Process, Not Categories
In my view, progress in medicine will depend on a greater understanding of whole body processes and phasing out category-based diagnosis. A proper biological method of medicine begins by recognizing and solving problems in food, air and water supplies. A steady flow of molecules from the environment enters the body of each individual through the air breathed and the food and liquids ingested. This body-input determines health and disease in whole populations over the long-term and the moment to moment functional capacity of the individual. A person's performance can change dramatically with changes in this molecular stream. Medical descriptions depend on the study of systems. Body systems are not discrete, however, and interact in complex ways.
While I appreciate that humans depend on categories to organize their interactions with each other, all categories are arbitrary and limit understanding. Thus, irritable bowel syndrome (IBS) and depression appear to be real things that are separate; but on closer analysis they are not real and not separate. At best, they are descriptions of packages of symptoms without distinct boundaries. These processes are also occurring inside and outside the bodies of symptomatic people. It is a mistake to believe that a symptomatic person owns the problem. The truth is that every patient manifests environmental conditions and group processes.
Here is a brief example of a process summary: Food processing involves a complex of procedures, starting in the digestive tract and emerging in all parts of the body minutes to days later. Long term effects of food intake emerge over years. Food is a sample of the local environment and food choices are determined by groups of humans, not individuals. Some of our understanding of what happens to food inside a body involves digestive processes, the microbiome and metabolism.
Usually missing in medicine is an understanding of the effects of xenobiotics and immune responses to food proteins. Digestive tract responses to food include signals that are sent to regulate digestive processes and to activate the metabolic activities required to utilize incoming nutrients. Other responses are defensive and produce symptoms that warn that other problems will follow downstream. Recurrent digestive symptoms suggest that disease may appear. When the digestive disease is not fully expressed, categories like IBS are used, just as depression is used as a placeholder for dysfunctions that are not fully manifest and not understood. Patients who are eventually diagnosed with celiac disease, for example, often spent years with a variety of wrong diagnoses, especially IBS. They accumulate other diseases that are seen as separate and unrelated.
A patient with "depression" first presented to his physician as a tired, sad man with digestive problems who had lost interest in all his activities; eventually, over several years, he progressed to further, more specific manifestations of brain dysfunction. He was diagnosed with depression and given antidepressant drugs that did not help. The question for physicians is: When do you switch from a psychiatric paradigm to a neurology paradigm? In other words, when to you realize that a collection of symptoms that you called "depression" are really symptoms of early Alzheimer's disease or some other neurological disease that eventually the pathologist can diagnose? You may be able to prevent progression of early disease with diet revision and exercise, if you start soon enough. Physicians in general have no idea how to prevent the progression of dementias. They tend to ignore early manifestations. I present these arguments in more detail in the book, the Human Brain.
Biochemistry is the indispensable science of nutrition. Food is the biochemical input to bodies and metabolism is the process by which nutrients are utilized. There are four major aspects to metabolism:
1 extraction of energy from food
2 biosynthesis and cell construction
3 detoxification and excretion of unwanted materials
4 Cell growth and replication
Most nutritional literature presents information about individual nutrients, usually considered in isolation. You are familiar with nutritional advice: "...nutrient X is really good for bones, be sure to get lots of X." This simplistic nutritional advice dominates popular nutrition. A more sophisticated approach is required. Nutrition can be thought of as an idealized, abstract look at the possible (but not real) outcomes of eating food.
Cellular metabolism involves the interconversion of thousands of metabolic substrates through enzyme-catalysed biochemical reactions. Food is the raw material input to this complex of chemical activity. Although the organization of individual pathways into metabolic networks is understood, the principles that govern their regulation and integration with different diets and under different growth and living conditions are not well understood.
The role of foods themselves, as objects of behavior and regulators of internal body dynamics, are relatively ignored. The possibility of things going wrong with digestion, absorption, and metabolism and with immune surveillance of these processes, while considered in medical science, is seldom a concern in medical practice. The dietitian often assumes that nothing will go wrong with food-body interactions; nutrients that are in the food are available to the body without complications. The physician generally assumes that nothing will go wrong or will consider a small number of adverse effects ignoring a number of pathological possibilities that may be the key to enigmatic disease.
A better idea is that a molecular stream flows through the body, interacts with DNA-determined metabolic machinery and decides the biological fate of the individual. If there is a mismatch between the incoming molecular stream and the ability of the metabolic processes to derive sustained, coherent meaning from it, then dysfunction and disease results. Ultimately, we may have the technology to monitor body chemistry in real-time, allowing us to design specific, optimal nutrient intake for an individual metabolism. For now, lacking this technology, we can utilize the patient's own self-monitoring and self-diagnostic abilities to better advantage NP concepts require patients to learn intelligent self-monitoring and self-control.