Personalizing Treatment and The Foundational Assessment

Overview

The Foundational Assessment is one of the first things we at Incubator Origins recommend doing during the initial appointment with a patient. This enables doctors to address a patient’s main complaint while not only taking a closer look at a patient’s lab results, but also targeting a patient’s lack of energy, insomnia, diarrhea, constipation, or any other health issue through nutrition, stress, sleep, and exercise. Doctors need to take the time during that initial appointment and educate the patient on how to change his or her lifestyle to reverse health issues. For this blog, we will take an individual approach with two different patients, one with hormone irregularities and one with gut-based health issues, showing how important the Foundational Assessment during the initial appointment is to get off on the right foot.

Introduction

Hi, everyone. I'm Dr. Linda Matteoli, and I help teach the practice management part of the Origins Incubator course. And today, I'd like to discuss how I recommend moving through the initial appointment, which we call the Foundational Assessment. The Foundational Assessment is where we discuss initial foundational bloodwork, how we use that appointment to educate the patient, how we might peel back the layers of the onion in terms of his or her health, how to use that information to recommend either further testing or treatment options, and how that might look in the context of a year-long membership program. So, in case you're new to the Incubator and what we teach, we teach a flow of appointments that have been helpful for me and my practice, for the past eight years or so, where we do a discovery call, followed by a Foundational Assessment, which is a one-time assessment, and then a year-long membership.

The Importance of Today's Focus

Today, I'm going to focus on that Foundational Assessment appointment, and we're going to compare two different patients, a hormone patient and a gut-based patient, with two different presenting issues, and how we might work through those recommendations and what that might look like.

The reason this is important is because with an integrative or functional approach, it is not cookie cutter; it is anything but, so we're not putting every single patient on this same sequence of testing and interventions. It's very much individualized. You're very much assessing and tailoring all your recommendations depending on how the person is presenting, what he or she is capable of, and what his or her resources are, things like that. 

Case Study #1: Hormone Patient

Case Study #1 is a 46-year-old female hormone patient who is presenting with brain fog, insomnia, some anxiety, lack of energy, and her menses might be heavy, somewhat irregular. And her dream outcome, so to speak, is that she wants to feel energized and basically like herself in her own skin. She wants to have good sleep and feel energized throughout the day. 

My initial approach for this patient, regarding lab draws, would be a combination of checking not only foundational markers, along with vitamins and minerals and things like that, but also checking the bloodwork for thyroid, estrogen, progesterone, testosterone, getting an idea of what the hormones are doing at that point. So, for the Foundational Assessment, I do recommend getting labs prior to the appointment and reviewing the labs at that appointment, so you get both objective and subjective things to assess during that time, enabling you to make accurate recommendations from there. When you are discussing, it's important to be able to interpret, when you make recommendations, to have them relate to what is occurring for that patient. This specific patient needs hormone stabilization, she needs precursors to make those hormones, and she really needs to be educated on the importance of that nervous system health. 

So, with the Foundational Assessment, my recommendations typically revolve not only around targeting anything that I see in the labs in terms of replacing vitamin D or B12 or iron or things like that, but also moving through the four main foundations of lifestyle: nutrition, stress, sleep, and exercise. So, in the background of my mind, I know that this person needs that hormone stabilization. As I am going through her lifestyle recommendations, nutrition for instance, I might discuss how the Hypothalamic-Pituitary-Adrenal Axis (HPA) (how our hormones interact with our adrenals, along with insulin and thyroid and our sex hormones), as a foundation to discuss stabilizing her insulin throughout the day, which, therefore, helps stabilize her cortisol levels and her thyroid and her sex hormones. She needs to make sure that she is not only not snacking all day, but also not having periods of prolonged fasting, which would make her blood sugar dip and then her cortisol responds to that. So, my nutrition recommendations will be based on a low inflammatory diet along with eating regular meals throughout the day, at certain times, to help stabilize those adrenals and stabilize that insulin. Now, we almost always get a question about intermittent fasting, but this is a separate topic. A short response would be, “I initially make sure that the adrenals aren't overly taxed and that the body can handle intermittent fasting before recommending that.” So, I almost always initially recommend best stabilization of blood sugar. With every foundational recommendation, we are making recommendations within the backdrop of his or her chief complaint of what he or she is here for. 

Moving on to movement or exercise, you need to find out what she is physically doing. So, say this person does a lot of HIIT workouts and is a marathon runner, just really pushing her body. Then I will take that opportunity to discuss the interactions of our nervous system and cortisol levels, and how that impacts progesterone levels, things like that. My recommendations for exercise at that point would be more related to more rejuvenating breathwork like yoga, Pilates, or Tai Chi. I'm not saying to completely disregard her current workout schedule, because a lot of times, that's very therapeutic for her, but starting to introduce some of these other exercise techniques that can really support that parasympathetic nervous system. So those cortisol levels can drop, and things like progesterone can rise, which will in turn help with sleep and help with anxiety. 

So, as you can see, the recommendations are always intertwined with a patient’s complaint. When we're talking about advanced testing, at the end of every appointment, I take a moment and recap, based on lab results. This lady is a little bit iron deficient, vitamin D deficient, and B12 deficient. Maybe her progesterone is a little bit lower compared to the estrogen, so I do that estrogen progesterone ratio, and I see that she is a little bit estrogen dominant. That might be like the typical labs that I might see for a woman who's presenting like this.  With these results, I would initially recommend, getting these nutrients replaced with vitamin D, B12, and Iron, and I might put her on a good D complex to help with that adrenal support along with vitamin C, which can also help support progesterone levels, and then working on that, those lifestyle foundations, to just start to create that signal of safety to the body. So, the body is starting to feel now that “okay, my blood sugar is stable throughout the day.” I'm not doing as strenuous of workouts as frequently, so that piece can calm down. So, the body has the precursors with the supplements to make the hormones, and the nervous system is starting to calm down. And then if it's purely a hormone approach, at that point to further investigate and heal on a deeper level, I would love to see a four-point cortisol curve. If that person is estrogen dominant on the bloodwork, then I might opt for a test such as the Dutch Test, or I can see more about her estrogen metabolism. So, then my offering to her would be, work on these foundational supplements and this foundational lifestyle approach, but then I'd love to get a four-point cortisol, as well as more information about how you're metabolizing your hormones, so we can better support you in that way. So, she would be able to do those advanced testing prior to our next appointment. 

Case Study #2: Gut-Based Patient

Case Study #2 is a 28-year-old, with just a lot of bloating; he might alternate between constipation and diarrhea: that is his main complaint. He has low energy; he just has a lot of GI symptoms, more of like an IBS, kind of presentation. So, when I'm looking at his foundational labs, I probably wouldn't do hormones for that person. I'm just doing, again, his vitamins and his minerals, and those foundational labs. What I'm really focused on during the Foundational Assessment, after I do his history and the physical and things like that, is really educating him about that permeability and the things that we know for certain really impacts our gut health, such as our food, any medications, stress, and then, of course, any dysbiosis like bacterial overgrowth, or yeast overgrowth. All these things can create an inflamed gut. I then take those and use that opportunity to take that foundation for gut healing and move through the process. 

For nutrition, I would recommend a low inflammatory diet, really focusing on foods that are easy to digest. I might really focus on, in terms of the stress part of my intervention, or plan, and really talk about the parasympathetic nervous system and how it's so important to support that for our rest and digest systems, everything from the environment, what you are eating, how your chewing impacts your digestive enzymes, to the ability for you to digest well. So just educating him on that process and really encouraging some meditative time and things like that to really “up regulate” that parasympathetic piece of it. Also, I might recommend some good core yoga support that just helps with the lymphatics and the blood flow to the gut area for him. Now in terms of lab review, I'm looking at vitamin and mineral deficiencies to see what his absorption status might be like. My treatment plan from a supplement standpoint would be replacement of those nutrients. If indicated, any sort of digestive support, some herbs or bitters, to just help calm that stomach. If diarrhea is dominant, I might prescribe a prebiotic to help support that. 

Then at the end of that appointment, as I'm recapping everything, I can say, “We’re starting to treat these symptoms by removing inflammatory foods and working on when and how you eat, also working on “up-regulating” your parasympathetic nervous system. So, your body can feel rested enough to digest appropriately, replacing any deficiencies or anything that we're seeing on the labs, of course, looking for liver enzymes and kidney health and making sure that all looks okay, inflammatory markers, things like that.” But then my deeper dive would be more gut-centric. To really investigate how he is digesting and to investigate for any dysbiosis in the gut, which is any bacterial or yeast overgrowth, I would recommend a stool analysis. I might recommend, in conjunction, a SIBO breath test or an OAT test to really get a full picture, but really explaining it, so he understands that it's a stepwise process. And for him, that would be our next step. 

He would be implementing these foundational pieces while he’s getting this advanced testing done, and then at our next appointment, we will be seeing what was working for him and what wasn't working for him with our previous plan, because I always tell people at every appointment, “Everything depends on what is going on in your life, what you're going through. We might need to adjust some things, and this is where we're partnering together in this process.” But then at that appointment, we can adjust as needed, review the advanced labs, and then move on from there. It really works beautifully in the context of a membership because he has this safe containment where we can work through it in a bit of a cadence. As the provider is a physician, you're having follow up, not worried about reviewing a stool analysis with somebody and then not following up for six or nine months, and then when he does, you are starting from scratch again. 

Conclusion

So, within this Incubator Course and process, we go through and teach you how we do all of this, but this is generally how I would walk through the different approaches for more of a hormone centric patient and also the gut centric patient.

I hope this was helpful for you. We will see you in the next blog. Thanks a lot!