detox systems.
Adequate phytonutrients. One of the simplest, most beneficial approaches to improve detox status is to encourage the patient to eat a colorful array of fruits and vegetables every day, sometimes described as "eating a rainbow" of food choices. Foods in red or green hues are often very beneficial in supporting the release of key antioxidants because they provide phytonutrients that improve detox enzymes. Delicious fruits such as cherries, pomegranates, and raspberries, and greens such as broccoli, kale, and spinach are at the top of the list of healthy detox foods.
Stage 2. Clearing Toxins Completely Rather than Quickly
Effective detoxification is not about how fast the detox occurs; rather, the clinician must assure that there is adequate time to sequence detox and to support the detoxification pathways. Naturopaths are well trained in sequencing patients safely through excretion and elimination, mitochondrial rehabilitation, and liver detoxification to ensure effective release of toxins, while minimizing the risk of re-toxifying the body. These are all considerations before starting a patient on a weight-loss program.
Excretion and elimination. While the initial phase of sequencing focuses on hydration status, the next phase emphasizes effective internal cleansing through excretion and elimination. We want to assure that the patient is moving their bowels, and that bile is effluxing properly from the liver. It is also important that the patient is sweating to discharge toxins through their skin and that their urinary system is working ideally – in short, that all the systems involved in eliminating metabolic byproducts are working efficiently.
Supporting bile production. Once toxins are processed and packaged within the liver, those toxins are effluxed with the bile, released into the upper portion of the small intestine (controlled by the sphincter of Oddi), and excreted in the stool. We want to keep the bile flowing, releasing toxins into the small intestine and eliminating them. To support both bile production and release, patients need to include small amounts of healthy fats in their diet, which may seem counterintuitive in a weight-loss program. My approach has been to follow the metabolic mentors in this field, who train providers that the key to healthy weight loss is to reduce metabolic toxicity through effective diet and exercise-related decisions. Loss of excess adipose tissue continues to be an important aspect of healthy metabolic balance.
Preventing toxin resorption. Patients dealing with sluggish bowel elimination may experience enterohepatic recirculation, placing them at risk of re-toxifying the body if toxins are introduced back into the bloodstream. An effective binding agent, such as bentonite clay or charcoal, will retain toxins in the gastrointestinal tract to support effective elimination in the stool.
Stabilizing the mitochondria. Many patients with fatigue, chronic pain, fibromyalgia, or multiple chemical sensitivities suffer from mitochondrial insufficiency, since the mitochondria play an imperative role in cellular cleansing and overall detox capacity. A naturopathic functional medicine approach helps patients jump-start mitochondrial function – an important step in detox preparation that may be overlooked in the clinical setting. Support for the mitochondria means stabilizing the inner membranes of mitochondria through healthy fats in the diet such as DHA (found in fish oils), coconut oil, and olive oil to balance membrane content and reduce inflammation in the tissues.
Key supplements for cellular energy production. Liver detox relies on the energy capacity of the mitochondria. The efficiency of these energy centers to support cellular detox serves as an essential foundation for a broader systemic detox, and key essential fatty acids are provided to improve mitochondrial energy production. Other important nutrients to support the mitochondria include CoQ10, lipoic acid, and a specific, highly focused B-complex formula designed to support Krebs cycle intermediates of the mitochondria in a rehabilitation program. Adequate magnesium and proper electrolytes should be included, particularly for patients with various fatigue syndromes.
Mitochondrial rehabilitation. These recommendations are customized to the specific health conditions and needs of the patient. For the patient with prediabetes or diabetes we recommend a mitochondrial rehabilitation protocol described by Dr. Stephen Sinatra in his book Metabolic Cardiology. This approach supports healing in cardiovascular and metabolically compromised patients, providing specific details and dosages for the rehabilitation of the heart muscle and the myocardial sites.
Supporting detox with nutrients and medical foods. Frequently clinicians use combination detoxification formulas developed to enhance and balance the multiple pathways of the cytochrome P450 enzymes with the conjugating pathways of phase II detox. Both medical and functional foods are increasingly available in the nutraceutical market to fulfill the need for more advanced nutritional support. Many of these combination formulas also integrate key botanicals that can further aid and improve liver or detox function, such as milk thistle, dandelion root, andrographis, rosemary, or turmeric.
Stage 3. Therapeutic Interventions for Detox
In my practice, the preparation and sequencing of a structured, medically supported detox program takes approximately two to three months on average. Very rarely do patients come to our clinic so incredibly healthy that they can go through a ten-day detox and feel great. Most patients need time to prepare: to go shopping, change products, read labels, etc. Patients with more involved chronic conditions often require lower doses of metabolic detox support and a slower-paced detox, enabling them to gradually eliminate various toxic insults from their environment. For patients with more severe conditions, the smallest lifestyle changes frequently have the greatest impact.
Advanced phytonutrient support. After reducing and removing toxins, the emphasis shifts to repletion, replacing nutrients through diet and nutraceutical supplementation. Applying a whole-food approach, naturopaths and functional medicine providers work with patients to increase the array of fruits and vegetables consumed in support of specific detox pathways. Nutrient-rich choices include cruciferous vegetables (glucosinolates such as bok choy, broccoli, broccoli flowers, brussels sprouts, cabbage, cauliflower, collard greens, and kale) which support the sulfation detox pathway. Traditionally we also recommend detoxifying leafy greens such as beet greens, dandelion greens, cilantro, and spinach. Greens can be taken in a salad, provided in various detox smoothies, or in hydro-nutrient smoothies. Liver function is strengthened through foods such as artichokes and beets. Other elements that aid detox pathways are provided in red and purple fruits and dark blue fruits such as blackberries and blueberries.
Hydrotherapy. Water therapies can be highly effective in pumping the blood and supporting microcirculation. A detox regimen is an opportune time to invoke the power of hot and cold to move and redistribute the blood supply. This could be as simple as the use of hot and cold showers or it might include saunas or detoxifying baths with Epsom salts or organic apple cider vinegar. Hot and cold stimulation can also be used to encourage the process of sweating. These are effective means of enhancing the elimination of toxins through the skin.
Managing leaky gut syndrome. It is imperative to repair the permeable gut before mobilizing stored toxins and moving them into the GI tract. Otherwise the patient is at a higher risk for auto-toxicity. Naturopathic providers are experienced in managing intestinal permeability/leaky gut, which is one of the principle causes of systemic toxicity. Consider the appropriate use of colon cleansing in this phase of elimination with various types of nutrients that support and repair the intestinal tract, particularly if there is any sign of inflammation. Supplements well recognized in the repair of intestinal mucosa include pre- and probiotics, plant fibers, nutrients such as L-glutamine, arabinogalactan (extracted from Western larch bark), and soothing extracts such as aloe vera and deglycyrrhizinated licorice root (DGL). These are effective ways to lower inflammation in the gut and manage leaky gut, so the patient is no longer dealing with endotoxicity or byproducts of their own immunologic food reactions.
Maintenance of healthy lifestyle modifications. The final stage of detox moves patients into a maintenance plan that will allow them to continue aspects of the program for life. A customized transition plan includes repeated testing to track the initial areas of concern, updating body composition results, and identifying unresolved health concerns.
Functional Medicine Detox Sequencing: PURE
Both the art and science of metabolic detoxification programs have evolved significantly in the last two decades. Clinicians are now able to offer their patients supervised detox that can be individualized to their specific medical needs. This is a paradigm shift in clinical practice that will involve educating consumers. Safe, effective medical detox requires far more than simply ordering a "Cleanse in a Box" kit or fasting with grapefruit juice.
In order to improve the clinical approach to metabolic detox, the faculty of the IFM provides a module on advanced practice detox. The module includes the acronym PURE to support clinical implementation of advanced detoxification programs.
Pattern recognition. For most patients, symptoms of toxicity are general and diffuse, developing slowly over time, which makes the patterns more challenging to identify for both provider and patient. We need to recognize when the patient is toxic by observing body composition, taking a good history, providing the TEQ and MSQ questionnaires, and evaluating lab results. Clinical management begins with this process of pattern recognition, by identifying the tissues that are most susceptible or experiencing the greatest impact. Patterns of toxicity that have been identified by Dr. Kenny Bock, described in his book Healing the New Childhood Epidemics, include mitochondrial toxicity, metabolic toxicity, neurodevelopmental toxicity, and immunotoxicity, to name a few. Since the total toxic burden cannot be fully quantified in all patients due to limitations in laboratory testing and/or financial constraints, pattern recognition is often an essential aspect of clinical strategy.
Undernourished. Patients tend to under-consume adequate protein and healthy fats in their diets, affecting their ability to detoxify. Inadequate levels of key nutrients can result from either insufficient dietary intake or enzymatic concerns secondary to epigenetic influences. Effective coaching on a detox diet starts by encouraging patients to consume a wide colorful array of phytonutrient-dense foods, coupled with an elimination diet while emphasizing detox-focused foods such as onions and garlic, broccoli and cauliflower, berries, greens, and green tea.
Reducing exposures. To reduce the toxic load, patients are encouraged to read labels, evaluate their personal beauty products, make wiser choices in terms of bottled water, and become aware of other significant sources of exposure in their environment. The goal is to reduce overall toxic load by buying more organics, and when animal protein is consumed, selecting free-range poultry and animals with less exposure to hormones, pesticides, and other contaminants.
Ensuring a safe detox. Today we have access to extensive detoxigenomic and toxicant testing that was not available in clinical practice a few years ago. Factoring in details from an extensive patient case history with results from lab tests and relevant genomic studies, clinicians are provided with a deeper understanding of the biochemically unique needs of the individual patient, enabling them to create a more personalized approach to reduce the body burden. These emerging assessment tools, in combination with advanced nutraceuticals, will help us manage detoxification protocols more safely and effectively, particularly for our most sensitive and vulnerable patients.
NATUROPATHIC MEDICINE AND THE FUNCTIONAL MEDICINE PARADIGM
As many of you know, key leaders in naturopathic medicine were instrumental in the creation and evolution of functional medicine more than twenty years ago. Currently, many naturopathic providers are involved in the global expansion of functional medicine, both in clinical practice and in the dissemination of advanced clinical strategies to other health care professionals. The therapeutic partnership taught in naturopathic medicine is congruent with the patient-centered approach of functional medicine. Today naturopathic physicians are leading the way in providing advanced detoxification and personalized programs for patients as they master the art and science of detox medicine.
Institute for Functional Medicine. IFM provides a philosophical and scientific framework in metabolic medicine that focuses on the underlying causes of disease, and supports early diagnosis and effective early intervention to improve patient outcomes. www.FunctionalMedicine.org
Metagenics. Metagenics' FirstLine Therapy is a clinically driven approach focused on well-defined protocols, nutritional products, and real-world case histories. These functional medicine interventions are now being disseminated around the globe. www.Metagenics.com
Metametrix. A clinical laboratory recognized in the development of metabolic, toxicant, microbial, and nutritional testing. www.Metametrix.com
Genova. Functional laboratory testing that supports personalized medicine, including panels of individual genomic evaluations. www.gdx.com
Environmental scorecard. A website that enables consumers to check the sources and severity of toxic exposures in their own community by zip code. www.scorecard.org
Books. Healing the New Childhood Epidemics: Autism, ADHD, Asthma, and Allergies by Dr. Kenneth Bock effectively describes the impact of toxins on our children, including gut-induced endotoxicity, environmental factors, methylation defects, and resulting neurotoxicity. Additional resources include The Sinatra Solution: Metabolic Cardiology by Stephen Sinatra, MD; Textbook of Functional Medicine 2010 published by the Institute for Functional Medicine; Detoxification and Healing: The Key to Optimal Health by Sidney MacDonald Baker, MD; and Advancing Medicine with Food and Nutrients, 2nd ed., Ingrid Kohlstadt, MD, MPH, editor.
Dr. Kristi Hughes, ND
Dr. Hughes serves as Associate Director of Medical Education for IFM, where her role includes the development and supervision of teaching teams in the Functional Medicine Certification Program and the Functional Nutrition Course. She is also the developer of the Functional Medicine Matrix for IFM and co-developer of the FirstLine Therapy Certification Program for Metagenics. As a trainer on lifestyle and functional medicine, she has lectured internationally for more than a decade and has been instrumental in providing functional medicine resources for clinicians and nutrition professionals in South Africa.
Founder and director of the Dynamic Healing Centers in Minnesota, Dr. Hughes manages an integrated team of health care providers. Her clinical sites also support preceptors, host a naturopathic residency program, and model the integration of functional medicine with a naturopathic foundation. Through the centers she provides distance consulting to physicians and to patients in conjunction with their physicians' participation, with an emphasis on therapeutics such as supervised detox.
Dynamic Healing Center
507 N Nokomis St Ste 201
Alexandria, Minnesota 56308
Our thanks to Jerry Stine, NC, Director of the Lifespan Institute (www.Lifespan-Institute.com) for technical support.
Nancy Faass, MSW, MPH, is a writer and editor in San Francisco who has worked on more than 40 books for publishers that include Elsevier, McGraw-Hill, Mosby, and others. Director of the Writers' Group, she also provides articles, white papers, and writing for the Web via www.HealthWritersGroup.com.
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