In this first of four lectures delivered at the IMMH Conference in San Antonio, Texas - September 19, 2014 - Dr. Cady touches on themes from last year's presentation and introduces fun and exciting new ways to look at function medicine. This year's talk heavily emphasizes the role of nutritional supplementation in supporting the structure and function of the human body. Updates from clinical cases encountered last year are also covered. General topics in this presentation include: - the importance of evaluating and balancing the thyroid axis - the importance of sex steroids and DHEA - the importance of antioxidants, mineral, multivitamins, and essential fatty acids in optimal health - the need to clearly identify, articulate, and treat the differences between something that is a pure "psychiatric" condition and the covert masqueraders which may actually represent undiagnosed and untreated physiological/medical conditions until addressed.

1. THE PHYSICIAN IN SPITE OF HIMSELF II:
The Pathway Toward Enlightened, Integrated & Holistic Practice
(The Adventure Continues!)
Louis B. Cady, MD – CEO & Founder –– CCaaddyy WWeellllnneessss IInnssttiittuuttee
5th Annual MMH CONFERENCE – San Antonio , TX
Friday, September 19, 2014

2. Continuing Medical Education Commercial Disclosure Requirement
I, Louis B. Cady, M.D., have the following commercial relationships to
disclose:
• Speaker faculties: Forest Pharmaceuticals, Sunovion, Shionogi,
Takeda-Lundbeck
•Testing laboratories: Immunolaboratories, Great Plains Diagnostic
Labs, LABRIX
•Commercial endeavors: Pharmanex distributor
•Historical honoraria, speaking: Bristol-Myers Squibb, Celltech,
Cephalon, Eli Lilly, Glaxo Smith Kline, Janssen, McNeil, Pfizer-Roerig,
Sanofi~aventis, Searle, Sepracor, Shire, Takeda, WorldLink Medical,
Wyeth-Ayerst

3. WHERE TO “GET THE
SLIDES”   
Syllabus
www.slideshare.net/
lcadymd
Cady Wellness Institute app.
THIS IN IN YOUR SYLLABUS ON THE
LAST SLIDE OF EACH TALK.

4. www.slideshare.net/lcadymd

5. Le medicin malgre lui –
Moliere, 1666
Microsynopsis: Sgnarelle – an alcoholic woodcutter forced into
posing as a doctor who becomes rich and respected.

6. Going from “Drunken Woodcutter”
status to the present….. With a little
help from my friends
• My colleagues & peers at this conference:
Dr. William Shaw Ph.D., Dr. Kurt Woeller
DO, Dr. Bill Code MD & many new friends!
• My mentors: especially Dr. John Graf, MD,
Mayo Clinic
• My patients:
– “You should be able to treat your clients as dear
and valued friends.” – Jay Abraham

7. “If you can only read one article
in your entire career at Mayo on
psychotherapy, read this one.”
- John Graf, MD
Greben, S.
Can Psychiatr. Assoc
Journ. Vol 22 (1977):
371-380
“On Being
Therapeutic”

8. Psychodynamics and functional medicine
• Some therapists stand out as uniquely
effective.
• Academics are no better.
• “Every potential therapist must have a floor
and a ceiling to his therapeutic capacity.”
• Some gifted therapists are able to say why
they succeed; others can’t explain it. “A
great deal of what they do ‘right’ is intuitive.”
“On Being Therapeutic” - Stanley Greben, MD [Canadian
Psychiatric Association Journal. Vol. 22(1977) 371-380].

9. Greben’s “Seven Habits”
• Empathy & concern
• Warmth
• Interaction
• Ability to arouse hope
• Expectation of improvement
• “Not to despair”
• Reliability & Friendliness
*
*Requires clinical depth and breadth of knowledge

10. Psychodynamics 101
• Patients can be vexing.
• Diagnostic impasses provoke narcissistic angst.
• Frustrated clinicians do not relate well with
patients.
• The more tools and capabilities one has, the
greater the freedom, the options, and the ability to
positively impact the patient.
• The greater the success, the better the patient
feels, the doctor feels, and the doctor-patient
relationship feels.
• The converse, worrisomely, also exists.

11. Animal, Vegetable, or Mineral?
The Case of the Phrustrated
Pharmacist

12. % Mineral depletion from the soil
during the past 100 years, by continent
North America 85%
South America 76%
Asia 76%
Africa 74%
Europe 72%
Australia 55%
Source: UN Earth Summit Report 1992

13. Huge reduction in Vit D & Iodine in
last 40 years (source: www.vitamindwiki.com)
2X to 3X less Vitamin D 4X less Iodine
Air conditioning, sunscreen, multi-media Less Iodine in milk (no longer used
on cows)
indoor jobs, less cholesterol, more obesity Less Iodine in bread (no longer
used in processing)
live in cities - which have less UVB Increased use of Iodine blockers:
Fluoride Chlorine and Bromide
(used in flour)
also perchlorate in some fertilizers
increased used of farmed fish (1/4 the Vit D) Less iodine in salt:
1) Use table salt much less
2)No Iodine in salt used in processed foods
3) half of iodized salt does not meet requirements
Swiss have increased iodine in ALL of their salt – from 3.75
mg/kg in 1975 to 20 mg/kg in 1998. Their intake > 2X US.

14. Magnesium mementos
• One of the first minerals to disappear with:
– Processed food
– Stress
• Decreased by EtOH, caffeine, sodas, meds
• Considered “anti-stress” mineral
– Decreases cortisol (rel to sleep disruption)
– Relaxes muscles, prevents cramps (sleep
disruption)
– Decreases anxiety; improves sleep

15. Symptoms of Magnesium Deficiency
PSYCHIATRIC ISSUES:
•Difficulty with memory
and concentration
•Depression, apathy
•Emotional lability
•Irritability, nervousness,
anxiety
•Insomnia
Autism
ADHD
Health Conditions Associated
with Magnesium Deficiency
 Migraine headaches
 PMS
 Dysmenorrhea
 Fibromyalgia
 Fatigue
 CONSTIPATION

16. http://epiphanyasd.blogspot.com/2013/11/magnesium-in-autism-and-other.html

17. SELENIUM DEFICIENCY in FASEB:
• “Adaptive dysfunction of
selenoproteins from the
perspective of the ‘triage’
theory: why modest
selenium deficiency
may increase risk
of diseases of
aging.”
Foundation of American
Societies for Experimental
Biology
McCann, J, Ames BM. FASEB J.
2011 Jun;25(6):1793-814.

18. “the foot soldier”
LifePak Nano has 200% of RDA of
selenium.
Se+

THYROID
HORMONE
& 76% the RDA for iodine

19. “The concomitant evolution between plasma Se
decrease over a 9-year period and cognitive decline
suggested that optimal Se status is potentially
important to maintain neuropsychological
functions in aging people.”

20. Negative downstream effects from
selenium deficiency:
“…cancer, heart disease, and
immune dysfunction are
prospectively associated with
modest selenium deficiency….
suggesting that Se deficiency could
be a CAUSATIVE factor”
McCann, J, Ames BM. FASEB J. 2011 Jun;25(6):1793-814.

21. Observational study of randomly selected men –
Boston
3 cohorts of men: 1987-1989; 1995-1997; 2002
-2004.
1374, 906, and 489 men, respectively.
“Age independent decline in T that does not appear to
be attributable to observed changes in explanatory
factors, including lifestyle characteristics such as
smoking and obesity.”
“Recent years have seen a SUBSTANTIAL, and as
yet UNRECOGNIZED age-independent population-level
November 2009
“Alpha Male” issue
decrease in T in American men.”
Travison, Araujo, et al. Jrnl of Clin. Endocrinol & Metabol 92:1; 196-202.

22. Fast food (low Zn) is bad for you.
• Fast food = high energy density = low essential
micronutrient density, ESPECIALLY ZINC
• Antioxidant processes are dependent on Zinc
• Fast food = severe decrease in antioxidant
vitamins and zinc, correlating with
inflammation in testicular tissue – with
underdevelopment of testicular tissue and
decreased testosterone levels

23. Special needs - Zinc
• Low Zinc- associated with low testosterone
– Per USDA, 60% of US men between 20 – 49
years of age do not get enough.
– N.B.: Do not supplement with > 50 mg daily
(can interfere with Cu+ metabolism)
• Tsai, E.C., Boyko, E.J., Leonetti, D.L., & Fujimoto,
W.Y. (2000). Low serum testosterone level as a
predictor of increased visceral fat in Japanese-
American men.
International Journal of Obesity and Related Metabolic Disorders,
24, 485-491

24. Special needs - Zinc
• Low Zinc- associated with low testosterone
– Found in meat, seafood, oysters & dairy
– Vegetarians at highest risk for zinc deficiency
– Per USDA, 60% of US men between 20 – 49
years of age do not get enough.
– (N.B.: Do not supplement with > 50 mg daily
-can interfere with Cu+ metabolism)
• Tsai, E.C., Boyko, E.J., Leonetti, D.L., & Fujimoto, W.Y. (2000). Low
serum testosterone level as a predictor of increased visceral fat in
Japanese-American men.
International Journal of Obesity and Related Metabolic Disorders,
24, 485-491

25. Balanced presentation inclusive of
women…
• Oral zinc raises testosterone levels in women.
– Vecchio M, et. Al. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD007747.
doi: 10.1002/14651858.CD007747.pub2.
• Transdermal testosterone improves:
– Sexual desire, arousal, orgasm frequency, and sexual
satisfaction in premenopausal and post-menopausal
women.
– Also associated with favorable effects on body
composition, bone, cardiovascular fxn, and COGNITION
• Davis SR. Androgen therapy in women, beyond libido.
Climacteric. 2013 Aug;16 Suppl 1:18-24. doi:
10.3109/13697137.2013.801736. Epub 2013 May 27.

26. Hormones, Cognitive Dysfunction &
Depression in Older Adults
Louis B. Cady, MD – CEO & Founder –– CCaaddyy WWeellllnneessss IInnssttiittuuttee
Adjunct Asst. Prof of Psychiatry – Indiana University School of Medicine
Department of Psychiatry
Child, Adolescent, Adult, Functional Neuropsychiatry – Evansville, Indiana
AMMG Fall Conference – Nov. 2, 2012 – General
Session Curriculum 2:00 – 2:45 pm Las Vegas, NV - USA

27. T vs Cognitive Function
Rosario ER. Age-related testosterone depletion and the
development of Alzhiemer disease. JAMA. 292(2004):1431-2

28. T vs. Cognitive Function
• 400 independently living men, 40-80yo
– 100 in each age decade
– MMSE 21-30, average 28
– TT: 208-1141ng/dL; Bio-avail T 78-470ng/dL
• HIGHER T = better cognitive performance in
OLDEST AGE category
• Men with lowest 1/5 T = worse than men with
highest 1/5 T
• Highest Bio-available T more significant
than TT, age, intelligence level, mood,
smoking, and alcohol.
Muller M, et al. Neurology. 2005 Mar;64(5): 866-71

29. T vs. Mood in men
• Study: 278 men, >45yo, followed 2 years
• Compared to eugonadal patients,
hypogonadal men w/TT <200ng/dL had
– 4-fold increase risk of depression
– Significantly shorter time to depression
diagnosis
• Depression risk inversely related to TT
w/statistical significance <280ng/dL
Shores MM, Arch Gen Psychiatry. 61(2004):162-7

30. T vs. Heart Disease
• Men with CAD have significantly LOWER
levels of androgens than normal controls.
– English, KM et al. Men with coronary artery disease have lower
levels of androgens than men with normal coronary angiograms.
Eur Heart J. 2000 June; 21(11):890-4.
• “There is early evidence from non-randomized
studies that physiological testosterone
replacement is extremely safe and may reduce
cardiovascular mortality.”
– Hackett G. Testosterone and the heart. Int J Clin Pract. 2012
July;66(7):648-55.

31. Low T’s (thyroid/testosterone) & presumptive
nutrient deficiencies in the aging male:
The Phrustrated Pharmacist (8/3/2014)
• 73 yo MWM retired (2009) R.Ph. “burned
out.” Essentially sitting home depressed.
Not going anywhere.
• Presenting Rx:
– Fluoxetine – 40 mg
– Seroquel 50 mg XR for sleep (bipolar)
– Hydralazine, amlodipine, Zocor, Metformin, ASA
• ROS: decrease in libido. Profound fatigue.

32. Mental Status Examination:
• Depression:
– Sad/depressed/down in the dumps
– Lack of/loss of interest in things.
– Trouble concentrating
– Insomnia/trouble sleeping at times.
– Decreased energy
– Guilty/worthless – which wasirrational – he had nothing
to feel guilty about it. (6 total symptoms; 5 = required)
• Other sxs:
– Weakness, hopeless, feeling life is not worth living,
sleeping too much, loss of libido, and full diagnostic
criteria met for generalized anxiety disorder

33. Relevant markers
• Thyroid functions
– TSH 0.43 {0.34 – 5.61}
– Free T4 1.34 {0.587-1.64}
– Free T3 2.8 {2.0 – 4.4}
– Reverse T3 32.1 (H) {9.2 - 24.1}
• Sex hormone
– LH 8.7 (H) {1.24 – 8.62}
– Total testosterone 199 (L) {348 – 1197}
– Free Testosterone 3.6 (L) {6.6 – 18.1}
– PSA 0.24 {0.0 – 4.0]
– Estradiol 13.6 {7.6 – 42.6}
• Coenzyme Q10 0.75 {0.37-2.20}
• Raman score 24,000 {>50,000}
– ( =1.44 MICROgrams carotenoids/ml serum)

34. Interventions – 8/14/2013
• Testosterone IM
– 200 mg ASAP, then 100 mg every 4 days until
levels better.
• DHEA – 25 mg timed release
• Liothyronine, timed release
• Excellent MVI/multi-mineral/fish oil
supplement/phytonutrient/antioxidant supplement
(with 200% Selenium; 100% Zinc RDA, 600 mg
EPA, 400 mg DHA)
• continued fluoxetine

35. The Phrustrated Pharmacist: What happened?
• 11/26/2013 – (3 ½ months later)
– Going to all grandchildren’s soccer games
– Out mowing his yard and mulching leaves
– Depressive symptoms ELIMINATED.
– Appetite has gone up; but clothes fitting better.
– Plenty of energy.
• 1/16/2014
– “I’ve been doing good – I’m doing everything. I walk the
dog every day. I go to the soccer games.”
– Has gone to get OSA checked.
– Has lost so much weight (60 lbs) he’s using clothes pins
on pajamas.

36. What happened to labs (1/6/2014)?
• Thyroid functions
– TSH 0.47 {0.34 – 5.61}
– Free T4 0.67 {0.587-1.64}
– Free T3 3.8  {2.0 – 4.4}
– Reverse T3 14.5  {9.2 - 24.1}
• Hormones (Rx of 80 mg T twice weekly)
– Total testosterone 582 {348 – 1197}
– Free Testosterone 12.0 {6.6 – 18.1}
– DHEA-Sulfate 378 (“H”) {30.9 – 295.6”; OPTIMAL
RANGE – per Cenegenics is about 500}

37. Frustrated Fpharmacist Follow-up –
4/15/2014
• Animated and alert.
• Got hired to tutor pharmacology at local
community college.
• Playing in handbell choir again.
– “I’m not very good – they let me play the half notes and
whole notes with the great big bells.”
• Quipped about a customer he recalled who came
in ask (in past) and asked for “methyl-testosteroney.”
• On CPAP for six weeks. Doing well.

38. Raman spectroscopic carotenoid
scans:
• 1.44 ugrams carotenoid/ml- 8/27/2013
• 2.4 ugrams carotenoid/ml - 9/27/2013
• 2.58 ugrams carotenoid/ml- 11/26/2013 (this is
without a lot of supplementation and none in the last two weeks. He is
eating more fruits and vegetables.)
• 2.52 ugrams carotenoid/ml- 1/16/2014 on one
pack of MVI/multi-minerals and fish oil (7 capsules)
• 2.82 ugrams carotenoid/ml - 7/15/2014

39. Antioxidant assessment
Reference:
www.cadywellness.com/cadywhitepaper2008.

40. (c) 2013 Louis B. Cady, M.D. - all
rights reserved

42. “The findings support studies that state that major depression is
associated with mitochondrial dysfunction and OXIDATIVE
STRESS, and that omega-3 supplementation could reverse some
of these changes, probably due to its antioxidant properties.”

43. Raman spectroscopic carotenoid
scans:
• 1.44 ugrams carotenoid/ml- 8/27/2013
• 2.4 ugrams carotenoid/ml - 9/27/2013
• 2.58 ugrams carotenoid/ml- 11/26/2013 (this is
without a lot of supplementation and none in the last two weeks. He is
eating more fruits and vegetables.)
• 2.52 ugrams carotenoid/ml- 1/16/2014 on one
pack of MVI/multi-minerals and fish oil (7 capsules)
• 2.82 ugrams carotenoid/ml - 7/15/2014

44. Final Follow-up – 7/15/2014
• Animated and alert.
• Has lost more weight – now down to 209 lbs.
• Played 18 holes of golf two weeks previous.
– “It was 46 – 47 years ago when I did that last time.”
• Local doc has told him he can drop one metformin
when his weight gets down to <200 lbs.
• Still on CPAP. Doing well.

45. Teaching points
• No change in antidepressants required to
ELIMINATE depression.
• MVI/multimineral/fish oil used to support the
structure & function of the body.
• Appropriate allopathic care given.
• Predictable results occurred.
• BUT WHAT ABOUT THE LAST 20 YEARS?
• This way of thinking works in ALL
specialties.

46. “Pending strong evidence …from randomized trials, it
appears prudent for all adults to take vitamin
supplements.” Fletcher & Fairfield, JAMA 2002

47. Bruce Ames, Ph.D.
395 citations in
PubMed, May 1952-
June 2014.
Most recent is
“Enough is Enough”
Ann Intern Med
2014 Jun 3, with
Frei, Blumberg and
Willett
November 2, 2012

49. Ames & Micronutrient Triage -
deconstructed
1. Inadequate dietary intakes of vitamins/minerals are
widespread.
– Excessive consumption of energy-rich, micronutrient-poor, refined
food
1. Deficiencies in many micronutrients cause DNA damage
in cultured or living human cells.
2. Proposal: DNA damage and late onset disease are
consequences of a triage allocation based on
micronutrient scarcity.
– Natural selection favors short-term survival at expense of long-term
health.
Ames B. Proc Natl Acad Sci U S A. 2006 Nov
21;103(47):17589-94. Epub 2006 Nov 13.

50. Ames & Micronutrient Triage -
deconstructed
4. If proposal is correct, “micronutrient deficiencies
that trigger the triage response would accelerate
cancer, aging, and neural decay but would leave
critical metabolic functions, such as ATP
production, intact.”
5. “A multivitamin-mineral supplement is one low-cost
way to ensure intake of the Recommended
Dietary Allowance of micronutrients throughout
life.”
Ames B. Proc Natl Acad Sci U S A. 2006 Nov
21;103(47):17589-94. Epub 2006 Nov 13.

51. 44 million inpatients, 460 sites, 2000-2010 = 20%
of all US inpatient episodes (1.6% were on ONS
during the inpatient episode.)
>/= 1188 yyeeaarrss.. NNoo tteerrmiinnaall ppaattiieennttss,, ttuubbee ffeeeeddiinnggss..
RESULTS for “ONS”:
•2.3 day shorter length of stay
•Decreased cost of $4,734 / episode
•2.3% reduced probability of early readmission.
CONCLUSIONS: “Use of ONS decreases length of
stay, episode cost, and 30 day readmission risk in the
inpatient population.”
Tomas J, et al. Am J Manag Care. 2013;19(2):121-
128

52. Symptoms of B12 Deficiency
Mental Physical
• Irritability
• Apathy
• Personality changes
• Depression
• Memory loss
• Dementia
• Hallucinations
• Violent behavior
• Anxiety
• Diminished sense
of touch and pain
• Clumsiness
• Weakness
• Pernicious anemia
• Chronic fatigue
• Tremors
• GI problems

53. The Effects of high dose B vitamins
on stress at work
• “Occupational stress is increasing in Western societies.”
• 3 month, double blind, placebo control, randomized study
• Measured: Personality, work demands, mood, anxiety, and
strain
• After variances in personality and work demands were
controlled, the vitamin B complex treated
group reported significantly lower personal
strain and a reduction in confusion and
depressed/dejected mood after 12 weeks.
Strough C et al. The effect of 90 day administration of a high dose vitamin B-coplex
on work stress. Hum Psychopharmacol. 2011 Sept 8. doi
10.1002/hup.1229 (Swinburne University of Technology – Hawhorn, Victoria,
Australia.)

54. Vitamin/mineral supplementation & cancer,
cardiovascular, and all-cause mortality
(EPIC-Heidelberg) Li K, Kaaks R., et al. Eur J Nutri July 2011
• Purpose: evaluate vitamin/mineral
supplementation with CA, CV dz, and mortality
• Methods:
– 23,943 healthy participants, followed x 11 years
– Baseline and “new-use” supplementation noted
• Results: 513 CA deaths, 264 CV deaths
– “No MVI supplement had any significant effect”
– Baseline users of antioxidant supplements
had significantly reduced risk of cancer [HR
0.52] and all cause mortality [0.58]
• “sick user” phenomenon discussed.

55. “Homocysteine lowering by B-Vitamins slows the rate of
accelerated brain atrophy in MCI”…
CONCLUSIONS: “The
accelerated rate of brain
atrophy in elderly with MCI can
be slowed by treatment with
homocysteine-lowering B-vitamins.”
Smith AD, Smith SM, de Jager CA, Whitbread P, et al. (2010) Homocysteine-Lowering by B Vitamins Slows the
Rate of Accelerated Brain Atrophy in Mild Cognitive Impairment: A Randomized Controlled Trial. PLoS ONE
5(9): e12244. doi:10.1371/journal.pone.0012244
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0012244

56. Regional loss of grey matter volume reduced
with B-vitamins
Douad G, et al. preventing Alzheimer’s disease-related gray matter atrophy by B-vitamin
treatment. Proc Natl Acad Sci U S A. Jun 4, 2013; 110(23): 9523–9528.

57. OK. It slows shrinkage. But are they sharper?
[deJager CA et al. Int J Geriatr Psychiatry. 2012 June;27(6):592-600]
“B-vitamins appear to slow cognitive and clinical
decline in people with MCI.”

58. The Glamorous Grandmother
• 4/8/11 – 80 yo returned to practice. No real
complaints. History of depression. On des-methylvenlafaxine.
– Daughter “handling her finances”
• 5/2/11 – “doing terrible.”
– TSH 3.84, Free T3 2.8 – on 50 MICROgrams T4
– Fasting BS 120; HgBA1C 6.5%
– Fasting insulin 36 (!!!) {3 – 25}
– Progesterone – 0.2 {0.2 – 1.4 follicular}
– Total testosterone 11
– DHEA-S = 25 MICROgrams/dL (!!)
• Age adjusted {10 – 90} . Optimal = {c. 350-500}
• Rouzier = {300 –females, 600 males}

59. G.G. - interventions 5/2/11 & Follow-up
• Interventions:
– RAISE T4 from 50 to 75 MICROgrams
– DHEA – 25 mg SR q a.m.
– Progesterone 50 mg then 100 mg HS, transdermal.
– Testosterone – 2 mg for one week, then 4 mg
transdermal
– Referred to better MD for intervention with AODM.
• 6/13/2011 – improvement in fatigue. Labs
rechecked.
• 7/11/2011 – “feeling wonderful”
• Started on MVI/multimineral/fish oil supplement

60. G.G. – labs before and after
` 4/11/11 interventions 7/11/11 changes
TSH 3.84 Raise T4 from
50 – 75 ug
0.01 (L) none
FT4 1.16 “ 1.24 “
FT3 2.8 “ 3.3 “
Progesterone <0.2 100mg topical
HS
0.9 None
Testosterone 11 4mg topical 15 4 mg LABIAL
DHEA-S 25 25 mg SR n/a continue

61. The glamorous grandmother – post tune-up:
DHEA, thyroid, testosterone, progesterone
Photo(s) removed for presentation posted on
internet
9/28/2011 (permission granted to use photos & data) 01/26/2012

62. October 12, 2012 – used with permission

63. July 29, 2014 – used with permission
• 85 years old – living
independently
• Reading books
• Driving car
• Dating nice man from
church
• Thyroid RX:
– T4 – 75 ug
– T3 – 5 ug 2x/d
• Hormones:
– DHEA 50 SR, Biest,
Progesterone,
Testosterone
• Supplements: MVI/Multi-mineral/
fish oil

64. G.G. – interventions & labs
` 4/11/11 Interventions,
current
6/9/2014 Ref range
TSH 3.84 Raise T4 from 50 –
75 MICROgrams,
add 10
MICROgrams T3
0.02 (L) {0.45-4.5}
FT4 1.16 “ 1.07 {0.80-1.76}
FT3 2.8 “ 4.0  {2.3 – 4.2}
Estradiol 0.4 mg E2 SL 20 {27-122}
Progesterone <0.2 10 mg SL HS 1.5 {0.2 – 1.4 =
follicular}
Testosterone 11 2 mg topical (wrists) 235(H) {5-32}
DHEA-S 25 50 mg SR 463 (“H”) {“10 – 90”}
NTX 19!!  {17 – 94 –
premenopausal}

65. ADHD as an exemplar of a
precision & functional approach

67. “Trying as hard as I can”
• ID: 20 year old biracial male.
• CC:
– “People seem to think I have ADHD for some reason.”
– “I’m trying to go to this DII school – and I know I won’t
be able to get through it if I don’t find out what’s wrong
with me.”
• Academic failure impacting his athletic eligibility
• HPI:
– Classic symptoms of ADHD since childhood.
– Parents were told that he wasn’t focused or doing his
best, but that he was a “good boy.”
– Worked up at 8 years of age. But dx’ed with “anxiety
disorder” and “learning disorder.”

70. BADNESS
GOODNESS

71. STATS:
•ATTENTIVE 12.5% (!!!) of the time
•Impulsive 72.5% (!!!)of the time
•Distracted 12.5% of the time
•Disengaged 2.5% of the time

73. BADNESS
GOODNESS

74. STATS:
•ATTENTIVE 60% (!!!) of the time
•Impulsive 32.5% of the time
•Distracted 7.5% of the time
•Disengaged 0% of the time

75. 7/08/2013 – post treatment
7/23/2013 – post treatment – 60 my Vyvanse (lis-dexamfetamine) per day

76. Most recent follow-up – 6/27/2014
• Pitching for DII school as a walk-on trial.
• Concentration excellent.
• May audition for major league baseball
team.
• No trace of ADHD.
• Only Rx is 70 mg of Vyvanse per day.

78. The Story of Alan
• 2/24/2010 – “ADHD hampers his ability to focus and
comprehend information. He becomes overwhelmed.
Lacks confidence in reading. Teacher believes he is
capable.”
• Past history: “a busy child. “Couldn’t keep him in a chair.”
• ADHD dx in kindergarten. Multiple Rx since, incl. Abilify
• At presentation:
– 20 mg Adderall XR in a.m., 3 mg Intuniv in a.m., 5 mg Abilify at 4
pm.
– “Heart is racing” for two months.
– Hx of stimulant rebound and having to push the dose
– Stools like tar since starting on Abilify.
• Rating scales:
– DSM-IV 9/8 before meds; DSM-IV 9/4 ON meds

79. Treatment summary and new developments
• Medications adjusted. Stimulant lowered and L-tyrosine
started with it (inc. to 1 gram twice daily ).
– Changed to Concerta + Ritalin (a.m.), Intuniv, Risperdal, and
Depakote (250 mg 3x/day)
• 11/9/10 and 12/6/10 – “meltdowns” at school. States “I am
going to KILL you,” when he is upset. Kicking the table at
school and not looking at the teacher.
• “Favorite food is pizza.”
• 12/6/2010 – not totally coherent on MSE. c/o “head
hurting.” Seems generally tired and ill-appearing.
– PE – grossly neurologically intact. (Examined).
• OAT test and IgG Food Allergy panel ordered.

80. “His favorite food is pizza.” – Mom
(reviewed December 7, 2010 when these labs were
ordered)

81. Organic acid testing – 12/23/2010
Pertains to energy production, Kreb cycle, B vitamins, CoQ10, Mg

82. Interventions
• 1/5/2011:
– School insisting he is “autistic” (meltdowns)
– At appt. told to remove wheat, peanuts, and milk from
diet
– Started on CoQ10, B-50, ALA, Vit C & E
• 2/8/2011:
– Alan - “for the first time I think the medicine is getting
right.”
– “We need to tell Dr. Cady that that Kroger store in ____
has a lot of gluten free stuff he needs to know about.”
• Liquid fish oil added.

83. SScchhooooll wwoorrkk 66 wweeeekkss llaatteerr……
School continuing to insist he is “autistic.”
NOTE: doesn’t spin, doesn’t flap, doesn’t engage in
stereotypical behaviors. Just had a history of “fits.”

84. Beginning of resolution….
• 4/1/2011 – five weeks of “awesome behavior” at school
with “no blow-ups whatsoever.”
– “The school authorities are amazed.”
– Won STUDENT OF THE WEEK (!!)
• 5/31/2011 – concluded school year; no blow-ups.
• 8/30/11 – some blowups, but not the “explosive kind like he
had last year.”
• 12/21/11- scored “distinguished” in math and “proficient” in
reading. (continues supplements and diet)
• 2/17/2012 – “Tired.” RX: lower Concerta from 54 to 36
mg
• Having more meltdowns at school. New labs ordered.

85. IgG results – 3/29/2012

86. - Started on Nystatin,
compounded, liquid – up
to 500,000 IU three times
daily. Also Probiotic.
- ELIMINATE MILK &
WHEAT

87. Progress!
Original IgG 3 7 2012
Repeat IgG testing 06/28/2012

88. Organic acid test – 6 26 2012
• Arabinose c/w candida (prev started on NYSTATIN)
• All B-vitamin markers improved
• Coenzyme Q10 high normal
• HVA, VMA, 5HIAA – all increased.
• Vit C low but c/w water solubility and a.m. spec.

89. Alan –7/31/2012
• On Nystatin for candida, plus all Rx.
• Concluded school year well.
• “Was more interactive and playing on the
playground.”
• Went up on state testing 17 points in reading. At
grade level in math.
• Playing outside more, riding his bicycle.
• Vitamin C increased 500 mg twice daily
• Start on Curcumin/turmeric for inflammation
• STABLE.

90. Alan –12/30/2013
• In 6th grade. Working at grade level.
• Going to retreats with church youth group.
• Continues with strict DF/GF diet
• RX:
– Allopathic: MPH-OROS decreased from 54 to 36mg;
MPH 20 mg in a.m.; Intuniv 3 mg HS. Risperidone 0.25
mg 1 ½ a.m. and 1 pm. Valproate 250 mg ER three
times daily. Nystatin dosing completed.
– HOLISTIC: L-tyrosine 1000 mg twice daily. Riboceine
containing supplement; MVI, Coenzyme Q10, B50 twice
daily , ALA, Vitamin E, Curcumin/turmeric 500 mg twice
daily

91. How I got a patient’s wife pregnant
and achieved fame in my time…

92. A “straight psych” workup?
• 26 yo MWM ref by therapist –
5/14/2012.
• Presenting issues:
– “obsessive unrealistic uncontrollable thoughts”
– “anxiety and constant worry”
– “I have strange thoughts that aren’t my thoughts”
– “I can’t get rid of some disturbing thoughts.”
– “have a low self-esteem & sense of
inadequacy” – “my whole life.”

93. A “straight psych” workup?
• HPI: 2 months ago, acute onset [ego-dystonic]
of images of his wife with her throat
cut.
• No previous formal psych history
• Med History: “dx with infertility and
inadequate sperm count.”
– “not feeling like having sex with wife.”
Eject button?

94. Labs 5/22/2012
TFT’s
TSH 1.4 {0.3 – 5.6}
Free T4 0.9 {0.6 – 1.1}|
T3 Uptake 37% {24 – 39 –
this is NOTE THE LAB I ORDERED.}
Reverse T3 31.9 {13.5 – 34.2}
TESTOSTERONE LEVELS:
Total testosterone 227 (L) {348 – 1197; it
probably should be in the 900 – 1000 range}
Free Testosterone 6.6 (L) 9.3 – 26.5}
LH 5.3 {1.7 – 8.6}
DHEA-Sulfate 301.3 {160-449}

95. Rx:
• Continue Vilazodone titration for psych
symptoms.
• Armour thyroid – ¼ grain x 7d, then ½ grain
• CLOMIPHENE CITRATE – 50 mg tabs – ½
daily x 3 – 5, then one daily
• HCG [human chorionic gonadotropin]
injections = 1500 IU twice weekly SQ
• DHEA – 25 mg timed release daily
• Repeat labs ordered.

96. Labs & sperm count compared:
• Previous:
– 400,000 {50 – 150 MILLION}
– 35% motility
– Low amount ejaculate
• New results - 6/21/2012 – one month later 
• Testosterone 956!! {348-1197}
– 125 million (!!!!!) {50 – 150 MILLION}
– 85% motility
– 4 cc ejaculate
• Patient && wwiiffee ttoolldd ttoo ggoo PPAARRTTYY DDOOWWNN!!!!

97. E-mail Oct. 19, 2012 –
Subject: “Our first baby pic”
(nine weeks gestation)
June 11, 2013

98. Interesting follow-up
• January 24, 2014 – happy with one child.
Feeding the baby at appt. Wife with him. OK
to go off clomiphene and HCG. Started on
Axiron.

99. 15 ½ months – Aug 27 2014
Surprise! New sister! (EDC –
10/21/2014

100. Teachable points for this case
• It’s not about the “age management” ideas.
• It’s about LISTENING to the patient.
• OPTIMIZE the biological platform
• Refer or consult if you don’t know, but don’t
“wimp out” and push the “delete” or “eject”
button on patient concerns.
– Don’t say, “it’s not my department; I don’t know
about that.”
• If the patient expresses it, it’s a problem.
• The body affects the mind and the thoughts.

101. How are you feeling?

102. Integrating functional medicine techniques
• Don’t blame the child, the parents, or the adult patient.
• If you do not KNOW it’s not a biological, physical problem,
then you simply don’t know. PERIOD.
• It’s most likely not a “Risperdal deficiency.”
• It’s not an “Axis II” issue unless you have DEFINITIVELY
RULED OUT a biological problem.
• Test test test test test. You can’t tell by “looking.”
– FUNCTIONAL MEDICINE TESTING in difficult cases.
• Recognize the importance of DIET.
• Appropriate – not excessive – use of supplements and
interventions.
– Be able to explain each one. (“The Peter Lynch rule.”)

103. Things to consider / action items:
• You must adapt; medicine is changing.
– Internet and wide information distribution
– Health care expenditures out of control
– New paradigms of nutrient insufficiency and
environmental toxins
– There are no new “magic bullets.”
• You don’t have to know it all and do it all...
But you must be willing to ACKNOWLEDGE
and REFER.

104. Things to consider / action items:
• Do not consider outside diagnoses as
indisputable. EVERYTHING is “up for
grabs” until proven.
• Integration of functional medicine is like
learning to walk – “You do it UNTIL.”
• Humble your ego, admit your ignorance,
and ask questions.
• Remain intellectually open and playful.

105. But what about the healers??
Or – “How do you want to spend
the rest of your professional
lives?”

106. “Today, almost 50% of doctors report
symptoms of burnout – emotional
exhaustion, low sense of
accomplishment, detachment.”

107. 40% OF DOCTORS ARE
BURNED OUT • Too many
bureaucratic tasks
• TOO MUCH
PAPERWORK
– ¼ of time is spent
in non-clinical
paperwork.
– Dealing with
“checkbox
medicine”
Source: Medscape’s 2013 Physician Lifestyle Report cited in
“Staying Sane as Medicine Goes Crazy” – July 25, 2014

108. How do YOU Want to
Practice?

109. Doctors quitting medicine
• Suicide* (2004):
• 1.41 X for male physicians vs. general pop.
• Schernhammer ES, Coldit GZ. Am J
Psychiatry. 2004 Dec; 161 (12):2295-302
• "Half of primary care physicians in survey would leave
medicine ... if they had an alternative." -- CNN, November
2008
*

110. “Why I Left Medicine: A Burnt-Out Doctor’s Decision
to Quit”*
• “It may be dramatic and
self-serving to frame my
career change as a way
to avoid suicide, but I
can attest that medicine
was not conducive to my
health.”
http://commonhealth.wbur.org/2013/10/why-i-left-medicine-a-burnt-out-doctors-decision-to-quit
10/18/2013 – accessed 01/07/2014

112. Are the Best and Brightest
Staying in Medicine?
“60% of physicians
would not recommend
medicine as a career to
their children.”
• – The Physicians’
Fhottpu://nwwdw.maatyoiroswnellnesscampaign.org/wp-content/
uploads/2009/05/merritt-hawkins-survey.pdf.
Accessed April 3, 2010.
Slide courtesy of John Adams, MBA – CEO, Cenegenics

113. THE ANTIDOTE
(and Wellness for Docs)
ACHIEVE PERSONAL MISSION:
Change people’s lives – don’t push
pills/drugs/ (or even supplements)
Healers: Take care of yourselves.

114. Seen for intake in my office – 9/5/2012
• Alert. Serious. Intent on toys.
Played with them loudly. Not
speaking in complete
sentences. Phonated
repetitively.
• Huddled down and pulled his
lunch box in front of him when
I asked him a question.
• Obsessive play with toys.
“Push push push.”
Extensive laboratory testing ordered. Armour restarted.

115. December 5, 2012 follow-up
• RX:
– Armour thyroid 1 ½ grains; Nystatin;
high dose MVI with B-complex; GSH
precursors, Cod liver oil, B6, Vit C,
probiotics, 1 mg ionic Lithium.
– On food antigen diet.
• Family now able to go to church and
sit in pew. Went to MGM’s 95th
birthday party.
• Mental Status Examination:
– Alert, pleasant, happy, engaging.
Talking more. Gait improved. Speech
much more intelligible. Played happily
and cooperatively with Dad.

116. The REST of the Story - Joey
9/5/2012 9/15/2013

117. Summer – 2014 – with Dad in their
organic garden

118. Apple Store – Chicago, Michigan Avenue © 2008 Louis B. Cady, MD.
“It’s not the
customer’s job to
know what he wants.”
- Steve Jobs

120. SUCCESS: Apple Store, Michigan Avenue,
September 20, 2013 – 8:20 PM

121. TODAY: September 19, 2014
1:16 a.m.

122. Start sipping your drinks at PUBMed.gov

123. Determining how patients (&
healers) age
2000

124. What you can do with an integrated
approach in 15 months:
(photo shot 15
months after tx)
RX: dairy free diet (+IgG test); D3 5000 IU/d; Armour thyroid,
Testosterone cypionate 100 mg IM q wk, MVI, Zinc, DHEA 50 mg
SR, CoQ10 400mg
(permission granted to use photos & data)

125. Cady Wellness Institute Synergy:
The Five Point Plan for Patients AND Docs
1) GET ALL THE LABS YOU
NEED.
2) Rx: Hormones, if needed.
3) MONITOR ANTIOXIDANT &
vitamins/minerals.
SUPPLEMENT AS NEEDED.
4) RATIONAL EATING
5) RATIONAL EXERCISING.
Mind
Body
Actions

126. Wrapping Up: The “Survival Curve” –
Where Are You?

127. “For me, the practice of medicine has
opened the door to the greatest adventure in
life. Medicine is like a hallway lined with
doors, each door opening into a different
room, and each room opening
into another hallway,
again lined with doors.
Medicine is always
wonderful and never will
be finished.”
- Charles H. Mayo, M.D.