Language keeps changing. We used to call questionable remedies “folk medicine,” “fringe medicine,” or “quackery.” In the 1970s, the term “alternative medicine” was coined, an umbrella term for all treatments that were not supported by good enough evidence to have earned them a place in mainstream medicine. Then came “complementary and alternative medicine” (CAM), and later, “integrative medicine.” Now there’s a new kid on the block, “functional medicine” (FM) which is really just the latest flavor of integrative medicine. These are all marketing terms, Trojan horses designed to sneak non-science-based medicine into conventional medical practice. The oft-quoted quip is appropriate here: Do you know what you call alternative medicine with evidence? Medicine.
How is Functional Medicine Different from Conventional Medicine?
Functional medicine was invented by a single individual: Jeffrey Bland. He’s not a medical doctor. He’s a Ph.D. who sells dietary supplements. His supplement companies have been fined repeatedly by the FTC and FDA and have been ordered to stop making medical claims for their products. A number of health care providers have “jumped on the Bland wagon” and claim to be practicing functional medicine.
It’s hard to pin down a definition of FM; each FM provider describes it differently. Dr. Mark Hyman says conventional medicine is dysfunctional, and FM is the opposite. He thinks conventional medicine is as obsolete as phrenology and bloodletting; he also rejects the germ theory of disease. He says diseases don’t exist; they are merely “the downstream symptoms of a mechanism.” The official organization, the Institute for Functional Medicine, says this:
Functional Medicine addresses the underlying causes of disease, using a systems-oriented approach and engaging both patient and practitioner in a therapeutic partnership. It is an evolution in the practice of medicine that better addresses the healthcare needs of the 21st century. By shifting the traditional disease-centered focus of medical practice to a more patient-centered approach, Functional Medicine addresses the whole person, not just an isolated set of symptoms. Functional Medicine practitioners spend time with their patients, listening to their histories and looking at the interactions among genetic, environmental, and lifestyle factors that can influence long-term health and complex, chronic disease. In this way, Functional Medicine supports the unique expression of health and vitality for each individual.
That sounds good, until you realize that it also describes good conventional medicine. Conventional medicine always addresses the underlying causes of disease: when you have appendicitis, you don’t just get morphine for the pain, you get an appendectomy to remove the cause of the pain. Conventional medicine deals with real underlying causes; FM makes up hypothetical, speculative, or imaginary causes.
Conventional medicine uses a systems-oriented approach when appropriate, but it is not helpful for setting a broken bone. Conventional doctors always engage their patients in a therapeutic partnership; the days of paternalistic medicine are long gone. Conventional doctors have always addressed the whole person. As early as ancient Greece, Hippocrates said it was more important to know which person had the disease than to know which disease the person had. Conventional doctors have to spend time with their patients, since the history is 70% of the diagnostic process. They look at genetic, environmental, and lifestyle factors; the standard medical history has sections for family history and social history, reminding doctors to look at everything that might have an impact on diagnosis or treatment, such as occupation and finances. They routinely ask about things such as tobacco, alcohol, and exercise.
The statement by the Institute for Functional Medicine is far from the only one offered. Alex Rinehart explains that FM is not focused on diagnosis; it sees health as a continuum and it addresses these 7 core imbalances: hormonal and neurotransmitter, oxidation reduction, detoxification, immune and inflammatory, digestive, structural, and mind-body/body-mind imbalances. Elsewhere, a chart shows an iceberg in the ocean: above the water are diseases like diabetes and cancer; below the surface are a long list of “imbalances” along with toxic chemical exposures and “toxic emotions.”
Then there’s the Functional Medicine Tree. The leaves are symptoms, conventional diagnoses, organ systems, and medical specialties. The soil is sleep, exercise, nutrition, stress levels, relationships, and genetics. The roots are antecedents, triggers, mediators, mental, emotional, and spiritual influences, genetic predispositions, experiences, attitudes, and beliefs. The tree trunk consists of the fundamental organizing systems of assimilation, defense and repair, energy, biotransformation and elimination, communication, transport, and structural integrity. In a further illustration, those six trunk factors are grouped around a core of mental, emotional, and spiritual factors. Jeffrey Bland says the five principles of FM are:
- Correct the precipitating factor and control oxidative stress.
- Get rid of sources of chronic inflammation.
- Manage the folate cycle.
- Regulate hormones.
- Manage insulin and control blood sugar.
FM also espouses principles like the myth that diet and lifestyle will prevent and treat most disease, the concept of ultra-wellness (that we should aim for better than normal), and they treat non-diseases like yeast, adrenal fatigue, “toxicity” requiring detoxification, and leaky gut.
A Case Report in Functional Medicine
Functional medicine practitioners disagree with each other. Nowhere do they actually explain how they could go about applying all these high-sounding principles to an actual patient. But fortunately they have published case reports that give us some insight into the process, and that also give us some insight into their concept of what constitutes evidence. One published case is a doozy. The patient was an 80-year-old woman who had conventional treatment for breast cancer. The surgery probably cured her. Her prognosis was excellent, but they offered her extra insurance in the form of postoperative radiation, which she refused. Two years after surgery she had no signs of recurrence, which is exactly what we would expect.
“Condimentary Medicine,” a term coined by Dr. Richard Rawlins, describes treatments that add spice and flavor but that have no actual effect on the outcome of the treatment. That applies in spades to Functional Medicine (FM).
So conventional treatment was successful, but FM practitioners got into the act and tried to take the credit for her good outcome. They gave her potentially toxic doses of vitamin C by intravenous injections—a whopping 97 doses! They admit that the use of vitamin C in cancer remains controversial, and that there are only preliminary trials showing it to be “safe and potentially effective in improving quality of life and fatigue.” Seems like thin gruel to justify 97 invasive treatments.
They prescribed a laundry list of dietary supplements: melatonin, digestive enzymes, probiotics, a medical food shake, vitamin D, EPA/DHA, wheat germ extract, oral vitamin C (in addition to the intravenous vitamin C!), and a “standardized herbal inflammation relief supplement.” They put her on a restricted diet: dairy free, gluten free, low glycemic index. They had her exercise by riding a bicycle 10 minutes a day and joining a Qigong class. They put her on a sleep program that consisted only of instructions and a log to record sleep; and they recommended group support, individual counselling, and a part time caregiver/ companion.
And then there were the lab tests! They did 154 of them, mostly nonstandard tests from a lab that is notorious for offering bogus tests—many I had never heard of. Putrefactive single chain fatty acids, urine representativeness index, pancreatic elastase, lignoceric acid, and 150 more. In most cases, the results were within the laboratory reference range; but if they weren’t, how would you know what to do about it, or even if anything needed to be done? They don’t explain how, or even if, they used these test results to guide the patient’s treatment.
The FM practitioners concluded: “This case study highlights the potential benefits of integrative therapy in the comanagement of patients with invasive ductal carcinoma of the breast.” It does no such thing! It shows how they abused this 80-year-old woman for no demonstrable benefit. They left her on her prescription medications and didn’t even attempt to identify the underlying cause of her high blood pressure, gastritis, and thyroid disease, or of her cancer. Did they consider genetics and the environment? Did they correct the 7 core imbalances? Did they address Bland’s 5 foundational principles? Did they use the best evidence-based practices? No, I don’t think they did any of the things they claim to be doing.
Why Functional Medicine is Bogus
The late Wally Sampson characterized FM as “claims cloaked in the language of science, but with the distinguishing characteristics of sectarianism—pluralities of approaches to illness, absence of evidence or efficacy, a unifying concept of illness as a body out of sync with Nature (with the capital N), undecipherable babble and descriptive word salad.” Medical doctor and sciencebasedmedicine.org blogger David Gorski says they take “making it up as you go along” to a whole new level, and that’s not a good thing in medicine.
Dr. Richard Rawlins, in his excellent book Real Secrets of Alternative Medicine, coined the term “condimentary medicine” to describe treatments that add spice and flavor but that have no actual effect on the outcome of the treatment. That applies in spades to FM. Patients of FM practitioners appreciate all the attention and the personalized treatment, and they say they feel better. Is there a problem with that? I think there is. As cancer researcher David Grimes said, “By clinging to delusion, belief in alternative medicine denigrates the very wonder of science and medicine and the massive strides we as a species have made over the last century or so in understanding the world around us, and how our bodies work.”
Vague claims, testimonials, and case reports do not constitute credible scientific evidence. FM claims that their individualized patient-centered treatment plans are not amenable to clinical trials, but that’s nonsense. It would be a simple matter to randomize patients to two groups, treat one with conventional medicine and the other with FM, and compare the outcomes. To my knowledge, that has never been done. I think I know why.
This article was originally published as a SkepDoc column in Skeptic magazine.