A Bottom-Up Approach: Transforming Patient Care in Rural South Carolina

In our previous blog, we shared an overview of our internal medicine practice in rural South Carolina and our commitment to holistic, patient-centered care. Today, we delve deeper into the philosophy that sets us apart: the “bottom-up” approach to healthcare. This method emphasizes addressing foundational biological processes that underlie complex health issues, contrasting sharply with the traditional “top-down” model. Let us explore how these approaches differ and why the bottom-up approach is better suited for managing the multifaceted health challenges faced by our patients.

Understanding the “Top-Down” vs. “Bottom-Up” Approach

Top-Down Approach

The top-down approach focuses on treating individual symptoms or isolated conditions, often relying on specialist referrals. This method prioritizes immediate symptom relief, frequently leading to fragmented care as various specialists manage separate issues without considering their interconnectedness.

• Example: A patient with chronic fatigue, Type 2 diabetes, and COPD might see an endocrinologist for diabetes, a pulmonologist for COPD, and a separate provider for fatigue. Each condition is treated independently, potentially overlooking their shared contributors like systemic inflammation and mitochondrial dysfunction.

Bottom-Up Approach

In contrast, the bottom-up approach begins by addressing the root causes of illness, such as systemic inflammation, oxidative stress, mitochondrial dysfunction, and neuroendocrine imbalances. This integrative strategy ensures that interconnected conditions are managed cohesively, focusing on restoring overall health and resilience rather than merely alleviating symptoms.

• Example: The same patient’s care would target reducing oxidative stress (affecting both diabetes and COPD), replenishing NAD to support mitochondrial function, and addressing chronic inflammation to improve overall energy levels and organ health.

References:

1. McEwen BS. “Stress, adaptation, and disease: Allostasis and allostatic load.” Ann N Y Acad Sci. 1998.
2. Wallace DC. “Mitochondria and metabolic diseases.” Science. 1999.

Advantages of the Bottom-Up Approach

1. Comprehensive Management: By targeting foundational issues, this approach treats the whole patient, not just isolated conditions.
2. Fewer Specialist Referrals: Managing complex cases in-house fosters continuity of care and avoids fragmented treatment.
3. Enhanced Resilience: Patients experience improved overall health by addressing systemic dysfunctions like inflammation and oxidative stress.
4. Personalized Care: This method tailors interventions to the unique biological and lifestyle factors influencing each patient.

Applying the Bottom-Up Approach in Our Practice

Reducing Systemic Inflammation and Oxidative Stress

• Top-Down: Treat conditions like COPD or Type 2 diabetes separately, using standard medications.
• Bottom-Up: Focus on the shared driver—oxidative stress—by incorporating intravenous antioxidants (e.g., vitamin C, glutathione) and an anti-inflammatory diet.

Replenishing NAD and Supporting Mitochondrial Function

• Top-Down: Address fatigue with symptomatic medications.
• Bottom-Up: Restore NAD levels using intravenous NAD, oral precursors (NR, NMN), and mitochondrial support supplements (e.g., L-carnitine, CoQ10).

Restoring Endothelial and Metabolic Health

• Top-Down: Manage hypertension and hypercholesterolemia with separate drugs.
• Bottom-Up: Address endothelial dysfunction as a shared mechanism by supporting nitric oxide production (L-arginine) and reducing oxidative damage with targeted therapies.

Balancing Neuroendocrine and Autonomic Systems

• Top-Down: Treat adrenal insufficiency or dysautonomia in isolation.
• Bottom-Up: Use interventions like transcutaneous vagus nerve stimulation to modulate autonomic balance and systemic inflammation.

Enhancing Metabolic Flexibility

• Top-Down: Prescribe medications for weight management or glycemic control.
• Bottom-Up: Promote metabolic flexibility through ketogenic diets, intermittent fasting, and exercise, optimizing the body’s ability to use diverse energy substrates.

Evidence Supporting the Bottom-Up Approach

1. Inflammation and Oxidative Stress: Chronic diseases often share systemic inflammation as a root cause. Treating this reduces the burden on multiple organ systems simultaneously.
   • Reference: Biswas SK, Rahman I. “Inflammation and oxidative stress in aging.” Mech Ageing Dev. 2014.

1. Mitochondrial Dysfunction: Mitochondria are central to energy production. Restoring mitochondrial health improves fatigue, resilience, and disease outcomes.

1. • Reference: Wallace DC. “A mitochondrial paradigm of metabolic and degenerative diseases.” Science. 2005.

1. Integrated Neuroendocrine Health: Autonomic imbalances contribute to systemic dysfunction. Targeted autonomic therapies enhance overall health.

1. • Reference: Tracey KJ. “The inflammatory reflex.” Nature. 2002.

Why the Bottom-Up Approach is Superior

1. Addresses Root Causes: Unlike symptom-focused treatment, it resolves the underlying drivers of disease.
2. Prevents Disease Progression: Targeting systemic issues slows or reverses the course of chronic conditions.
3. Reduces Polypharmacy: By managing interconnected systems, this approach reduces reliance on multiple medications.
4. Improves Patient Engagement: Patients benefit from personalized care and a clearer understanding of how their conditions interrelate.

Our Commitment to Holistic, Patient-Centered Care

Our rural South Carolina practice exemplifies the bottom-up approach by:

• Offering in-house diagnostics and therapies like intravenous NAD, antioxidants, and lidocaine.
• Incorporating lifestyle modifications such as tailored diets and stress management strategies.
• Using shared decision-making to empower patients in their care.

By integrating foundational health strategies into every treatment plan, we aim to optimize health outcomes and improve the quality of life for our community. This approach is not only innovative but also grounded in science and compassion—a hallmark of our dedication to holistic internal medicine.

Steven E. Freeman, MD, PhD