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On the Root Cause Medicine Podcast, Dr. Lara Zakaria joins Dr. Malisa Carulo to explore specialized pro-resolving mediators (SPMs), omega-3-derived precursors, and emerging pain research, with a focus on evidence limits and clinical decision-making.

1. Distinguish SPMs from their precursors. TSPMs are lipid signals that help steer inflammation toward resolution. (Serhan 2018) SPM-focused marine-oil supplements contain upstream intermediates, a few enzymatic steps closer to finished SPMs than EPA and DHA, but these are not equivalent to finished SPMs. (Souza 2020)
2. Separate mechanisms from clinical outcomes.  condition.Mechanistic research outpaces human trials, which so far center on pain and musculoskeletal conditions such as osteoarthritis. (Callan 2020) (Möller 2023) Evidence does not yet support broad benefits for autoimmune disease, gut health, or every inflammatory condition.
3. Keep clinical response central. The conversation emphasizes pain, stiffness, and mobility alongside foundational care. Acute high-dose strategies and bedtime use are discussed as anecdotes, not validated protocols.

Dr. Malisa Carulo holds a doctorate in naturopathic medicine and an MS in biology. Introduced as Senior Manager of Medical Information and Safety at Metagenics, her interests include chronic disease, healthy aging, and sports medicine.

1. What are specialized pro-resolving mediators?

SPMs, including resolvins, protectins, and maresins, as lipid signals involved in the active resolution of inflammation. (Serhan 2018)

2. How do SPM-focused supplements differ from fish oil?

The guest distinguishes EPA and DHA from downstream intermediates such as 18-HEPE, 17-HDHA, and 14-HDHA. This distinction alone does not establish superior clinical outcomes. (Möller 2023)

3. What evidence for SPMs and joint pain does the episode discuss?

The guest highlights early human research in musculoskeletal pain, including osteoarthritis, while acknowledging that clinical evidence remains limited relative to mechanistic research. (Callan 2020) (Möller 2023)

4. Are SPM supplements established therapies for autoimmune or gut conditions?

The discussion does not establish that use. The guest describes clinical experiences and biological hypotheses rather than condition-specific evidence sufficient to support broad treatment claims.

5. Does the episode establish an SPM dosing protocol?

No. Studies have used doses ranging from about 250 mg per day in early research to 500 mg and 1 g in human trials, but the guest cautions that evidence-guided dosing recommendations remain limited. (Callan 2020) (Möller 2023)

03:56 SPM biology and marine-oil intermediates

07:42 Conversion pathways and inflammation resolution

11:15 Mechanistic research versus human evidence

13:21 Evaluating formulations and clinical outcomes

18:44 Measurement limitations and pain research

24:38 Dosing discussion and anecdotal strategies

30:25 Tracking pain, stiffness, and mobility

Disclaimer

The views expressed on this podcast are those of the hosts and the guests, and they don't necessarily reflect the views of FullScript or any affiliated organizations. This podcast is for informational and educational purposes only, and it's not intended to be medical advice. For your safety, always check with your healthcare provider before making any changes to your healthcare routine.

References

1. Callan, N., Hanes, D., & Bradley, R. (2020). Early evidence of efficacy for orally administered SPM-enriched marine lipid fraction on quality of life and pain in a sample of adults with chronic pain. Journal of Translational Medicine, 18(1), Article 401. https://doi.org/10.1186/s12967-020-02569-5
2. Möller, I., Rodas, G., Villalón, J. M., Rodas, J. A., Angulo, F., Martínez, N., & Vergés, J. (2023). Randomized, double-blind, placebo-controlled study to evaluate the effect of treatment with an SPMs-enriched oil on chronic pain and inflammation, functionality, and quality of life in patients with symptomatic knee osteoarthritis: GAUDI study. Journal of Translational Medicine, 21(1), Article 423. https://doi.org/10.1186/s12967-023-04283-4 
3. Serhan, C. N., & Levy, B. D. (2018). Resolvins in inflammation: Emergence of the pro-resolving superfamily of mediators. Journal of Clinical Investigation, 128(7), 2657–2669. https://doi.org/10.1172/JCI97943
4. Souza, P. R., Marques, R. M., Gomez, E. A., Colas, R. A., De Matteis, R., Zak, A., Patel, M., Collier, D. J., & Dalli, J. (2020). Enriched marine oil supplements increase peripheral blood specialized pro-resolving mediators concentrations and reprogram host immune responses: A randomized double-blind placebo-controlled study. Circulation Research, 126(1), 75–90. https://doi.org/10.1161/CIRCRESAHA.119.315506

Dr. Kate Kresge is joined by psychiatrist James Greenblatt, MD, to discuss themes from his book Finally Hopeful, including nutrition, depression, laboratory assessment, and antidepressant withdrawal.

Clinical Takeaways

• Depression warrants a broad clinical assessment. Symptoms may overlap with medical conditions and nutritional deficiencies. (Bode 2021) (Lee 2020) (Bender 2017) The episode discusses thyroid function, iron, vitamin B12, folate, vitamin D, and other factors as part of a broader evaluation—not as universal causes of depression.
• Antidepressant discontinuation should be individualized. Abruptly stopping an antidepressant can cause withdrawal symptoms. (Henssler 2024) (Horowitz 2019) Gradual, clinician-supervised tapering is important; nutritional status may also be considered, although supplementation has not been established as a way to prevent withdrawal. (Horowitz 2019)
• Nutrition can be considered within whole-person mental healthcare. Protein, amino acids, omega-3 fatty acids, B vitamins, zinc, and magnesium are discussed. Testing and supplementation should reflect individual needs rather than assuming a common deficiency.

Guest: James Greenblatt, MD

James Greenblatt, MD, is a psychiatrist and educator in integrative and functional psychiatry. He discusses a whole-person framework for evaluating depression, nutritional status, and antidepressant discontinuation.

Clinician FAQ

1. Can nutritional deficiencies contribute to depressive symptoms?

Yes, nutritional status can be clinically relevant, but depression is multifactorial. (Bender 2017) (Malhi 2018) The episode discusses iron, vitamin B12, folate, vitamin D, zinc, and other nutrients clinicians may evaluate when appropriate.

2. Why distinguish antidepressant withdrawal from depression?

Withdrawal can occur when antidepressants are reduced or stopped, and symptoms may overlap with psychiatric symptoms. (Henssler 2024) (Horowitz 2019) Distinguishing withdrawal from recurrence of depression is important during discontinuation. (Horowitz 2019) 

3. Should nutritional status be assessed before antidepressant tapering?

The episode proposes evaluating nutritional status before and during tapering. Medication changes should be individualized and managed with the prescribing clinician.

4. What role do amino acids play in mental health?

Amino acids from dietary protein are precursors for many biologically important molecules, including neurotransmitters. (Tang 2025) The episode discusses amino acid assessment as part of Dr. Greenblatt’s clinical approach.

5. Why screen for medical conditions in patients with depression?

Some medical conditions may produce symptoms that resemble or coexist with depression. (Bode 2021) (Lee 2020) (Clappison 2020) The episode highlights thyroid disorders, anemia, and celiac disease as examples clinicians may investigate when clinically indicated.

Key Moments

03:44 Whole-person framework for depression

07:46 Antidepressant withdrawal

11:29 Nutritional assessment before tapering

23:23 Amino acids and nutrition

37:26 B vitamins and minerals

46:15 Depression and celiac disease case

Disclaimer

The views expressed on this podcast are those of the hosts and the guests, and they don't necessarily reflect the views of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only, and it's not intended to be medical advice. For your safety, always check with your healthcare provider before making any changes to your healthcare routine.

References

1. Bender, A., Hagan, K. E., & Kingston, N. (2017). The association of folate and depression: A meta-analysis. Journal of Psychiatric Research, 95, 9–18. https://doi.org/10.1016/j.jpsychires.2017.07.019
2. Bode, H., Ivens, B., Bschor, T., Schwarzer, G., Henssler, J., & Baethge, C. (2021). Association of hypothyroidism and clinical depression: A systematic review and meta-analysis. JAMA Psychiatry, 78(12), 1375–1383. https://doi.org/10.1001/jamapsychiatry.2021.2506
3. Clappison, E., Hadjivassiliou, M., & Zis, P. (2020). Psychiatric manifestations of coeliac disease, a systematic review and meta-analysis. Nutrients, 12(1), 142. https://doi.org/10.3390/nu12010142
4. Henssler, J., Schmidt, Y., Schmidt, U., Schwarzer, G., Bschor, T., & Baethge, C. (2024). Incidence of antidepressant discontinuation symptoms: A systematic review and meta-analysis. The Lancet Psychiatry, 11(7), 526–535. https://doi.org/10.1016/S2215-0366(24)00133-0
5. Horowitz, M. A., & Taylor, D. (2019). Tapering of SSRI treatment to mitigate withdrawal symptoms. The Lancet Psychiatry, 6(6), 538–546. https://doi.org/10.1016/S2215-0366(19)30032-X
6. Lee, Y.-J., & Kim, H.-B. (2020). Association between anaemia and adult depression: A systematic review and meta-analysis of observational studies. Journal of Epidemiology and Community Health, 74(7), 565–572. https://doi.org/10.1136/jech-2020-213842
7. Malhi, G. S., & Mann, J. J. (2018). Depression. The Lancet, 392(10161), 2299–2312. https://doi.org/10.1016/S0140-6736(18)31948-2
8. Tang, J., Krushelnycky, L., Shaqo, A., & Cho, C. E. (2025). A comprehensive review of nutritional influences on the serotonergic system. Advances in Nutrition, 16(11), 100524. https://doi.org/10.1016/j.advnut.2025.100524

Dr. Holly Lucille, ND, is joined by Lara Zakaria, PharmD, MS, CNS, to discuss what people can do when a scratchy throat, fatigue, or other early respiratory symptoms begin. The conversation covers rest and recovery, respiratory virus testing, zinc, vitamin C, elderberry, echinacea, honey, green tea, garlic, ginger, turmeric, and practical ways to prepare for cold and flu season.

Early symptoms of COVID-19, influenza, and other respiratory infections can overlap, making symptom pattern alone an unreliable way to identify the cause. Testing, individual risk factors, symptom severity, and timing can all affect the appropriate next step. (CDC 2026a) (CDC 2025) 

Clinical Takeaways

• Start with the fundamentals: rest, fluids, testing when appropriate, and risk assessment. Most uncomplicated colds improve without specific treatment, and supportive measures such as adequate rest and fluids remain foundational. (CDC 2026b) Testing can help distinguish respiratory infections such as COVID-19 and influenza when the result may affect treatment or precautions, particularly for patients at higher risk of severe illness. (CDC 2025) 
• Zinc and vitamin C have different levels of evidence for the common cold. Zinc has been studied extensively, particularly as lozenges started early in a cold, but results vary substantially by formulation, dose, and study design. (Nault 2024) (Hemilä 2017) (Hemilä 2020) Regular vitamin C supplementation may modestly shorten cold duration, while evidence for starting vitamin C only after symptoms appear has been less consistent. Long-term or excessive zinc supplementation also warrants attention because sustained high intake can interfere with copper status. (NIH 2022)
• Botanical evidence is ingredient- and formulation-specific. (Karsch-Völk 2014) Elderberry and echinacea have both been studied for respiratory infections, but findings are mixed and should not be generalized across products. (Wieland 2021) (Karsch-Völk 2014) (David 2019) Evidence for elderberry remains limited and uncertain, while echinacea studies vary considerably according to species, plant part, extraction method, and formulation. (Wieland 2021) (Karsch-Völk 2014) Garlic, green tea, ginger, turmeric, and honey may have nutritional or symptom-support roles, but they should not be presented as established treatments for viral respiratory infections. (Lissiman 2014) (Abuelgasim 2021)

Guest: Lara Zakaria, PharmD, MS, CNS

Lara Zakaria is a pharmacist and clinical nutritionist with a background spanning community pharmacy, functional medicine, and personalized nutrition. In this episode, she discusses how conventional pharmacy knowledge and nutrition can be brought together when thinking about early respiratory symptoms, supplement use, and practical supportive care.

Clinician FAQ

1. What should patients do when they first feel a cold coming on?

Supportive care is a reasonable starting point for uncomplicated symptoms. Rest, adequate fluids, and attention to symptom progression can help patients through a typical viral illness. Testing for COVID-19 or influenza may also be useful when results could affect treatment or precautions, particularly in higher-risk patients. (CDC 2026b) (CDC 2025)

Patients at increased risk for severe respiratory illness should contact a healthcare provider promptly because prescription antiviral treatment for influenza and COVID-19 is time-sensitive. (CDC 2026a)

2. Does zinc shorten a cold?

Possibly, but the evidence is formulation-dependent. (Nault 2024) Trials of zinc lozenges have produced conflicting findings, with some showing shorter illness duration and others showing no meaningful benefit. (Hemilä 2017) (Hemilä 2020) Differences in zinc salt, formulation, dose, timing, and lozenge composition complicate comparisons across studies. (Nault 2024)

This means findings from a specific zinc-lozenge trial should not automatically be extrapolated to zinc supplements in general. Prolonged high zinc intake can also impair copper absorption, making duration and total intake relevant to safety. (NIH 2022)

3. Should vitamin C be started when cold symptoms appear?

The evidence is stronger for regular supplementation than for starting vitamin C after symptoms begin. A large systematic review found that routine vitamin C supplementation did not substantially reduce cold incidence in the general population but was associated with modest reductions in cold duration. (Hemilä 2013) Trials starting vitamin C therapeutically after symptom onset have not demonstrated a consistent benefit. (Hemilä 2013) 

Practitioners should therefore distinguish evidence for ongoing vitamin C intake from evidence for using vitamin C as an acute intervention.

4. Do elderberry and echinacea help with colds and respiratory infections?

The evidence is mixed. A systematic review of elderberry found that it may reduce the duration or severity of some viral respiratory illnesses, but the certainty of the evidence was insufficient for firm conclusions. (Wieland 2021) Echinacea research is complicated by substantial differences among preparations. (Karsch-Völk 2014) Systematic reviews and individual trials have reached differing conclusions, and some well-controlled studies have not found significant reductions in cold duration or severity. (Karsch-Völk 2014) (David 2019) Product-specific evidence matters when interpreting these findings.

5. When should respiratory symptoms prompt testing or medical evaluation?

Testing becomes particularly important when identifying COVID-19 or influenza could change treatment or precautions. (CDC 2025) Patients at higher risk for severe illness should seek healthcare promptly because antiviral treatments for influenza and COVID-19 work best when initiated early. (CDC 2026a) (CDC 2026b) Trouble breathing, chest pain or pressure, confusion, inability to stay awake, dehydration, severe weakness, or symptoms that improve and then significantly worsen warrant prompt medical assessment. (CDC 2026a)

Timestamps / Key Moments

00:03:00 Early signs that an illness may be developing

00:04:00 Temperature, heart rate, and HRV changes

00:06:35 When testing and medical evaluation may be appropriate

00:08:46 Why rest and recovery matter

00:09:55 Respiratory virus testing and RSV

00:12:15 Vitamin C and zinc

00:14:35 Vitamin C formulations and intake

00:15:24 Zinc supplements and lozenges

00:17:15 Long-term zinc intake and copper balance

00:20:30 Vitamin D status and seasonal preparation

00:22:33 Elderberry, echinacea, honey, and other botanicals

00:26:45 Symptom relief versus the underlying infection

00:30:20 Echinacea preparations

00:32:47 Green tea and EGCG

00:34:10 Garlic and allicin

00:35:15 Ginger and turmeric

00:36:49 Building a practical early-symptom toolkit

Nutrients and botanicals discussed

• Zinc
• Vitamin C
• Vitamin D
• Elderberry
• Echinacea
• Honey
• Manuka honey
• Green tea
• EGCG
• Garlic
• Allicin
• Ginger
• Turmeric

Supportive strategies discussed

• Rest and sleep
• Hydration
• Respiratory virus testing
• Monitoring symptoms
• Reviewing wearable trends
• Warm fluids and tea
• Supplement preparation before cold and flu season
• Evaluating zinc intake and copper balance
• Individualizing supplement use

Want to elevate your practice?

This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript helps clinicians bring supplement dispensing, lab ordering, and patient education into one centralized workflow.

For more practitioner education on supplements, nutrition, and evidence-informed clinical care, visit Fullscript Academy at academy.fullscript.com.

Disclaimer

The views expressed on this podcast are those of the host and guest and do not necessarily reflect those of Fullscript or affiliated organizations. This episode is for informational and educational purposes only and is not medical advice. Dietary supplements can cause adverse effects and interact with medications. Patients should consult a qualified healthcare professional when symptoms are severe, persistent, worsening, or when individual health conditions or medications may affect appropriate care.

References

1. Abuelgasim, H., Albury, C., & Lee, J. (2021). Effectiveness of honey for symptomatic relief in upper respiratory tract infections: A systematic review and meta-analysis. BMJ Evidence-Based Medicine, 26(2), 57–64. https://doi.org/10.1136/bmjebm-2020-111336
2. Centers for Disease Control and Prevention. (2025, August 18). Testing and respiratory viruses. https://www.cdc.gov/respiratory-viruses/prevention/testing.html
3. Centers for Disease Control and Prevention. (2026a, September 10). About respiratory illnesses. https://www.cdc.gov/respiratory-viruses/about/index.html
4. Centers for Disease Control and Prevention. (2026b, March 11). Manage common cold. https://www.cdc.gov/common-cold/treatment/index.html
5. David, S., & Cunningham, R. (2019). Echinacea for the prevention and treatment of upper respiratory tract infections: A systematic review and meta-analysis. Complementary Therapies in Medicine, 44, 18–26. https://doi.org/10.1016/j.ctim.2019.03.011
6. Hemilä, H., & Chalker, E. (2013). Vitamin C for preventing and treating the common cold. Cochrane Database of Systematic Reviews, 2013(1), Article CD000980. https://doi.org/10.1002/14651858.CD000980.pub4
7. Hemilä, H., Fitzgerald, J. T., Petrus, E. J., & Prasad, A. (2017). Zinc acetate lozenges may improve the recovery rate of common cold patients: An individual patient data meta-analysis. Open Forum Infectious Diseases, 4(2), ofx059. https://doi.org/10.1093/ofid/ofx059
8. Hemilä, H., Haukka, J., Alho, M., Vahtera, J., & Kivimäki, M. (2020). Zinc acetate lozenges for the treatment of the common cold: A randomised controlled trial. BMJ Open, 10(1), e031662. https://doi.org/10.1136/bmjopen-2019-031662
9. Karsch-Völk, M., Barrett, B., Kiefer, D., Bauer, R., Ardjomand-Woelkart, K., & Linde, K. (2014). Echinacea for preventing and treating the common cold. Cochrane Database of Systematic Reviews, 2014(2), Article CD000530. https://doi.org/10.1002/14651858.CD000530.pub3
10. Lissiman, E., Bhasale, A. L., & Cohen, M. (2014). Garlic for the common cold. Cochrane Database of Systematic Reviews, 2014(11), Article CD006206. https://doi.org/10.1002/14651858.CD006206.pub4
11. National Institutes of Health, Office of Dietary Supplements. (2022). Copper: Fact sheet for health professionals. Retrieved October 21, 2026, from https://ods.od.nih.gov/factsheets/Copper-HealthProfessional/
12. Nault, D., Machingo, T. A., Shipper, A. G., Antiporta, D. A., Hamel, C., Nourouzpour, S., Konstantinidis, M., Phillips, E., Lipski, E. A., & Wieland, L. S. (2024). Zinc for prevention and treatment of the common cold. Cochrane Database of Systematic Reviews, 2024(5), Article CD014914. https://doi.org/10.1002/14651858.CD014914.pub2
13. Wieland, L. S., Piechotta, V., Feinberg, T., Ludeman, E., Hutton, B., Kanji, S., Seely, D., & Garritty, C. (2021). Elderberry for prevention and treatment of viral respiratory illnesses: A systematic review. BMC Complementary Medicine and Therapies, 21(1), 112. https://doi.org/10.1186/s12906-021-03283-5

Health Meets Wellness: The App and Dr. Edens’ Story

Dr. Elizabeth Sharp Edens is the founder of Health Meets Wellness, an integrative practice where every patient gets three plans: a medical plan, a movement plan and a nutrition plan. Guideline-based medicine is her North Star, and she layers in nutrition, yoga, herbal therapies and acupuncture, with dietitians on her team. It’s whole-person care built around how each patient actually lives.

But she didn’t stop at the exam room. She’s spent three years building the Health Meets Wellness app to bring that same care to patients between visits, and to people far beyond her own practice. It features meal plans, photo food logging, an AI health coach, symptom tracking for patients on GLP-1s, yoga videos she filmed herself, and 20-minute, no-equipment strength workouts developed with a former Milwaukee Bucks performance lead. Now it’s being rebranded for women, with cycle tracking that adapts meal and exercise plans to each phase. There’s a free version, and practitioners can use it with their own patients.

Elizabeth is double board-certified in internal medicine and obesity medicine, certified in functional medicine and a certified yoga instructor, and her path ran through Mount Sinai, a healthcare startup and One Medical. We talk about how she built her practice and her app without a tech background, why she became a yoga teacher, and how she supports patients on GLP-1s with movement and nutrition.

If you love whole-person care but work in a hospital or conventional system without a roadmap, this one’s for you.

Timestamps

• 03:33 — What drew Dr. Elizabeth to medicine, and then to functional medicine
• 08:15 — What her practice looks like today
• 11:25 — From Mount Sinai to a startup to One Medical to her own practice
• 14:14 — How to find opportunities beyond one-to-one care
• 18:38 — Why she built an app, and why it’s designed for women
• 25:54 — Advice if you’re not tech-savvy
• 28:57 — Why she became a yoga teacher + fitting training into a full schedule
• 32:25 — Metabolic health and what she sees as non-negotiable with GLP-1s
• 35:41 — Movement on a GLP-1: building and measuring muscle at home

Want to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

Disclaimer: The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.

Dr. Oscar Coetzee joins Dr Lara Zakaria on the Root Cause Medicine Podcast to discuss emerging research on keystone commensal organisms and how microbial communities interact within the gut ecosystem.

The conversation focuses on organisms including Akkermansia muciniphila, Faecalibacterium prausnitzii, Roseburia, Bifidobacterium longum, and Bifidobacterium adolescentis. Rather than viewing individual microbes in isolation, Dr. Coetzee describes an ecosystem model centered on cross-feeding, short-chain fatty acid production, and the intestinal environment.

The episode also notes an important context: research on next-generation commensals is still developing, meaning findings from mechanistic studies, case reports, and early clinical research offer initial insights that complement rather than replace evidence from larger randomized controlled trials. (Jan 2024) (Kern 2026)

• Keystone organisms are discussed as members of an interconnected ecosystem. The episode explores how organisms can produce metabolites or modify environmental conditions that may influence other members of the microbial community. (Belzer 2017) (Fusco 2023)
• Short-chain fatty acids are a major theme. Akkermansia, Faecalibacterium, and Roseburia are discussed in relation to acetate, propionate, and butyrate production and their potential roles within the intestinal environment. (Martin-Gallausiaux 2021) (Tingler 2025)
• Clinical evidence remains emerging. Dr. Coetzee describes early clinical observations and studies in progress, while the conversation acknowledges the need for additional published research, including controlled trials, before broader clinical conclusions can be drawn. (Jan 2024) (Kern 2026)

Dr. Oscar Coetzee is Vice President of Clinical Education and Practitioner Support at Designs for Health. In the episode, he discusses his work in nutrition and microbiome research and his interest in next-generation commensal organisms.

His discussion centers on moving beyond a single-organism view of probiotics toward understanding microbial communities, cross-feeding, and the environment in which commensal organisms coexist.

They are microbes discussed for their potentially important roles within the broader gut ecosystem. (Rios Garza 2026)

The episode focuses on how selected commensals interact with other organisms and their environment rather than evaluating them solely by abundance. (Banerjee 2018)

The main organisms include Akkermansia muciniphila, Faecalibacterium prausnitzii, Roseburia, Bifidobacterium longum, and Bifidobacterium adolescentis.

The conversation also discusses Anaerostipes caccae separately in the context of butyrate production and microbial cross-feeding. (Belzer 2017)

Cross-feeding describes how metabolites produced by one organism can serve as substrates or influence conditions for another. (Culp 2023) (Louis 2017)

The episode uses this concept to explain why microbial communities may be more informative than considering individual organisms in isolation. (Culp 2023)

They are microbial metabolites that form part of the communication between gut microbes and their environment. (Martin-Gallausiaux 2021)

The conversation highlights acetate, propionate, and butyrate while exploring how different commensal organisms contribute to their production. (Martin-Gallausiaux 2021)

Research on these next-generation commensals is still evolving. (Jan 2024) (Kern 2026)

The guest describes case observations, prospective studies, and additional research underway. These early findings can generate hypotheses, but they do not establish that a specific probiotic combination prevents or treats disease.

00:00:00 Introducing keystone commensal organisms

00:05:35 Why newer technology matters for anaerobic microbes

00:08:09 Moving beyond probiotic quantity and individual strains

00:13:32 Microbial compensation and ecosystem dynamics

00:18:00 Keystone organisms and emerging clinical observations

00:21:28 Akkermansia and microbial metabolites

00:24:08 Faecalibacterium prausnitzii and butyrate

00:30:49 Roseburia and the anaerobic environment

00:32:24 Bifidobacterium species in the microbial community

00:35:52 Anaerostipes caccae and cross-feeding

00:39:58 Supporting the microbial ecosystem

00:44:18 Current research and evidence limitations

00:48:02 Clinical considerations and unanswered questions

01:02:15 Future research and closing discussion

This episode highlights an evolving way of thinking about the microbiome: not simply as a collection of individual organisms, but as an ecosystem shaped by microbial interactions, metabolites, available substrates, and environmental conditions.

For additional practitioner education on supplement quality and clinical decision-making, visit Fullscript Academy.

The views expressed on this podcast are those of the host and guest and do not necessarily reflect those of Fullscript or affiliated organizations.

This episode is for informational and educational purposes only and is not medical advice. Research on next-generation commensal organisms and related probiotic formulations is evolving, and emerging findings should be interpreted in the context of the strength and limitations of the available evidence.

1. Banerjee, S., Schlaeppi, K., & van der Heijden, M. G. A. (2018). Keystone taxa as drivers of microbiome structure and functioning. Nature Reviews Microbiology, 16(9), 567–576. https://doi.org/10.1038/s41579-018-0024-1
2. Belzer, C., Chia, L. W., Aalvink, S., Chamlagain, B., Piironen, V., Knol, J., & de Vos, W. M. (2017). Microbial metabolic networks at the mucus layer lead to diet-independent butyrate and vitamin B12 production by intestinal symbionts. mBio, 8(5), e00770-17. https://doi.org/10.1128/mBio.00770-17
3. Culp, E. J., & Goodman, A. L. (2023). Cross-feeding in the gut microbiome: Ecology and mechanisms. Cell Host & Microbe, 31(4), 485–499. https://doi.org/10.1016/j.chom.2023.03.016
4. Fusco, W., Lorenzo, M. B., Cintoni, M., Porcari, S., Rinninella, E., Kaitsas, F., Lener, E., Mele, M. C., Gasbarrini, A., Collado, M. C., Cammarota, G., & Ianiro, G. (2023). Short-chain fatty-acid-producing bacteria: Key components of the human gut microbiota. Nutrients, 15(9), 2211. https://doi.org/10.3390/nu15092211
5. Jan, T., Negi, R., Sharma, B., Kumar, S., Singh, S., Rai, A. K., Shreaz, S., Rustagi, S., Chaudhary, N., Kaur, T., Kour, D., Sheikh, M. A., Kumar, K., Yadav, A. N., & Ahmed, N. (2024). Next generation probiotics for human health: An emerging perspective. Heliyon, 10(16), e35980. https://doi.org/10.1016/j.heliyon.2024.e35980
6. Kern, L., Tofield, A., Frame, J., & Elinav, E. (2026). Next-generation probiotics: An outlook into current applications and future developments. Nature Reviews Microbiology, 24(8), 539–558. https://doi.org/10.1038/s41579-026-01311-0
7. Louis, P., & Flint, H. J. (2017). Formation of propionate and butyrate by the human colonic microbiota. Environmental Microbiology, 19(1), 29–41. https://doi.org/10.1111/1462-2920.13589
8. Martin-Gallausiaux, C., Marinelli, L., Blottière, H. M., Larraufie, P., & Lapaque, N. (2021). SCFA: Mechanisms and functional importance in the gut. Proceedings of the Nutrition Society, 80(1), 37–49. https://doi.org/10.1017/S0029665120006916
9. Rios Garza, D., Gonze, D., & Faust, K. (2026). Keystone concept revisited: Insights into microbial community dynamics and control. Nature Reviews Microbiology, 24(5), 359–371. https://doi.org/10.1038/s41579-025-01266-8
10. Tingler, A. M., & Engevik, M. A. (2025). Breaking down barriers: Is intestinal mucus degradation by Akkermansia muciniphila beneficial or harmful? Infection and Immunity, 93(9), e0050324. https://doi.org/10.1128/iai.00503-24

Dr. Eric Viegas joins the Root Cause Medicine Podcast to discuss an often-overlooked part of evaluating botanical supplements for menopause: whether the product being used actually matches the ingredient that was studied.

The conversation focuses on five botanicals and botanical categories—black cohosh, Vitex (chasteberry), rhapontic rhubarb, maca, and soy isoflavones. Rather than framing individual herbs as simply effective or ineffective, Dr. Viegas emphasizes three considerations: identity, standardization, and patience.

Identity refers to confirming the correct plant species and plant part. Standardization addresses whether relevant constituents or studied extracts are consistently represented in a product. Patience refers to allowing an appropriate evaluation period rather than judging a botanical after only a few days of use.

• Botanical evidence is closely tied to the ingredient that was actually studied. Dr. Viegas emphasizes that results from research on a particular species, plant part, extract, or standardized preparation cannot automatically be generalized to every product carrying the same botanical name.
• Black cohosh has a substantial research history, but product characteristics matter. The episode discusses Actaea racemosa and the importance of confirming botanical identity, the appropriate plant part, and the characteristics of the extract being used. Standardized preparations feature prominently in the research discussed. (Castelo-Branco 2021) (NIDDK 2025) 
• Vitex is discussed primarily in the context of cyclical symptoms and perimenopause. Also known as chasteberry (Vitex agnus-castus), Vitex is presented as having a stronger research history for premenstrual and cyclical symptoms than for classic postmenopausal symptoms. The episode also highlights variation in extracts and marker compounds. (Csupor 2019) 
• Rhapontic rhubarb illustrates the importance of extract-specific evidence. The discussion focuses on the studied rhapontic rhubarb extract ERr 731 rather than treating all rhubarb preparations as interchangeable. This provides an example of why practitioners should identify the exact preparation evaluated in clinical research. (Dubey 2024) 
• Maca presents additional standardization challenges. The episode discusses differences among maca varieties and processing methods and notes that there is not one universally dominant marker used across all products. Maca is discussed in relation to menopausal symptoms, mood, and sexual function without positioning it as a direct hormone replacement. (Lee 2011)
• Soy isoflavone response may vary between individuals and formulations. The conversation highlights differences among individual isoflavones and discusses equol production as one possible contributor to variability in response. (Mayo 2019)
• Time is part of interpreting a botanical trial. A recurring theme throughout the episode is that botanical interventions studied over weeks or months should not necessarily be judged after a very short trial. Appropriate duration depends on the ingredient, formulation, patient, and clinical context.

Dr. Eric Viegas is a naturopathic doctor based in Ottawa, Canada, and works with Fullscript’s quality program.

In the episode, he describes Fullscript’s approach to supplement quality, including supplier qualification and review of product documentation. He also discusses Fullscript Tested, a program in which products are selected from Fullscript distribution centers and submitted to third-party laboratories for testing related to factors such as identity, potency, and contaminants.

His discussion of menopause botanicals centers on connecting published research with the practical question practitioners face when evaluating supplements: Does the ingredient in the product correspond to the ingredient evaluated in the research?

Identity refers to confirming what botanical material is actually present, while standardization addresses consistency in relevant constituents or preparations.

Depending on the botanical, identity can include species, plant part, variety, and other characteristics. Standardization may involve a marker compound, defined extract, or another specification associated with the preparation used in research.

Because botanical research generally evaluates outcomes over a defined period rather than after only a few doses.

Dr. Viegas argues that stopping a botanical substantially earlier than the period evaluated in research can make it difficult to determine whether the preparation received a meaningful trial. The appropriate evaluation period varies by ingredient and clinical context.

Black cohosh is presented as a botanical for which product identity and extract characteristics can affect how research is interpreted.

The discussion focuses on Actaea racemosa, particularly root and rhizome preparations, and distinguishes studied standardized extracts from unspecified black cohosh products. (Castelo-Branco 2021) (NIDDK 2025)

The episode describes its strongest evidence base as being related to premenstrual and cyclical symptoms rather than classic menopause symptoms. (Csupor 2019)

Dr. Viegas discusses why Vitex may nevertheless appear in conversations about perimenopause and also notes that some research evaluates it as part of multi-ingredient botanical combinations.

The discussion centers on a specific studied extract rather than rhapontic rhubarb as a broad ingredient category.

Dr. Viegas identifies ERr 731 as the preparation featured in the research discussed during the episode. This serves as an example of why botanical extract identity can matter when translating research findings to commercial products. (Dubey 2024) 

The episode highlights botanical variety, processing, and the absence of a single universally dominant standardization marker. (Lee 2011)

Different maca varieties and processing approaches can make product-to-product comparisons more complicated than simply confirming that “maca” appears on the label.

Both formulation and individual biology may contribute to variation.

The episode discusses differences among isoflavones and describes the conversion of daidzein to equol by certain gut microorganisms as one potential source of individual variation. (Mayo 2019)

Not necessarily.

The episode emphasizes checking the species, plant part, preparation or extract, relevant standardization information, and other product specifications before assuming that findings from a particular study apply to another formulation.

00:00:00 Introducing menopause botanicals, identity, standardization, and patience

00:02:59 The three themes: identity, standardization, and patience

00:04:15 Black cohosh and its research history

00:07:41 Standardized black cohosh extracts and product testing

00:10:13 Vitex (chasteberry) and where it fits clinically

00:14:14 Introducing rhapontic rhubarb

00:16:28 Maca, menopause, libido, and mood

00:20:04 Soy isoflavones and the evidence discussion

00:21:15 Daidzein, equol, and individual response

00:22:54 Soy isoflavones and evaluation over time

00:25:08 Fullscript Academy and closing remarks

This episode highlights how botanical identity, standardization, formulation, and research design can affect the way practitioners interpret supplement evidence.

For additional practitioner education on supplement quality and clinical decision-making, visit Fullscript Academy.

The goal is not to reduce botanical selection to a single marker or label claim, but to help practitioners evaluate whether a product meaningfully corresponds to the ingredient and preparation described in the available evidence.

The views expressed on this podcast are those of the host and guest and do not necessarily reflect those of Fullscript or affiliated organizations.

This episode is for informational and educational purposes only and is not medical advice. Botanical supplements may have contraindications, adverse effects, and medication interactions, and suitability can vary by patient. Patients should consult a qualified healthcare professional before making changes to their healthcare routine.

1. Castelo-Branco, C., Gambacciani, M., Cano, A., Minkin, M. J., Rachoń, D., Ruan, X., Beer, A.-M., Schnitker, J., Henneicke-von Zepelin, H.-H., & Pickartz, S. (2021). Review & meta-analysis: Isopropanolic black cohosh extract iCR for menopausal symptoms – an update on the evidence. Climacteric, 24(2), 109–119. https://pubmed.ncbi.nlm.nih.gov/33021111/
2. Csupor, D., Lantos, T., Hegyi, P., Benkő, R., Viola, R., Gyöngyi, Z., Csécsei, P., Tóth, B., Vasas, A., Márta, K., Rostás, I., Szentesi, A., & Matuz, M. (2019). Vitex agnus-castus in premenstrual syndrome: A meta-analysis of double-blind randomised controlled trials. Complementary Therapies in Medicine, 47, 102190. https://pubmed.ncbi.nlm.nih.gov/31780016/
3. Dubey, V. P., Sureja, V. P., & Kheni, D. B. (2024). Efficacy evaluation of standardized Rheum rhaponticum root extract (ERr 731) on symptoms of menopause: A systematic review and meta-analysis study. Journal of Biomedical Research, 38(3), 278–286. https://pubmed.ncbi.nlm.nih.gov/38646867/
4. Lee, M. S., Shin, B.-C., Yang, E. J., Lim, H.-J., & Ernst, E. (2011). Maca (Lepidium meyenii) for treatment of menopausal symptoms: A systematic review. Maturitas, 70(3), 227–233. https://pubmed.ncbi.nlm.nih.gov/21840656/
5. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury. (2025). Black cohosh. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.ncbi.nlm.nih.gov/books/NBK547990/
6. Mayo, B., Vázquez, L., & Flórez, A. B. (2019). Equol: A bacterial metabolite from the daidzein isoflavone and its presumed beneficial health effects. Nutrients, 11(9), 2231. https://www.mdpi.com/2072-6643/11/9/2231

You've been hearing new voices in the host chair lately — so this week we're pulling back the curtain to introduce them properly. Dr. Kate Kresge sits down with Dr. Holly Lucille, Dr. Lara Zakaria, and Dr. Jessica Christie for a roundtable on the winding, deeply personal paths that led each of them into root-cause medicine.

A pharmacist nearly buried under her own stack of nutrition books who came out dual-licensed. A psychology student who couldn't find a medical school that took food and sleep seriously, so she built her own path. A holistic nurse turned naturopathic doctor who fought for her profession on the statehouse floor. And a host whose decade-long "mystery illness" resolved in three days once the right test was finally run. What ties them together is a stubborn refusal to stop at the easy answer — the instinct to say, let's think this through, because so often the protocol failed the patient, not the other way around.

Consider this your proper introduction to the team learning and sharing what works, right alongside you.

What you'll hear

• Why every one of these clinicians came to functional medicine as a "detective" — and often as a patient first.
• Dr. Lara Zakaria's path from community pharmacist to dual-licensed nutritionist, and a clear-eyed explainer on what the CNS credential actually requires.
• Dr. Jessica Christie's move from developmental psychology into naturopathic medicine, becoming her own first patient, and finding her way into fertility and women's health.
• Dr. Holly Lucille's journey through holistic nursing and naturopathic medicine — and helping pass California's ND licensing bill (SB 907) in 2004.
• Dr. Kate Kresge's decade of misdiagnosed illness that resolved in days once the root cause was identified — and why it reshaped how she thinks about mental-health symptoms with a physiological root cause.
• How Rupa and Fullscript coming together puts labs, education, boot camps, webinars and AI-assisted evidence in one free place for clinicians.
• The team's reframe of "the patient failed treatment" into "the treatment failed the patient" — and what patient-centered care really means.

Key themes

• Let's think things through — clinical reasoning over the 15-minute prescribe-and-go visit.
• The empowered, informed patient is a good thing; clinicians add the nuance.
• Whole-person care means mind and body are never truly separate.
• Personalization: the protocol fits the patient, not the other way around.

Timestamps

• 02:21 — Welcoming the hosts
• 03:13 — Naming the listeners
• 05:35 — "Let's think things through"
• 06:40 — Nuance and the empowered patient
• 09:02 — Dr. Lara Zakaria's story
• 12:16 — Dr. Jessica Christie's story
• 16:00 — Rupa magazine + free education
• 17:03 — What a CNS is
• 20:10 — Dr. Holly Lucille's story
• 28:17 — Whiskey Flower + Wipeout
• 30:16 — Rupa + Fullscript coming together
• 32:20 — AI Assist for whole-person care
• 34:00 — Dr. Kate Kresge's story
• 44:11 — The protocol failed the patient
• 46:05 — What excites the team next
• 53:21 — Wrap-up + listener name reveal

Want to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

Disclaimer: Views expressed are those of the hosts and guests and do not necessarily reflect Fullscript or affiliated organizations. For informational and educational purposes only; not medical advice.

Dr. Lara Zakaria is joined by Stephanie Venn-Watson, DVM, MPH, to explore emerging research on pentadecanoic acid (C15:0), an odd-chain saturated fatty acid initially studied through research involving bottlenose dolphins.

The conversation connects C15:0 with cell-membrane composition, lipid peroxidation, ferroptosis, iron metabolism, metabolic health, and steatotic liver disease. It also examines research on circulating C15:0 as a biomarker associated with cardiometabolic outcomes and early human trials of C15:0 supplementation. (Imamura 2018) (Sawh 2021) 

C15:0 has been proposed as a candidate essential fatty acid, however, that classification and a specific human “C15:0 deficiency syndrome” remain emerging hypotheses rather than established clinical diagnoses.

Clinical Takeaways

• Ferroptosis is an iron-dependent form of regulated cell death. First characterized in 2012, ferroptosis involves iron-dependent lipid peroxidation and differs mechanistically from apoptosis and other forms of cell death. (Dixon 2012) Polyunsaturated fatty acids in phospholipids are particularly relevant substrates for ferroptotic lipid peroxidation. (Yang 2016)
• C15:0 is an odd-chain saturated fatty acid being studied for metabolic effects. Pentadecanoic acid, or C15:0, is found in dairy fat and smaller amounts in other foods. Higher circulating C15:0 has been associated with lower incidence of type 2 diabetes in prospective observational research, but these associations do not establish that C15:0 itself prevents diabetes. (Imamura 2018)
• Calling C15:0 an “essential fatty acid” remains an emerging scientific proposal. Experimental work has proposed C15:0 as a candidate essential fatty acid based on dietary exposure, biological activity, and associations between circulating levels and health outcomes. More research is needed before C15:0 can be treated as equivalent to the established essential fatty acids linoleic acid and alpha-linolenic acid. (Venn-Watson 2020) (Venn-Watson 2022) 
• Metabolic hyperferritinemia is a recognized clinical framework, but it is not synonymous with ferroptosis or C15:0 deficiency. Metabolic hyperferritinemia describes elevated ferritin occurring with metabolic dysfunction. Ferritin is also an acute-phase reactant, so elevated values require evaluation in clinical context rather than being interpreted as tissue iron overload by themselves. (Valenti 2023)
• Human C15:0 supplementation evidence is early. Within this broader metabolic context, circulating C15:0 is an emerging biomarker of interest. In a small 12-week randomized, placebo-controlled trial in young adults with overweight or obesity, 200 mg/day oral C15:0 significantly increased circulating C15:0 concentrations. Exploratory analyses suggested that participants who achieved post-treatment circulating C15:0 concentrations above 5 µg/mL had greater reductions in ALT and AST and a greater increase in hemoglobin; these achieved-level findings were not definitive treatment effects and require replication in larger trials designed for liver and hematologic outcomes. (Robinson 2024)
• Diet and lifestyle remain the better-established foundation for metabolic and liver health. Dairy fat is the principal dietary source of C15:0, although circulating odd-chain fatty acids may also be influenced by endogenous production. (Weitkunat 2017) For people who avoid or tolerate little dairy, C15:0 supplementation is an emerging option that may be useful alongside high-fiber, Mediterranean-style minimally processed dietary patterns, regular exercise, metabolic-risk reduction, and appropriate evaluation and treatment of fatty liver disease or abnormal iron markers. (Chooi 2024)

Guest: Stephanie Venn-Watson, DVM, MPH

Stephanie Venn-Watson is a veterinary epidemiologist whose research has included comparative medicine and the health of bottlenose dolphins cared for through the U.S. Navy Marine Mammal Program.

Research involving dolphins identified similarities in metabolic and age-associated physiology that led investigators to study odd-chain saturated fatty acids, including C15:0 and C17:0. Her subsequent research has focused on the biological activity of C15:0 and the hypothesis that inadequate C15:0 may contribute to cellular vulnerability.

Some of this research is connected with patents and commercial C15:0 products, making independent replication and larger human clinical trials particularly important when interpreting the findings.

Clinician FAQ

1. What is C15:0?

C15:0, or pentadecanoic acid, is a 15-carbon odd-chain saturated fatty acid.

It occurs in foods including dairy fat and has historically been studied as a biomarker related to dairy-fat intake. (Imamura 2018) More recent research is examining whether C15:0 itself has biologically relevant metabolic effects. (Venn-Watson 2020)

2. Is C15:0 an essential fatty acid?

Not yet by established nutritional consensus.

C15:0 has been proposed as a candidate essential fatty acid, but this remains an emerging area of research. (Venn-Watson 2020) (Venn-Watson 2022) Linoleic acid and alpha-linolenic acid remain the conventionally recognized essential fatty acids in human nutrition.

3. What is ferroptosis?

Ferroptosis is a regulated, iron-dependent form of cell death characterized by damaging lipid peroxidation. (Dixon 2012)

The process involves interactions among cellular iron, oxidizable membrane phospholipids, and antioxidant defense systems. Ferroptosis is being investigated across metabolic, neurologic, cardiovascular, liver, and cancer biology.

4. Is high ferritin evidence that a patient is undergoing ferroptosis?

No.

Ferritin reflects iron storage but is also an acute-phase reactant. Elevated ferritin can occur with inflammation, liver disease, metabolic dysfunction, infection, malignancy, iron overload, and other conditions. (Valenti 2023) Ferroptosis cannot be diagnosed from serum ferritin alone.

5. What is metabolic hyperferritinemia?

Metabolic hyperferritinemia describes elevated serum ferritin occurring in the context of metabolic dysfunction.

A published consensus framework proposes ferritin above 300 ng/mL in men or 200 ng/mL in women together with specified metabolic criteria, while excluding or reassessing alternative explanations for hyperferritinemia. (Valenti 2023) The framework also distinguishes hyperferritinemia from confirmed tissue iron accumulation. (Liu 2024)

6. Does elevated ferritin mean a patient needs phlebotomy?

Not necessarily.

The metabolic hyperferritinemia consensus states that evidence supporting routine iron-depletion therapy is insufficient. (Valenti 2023) Phlebotomy should not be inferred from ferritin alone; evaluation of the cause of hyperferritinemia and, when appropriate, tissue iron burden is important.

7. What foods contain C15:0?

Dairy fat is one dietary source of C15:0, and C15:0 is also present in smaller amounts in some meats, fish, and other foods.

Circulating odd-chain fatty acids are not exclusively determined by dairy intake. Research also suggests that endogenous pathways involving gut-derived propionate can contribute to odd-chain fatty acid production. (Weitkunat 2017)

8. Does eating more full-fat dairy increase C15:0?

Dietary dairy fat can contribute to circulating C15:0, but the health implications of increasing full-fat dairy cannot be reduced to C15:0 alone.

Dairy foods contain multiple fatty acids, proteins, carbohydrates, minerals, and other components, and observational evidence differs by dairy-food type. (Imamura 2018) (Sawh 2021) Dietary recommendations should therefore consider the patient's overall diet and clinical context.

9. What has human supplementation research shown?

Human evidence remains limited.

One randomized trial studied 200 mg/day of C15:0 for 12 weeks in 30 young adults with overweight or obesity and found increased circulating C15:0. (Robinson 2024) A separate randomized trial evaluated 300 mg/day as an addition to an Asian-adapted Mediterranean-style diet in women with fatty liver and reported an additional reduction in LDL cholesterol and an increase in Bifidobacterium adolescentis abundance. (Chooi 2024)

Neither study establishes C15:0 supplementation as treatment for metabolic disease, ferroptosis, or metabolic hyperferritinemia.

10. Can C15:0 levels be used as a clinical treatment target?

A standardized clinical target has not been established.

Thresholds such as 5 μg/mL or 0.2% of total fatty acids have been proposed and explored in C15:0 research, but they should not currently be treated as universally validated diagnostic thresholds for deficiency or treatment targets. (Robinson 2024) (Venn-Watson 2024) 

Timestamps / Key Moments

00:00:18 Introducing C15:0, cellular aging, and ferroptosis

00:02:19 Stephanie Venn-Watson’s background and dolphin research

00:05:29 How C15:0 emerged from metabolomics research

00:10:20 Alzheimer’s disease-like pathology in dolphins

00:11:33 What C15:0 is and how fatty acids are classified

00:18:18 C15:0, membrane stability, and lipid peroxidation

00:19:25 Understanding ferroptosis

00:24:34 Metabolic hyperferritinemia and clinical patterns

00:27:37 Proposed C15:0 thresholds and metabolic research

00:30:43 Dietary sources of C15:0

00:40:19 Measuring circulating C15:0

00:45:49 Human clinical research on C15:0

Fatty acids and biological processes discussed

• Pentadecanoic acid (C15:0)
• Heptadecanoic acid (C17:0)
• Odd-chain saturated fatty acids
• Saturated fatty acids
• Polyunsaturated fatty acids
• Linoleic acid
• Alpha-linolenic acid
• EPA
• DHA
• Cell-membrane lipids
• Lipid peroxidation
• Ferroptosis
• Reactive oxygen species
• Mitochondrial function
• Iron metabolism
• Ferritin

Clinical markers and conditions discussed

• Ferritin
• Transferrin saturation
• Hemoglobin
• Red blood cell distribution width (RDW)
• ALT
• AST
• GGT
• Lipid peroxidation
• LDL cholesterol
• Glucose
• Insulin
• Metabolic hyperferritinemia
• Insulin resistance
• Type 2 diabetes
• Metabolic syndrome
• MASLD
• MASH
• Iron overload
• Cognitive decline

Want to elevate your practice?

This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript helps practitioners bring supplement dispensing, lab ordering, patient education, and care planning into a centralized workflow.

The goal is not to replace clinical judgment, but to support thoughtful, individualized care and reduce unnecessary administrative steps.

For more practitioner education on supplement quality, metabolic health, and clinical decision-making, visit Fullscript Academy.

Disclaimer

The views expressed on this podcast are those of the host and guest and do not necessarily reflect those of Fullscript or affiliated organizations. This episode is for informational and educational purposes only and is not medical advice.

C15:0 research is evolving. C15:0 is not currently an established treatment for ferroptosis, metabolic hyperferritinemia, diabetes, MASLD, MASH, or neurodegenerative disease. Elevated ferritin has multiple potential causes and should be interpreted in clinical context. Patients should consult a qualified healthcare professional before changing their diet, supplements, iron intake, or treatment plan.

References

1. Chooi, Y. C., Zhang, Q. A., Magkos, F., Ng, M., Michael, N., Wu, X., Brok Volchanskaya, V. S., Lai, X., Wanjaya, E. R., Elejalde, U., Goh, C. C., Yap, C. P. L., Wong, L. H., Lim, K. J., Velan, S. S., Yaligar, J., Muthiah, M. D., Chong, Y. S., Loo, E. X. L., … Eriksson, J. G. (2024). Effect of an Asian-adapted Mediterranean diet and pentadecanoic acid on fatty liver disease: The TANGO randomized controlled trial. American Journal of Clinical Nutrition, 119(3), 788–799. https://pubmed.ncbi.nlm.nih.gov/38035997/
2. Dixon, S. J., Lemberg, K. M., Lamprecht, M. R., Skouta, R., Zaitsev, E. M., Gleason, C. E., Patel, D. N., Bauer, A. J., Cantley, A. M., Yang, W. S., Morrison, B., III, & Stockwell, B. R. (2012). Ferroptosis: An iron-dependent form of nonapoptotic cell death. Cell, 149(5), 1060–1072. https://pubmed.ncbi.nlm.nih.gov/22632970/
3. Imamura, F., Fretts, A., Marklund, M., Ardisson Korat, A. V., Yang, W.-S., Lankinen, M., Qureshi, W., Helmer, C., Chen, T.-A., Wong, K., Bassett, J. K., Murphy, R., Tintle, N., Yu, C. I., Brouwer, I. A., Chien, K.-L., Frazier-Wood, A. C., del Gobbo, L. C., Djoussé, L., … Forouhi, N. G. (2018). Fatty acid biomarkers of dairy fat consumption and incidence of type 2 diabetes: A pooled analysis of prospective cohort studies. PLOS Medicine, 15(10), e1002670. https://pubmed.ncbi.nlm.nih.gov/30303968/
4. Liu, W.-Y., Lian, L.-Y., Zhang, H., Chen, S.-D., Jin, X.-Z., Zhang, N., Ye, C.-H., Chen, W.-Y., Goh, G. B. B., Wang, F.-D., Miele, L., Corradini, E., Valenti, L., & Zheng, M.-H. (2024). A population-based and clinical cohort validation of the novel consensus definition of metabolic hyperferritinemia. Journal of Clinical Endocrinology & Metabolism, 109(6), 1540–1549. https://pubmed.ncbi.nlm.nih.gov/38124275/
5. Robinson, M. K., Lee, E., Ugalde-Nicalo, P. A., Skonieczny, J. W., Chun, L. F., Newton, K. P., & Schwimmer, J. B. (2024). Pentadecanoic acid supplementation in young adults with overweight and obesity: A randomized controlled trial. Journal of Nutrition, 154(9), 2763–2771. https://pubmed.ncbi.nlm.nih.gov/39069269/
6. Sawh, M. C., Wallace, M., Shapiro, E., Goyal, N. P., Newton, K. P., Yu, E. L., Bross, C., Durelle, J., Knott, C., Gangoiti, J. A., Barshop, B. A., Gengatharan, J. M., Meurs, N., Schlein, A., Middleton, M. S., Sirlin, C. B., Metallo, C. M., & Schwimmer, J. B. (2021). Dairy fat intake, plasma C15:0, and plasma iso-C17:0 are inversely associated with liver fat in children. Journal of Pediatric Gastroenterology and Nutrition, 72(4), e90–e96. https://pubmed.ncbi.nlm.nih.gov/33399331/
7. Vacher, M. C., Durrant, C. S., Rose, J., Hall, A. J., Spires-Jones, T. L., Gunn-Moore, F., & Dagleish, M. P. (2023). Alzheimer's disease-like neuropathology in three species of oceanic dolphin. European Journal of Neuroscience, 57(7), 1161–1179. https://pubmed.ncbi.nlm.nih.gov/36514861/
8. Valenti, L., Corradini, E., Adams, L. A., Aigner, E., Alqahtani, S., Arrese, M., Bardou-Jacquet, E., Bugianesi, E., Fernandez-Real, J.-M., Girelli, D., Hagström, H., Henninger, B., Kowdley, K., Ligabue, G., McClain, D., Lainé, F., Miyanishi, K., Muckenthaler, M. U., Pagani, A., … Zoller, H. (2023). Consensus statement on the definition and classification of metabolic hyperferritinaemia. Nature Reviews Endocrinology, 19(5), 299–310. https://pubmed.ncbi.nlm.nih.gov/36805052/
9. Venn-Watson, S., Smith, C. R., Stevenson, S., Parry, C., Daniels, R., Jensen, E., Cendejas, V., Balmer, B., Janech, M., Neely, B. A., & Wells, R. (2013). Blood-based indicators of insulin resistance and metabolic syndrome in bottlenose dolphins (Tursiops truncatus). Frontiers in Endocrinology, 4, 136. https://pubmed.ncbi.nlm.nih.gov/24130551/
10. Venn-Watson, S., Parry, C., Baird, M., Stevenson, S., Carlin, K., Daniels, R., Smith, C. R., Jones, R., Meegan, J., Simmons, J., Gomez, F., & Jensen, E. D. (2015). Increased dietary intake of saturated fatty acid heptadecanoic acid (C17:0) associated with decreasing ferritin and alleviated metabolic syndrome in dolphins. PLOS ONE, 10(7), e0132117. https://pubmed.ncbi.nlm.nih.gov/26200116/
11. Venn-Watson, S., Lumpkin, R., & Dennis, E. A. (2020). Efficacy of dietary odd-chain saturated fatty acid pentadecanoic acid parallels broad associated health benefits in humans: Could it be essential? Scientific Reports, 10, 8161. https://pubmed.ncbi.nlm.nih.gov/32424181/
12. Venn-Watson, S. K., & Butterworth, C. N. (2022). Broader and safer clinically-relevant activities of pentadecanoic acid compared to omega-3: Evaluation of an emerging essential fatty acid across twelve primary human cell-based disease systems. PLOS ONE, 17(5), e0268778. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0268778
13. Venn-Watson, S. (2024). The cellular stability hypothesis: Evidence of ferroptosis and accelerated aging-associated diseases as newly identified nutritional pentadecanoic acid (C15:0) deficiency syndrome. Metabolites, 14(7), 355. https://www.mdpi.com/2218-1989/14/7/355
14. Weitkunat, K., Schumann, S., Nickel, D., Hornemann, S., Petzke, K. J., Schulze, M. B., Pfeiffer, A. F. H., & Klaus, S. (2017). Odd-chain fatty acids as a biomarker for dietary fiber intake: A novel pathway for endogenous production from propionate. American Journal of Clinical Nutrition, 105(6), 1544–1551. https://pubmed.ncbi.nlm.nih.gov/28424190/
15. Yang, W. S., Kim, K. J., Gaschler, M. M., Patel, M., Shchepinov, M. S., & Stockwell, B. R. (2016). Peroxidation of polyunsaturated fatty acids by lipoxygenases drives ferroptosis. Proceedings of the National Academy of Sciences, 113(34), E4966–E4975. https://pubmed.ncbi.nlm.nih.gov/27506793/

Dr. Geeta Maker-Clark joins the Root Cause Medicine Podcast to discuss ideas from her book, Medicine for All People: Science and Ancient Wisdom for Revolutionary Healing. Drawing from family medicine, integrative medicine, culinary medicine, community health and her own upbringing, she explores a broader view of medicine that includes food, plants, nature, community, service, trust, dance, gratitude, and play.

The conversation centers on a simple idea: health is shaped not only by what happens in the clinic, but also by the environments, relationships, resources, cultural traditions, and daily practices that surround a person. Dr. Maker-Clark organizes these ideas into three areas—medicines of the earth, medicines of connection, and medicines of spirit—and discusses how practitioners can think about them alongside conventional medical care.

Clinical Takeaways

• Food and nutrition are part of whole-person care. Dr. Maker-Clark describes food as a central part of her clinical philosophy and discusses culinary medicine as a way to combine nutrition education with practical cooking skills. Her University of Chicago culinary medicine work includes medical students, community members, and middle school students, with an emphasis on nutrition literacy, accessibility, and culturally relevant food education. (Maker-Clark 2023)
• Nature exposure may support stress regulation and mental well-being. The episode frames time outdoors and connection with the natural environment as accessible ways to support well-being. Research has associated nature exposure with lower perceived and physiologic stress, although study designs, settings, and outcomes vary. (Shuda 2020)
• Social connection deserves attention in clinical assessment. Dr. Maker-Clark emphasizes community, belonging, and service as dimensions of health. Research supports associations between loneliness and social isolation and adverse cardiovascular, brain, mental health, and inflammatory outcomes, although mechanisms and the effectiveness of specific interventions continue to be studied. (Cené 2022) (Smith 2020)
• Trust includes both healthcare relationships and self-trust. The conversation explores how previous negative healthcare experiences, chronic illness, and unexplained symptoms can affect trust. Dr. Maker-Clark describes rebuilding trust through relationships and small, achievable commitments rather than treating trust as something patients should simply provide.
• Dance combines movement, cognition, emotion, and often social interaction. Dance is presented as an accessible form of joyful movement rather than a replacement for clinical care. Research suggests dance can influence cognitive and neuroplasticity-related outcomes, particularly in older adults, although effects vary by population and intervention. (Teixeira-Machado 2019) (Hewston 2021)
• Gratitude and play can be viewed as practices that support well-being. Gratitude interventions have shown generally modest benefits for well-being and some psychological outcomes. (Diniz 2023) (Kerry 2023) Adult play can take many forms, including creativity, competition, collecting, storytelling, exploration, and restorative activities. (Blanche 2024)

Guest: Geeta Maker-Clark, MD

Dr. Geeta Maker-Clark is a family and integrative medicine physician whose work spans patient care, nutrition education, culinary medicine, and community health. In the episode, she describes early clinical work in high-risk obstetrics and underserved communities as formative in expanding her understanding of health beyond the clinic.

She co-developed culinary medicine programming connected with the University of Chicago, including medical student education and community-based nutrition programs. Her book, Medicine for All People: Science and Ancient Wisdom for Revolutionary Healing, brings together themes of ancestral knowledge, scientific research, social justice, connection, and accessible approaches to well-being.

Clinician FAQ

1. What does Dr. Maker-Clark mean by “medicine for all people”?

She uses the phrase to describe a broader framework for health that includes conventional medicine alongside food, nature, relationships, community, cultural knowledge, and everyday practices. Accessibility and social justice are central themes in the framework.

2. What is culinary medicine?

Culinary medicine combines nutrition education with practical food preparation and cooking skills. In the program discussed in the episode, medical students learn nutrition counseling and cooking skills while community and middle school programs focus on nutrition literacy, food preparation, food justice, and culturally relevant education. (Maker-Clark 2023)

3. What does research say about nature exposure and stress?

Research generally supports an association between exposure to natural environments and improvements in some measures of perceived and physiological stress. Results vary across studies, and the effects depend on factors such as the population, type of nature exposure, comparison environment, and outcome measured. (Shuda 2020)

4. Why are loneliness and social connection clinically relevant?

Social isolation and loneliness have been associated with poorer cardiovascular and brain health and with some inflammatory markers. However, loneliness and objective social isolation are distinct concepts, and evidence does not establish that every health effect attributed to social disconnection operates through inflammation. (Cené 2022) (Smith 2020)

5. Can dance support brain health?

Dance combines physical movement with rhythm, learning, coordination, and sometimes social interaction. Systematic reviews have reported changes in cognitive and neuroplasticity-related outcomes, particularly among middle-aged and older adults. The magnitude of benefit and the cognitive domains affected vary across studies. (Teixeira-Machado 2019) (Hewston 2021) (Fong Yan 2024)

6. Does practicing gratitude improve mental health?

Gratitude interventions have been associated with small improvements in well-being and, in some studies, psychological symptoms. Results are heterogeneous, and gratitude should be viewed as a supportive practice rather than a substitute for appropriate mental healthcare. (Diniz 2023) (Kerry 2023)

Timestamps / Key Moments

00:01:41 Fullscript and whole-person care

00:02:39 Introducing Medicine for All People

00:03:09 How the book’s title and philosophy developed

00:06:07 Family medicine, obstetrics, and community health

00:07:18 How living conditions shaped Dr. Maker-Clark’s view of medicine

00:10:00 Food as a central part of whole-person care

00:11:02 Growing up with food and traditional practices

00:13:19 Bringing nutrition back into clinical practice

00:15:14 Culinary medicine and medical student education

00:16:03 Bringing food education into Chicago public schools

00:17:23 Plants, ancestral knowledge, and connection with the natural world

00:20:29 Developing relationships with plants in everyday environments

00:22:49 Plants and the history of medicines

00:24:52 Nature, stress regulation, and belonging

00:27:19 Access to nature as a health-equity issue

00:31:26 Community as a medicine of connection

00:35:16 Service, or seva, and connection with others

00:41:31 Trust in healthcare relationships

00:45:22 Rebuilding trust in the body during chronic illness

00:46:39 Small practices for rebuilding self-trust

00:49:21 Why dance, gratitude, and play are “medicines of spirit”

00:50:36 Dance, movement, and neuroplasticity

00:53:28 Dance as culture, ancestry, and expression

00:54:27 Gratitude without toxic positivity

00:58:22 Why adults still need play

01:00:44 Different adult play personalities

01:03:20 Play and social development

01:05:56 Where to find Dr. Maker-Clark and her book

Want to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

Disclaimer

The views expressed on this podcast are those of the host and guest and do not necessarily reflect those of Fullscript or affiliated organizations. This episode is for informational and educational purposes only and is not medical advice. Practices discussed in the episode should not replace individualized medical assessment or treatment. Patients should consult a qualified healthcare professional before making changes to their healthcare routine.

References

1. Maker-Clark G, McHugh A, Shireman H, et al. Empowering Future Physicians and Communities on Chicago’s South Side through a 3-Arm Culinary Medicine Program. Nutrients. 2023;15(19):4212.
2. Shuda Q, Bougoulias ME, Kass R. Effect of nature exposure on perceived and physiologic stress: A systematic review. Complement Ther Med. 2020;53:102514.
3. Smith KJ, Gavey S, Riddell NE, Kontari P, Victor C. The association between loneliness, social isolation and inflammation: A systematic review and meta-analysis. Neurosci Biobehav Rev. 2020;112:519–541.
4. Cené CW, Beckie TM, Sims M, et al. Effects of Objective and Perceived Social Isolation on Cardiovascular and Brain Health: A Scientific Statement From the American Heart Association. J Am Heart Assoc. 2022.
5. Teixeira-Machado L, Arida RM, de Jesus Mari J. Dance for neuroplasticity: A descriptive systematic review. Neurosci Biobehav Rev. 2019;96:232–240.
6. Hewston P, Kennedy CC, Borhan S, et al. Effects of dance on cognitive function in older adults: a systematic review and meta-analysis. Age Ageing. 2021;50(4):1084–1092.
7. Fong Yan A, Nicholson LL, Ward RE, et al. The Effectiveness of Dance Interventions on Psychological and Cognitive Health Outcomes Compared with Other Forms of Physical Activity: A Systematic Review with Meta-analysis. Sports Med. 2024.
8. Diniz G, Korkes L, Tristão LS, et al. The effects of gratitude interventions: a systematic review and meta-analysis. Einstein (São Paulo). 2023.
9. Kerry N, Chhabra R, Clifton JDW. Being Thankful for What You Have: A Systematic Review of Evidence for the Effect of Gratitude on Life Satisfaction. Psychol Res Behav Manag. 2023;16:4799–4816.
10. Blanche EI, Chang MC, Parham LD. Experiences of Adult Play. Am J Occup Ther. 2024;78(4).

Dr. Holly Lucille, ND, is joined by Ellie Abraham, PhD, to explain why two curcumin or Boswellia supplements may not be equivalent, even when the front of the label looks similar. The conversation covers boswellic acid standardization, AKBA, curcumin delivery systems, piperine, botanical sourcing, finished-product testing, certificates of analysis, and supply-chain controls. Research supports meaningful variation in Boswellia composition and curcumin formulations, making the specific extract and formulation relevant when interpreting product labels and published evidence. (Meins 2016) (Mimica 2022)

Clinical Takeaways

• “Boswellic acids” describes a group of compounds. Boswellia preparations can contain different proportions of individual boswellic acids, including AKBA, KBA, and alpha- and beta-boswellic acids. Products with similar total boswellic acid claims therefore may not have identical chemical profiles. (Mannino 2016) (Meins 2016)
• Curcumin formulation matters. Conventional oral curcumin has low bioavailability, and formulations including phytosomes, liposomes, micelles, and piperine combinations have been studied as strategies to alter absorption. However, different formulations should not automatically be treated as interchangeable because comparative pharmacokinetic results vary. (Hegde 2023) (Fança-Berthon 2021)
• Standardization provides more information than an ingredient name alone. Botanical composition can vary with species, growing conditions, extraction, processing, and other supply-chain factors. Standardization and appropriate quality controls can help establish more consistent composition. (Ribnicky 2008) (Sarma 2021)
• Potency is only one part of quality. Botanical quality also involves identity, purity, contaminants, adulteration, and finished-product verification. Published investigations have identified labeling and authenticity concerns in both Boswellia and turmeric/curcumin products. (Meins 2016) (You 2022)
• Quality does not equal clinical fit. A well-characterized supplement still needs to be considered in the context of the individual patient, including the formulation, dose, supporting evidence, medication use, and potential botanical-drug interactions. (van Breemen 2008)

Guest: Ellie Abraham, PhD

Ellie Abraham has a PhD in plant biology, with research focused on developing analytical methods for testing finished botanical products. Her background includes botanical chemistry, finished-product testing, standardization, and dietary supplement quality. In this episode, she explains how practitioners can look beyond an ingredient name to assess what a curcumin or Boswellia product is actually formulated to deliver.

These five questions best match the broad topics addressed in the episode, particularly searches around Boswellia standardization, AKBA, curcumin absorption, piperine, and supplement quality. Exact search volume is not publicly available from a standard web search. These topics are also represented in published research on botanical quality and curcumin formulation.

Clinician FAQ

1. Are all Boswellia supplements the same?

No. Boswellia products may differ in species, extract composition, total boswellic acid content, and concentrations of individual boswellic acids such as AKBA and KBA. A survey of commercial Boswellia supplements found substantial variation in composition and label compliance. (Meins 2016)

2. What does boswellic acid standardization mean?

It indicates that an extract is standardized to a stated amount of boswellic acids or, in some products, a particular constituent such as AKBA. Boswellia contains multiple boswellic acids, and their relative concentrations can vary by species and extract. (Mannino 2016) (Lauß 2024)

3. Why is AKBA listed separately on some Boswellia products?

AKBA, or 3-O-acetyl-11-keto-β-boswellic acid, is one individual boswellic acid that has received substantial pharmacologic research attention. Calling it out separately provides more specific compositional information than reporting total boswellic acids alone. (Ammon 2016)

4. Why do curcumin supplements use phytosomes, liposomes, or piperine?

Conventional oral curcumin has limited bioavailability. Phospholipid complexes, liposomal and micellar systems, and co-administration with piperine are among the approaches studied to alter its absorption and pharmacokinetics. Results vary by formulation, so an “enhanced absorption” format does not by itself establish that two products are equivalent. (Mirzaei 2017) (Heidari 2023) (Mimica 2022)

5. How can practitioners assess curcumin and Boswellia supplement quality?

Look beyond the ingredient name. Relevant product information may include botanical identity, extract and standardization details, branded ingredients tied to specific research, contaminant and adulteration testing, finished-product verification, and manufacturer transparency. Published studies have documented variability and authenticity concerns in commercial Boswellia and turmeric products. (Meins 2016) (You 2022)

Timestamps / Key Moments

00:00:36 Why familiar botanical names do not make products equivalent

00:01:27 Understanding Boswellia and boswellic acid standardization

00:02:05 Total boswellic acids and individual compounds

00:03:47 Why the boswellic acid profile matters

00:05:40 Matching botanical extracts to the supporting evidence

00:06:09 Curcumin delivery methods and formulation differences

00:07:12 Phospholipid-based curcumin formulations

00:08:29 How piperine is used with curcumin

00:10:43 Finished-product testing and label claims

00:13:43 Heavy metals and synthetic curcumin concerns

00:14:09 Understanding California Proposition 65

00:16:40 Curcuminoid complexes and certificates of analysis

00:18:18 How supply-chain controls affect botanical composition

00:20:07 Why standardization matters from batch to batch

00:21:05 What practitioners can look for when reviewing products

00:22:40 Fullscript's approach to supplier and product quality review

Botanicals and Compounds Discussed

• Boswellia
• Boswellia extracts
• Boswellic acids
• AKBA (3-O-acetyl-11-keto-β-boswellic acid)
• Beta-boswellic acid
• Turmeric
• Curcumin
• Curcuminoids
• Piperine
• Phospholipids

Quality Methods and Documents Discussed

• Botanical standardization
• Finished-product testing
• Ingredient identity verification
• Potency testing
• Heavy-metal testing
• Adulteration screening
• Synthetic curcumin testing
• Certificates of analysis
• Branded ingredient documentation
• Raw-material sourcing
• Supply-chain controls
• Extraction methods
• Stability data
• Batch-to-batch consistency
• Supplier and brand vetting

Want to elevate your practice?

This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one centralized system. For practitioners, Fullscript provides access to professional-grade supplements and practitioner education while incorporating quality review processes for brands and products offered through its catalog. The goal is not to replace clinical judgment, but to help practitioners make thoughtful, individualized decisions with clearer product and quality information.

For more practitioner education on supplement quality and clinical decision-making, visit Fullscript Academy at academy.fullscript.com.

Disclaimer

The views expressed on this podcast are those of the host and guest and do not necessarily reflect those of Fullscript or affiliated organizations. This episode is for informational and educational purposes only and is not medical advice. Dietary supplements may cause side effects or interact with medications. Patients should consult a qualified healthcare professional before changing their healthcare routine.

References

1. Ammon, H. P. T. (2016). Boswellic acids and their role in chronic inflammatory diseases. Advances in Experimental Medicine and Biology, 928, 291–327. https://pubmed.ncbi.nlm.nih.gov/27671822/
2. Fança-Berthon, P., et al. (2021). Pharmacokinetics of a single dose of turmeric curcuminoids depends on formulation: Results of a human crossover study. The Journal of Nutrition, 151(7), 1802–1816. https://pubmed.ncbi.nlm.nih.gov/34363434/
3. Hegde, M., Girisa, S., BharathwajChetty, B., Vishwa, R., & Kunnumakkara, A. B. (2023). Curcumin formulations for better bioavailability: What we learned from clinical trials thus far? ACS Omega, 8(12), 10713–10746. https://pubmed.ncbi.nlm.nih.gov/37008131/
4. Heidari, H., Bagherniya, M., Majeed, M., Sathyapalan, T., Jamialahmadi, T., & Sahebkar, A. (2023). Curcumin-piperine co-supplementation and human health: A comprehensive review of preclinical and clinical studies. Phytotherapy Research, 37(4), 1462–1487. https://pubmed.ncbi.nlm.nih.gov/36720711/
5. Lauß, J., Kappacher, C., Isser, O., Huck, C. W., & Rainer, M. (2024). Species-specific quantification of bioactive boswellic acids in Boswellia resin using NIR spectroscopy, HPLC and multivariate data analysis. Spectrochimica Acta Part A: Molecular and Biomolecular Spectroscopy, 316, 124384. https://pubmed.ncbi.nlm.nih.gov/38701576/
6. Mannino, G., Occhipinti, A., & Maffei, M. E. (2016). Quantitative determination of 3-O-acetyl-11-keto-β-boswellic acid (AKBA) and other boswellic acids in Boswellia sacra and Boswellia serrata. Molecules, 21(10), 1329. https://pubmed.ncbi.nlm.nih.gov/27782055/
7. Meins, J., Artaria, C., Riva, A., Morazzoni, P., Schubert-Zsilavecz, M., & Abdel-Tawab, M. (2016). Survey on the quality of the top-selling European and American botanical dietary supplements containing boswellic acids. Planta Medica, 82(6), 573–579. https://pubmed.ncbi.nlm.nih.gov/27054914/
8. Mimica, B., Bučević Popović, V., Banjari, I., Jeličić Kadić, A., & Puljak, L. (2022). Methods used for enhancing the bioavailability of oral curcumin in randomized controlled trials: A meta-research study. Pharmaceuticals, 15(8), 939. https://pubmed.ncbi.nlm.nih.gov/36015087/ 
9. Mirzaei, H., Shakeri, A., Rashidi, B., Jalili, A., Banikazemi, Z., & Sahebkar, A. (2017). Phytosomal curcumin: A review of pharmacokinetic, experimental and clinical studies. Biomedicine & Pharmacotherapy, 85, 102–112. https://pubmed.ncbi.nlm.nih.gov/27930973/
10. Ribnicky, D. M., et al. (2008). Evaluation of botanicals for improving human health. The American Journal of Clinical Nutrition, 87(2), 472S–475S. https://pubmed.ncbi.nlm.nih.gov/18258640/
11. Sarma, N., Upton, R., Rose, U., Guo, D.-A., Marles, R., Khan, I., & Giancaspro, G. (2021). Pharmacopeial standards for the quality control of botanical dietary supplements in the United States. Journal of Dietary Supplements, 20(3), 485–504. https://pubmed.ncbi.nlm.nih.gov/34699287/
12. van Breemen, R. B., Fong, H. H. S., & Farnsworth, N. R. (2008). Ensuring the safety of botanical dietary supplements. The American Journal of Clinical Nutrition, 87(2), 509S–513S. https://pubmed.ncbi.nlm.nih.gov/18258648/
13. You, H., Gershon, H., Goren, F., Xue, F., Kantowski, T., & Monheit, L. (2022). Analytical strategies to determine the labelling accuracy and economically-motivated adulteration of “natural” dietary supplements in the marketplace: Turmeric case study. Food Chemistry, 370, 131007. https://pubmed.ncbi.nlm.nih.gov/34507212/

What if metabolism and immune function aren’t separate systems, but part of one continuous conversation?

In this episode of the Root Cause Medicine Podcast, Dr. Jeffrey Bland joins Kate Kresge to explore immunometabolism, the study of how immune activity and cellular metabolism influence one another. They discuss how inflammation can affect energy use across tissues, why metabolic health is about far more than weight, and how systems biology is changing the way clinicians think about chronic disease. (O'Neill 2016)

Dr. Bland also introduces emerging inflammatory indices—including the Systemic Immune-Inflammation Index (SII) and Systemic Inflammation Response Index (SIRI)—that can be derived from components of a routine CBC with differential. (Islam 2024) The conversation explores their potential role as contextual markers of inflammatory activity, while emphasizing how Journeys can help to automate CBC calculations and help create customized reports for practitioners using blood labs values, history, symptoms and more. 

The episode closes with a practical look at nutrition, polyphenol-rich foods, lifestyle medicine, large-scale health data, and the growing potential for personalized care.

• Immunometabolism connects immune signaling with cellular energy use. Immune cells alter their metabolic activity when activated, and immune-derived signals can influence the function of tissues throughout the body. (O'Neill 2016)
• Chronic inflammation is a systems-level process. Rather than viewing inflammation as an isolated problem within one organ, immunometabolism highlights communication among adipose tissue, the liver, brain, muscles, immune cells, and other tissues. (Burak 2024) (Juárez-Rojas 2024)
• A CBC may contain more information than clinicians traditionally use. SII and SIRI combine routinely measured blood-cell populations into indices being studied as markers of systemic inflammatory and immune activity. (Islam 2024) They should be interpreted in clinical context rather than used independently to diagnose disease or dictate treatment. (Mangoni 2024)
• Lifestyle interventions affect multiple biological systems at once. Dr. Bland discusses dietary patterns rich in diverse plant compounds alongside movement, sleep, and stress management as components of a broader approach to metabolic and immune health. (Koelman 2022)
• Practitioners can order Dr. Jeff Bland’s Immunometabolic Journey on Fullscript.com

Dr. Jeffrey Bland is a longtime leader in functional and systems-based approaches to health and one of the influential voices behind the development of functional medicine. His work focuses on translating complex biology—including immunology, metabolism, nutrition, genetics, and systems medicine—into clinically meaningful ways of thinking about health. In this conversation, he brings that systems perspective to immunometabolism and explores how clinicians may begin connecting familiar laboratory data with a deeper understanding of immune and metabolic function.

Immunometabolism examines the two-way relationship between immune function and metabolism. Immune cells require energy to perform their functions, and changes in their metabolic state can influence inflammatory signaling and communication with other tissues. (O'Neill 2016)

SII and SIRI are calculated indices derived from blood-cell counts commonly included in a CBC with differential. They have been studied across several clinical populations as markers associated with systemic inflammatory and immune activity, but they are nonspecific and should be interpreted alongside the broader clinical picture. (Islam 2024)

No single index can establish the cause or clinical significance of inflammation on its own. These measures may provide additional context, but symptoms, medical history, other laboratory findings, medications, acute illness, and underlying conditions can all influence blood-cell counts. (Mangoni 2024)

Immune activation changes cellular energy demands. Because mitochondria and other metabolic pathways help determine how cells generate and use energy, cellular metabolism is closely connected with immune-cell behavior. (O'Neill 2016)

Ordering a CBC and other biomarkers included in the Immuno-Metabolic Journey from Dr. Jeff Bland allows for automatic calculation of SIRI and SII, as well as recommending next steps for clinicians depending on findings. 

02:22 — What immunometabolism means

Why immune function and metabolism can no longer be viewed as separate biological systems.

06:15 — From “angry fat” to systems biology

How communication between immune cells and adipose tissue helped shape modern thinking about immunometabolism.

09:31 — Immunometabolism and root-cause thinking

Looking upstream from organ dysfunction toward the processes that may be influencing it.

17:23 — Metabolism is more than weight

Cellular energy production, mitochondria, inflammation, and why metabolic function affects the entire body.

22:01 — What a routine CBC may reveal

Moving beyond gross abnormalities to explore patterns within the CBC with differential.

23:20 — Introducing SII and SIRI

How researchers combine neutrophils, lymphocytes, platelets, and monocytes into inflammatory indices.

34:06 — Translating biomarkers into whole-person care

Nutrition, polyphenols, movement, sleep, and stress management enter the conversation.

39:27 — Why food complexity matters

Dr. Bland uses buckwheat to illustrate the diversity of plant polyphenols.

46:38 — Big data and personalized medicine

How large health datasets may help researchers identify more individualized biological patterns.

54:43 — Owning your health

Dr. Bland closes with a message about agency, personalization, and creating healthier patterns over time.

Want to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

Disclaimer: The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.

1. Burak, M. F., Stanley, T. L., Lawson, E. A., Campbell, S. L., Lynch, L., Hasty, A. H., Domingos, A. I., Dixit, V. D., Hotamışlıgil, G. S., Sheedy, F. J., Dixon, A. E., Brinkley, T. E., Hill, J. A., Donath, M. Y., & Grinspoon, S. K. (2024). Adiposity, immunity, and inflammation: Interrelationships in health and disease—A report from the 24th Annual Harvard Nutrition Obesity Symposium, June 2023. The American Journal of Clinical Nutrition, 120(1), 257–268. https://www.sciencedirect.com/science/article/abs/pii/S0002916524004556
2. Islam, M. M., Osoydan Satici, M., & Eroglu, S. E. (2024). Unraveling the clinical significance and prognostic value of the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, systemic immune-inflammation index, systemic inflammation response index, and delta neutrophil index: An extensive literature review. Turkish Journal of Emergency Medicine, 24(1), 8–19. https://pubmed.ncbi.nlm.nih.gov/38343523/
3. Juárez-Rojas, J. G., Reyes-Barrera, J., & Medina-Urrutia, A. X. (2024). Adipose tissue immunometabolism: Unveiling the intersection of metabolic and immune regulation. Revista de Investigación Clínica, 76(2), 65–79. https://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0034-83762024000200001
4. Koelman, L., Egea Rodrigues, C., & Aleksandrova, K. (2022). Effects of dietary patterns on biomarkers of inflammation and immune responses: A systematic review and meta-analysis of randomized controlled trials. Advances in Nutrition, 13(1), 101–115. https://pmc.ncbi.nlm.nih.gov/articles/PMC8803482/
5. Mangoni, A. A., & Zinellu, A. (2024). The diagnostic role of the systemic inflammation index in patients with immunological diseases: A systematic review and meta-analysis. Clinical and Experimental Medicine, 24(1), Article 27. https://link.springer.com/article/10.1007/s10238-024-01294-3
6. O'Neill, L. A. J., Kishton, R. J., & Rathmell, J. (2016). A guide to immunometabolism for immunologists. Nature Reviews Immunology, 16(9), 553–565. https://pubmed.ncbi.nlm.nih.gov/27396447/
7. Zeevi, D., Korem, T., Zmora, N., Israeli, D., Rothschild, D., Weinberger, A., Ben-Yacov, O., Lador, D., Avnit-Sagi, T., Lotan-Pompan, M., Suez, J., Mahdi, J. A., Matot, E., Malka, G., Kosower, N., Rein, M., Zilberman-Schapira, G., Dohnalová, L., Pevsner-Fischer, M., … Segal, E. (2015). Personalized nutrition by prediction of glycemic responses. Cell, 163(5), 1079–1094. https://www.cell.com/cell/fulltext/S0092-8674(15)01481-6

What happens when a patient with multiple autoimmune conditions has already addressed the obvious contributors—but continues to experience flares?

In this Root Cause Medicine Podcast case study, Dr. Kate Kreske sits down with clinical nutritionist and IFM-certified practitioner Robyn Puglia to explore a complex case involving polyautoimmunity and persistent immune dysregulation. The patient had already worked with multiple practitioners and undergone extensive evaluation, including assessments related to gut health, food reactivity, mold, and stress. Yet something was still being missed.

Robyn explains how additional testing shifted her attention away from the gut and toward an unexpected area: the respiratory tract. She walks through how those findings changed her clinical thinking, why complex cases sometimes require practitioners to reconsider their assumptions, and what happened when the care plan was adjusted based on this new information.

The conversation offers an important reminder for practitioners: deeper testing can sometimes provide useful clues, but results need to be interpreted within the broader clinical picture rather than treated as a diagnosis on their own.

• How Robyn approaches highly complex patients who have already addressed many common contributors
• Why gut health should not automatically be assumed to be the primary driver of every autoimmune presentation
• How testing identified a respiratory microbial pattern that had not been clinically obvious
• Why laboratory findings are most useful when interpreted alongside symptoms, history, prior testing, and the overall clinical picture
• How unexpected findings can change clinical decision-making in complex cases
• Why an individual case can illustrate clinical reasoning without establishing that the same testing or intervention will produce similar outcomes in other patients

When the obvious answers have already been explored

Robyn describes her practice as serving patients at the “zebra” or even “unicorn” stage—people who have often seen multiple experienced practitioners and already addressed common areas such as nutrition, metabolic health, circadian rhythms, stress, and gut health.

Looking beyond the gut in autoimmunity

The featured patient had four autoimmune conditions and continued experiencing immune dysregulation and flares despite significant previous investigation and improvement. Rather than assuming the gastrointestinal tract remained the primary contributor, Robyn expanded the investigation.

An unexpected respiratory finding

Testing suggested a respiratory tract microbial pattern despite the absence of obvious respiratory symptoms. This finding shifted Robyn's clinical hypothesis and became an important part of how she approached the case.

When a complex patient has already addressed the most plausible contributors but continues to experience symptoms, repeating the same investigation may not provide the missing answer. Consider stepping back and asking whether another system, exposure, infection, or contributor deserves evaluation.

At the same time, avoid allowing a single specialized test result to become the new explanation for the entire case. Use testing to inform clinical reasoning alongside the patient's history, symptoms, conventional evaluation, and other relevant findings.

Want to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

The views expressed on this podcast are those of the hosts and the guests, and they don't necessarily reflect the views of FullScript or any affiliated organizations. This podcast is for informational and educational purposes only, and it's not intended to be medical advice. For your safety, always check with your healthcare provider before making any changes to your healthcare routine.

What if some of the immune activity we’re looking for isn’t showing up where we expect to find it?

In this episode, I sit down with Robyn Puglia of Cyrex Laboratories to explore TG6, lymphocyte patterns, and early autoimmunity—and specialized testing many practitioners may not realize is available through Cyrex Wheat Burden panel, the Lymphocyte Map, and Array 5.

We look at neurological manifestations of gluten-related disease, what different immune cell populations may add to the clinical picture, and how autoantibodies can sometimes appear before autoimmune disease is diagnosed.

The bigger question: Can seeing more of the immune story help us ask better questions about what may be driving a complex presentation?

• Why gluten reactivity isn’t always a gut story. TG6 has been studied in gluten-related neurological disorders, particularly gluten ataxia. (Hadjivassiliou 2019) We discuss why neurological symptoms may belong in the gluten conversation and what Cyrex Wheat Burden Panel is designed to investigate beyond conventional celiac markers. (Mearns 2019)
• What your lymphocyte count may not tell you. T cells, B cells, natural killer cells, and their subsets have different jobs. Robyn explains how the Cyrex Lymphocyte Map looks at these populations and how patterns may help practitioners decide what to investigate next.
• Why autoimmunity may start before the diagnosis. Disease-associated autoantibodies can precede clinical disease in several autoimmune conditions. (Ma 2017) We explore Cyrex Array 5, tissue-associated autoantibodies, and what these earlier immune signals may—and may not—tell us. (Frazzei 2022)

Robyn Puglia’s work with celiac disease, neurological symptoms, autoimmunity, and complex chronic illness pushed her to ask what the immune system might be telling us beyond a routine workup. Today, as Vice President of Practitioner Education at Cyrex Laboratories, she teaches practitioners how to think about specialized immune testing without treating an abnormal biomarker as a diagnosis.

Most practitioners know tissue transglutaminase 2 (TG2) from celiac testing. Tissue transglutaminase 6 (TG6) has been studied in gluten-related neurological disorders, particularly gluten ataxia. (Hadjivassiliou 2019)

TG6 isn’t part of routine guideline-supported celiac screening, but it highlights an important point: gluten-related immune disease can have extraintestinal manifestations, including neurological symptoms. (Mearns 2019) (Rubio-Tapia 2023)

The Wheat Burden panel evaluates antibody reactivity to multiple wheat-associated antigens and transglutaminases, including TG6.

It provides a broader look at wheat-associated immune reactivity than conventional celiac serology. It shouldn’t replace established evaluation for celiac disease or wheat allergy; the value of additional biomarkers depends on the clinical question and the evidence supporting their intended use. (Rubio-Tapia 2023) (Leonard 2017)

The Cyrex Lymphocyte Map examines populations and subsets of T cells, B cells, and natural killer cells.

Instead of asking whether one value is simply high or low, Robyn looks at the pattern and asks what might explain it. Infection? Medication effects? Immune dysfunction? Another clinical process?

The pattern isn’t the diagnosis. It helps sharpen the investigation.

Yes. In several autoimmune diseases, researchers have detected disease-associated autoantibodies before patients meet formal diagnostic criteria—sometimes years earlier. (Ma 2017)

Cyrex Array 5 evaluates multiple tissue-associated autoantibodies that Robyn discusses in this context. But an autoantibody isn’t a crystal ball. Its significance depends on the specific marker, the patient, and the evidence supporting its clinical use. (Ma 2017)

Yes. Cyrex offers the specialized tests discussed in this episode, including Wheat Burden Panel, the Lymphocyte Map, and Array 5, along with additional testing related to mucosal immunity and barrier function.

The important question isn’t, “How much can I test?”

It’s “What am I trying to understand, and will this result change what I do next?”

02:42 — The patients who pulled Robyn deeper into immunology

How celiac disease and unexplained illness changed her approach to complex patients.

11:41 — TG6: When gluten becomes a brain conversation

Why gluten-related immune activity isn’t necessarily confined to the gut.

13:49 — Are we asking enough questions about wheat?

The thinking behind Cyrex Wheat Burden Panel and its broader look at wheat-associated antigens and transglutaminases.

28:29 — What if autoimmunity starts before the diagnosis?

Tissue-associated autoantibodies, Array 5, and preclinical autoimmunity.

33:49 — Your lymphocyte count isn’t the whole story

T cells, B cells, natural killer cells, and the Cyrex Lymphocyte Map.

39:25 — The abnormal result is where the investigation starts

How immune patterns can generate better clinical questions.

44:20 — Stop looking for one perfect root cause

Robyn’s “aggregate gains” approach to complex illness.

50:49 — What else can we see in the immune system?

Tissue autoantibodies, mucosal immunity, and barrier biomarkers.

57:42 — When neurological symptoms change the workup

Why brain symptoms may require a broader metabolic, vascular, and immune picture.

Want to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

The views expressed on this podcast are those of the hosts and the guests, and they don't necessarily reflect the views of FullScript or any affiliated organizations. This podcast is for informational and educational purposes only, and it's not intended to be medical advice. For your safety, always check with your healthcare provider before making any changes to your healthcare routine.

1. Frazzei, G., van Vollenhoven, R. F., de Jong, B. A., Siegelaar, S. E., & van Schaardenburg, D. (2022). Preclinical autoimmune disease: A comparison of rheumatoid arthritis, systemic lupus erythematosus, multiple sclerosis and type 1 diabetes. Frontiers in Immunology, 13, 899372. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9281565/
2. Hadjivassiliou, M., Croall, I. D., Zis, P., Sarrigiannis, P. G., Sanders, D. S., Aeschlimann, P., Grünewald, R. A., Armitage, P. A., Connolly, D., Aeschlimann, D., & Hoggard, N. (2019). Neurologic deficits in patients with newly diagnosed celiac disease are frequent and linked with autoimmunity to transglutaminase 6. Clinical Gastroenterology and Hepatology, 17(13), 2678–2686. https://www.cghjournal.org/article/S1542-3565(19)30278-2/fulltext
3. Leonard, M. M., Sapone, A., Catassi, C., & Fasano, A. (2017). Celiac disease and nonceliac gluten sensitivity: A review. JAMA, 318(7), 647–656. https://jamanetwork.com/journals/jama/article-abstract/2648637
4. Ma, W. T., Chang, C., Gershwin, M. E., & Lian, Z. X. (2017). Development of autoantibodies precedes clinical manifestations of autoimmune diseases: A comprehensive review. Journal of Autoimmunity, 83, 95–112. https://www.sciencedirect.com/science/article/abs/pii/S0896841117303542
5. Mearns, E. S., Taylor, A., Thomas Craig, K. J., Puglielli, S., Cichewicz, A. B., Leffler, D. A., Sanders, D. S., Lebwohl, B., & Hadjivassiliou, M. (2019). Neurological manifestations of neuropathy and ataxia in celiac disease: A systematic review. Nutrients, 11(2), 380. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6412791/
6. Rubio-Tapia, A., Hill, I. D., Semrad, C., Kelly, C. P., Greer, K. B., Limketkai, B. N., & Lebwohl, B. (2023). American College of Gastroenterology guidelines update: Diagnosis and management of celiac disease. The American Journal of Gastroenterology, 118(1), 59–76. https://pubmed.ncbi.nlm.nih.gov/36602836/

What does it take to help young athletes perform at their best—not just today, but for decades to come?

In this episode of Root Cause Medicine, Dr. Kate Kresge sits down with emergency medicine physician and functional medicine practitioner Dr. Erik Peterson to discuss a whole-person approach to adolescent athletic performance. Drawing from more than 20 years in emergency medicine, his background as a collegiate athlete, and his work caring for young competitors, Dr. Peterson explains why optimizing performance starts with supporting the developing body rather than simply pushing it harder.

The conversation explores how nutrition, sleep, recovery, body composition, metabolic health, and resilience influence athletic success during adolescence. Dr. Peterson also shares why he believes healthcare providers, coaches, and parents have an opportunity to improve long-term health by focusing on foundational physiology during these critical developmental years. Beyond sports performance, this episode is also a conversation about the evolution of medicine—from treating illness in the emergency department to helping people stay healthy through proactive, root-cause care.

Listen If You...

• Treat adolescent athletes in your practice
• Coach youth sports
• Parent a competitive athlete
• Work in sports medicine, functional medicine, pediatrics, or primary care
• Want to better understand the foundations of long-term athletic performance

What You'll Learn

• How Dr. Peterson gets his athletes results using only food, supplements and lifestyle
• Common mistakes young athletes make when trying to optimize performance
• Why body composition and metabolic health matter more than weight alone
• The important role parents and coaches play in creating healthy performance habits
• Dr. Peterson's journey from emergency medicine physician to functional medicine practitioner

Who Is Dr. Erik Peterson?

Dr. Erik Peterson is a board-certified emergency medicine physician who has practiced emergency medicine for more than two decades while also leading a precision medicine practice focused on performance optimization, men's health, women's health, and preventive care. A former collegiate athlete, he combines his experience in acute care with evidence-informed lifestyle medicine to help athletes and active individuals optimize health, resilience, and long-term performance. Learn more about his program at https://firstcallperformance.com/ 

Key Takeaways

• Performance is Built Outside the Gym: Training is only one part of athletic success. Nutrition, sleep, recovery, stress management, and overall metabolic health create the foundation that allows athletes to adapt and perform. (Mountjoy 2023) (Cunha 2023)
• Adolescence Is a Critical Opportunity: The teenage years represent an important period for developing healthy habits that influence performance, injury risk, and long-term health. (Blyth 2025) 
• Parents and Coaches Matter: The adults surrounding young athletes often shape their relationship with food, training, recovery, and health. Creating supportive environments can have lasting effects beyond sports. (Baceviciene 2023)
• Functional Medicine Complements Performance Care: Looking upstream at nutrition, biomarkers, lifestyle, and physiology may help identify opportunities to support athletic performance while promoting long-term wellness. (Haller 2023) 

Want to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

Disclaimer: The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.

Sources: 

1. Baceviciene, M., Jankauskiene, R., & Rutkauskaite, R. (2023). The comparison of disordered eating, body image, sociocultural and coach-related pressures in athletes across age groups and groups of different weight sensitivity in sports. Nutrients, 15(12), 2724. https://www.mdpi.com/2072-6643/15/12/2724
2. Blyth, F., Haycraft, E., Peral-Suarez, A., & Pearson, N. (2025). Tracking and changes in the clustering of physical activity, sedentary behavior, diet, and sleep across childhood and adolescence: A systematic review. Obesity Reviews, 26(6), e13909. https://onlinelibrary.wiley.com/doi/10.1111/obr.13909
3. Cunha, L. A., Costa, J. A., Marques, E. A., Brito, J., Lastella, M., & Figueiredo, P. (2023). The impact of sleep interventions on athletic performance: A systematic review. Sports Medicine – Open, 9(1), 58. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10354314/
4. Haller, N., Behringer, M., Reichel, T., Wahl, P., Simon, P., Krüger, K., Zimmer, P., & Stöggl, T. (2023). Blood-based biomarkers for managing workload in athletes: Considerations and recommendations for evidence-based use of established biomarkers. Sports Medicine, 53(7), 1315–1333. https://pubmed.ncbi.nlm.nih.gov/37204619/
5. Mountjoy, M., Ackerman, K. E., Bailey, D. M., Burke, L. M., Constantini, N., Hackney, A. C., Heikura, I. A., Melin, A., Pensgaard, A. M., Stellingwerff, T., Sundgot-Borgen, J. K., Torstveit, M. K., Jacobsen, A. U., Verhagen, E., Budgett, R., Engebretsen, L., & Erdener, U. (2023). 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). British Journal of Sports Medicine, 57(17), 1073–1097. https://pubmed.ncbi.nlm.nih.gov/37752011/

How to Build a Thriving Practice Without Burning Out

One of my favorite parts of hosting the Root Cause Medicine Podcast is introducing you to practitioners who are making a real difference—not only in the lives of their patients, but in the lives of other clinicians.

Today's guest is Lesli Bitel, a registered dietitian whose career has taken a path that many practitioners may recognize pieces of. She began in clinical practice, spent years in leadership roles across the pharmaceutical and diagnostics industries, and eventually found her way back to patient care with an entirely new perspective. Today, she helps practitioners build businesses that allow them to do their best work without burning themselves out along the way.

Because the reality is, most of us were trained to care for patients. Very few of us were taught how to build a practice that can sustainably support both our patients and ourselves.

In this conversation, Lesli shares how her experience in business transformed the way she thought about practice ownership. We talk about why marketing doesn't have to feel uncomfortable, how thoughtful systems can create more time for patient care, and why building a successful practice isn't about doing more—it's about building one that's aligned with your values.

Whether you're just starting your practice or looking for a more sustainable way to grow, I think you'll come away from this conversation with practical ideas—and maybe a little reassurance—that it's possible to build a thriving practice without losing sight of why you became a clinician in the first place.

In This Conversation

• Lesli's journey from aspiring clinician to healthcare executive and back to patient care
• What years in corporate healthcare taught her about running a successful practice
• Why so many practitioners feel confident clinically but overwhelmed by the business side of medicine
• How marketing can become an authentic extension of patient education
• Simple systems that create more time, less stress, and better patient experiences
• The connection between practice design, boundaries, and practitioner well-being
• Building a practice that reflects your strengths, values, and vision for your career

A Few Takeaways I'll Be Thinking About

• Authentic marketing starts with clarity, not self-promotion.
• Good systems free you to spend more time doing what only you can do.
• Sustainable growth should support your life, not just your business.

Who Should Listen?

This episode is for any clinician who has ever wondered:

• How do I build a practice that actually feels sustainable?
• How can I grow without sacrificing patient care?
• Is there a way to market my practice that still feels authentic?
• What does long-term success really look like?

Whether you're starting your first practice or reimagining an established one, I think you'll find something valuable in Lesli's story.

Episode Timeline

00:00 — Welcome and introduction

02:30 — Lesli's journey into healthcare

05:00 — Lessons from corporate healthcare

10:00 — Why clinicians struggle with practice ownership

18:00 — Rethinking marketing

28:00 — Systems that support sustainable growth

39:00 — Burnout, boundaries, and practice design

48:00 — Building a practice around your values

55:00 — Final reflections

Want to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

Disclaimer: The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.

Dr. Holly Lucille is joined by Ellie Abraham, PhD, to explain why two ashwagandha supplements may not be the same, even when they list the same ingredient. (Thalhamer 2024) This conversation covers differences between root and leaf extracts, withanolide standardization, botanical identity testing, certificates of analysis, and manufacturing quality. It also emphasizes that a well-made product may still not be appropriate for every patient. (NCCIH 2025)

Clinical Takeaways

• Plant part matters. Ashwagandha root, leaf, and combined extracts may have different chemical profiles and should not automatically be treated as interchangeable. (Chaurasiya 2008)
• Higher is not always better. The most concentrated product is not necessarily the safest or most effective. Clinical relevance depends on the extract, dose, intended use, and supporting research. (Thalhamer 2024) (NCCIH 2025)
• Quality testing matters. Botanical authentication, contaminant testing, certificates of analysis, and cGMP compliance can help confirm that a product meets its specifications. (ECFR 2026)
• Quality does not equal clinical fit. Patient history, medications, allergies, diagnoses, and potential interactions must still be considered. (NCCIH 2025)

Guest: Ellie Abraham has a PhD in plant biology and a background in analytical chemistry, ethnobotany, botanical testing, and dietary supplement quality control. She explains how manufacturers and laboratories verify botanical identity, plant part, standardization, contaminants, and product documentation.

Clinician FAQ

1. Are all ashwagandha supplements the same? No. Products may differ in plant part, extraction method, dose, standardization, chemical profile, and manufacturing quality. (Thalhamer 2024)

2. Why does ashwagandha root versus leaf matter? The root and leaf  of ashwagandha contain different combinations of plant compounds. These differences may affect the product’s clinical properties, supporting research, and safety profile. (Chaurasiya 2008)

3. What does “standardized to 5% withanolides” mean? It means withanolides account for approximately 5% of the tested material. It does not identify each individual withanolide or describe the rest of the extract. (Thalhamer 2024)

4. Is a higher withanolide percentage better? Not necessarily. A higher percentage does not automatically mean that a product is safer or more effective. The appropriate concentration depends on the extract, dose, intended use, and supporting research. (Thalhamer 2024)

5. Can ashwagandha cause liver injury? Rare cases of liver injury associated with ashwagandha products have been reported. The exact cause and individual risk factors remain uncertain, but practitioners should consider supplement use when evaluating unexplained liver symptoms or abnormal liver tests. (NCBI 2012) (Philips 2023) (Björnsson 2020)

Timestamps / Key Moments

00:01:43 Ellie Abraham’s background in botanical testing

00:02:36 The ashwagandha leaf discussion in India

00:04:00 Differences between root and leaf

00:05:44 How botanical identity is verified

00:07:25 Why standardization matters

00:09:07 Why higher withanolides are not always better

00:10:56 Comparing two ashwagandha products

00:12:17 Red flags on supplement labels

00:14:42 When to request a certificate of analysis

00:16:27 Why cGMP compliance matters

Botanicals and Compounds Discussed

• Ashwagandha root and leaf
• Withanolides
• Glycosides
• Withanone
• Curcumin and curcuminoids

Quality Methods and Documents Discussed

• Botanical identity testing
• Plant-part verification
• HPTLC chemical fingerprinting
• Standardization testing
• Adulterant screening
• Microbial and heavy-metal testing
• Certificates of analysis
• Third-party testing
• cGMP compliance
• Batch-to-batch consistency
• Branded ingredient research

Want to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

Disclaimer

The views expressed on this podcast are those of the host and guest and do not necessarily reflect those of Fullscript or affiliated organizations. This episode is for educational purposes only and is not medical advice. Dietary supplements may cause side effects or interact with medications. Patients should consult a qualified healthcare professional before changing their healthcare routine.

References

1. Björnsson, H. K., Björnsson, E. S., Avula, B., Khan, I. A., Jonasson, J. G., Ghabril, M., Hayashi, P. H., & Navarro, V. (2020). Liver injury due to ashwagandha: A case series from Iceland and the U.S. Drug-Induced Liver Injury Network. Liver International, 40(4), 825–829. https://pubmed.ncbi.nlm.nih.gov/31991029/
2. Chaurasiya, N. D., Uniyal, G. C., Lal, P., Misra, L., Sangwan, N. S., Tuli, R., & Sangwan, R. S. (2008). Analysis of withanolides in root and leaf of Withania somnifera by HPLC with photodiode array and evaporative light scattering detection. Phytochemical Analysis, 19(2), 148–154. https://pubmed.ncbi.nlm.nih.gov/17879227/
3. ECFR. (2026). Current good manufacturing practice in manufacturing, packaging, labeling, or holding operations for dietary supplements (21 C.F.R. Part 111). https://www.ecfr.gov/current/title-21/chapter-I/subchapter-B/part-111
4. National Center for Complementary and Integrative Health (NCCIH). (2025). Ashwagandha. National Institutes of Health, U.S. Department of Health and Human Services. https://www.nccih.nih.gov/health/ashwagandha
5. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (2024). Ashwagandha. In LiverTox: Clinical and research information on drug-induced liver injury. https://www.ncbi.nlm.nih.gov/books/NBK548536/
6. NCBI. (2012). Ashwagandha [Review of Ashwagandha]. PubMed; National Institute of Diabetes and Digestive and Kidney Diseases. https://www.ncbi.nlm.nih.gov/books/NBK548536/
7. Philips, C. A., Valsan, A., Theruvath, A. H., Ravindran, R., Oommen, T. T., Rajesh, S., Bishnu, S., & Augustine, P. (2023). Ashwagandha-induced liver injury: A case series from India and literature review. Hepatology Communications, 7(10), e0270. https://pubmed.ncbi.nlm.nih.gov/37756041/
8. Thalhamer, B., Himmelsbach, M., Schatzmann, B., Klampfl, C., & Buchberger, W. (2024). A feasible procedure to detect widespread wrong labeling of ashwagandha root extracts in dietary supplements. Exploration of Foods and Foodomics, 2, 460–470. https://www.explorationpub.com/Journals/eff/Article/101046

This episode explores the role of immune-mediated testing in the evaluation of complex, chronic symptoms that may not respond to conventional approaches. Dr. Jessica Christie is joined by Veronica Kent, CEO of Alletess Medical Laboratory, and Kristen Trainer, Registered Dietitian and Clinical Educator, to discuss food allergies, food sensitivities, mold exposure, Candida, Alpha-gal syndrome, elimination diets, and the evolving landscape of laboratory testing.

The conversation examines the differences between IgE-mediated food allergies and IgG food sensitivity testing, when clinicians may consider specialized laboratory assessments, and the importance of combining laboratory data with a comprehensive patient history and individualized care plans. The guests also discuss laboratory quality standards, patient education, and why test interpretation should be viewed as one component of clinical decision-making rather than a standalone diagnostic tool. (Santos 2023)

• Not all adverse food reactions are food allergies. The episode distinguishes between IgE-mediated food allergies and other forms of food-related symptoms, including food sensitivities, while acknowledging that diagnostic approaches differ depending on the clinical presentation. (Sicherer 2018)
• Patient history remains foundational. Laboratory testing should be interpreted alongside symptoms, clinical history, dietary patterns, and physical examination rather than in isolation. (Santos 2023)
• Elimination diets require structured implementation. The guests discuss elimination and systematic food reintroduction as part of evaluating whether certain foods may contribute to symptoms, emphasizing individualized guidance and monitoring. (Santos 2023)
• Alpha-gal syndrome is an emerging clinical consideration. Tick-associated mammalian meat allergy is becoming increasingly recognized and may present with delayed allergic reactions that can be difficult to identify. (Platts-Mills 2025) (Thompson 2023)
• Environmental exposures may contribute to symptom burden. Mold exposure is discussed as one possible consideration in select patients presenting with persistent respiratory or inflammatory symptoms, although appropriate testing strategies remain an area of ongoing research and debate. (Cai 2024) 
• Patient education is essential. Laboratory testing alone does not improve outcomes; patients benefit from clear interpretation, education, and individualized follow-up plans. (Santos 2025)
• Quality systems matter in laboratory medicine. The discussion highlights the importance of standardized laboratory procedures, quality assurance, and timely reporting in supporting clinical decision-making. (Pillai 2025)
• 
  

Veronica Kent is the Chief Executive Officer and owner of Alletess Medical Laboratory. She has spent decades working in specialty laboratory medicine and oversees operations focused on allergy, immunology, and immune-based laboratory testing. During the episode, she discusses laboratory quality systems, emerging testing technologies, and the role of clinician education in laboratory medicine.

Website: https://foodallergy.com

Kristen Trainer is a Registered Dietitian and Clinical Educator at Alletess Medical Laboratory. She has worked with clinicians and patients for more than two decades, helping interpret laboratory results and develop individualized nutrition and elimination diet plans for patients undergoing food allergy and food sensitivity testing.

Note: Discussion of these tests during the episode should not be interpreted as endorsement or guideline recommendations. Clinical appropriateness depends on the individual patient and current evidence.

• IgE food allergy testing
• Environmental allergy testing
• Component-resolved allergy diagnostics
• IgG food sensitivity testing
• IgA food sensitivity testing
• Candida antibody testing (IgG, IgA, IgM)
• Candida immune complex testing
• Mold antibody testing
• Alpha-gal IgE testing
• Tick-borne immune testing
• Celiac disease testing
• Total IgE testing

• Structured elimination diets
• Gradual food reintroduction
• Individualized meal planning
• Rotation diets
• Shopping list development
• Family-based nutrition planning
• Reducing environmental mold exposure
• Personalized patient education
• Long-term dietary follow-up
• Collaboration between laboratory professionals and clinicians

The discussion differentiates IgE-mediated food allergies, which may produce immediate immune reactions, from food sensitivities, which are proposed to involve different immune pathways and may present differently clinically. (Santos 2023) The role of IgG food sensitivity testing remains controversial and is not universally recommended by major allergy organizations. (Kelso 2018) 

According to the discussion, testing decisions should begin with a comprehensive patient history and symptom evaluation. Testing should be selected based on the suspected underlying mechanism rather than using broad screening panels indiscriminately. (Santos 2023) 

Component-resolved diagnostics evaluates specific proteins within an allergen rather than testing only the whole allergen, potentially providing additional information regarding sensitization patterns in certain allergic conditions. (Santos 2023) 

Alpha-gal syndrome is an IgE-mediated allergy associated with tick bites that may result in delayed allergic reactions after consuming mammalian meat or products derived from mammals. Recognition of this condition has increased in recent years. (Platts-Mills 2025) (Thompson 2023)

The guests describe elimination diets as a structured process involving temporary removal of selected foods followed by gradual reintroduction while monitoring symptoms under clinician supervision. (Santos 2023) 

The episode stresses that laboratory testing is only one part of patient care and that interpretation, counseling, dietary guidance, and follow-up are necessary to help patients implement meaningful changes. (Santos 2025)

Standardized testing procedures, accreditation, quality control, and timely reporting all contribute to reliable laboratory results that clinicians can incorporate into patient care. (Chaudhry 2023)

The guests discuss advances including miniaturized laboratory technologies, capillary blood collection, microbiome research, and genetics as potential future areas of development in allergy and immunology testing.

00:02:22 Veronica Kent and Kristen Trainer introduce Alletess

00:03:36 Food allergy, sensitivity, candida, mold, and tick-borne testing

00:04:54 How Alletess began as a specialized laboratory

00:08:16 Bridging the gap between lab results and patient care

00:09:27 How allergy and immunology testing has evolved

00:13:23 How elimination diets and reintroduction work

00:15:19 When mold-related illness testing may be warranted

00:17:38 Alpha-gal syndrome and missed tick-borne allergy cases

00:25:38 Common misconceptions about food allergy testing

This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

The views expressed on this podcast are those of the hosts and guests and do not necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to provide medical advice. Healthcare decisions should be made in consultation with a qualified healthcare professional.

1. Ahmed Shabbir Chaudhry, Inata, Y., & Nakagami-Yamaguchi, E. (2023). Quality Analysis of the Clinical Laboratory Literature and Its Effectiveness on Clinical Quality Improvement: A Systematic Review. Journal of Clinical Biochemistry and Nutrition, 73(2), 108–115. https://doi.org/10.3164/jcbn.23-22
2. Cai, J., Yang, M., Zhang, N., Chen, Y., Wei, J., Wang, J., Liu, Q., Li, W., Shi, W., & Liu, W. (2024). Effects of residential damp indicators on asthma, rhinitis, and eczema among children: A systematic review and meta-analysis of the literature in the past 33 years. Building and Environment, 251, Article 111226. https://www.sciencedirect.com/science/article/abs/pii/S0360132324000684
3. Kelso, J. M. (2018). Unproven diagnostic tests for adverse reactions to foods. The Journal of Allergy and Clinical Immunology: In Practice, 6(2), 362–365. https://pubmed.ncbi.nlm.nih.gov/29524991/
4. Pillai, S. P., & Fox, E. (2025). Laboratory quality management system fundamentals [Review of Laboratory quality management system fundamentals]. Frontiers in Bioengineering and Biotechnology, 13. https://doi.org/10.3389/fbioe.2025.1578654
5. Platts-Mills, T. A. E., Gangwar, R. S., Workman, L., & Wilson, J. M. (2025). The immunology of alpha-gal syndrome: History, tick bites, IgE, and delayed anaphylaxis to mammalian meat. Immunological Reviews, 332(1), Article e70035. https://onlinelibrary.wiley.com/doi/10.1111/imr.70035
6. Santos, A. F., Riggioni, C., Agache, I., Akdis, C. A., Akdis, M., et al. (2023). EAACI guidelines on the diagnosis of IgE-mediated food allergy. Allergy, 78(12), 3057–3076. https://onlinelibrary.wiley.com/doi/10.1111/all.15902
7. Santos, A. F., Riggioni, C., Agache, I., Akdis, C. A., Akdis, M., et al. (2025). EAACI guidelines on the management of IgE-mediated food allergy. Allergy, 80(1), 14–36. https://onlinelibrary.wiley.com/doi/10.1111/all.16345
8. Thompson, J. M., Carpenter, A., Kersh, G. J., Wachs, T., Commins, S. P., & Salzer, J. S. (2023). Geographic distribution of suspected alpha-gal syndrome cases — United States, January 2017–December 2022. MMWR. Morbidity and Mortality Weekly Report, 72(30), 815–820. https://www.cdc.gov/mmwr/volumes/72/wr/mm7230a2.htm

What if the most powerful shift in how we practice medicine starts with one person deciding to do it differently?

Aviva’s story is that kind of shift.

Long before she ever sat in a medical classroom, she had already built a life as a midwife, herbalist, and mother of four who was deeply embedded in her community. Then, in what most of us would consider the busiest, most demanding years of life - years that often overlap with perimenopause - she made a radical decision: she went back to school. Back into training. Back into the system she wanted to help change.

Not because something was broken, but because she saw what was missing.

That’s what makes this episode different. It’s about what happens when women get to reframe the perimenopausal transition as one of the most powerful, generative, expansive years of their lives.

Instead of accepting the status quo, Dr. Aviva Romm built an entirely different way of seeing things - one that doesn’t reduce symptoms to problems, but places them in context. One that connects sleep, stress, nourishment, physiology, and even relationships into a bigger picture of health.

You can feel that perspective ripple through the entire conversation. It gently challenges the idea that you need more interventions, more testing, more fixing, and replaces it with something both simpler and harder: paying attention, understanding what your body is asking for, and supporting it instead of overriding it.

By the end, something shifts.

You’re not just thinking differently about perimenopause - you’re thinking differently about what’s possible during this phase of life. And maybe, like Aviva did, you start to wonder: what could change if perimenopause wasn’t seen as the end of something, but the beginning of something else entirely?

Clinical Takeaways from This Episode

• A root-cause, whole-person approach to perimenopause may support more sustainable outcomes. Perimenopause often includes symptoms like sleep disruption, mood changes, and cycle irregularities, and may benefit from a broader, individualized care approach rather than a single intervention (Santoro et al., 2018).
• Stress physiology and HPA axis patterns may influence how symptoms show up. Chronic stress is associated with changes in inflammatory signaling and neuroendocrine regulation, which may shape mood, immune function, and metabolic health (Russell, 2019).
• Sleep is foundational—and CBT-I is an evidence-informed place to start. Cognitive Behavioral Therapy for Insomnia (CBT-I) is supported by clinical evidence and may help improve sleep quality without medication in many individuals (Rossman, 2019).
• Connection and community are not “extras”—they’re part of physiology. Social isolation has been associated with increased mortality risk, which reinforces the importance of connection as part of whole-person care (Naito et al., 2023).
• Thoughtful, targeted lab testing supports better clinical decision-making. Strategic use of labs—guided by symptoms and clinical context—may reduce unnecessary testing and help clinicians focus on meaningful data.

Guest Introduction

Dr. Aviva Romm, MD, is a Yale-trained physician, herbalist, and midwife with over four decades of experience in women’s health. She has trained hundreds of clinicians in integrative and functional medicine and is the author of multiple bestselling books, including Hormone Intelligence and The Adrenal Thyroid Revolution. Her work bridges conventional and integrative medicine in a way that centers women and their paths to thriving.

Interested in advancing your clinical training? Explore Dr. Aviva Romm’s Women’s Integrative Functional Medicine Certification Program. Use code FULLSCRIPT26 in the “How did you learn about the course?” box to receive $1,000 off.

FAQ: Clinician & Patient Questions on Perimenopause and Integrative Care

What symptoms are common during perimenopause?

• Perimenopause may include:
• Sleep disruption
• Mood changes
• Hot flashes or night sweats
• Changes in menstrual cycles
• These are part of a normal physiologic transition, though symptom severity varies. Dr. Aviva uses a whole-person, root cause approach to successfully manage many of these symptoms. (Crandall, 2023).

What can I do if I’m struggling with sleep in midlife?

• Cognitive Behavioral Therapy for Insomnia (CBT-I) is a well-studied, non-pharmacologic option clinicians may consider (Rossman, 2019). 
• It may also help to evaluate:
• Stress levels
• Blood sugar patterns
• Sleep habits and environment

How does stress actually affect my health?

• Chronic stress may influence:
• Hormone signaling
• Immune and inflammatory pathways
• Mood and cognitive function
• These effects are mediated in part through the HPA axis and inflammatory signaling pathways (Russell, 2019).

Key Moments from This Episode

• 02:30 – Aviva’s journey: from herbalist and midwife to Yale-trained medical doctor
• 10:41 – Going back to medical school as a parent: what it really takes
• 28:14 – Stress physiology and the root causes of chronic symptoms
• 32:58 – Reframing perimenopause as a transition, not a decline
• 35:17 – Building a real-world toolkit: sleep, nourishment, nervous system support
• 41:01 – Botanical medicine in practice: motherwort and lemon balm
• 57:28 – Hypervigilance, burnout, and how they show up in the body
• 01:17:18 – The Yerkes-Dodson curve: finding your optimal stress zone
• 01:19:41 – How to think about labs without overtesting

Want to elevate your practice?

This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

Disclaimer

The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.

Citations

1. Crandall CJ, Mehta JM, Manson JE. Management of Menopausal Symptoms: A Review. JAMA. 2023 Feb 7;329(5):405-420. doi: 10.1001/jama.2022.24140. PMID: 36749328.
2. Rossman J. Cognitive-Behavioral Therapy for Insomnia: An Effective and Underutilized Treatment for Insomnia. Am J Lifestyle Med. 2019 Aug 12;13(6):544-547. doi: 10.1177/1559827619867677. PMID: 31662718; PMCID: PMC6796223.
3. Russell G, Lightman S. The human stress response. Nat Rev Endocrinol. 2019 Sep;15(9):525-534. doi: 10.1038/s41574-019-0228-0. Epub 2019 Jun 27. PMID: 31249398.
4. Naito R, McKee M, Leong D, Bangdiwala S, Rangarajan S, Islam S, Yusuf S. Social isolation as a risk factor for all-cause mortality: Systematic review and meta-analysis of cohort studies. PLoS One. 2023 Jan 12;18(1):e0280308. doi: 10.1371/journal.pone.0280308. PMID: 36634152; PMCID: PMC9836313.

What happens when patients leave an integrative or functional medicine appointment with multiple recommendations but limited practical support for implementation?

In this episode, Kate Kresge sits down with Monique Richard, Holly Van Poots, and Sudha Raj to discuss the evolving role of Registered Dietitian Nutritionists (RDNs) trained in Integrative and Functional Nutrition (IFN). The conversation centers on the Revised 2025 Scope and Standards of Practice for RDNs in Nutrition in Integrative and Functional Medicine, which clarifies the scope, standards, and clinical contribution of IFN practitioners. (Crowe-White 2025)

Together they explore why nutrition may remain underused in some conventional care settings, including concerns that many medical providers receive limited formal nutrition training. (Adams 2010) They also discuss why sustained behavior change often requires more time, context, and follow-up than a brief visit can provide, and why food choices are shaped by more than nutrient content alone. The discussion highlights how IFN dietitians can help translate complex plans into sustainable daily habits while helping patients connect symptoms, lifestyle patterns, culture, stress, and nutrition.

The episode makes a practical case for team-based care and shows how integrative nutrition practitioners can help bridge the gap between clinical recommendations and meaningful long-term change.

Many visits focus on diagnosis and treatment decisions, while meaningful behavior change takes time, relationship-building, and ongoing support. (Crowe-White 2025) (Körner 2016) IFN dietitians help patients put recommendations into practice in real-world settings.

Food choices are shaped by culture, identity, family history, emotional experience, access, and lifestyle. Accounting for these factors may help make nutrition recommendations more realistic, acceptable, and sustainable; effects on clinical outcomes depend on the condition, intervention, and patient context. (Odoms-Young 2024) (Crowe-White 2025)

Many patients present with concerns where nutrition may be one component of care, including issues related to digestive health, metabolic health, immune function, and quality of life. (Crowe-White 2025) (Moloney 2025)

Many patients leave appointments with extensive recommendations. IFN practitioners can help patients prioritize, personalize, and implement clinician recommendations within the patient’s preferences, resources, culture, and care plan. (Moloney 2025) (Senkus 2024)

Integrative care tends to work best when physicians, naturopathic doctors, nurse practitioners, health coaches, and nutrition professionals collaborate on whole-person care. (Körner 2016) (Crowe-White 2025)

Guest Introduction

Monique Richard is an experienced registered dietitian nutritionist specializing in integrative and functional nutrition. Known for her practical and patient-centered approach, she helps individuals explore lifestyle, nutrition, and environmental factors that may be relevant to their health goals and care plans. She often describes IFN practitioners as "nutrition detectives" who help connect the dots between symptoms, habits, and underlying patterns.

Holly Van Poots is a leader in integrative and functional nutrition education and one of the contributors to the newly published guidance paper on the role of IFN dietitians. Her work focuses on defining how nutrition professionals contribute to whole-person care beyond traditional dietary counseling.

Sudha Raj brings a deep understanding of nutrition behavior change, cultural competency, and patient-centered care. Her work emphasizes the importance of relationship-based nutrition counseling and understanding the lived experiences that shape food choices and health behaviors.

The statements, information and opinions shared by each individual are not in the capacity as official spokespeople, or, on behalf, of the Academy of Nutrition and Dietetics. They volunteered to be authors/contribute to the NIFM SOP and received no funding from the Academy.

Integrative and functional nutrition combines evidence-informed nutrition science with a whole-person approach that considers lifestyle, environment, stress, sleep, culture, and other contributors to health.

While foundational nutrition principles remain the same, IFN practitioners often spend more time exploring nutrition- and lifestyle-related factors, patient context, and personalized behavior-change strategies.

Dietitians can help patients translate complex recommendations into practical daily actions, which may support adherence and follow-through. Evidence for clinical outcomes varies by condition and intervention. (Moloney 2025)

Patients frequently understand what they should do but struggle with how to implement recommendations. IFN practitioners help bridge that gap.

Food carries cultural, emotional, social, and historical meaning. Accounting for these factors can help build realistic, sustainable nutrition strategies. (Odoms-Young 2024)

00:00:00 – Why nutrition changes are powerful but hard for patients to implement

00:02:17 – Why the new IFN dietitian scope paper matters now

00:03:51 – Integrative vs. functional nutrition and the “nutrition detective” role

00:05:00 – The biggest gaps IFN-trained RDNs can fill in patient care

00:08:22 – What a visit with an integrative and functional RDN actually looks like

00:12:16 – How labs and testing fit into nutrition care

00:15:11 – How dietitians train in integrative and functional nutrition

00:18:59 – Eating disorders, elimination diets, and the need for collaboration

00:25:55 – Where to find IFN-trained dietitians and build referral relationships

00:29:43 – The future of medical nutrition, value-based care, and whole person health

00:35:09 – Rapid-fire: misconceptions, sustainable habits, and underappreciated nutrition care

Future Discussion — The expanding role of RDNs in multidisciplinary healthcare teams

Want to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

Disclaimer: The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.

1. Adams, K. M., Kohlmeier, M., & Zeisel, S. H. (2010). Nutrition education in U.S. medical schools: Latest update of a national survey. Academic Medicine, 85(9), 1537–1542. https://doi.org/10.1097/ACM.0b013e3181eab71b
2. Crowe-White, K. M., Richard, M., & Raj, S. (2025). Revised 2025 scope and standards of practice for registered dietitian nutritionists in nutrition in integrative and functional medicine. Commission on Dietetic Registration. https://www.cdrnet.org/vault/2459/web//20251215%20NIFM%20Article%20FINAL%20-%202.pdf
3. Federal Trade Commission. (2022). Health products compliance guidance. https://www.ftc.gov/business-guidance/resources/health-products-compliance-guidance
4. Körner, M., Bütof, S., Müller, C., Zimmermann, L., Becker, S., & Bengel, J. (2016). Interprofessional teamwork and team interventions in chronic care: A systematic review. Journal of Interprofessional Care, 30(1), 15–28. https://doi.org/10.3109/13561820.2015.1051616
5. Moloney, L., Rozga, M., Steiber, A., & Handu, D. (2026). The effectiveness of medical nutrition therapy in prevention and treatment of chronic disease: A position paper of the Academy of Nutrition and Dietetics. Journal of the Academy of Nutrition and Dietetics, 126(2), Article 156219. https://doi.org/10.1016/j.jand.2025.10.010
6. Odoms-Young, A., Stanford, F. C., Palacios, C., Anderson, C. A. M., Andres, A., Fisher, J. O., Gardner, C. D., Giovannucci, E., Hoelscher, D. M., Jernigan, V. B. B., Raynor, H. A., Webster, A., Fultz, A. K., Bahnfleth, C., English, L. K., Higgins, M., Lawless, M., Momin, S., Butera, G., … Obbagy, J. (2024). Culturally tailored dietary interventions and diet-related psychosocial factors, dietary intake, diet quality, and health outcomes: An evidence scan. U.S. Department of Agriculture, Nutrition Evidence Systematic Review. https://doi.org/10.52570/NESR.DGAC2025.ES01
7. Senkus, K. E., Dudzik, J. M., Lennon, S. L., DellaValle, D. M., Moloney, L. M., Handu, D., & Rozga, M. (2024). Medical nutrition therapy provided by a dietitian improves outcomes in adults with prehypertension or hypertension: A systematic review and meta-analysis. The American Journal of Clinical Nutrition, 119(6), 1417–1442. https://doi.org/10.1016/j.ajcnut.2024.04.012

This episode explores one of the most significant developments in women's health in recent years: the proposed transition from Polycystic Ovary Syndrome (PCOS) to Polyendocrine Metabolic Ovarian Syndrome (PMOS). (Teede 2026) Dr. Jessica Christie and Dr. Camille Krause discuss why experts believe the traditional name no longer reflects the full complexity of the condition and how the PMOS framework better captures its endocrine, metabolic, reproductive, inflammatory, and neuroendocrine dimensions. (Teede 2026) Clinicians will learn why insulin resistance, androgen excess (Houston 2025), stress physiology, sleep, inflammation, and cardiometabolic health (Wekker 2020) are central to understanding PMOS, and how a systems-based approach can improve earlier identification, assessment, and treatment. (Teede 2026)

• PMOS reflects a multisystem condition: The proposed name change recognizes that the condition extends beyond ovarian function and includes endocrine, metabolic, inflammatory, and neuroendocrine dysfunction. (Teede 2026)
• Insulin resistance is a major physiologic driver: Hyperinsulinemia may contribute to increased ovarian androgen production, ovulatory dysfunction, and metabolic symptoms, often before glucose markers become abnormal. (Houston 2025)
• PMOS is not defined by ovarian cysts: Many individuals diagnosed with PCOS do not demonstrate polycystic ovarian morphology, and the follicles observed are not true ovarian cysts. (Houston 2025) (Teede 2026)
• Early metabolic screening matters: Fasting insulin, glucose regulation, lipid markers, liver function, and cardiometabolic risk factors may shift years before overt disease develops. (Houston 2025) (Teede 2026)
• Clinical presentations vary widely: Symptoms may include irregular cycles, infertility, acne, hirsutism, hair thinning, fatigue, mood changes, sleep disruption, dyslipidemia, and fatty liver patterns. (Manzano-Nunez 2023) Lean PMOS can occur and is often overlooked. (Zheng 2025)
• Treatment requires a whole-person approach: Nutrition, movement, sleep, stress regulation, inflammation management, and metabolic support should be considered alongside conventional treatment options. (Teede 2023)

Dr. Camille Krause is a Naturopathic Doctor with a clinical focus on fertility, women’s hormones, and nutrition. She works collaboratively with fertility physicians to provide evidence-based, complementary care, using specialized testing, nutrition, botanical medicine, lifestyle interventions, and acupuncture to support reproductive health. Dr. Krause is a member of the Canadian and Ontario Associations of Naturopathic Doctors. She holds an Honours Bachelor of Science from the University of Toronto and completed her naturopathic training at the Canadian College of Naturopathic Medicine.

Website: https://www.conceivehealth.com/staff/camille-krause-naturopathic-doctor/

Instagram: @waterloo_fertility_naturopath

• Fasting insulin
• Fasting glucose
• Hemoglobin A1c (HbA1c)
• Lipid panel
• Liver enzymes
• Testosterone
• DHEA-S
• Sex Hormone Binding Globulin (SHBG)
• Thyroid markers
• Blood pressure
• Waist circumference assessment

• Blood sugar stabilization
• Higher protein intake
• Increased dietary fiber intake
• Resistance training
• Regular movement and exercise
• Sleep optimization
• Circadian rhythm support
• Nervous system regulation
• Stress management
• Inflammation reduction strategies
• Nutrient sufficiency
• Recovery optimization

The proposed term Polyendocrine Metabolic Ovarian Syndrome better reflects the endocrine, metabolic, reproductive, and inflammatory aspects of the condition rather than focusing primarily on ovarian findings. (Teede 2023)

No. Many individuals diagnosed with PCOS do not have polycystic ovarian morphology. The follicles seen on imaging are generally immature follicles associated with disrupted ovulation rather than true ovarian cysts. (Teede 2026) (Houston 2025)

Elevated insulin levels may occur years before fasting glucose or HbA1c become abnormal and can contribute directly to ovarian androgen production and ovulatory dysfunction. (Houston 2025)

PMOS may involve insulin signaling, androgen regulation, neuroendocrine function, inflammatory pathways, reproductive physiology, sleep, circadian rhythms, and cardiometabolic health. (Teede 2026) (Wekker 2020)

Yes. Lean PMOS exists and may be underrecognized. Patients can experience reproductive, metabolic, and hormonal symptoms across a wide range of body compositions. (Zheng 2025)

Current criteria include combinations of:

• Ovulatory dysfunction or irregular cycles
• Clinical or biochemical hyperandrogenism
• Polycystic ovarian morphology or elevated AMH in adults

Adolescents generally require the first two criteria rather than ovarian imaging findings. (Teede 2023)

Presentations vary substantially, and many patients do not fit traditional stereotypes. Symptoms may emerge years before fertility concerns arise, contributing to missed or delayed diagnosis. (Gibson-Helm 2017)

Lifestyle interventions targeting blood sugar regulation, nutrition, physical activity, sleep, stress physiology, and inflammation are foundational components of a whole-person treatment strategy. (Teede 2023)

• The decade-long effort behind the name change
• Why the old terminology was biologically inaccurate
• Understanding PMOS as a multisystem condition
• Insulin resistance and androgen excess
• The role of inflammation, sleep, and stress physiology
• Lean PMOS and underrecognized presentations
• Current diagnostic criteria and clinical considerations
• Root-cause laboratory assessment strategies
• Whole-person treatment approaches for PMOS
• Why lifestyle medicine remains foundational
• The future of women's endocrine and metabolic care

00:00 - Why the shift from PCOS to PMOS matters

02:10 - How language shapes diagnosis and care

03:29 - Why the old terminology missed the bigger picture

05:18 - The root physiology of PMOS

07:47 - How PMOS can present beyond the stereotypical picture

09:33 - Why diagnosis requires a deeper clinical lens

11:23 - A whole-person approach to PMOS care

12:25 - Why this shift is so meaningful for patients and practitioners

Want to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.

1. Gibson-Helm, M., Teede, H., Dunaif, A., & Dokras, A. (2017). Delayed diagnosis and a lack of information associated with dissatisfaction in women with polycystic ovary syndrome. The Journal of Clinical Endocrinology & Metabolism, 102(2), 604–612. https://doi.org/10.1210/jc.2016-2963
2. Houston, E. J., & Templeman, N. M. (2025). Reappraising the relationship between hyperinsulinemia and insulin resistance in PCOS. Journal of Endocrinology, 265(2), e240269.
3. Manzano-Nunez, R., Santana-Dominguez, M., Rivera-Esteban, J., Sabiote, C., Sena, E., Bañares, J., Tacke, F., & Pericàs, J. M. (2023). Non-alcoholic fatty liver disease in patients with polycystic ovary syndrome: A systematic review, meta-analysis, and meta-regression. Journal of Clinical Medicine, 12(3), 856. https://doi.org/10.3390/jcm12030856
4. Teede, H. J., Tay, C. T., Laven, J. J. E., Dokras, A., Moran, L. J., Piltonen, T. T., Costello, M. F., Boivin, J., Redman, L. M., Boyle, J. A., Norman, R. J., Mousa, A., & Joham, A. E. (2023). Recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome. The Journal of Clinical Endocrinology & Metabolism, 108(10), 2447–2469. https://doi.org/10.1210/clinem/dgad463
5. Teede, H. J., Khomami, M. B., Morman, R., Laven, J. S. E., Joham, A. E., Costello, M. F., Patil, M., Rees, D. A., Berry, L., Cree, M. G., Zhao, H., Norman, R. J., Dokras, A., & Piltonen, T. (2026). Polyendocrine metabolic ovarian syndrome, the new name for polycystic ovary syndrome: A multistep global consensus process. The Lancet. Advance online publication.
6. Wekker, V., van Dammen, L., Koning, A., Heida, K. Y., Painter, R. C., Limpens, J., & Hoek, A. (2020). Long-term cardiometabolic disease risk in women with PCOS: A systematic review and meta-analysis. Human Reproduction Update, 26(6), 942–960.
7. Zheng, C., Lin, Y., Zhang, Z., Ye, J., Lin, Y., & Tian, J. (2025). Analyzing and evaluating the metabolic and endocrine characteristics between lean and obese patients with polycystic ovary syndrome: A systematic review and meta-analysis. Frontiers in Endocrinology, 16, 1680685.

Adult Acne in Perimenopause: Hormones, Diet, Supplements, and Root Causes With Dr. Mamina Turegano

Adult acne can be especially frustrating when it appears after years—or even decades—of relatively clear skin. In this bonus episode, Dr. Kate Kresge sits down with dermatologist Dr. Mamina Turegano to explore why acne often emerges or worsens during perimenopause and what may be driving those changes beneath the surface.

Dr. Turegano explains how shifting hormone patterns, particularly changes in the balance between estrogen and androgens, may contribute to breakouts during midlife. She also discusses the potential roles of stress, diet, skincare habits, environmental exposures, and select supplements in acne management.

The conversation offers a practical, evidence-informed look at adult female acne, emphasizing individualized treatment approaches that support both skin health and overall wellbeing.

Many women are surprised when acne appears in their 30s, 40s, or 50s. Adult female acne is increasingly common and often requires a different treatment approach than adolescent acne. Understanding the hormonal, metabolic, and lifestyle factors that may contribute to breakouts can help patients make more informed decisions about treatment and self-care.

Hormonal changes during the menopausal transition may alter the balance between estrogen and androgen activity, contributing to increased sebum production and acne in susceptible individuals. (Bagatin 2019) (Alexandre 2024)

Compared to adolescent acne, adult female acne often occurs in skin that is more prone to dryness, irritation, and barrier dysfunction, making gentle treatment approaches especially important. (Dréno 2013)

Evidence-based acne management continues to rely heavily on topical retinoids, benzoyl peroxide, and other targeted therapies such as azelaic acid. (Reynolds 2024)

Research suggests that higher-glycemic dietary patterns may contribute to acne severity, while evidence regarding dairy intake remains mixed and population dependent. (Meixiong 2022)

Some nutraceuticals—including zinc, probiotics, vitamin D, omega-3 fatty acids, and pantothenic acid—have been studied for acne support, but evidence varies considerably by ingredient and study quality. (Shields 2023)

Although uncommon, acneiform eruptions associated with vitamin B12 supplementation have been reported in the medical literature. (Bowden 2023)

• Why adult acne is becoming more common
• Acne during perimenopause and menopause
• Hormonal changes and androgen activity
• Stress and skin health
• Environmental and lifestyle contributors
• Retinoids, azelaic acid, sulfur, and benzoyl peroxide
• When systemic therapies may be appropriate
• Diet, blood sugar regulation, and dairy
• Supplements commonly discussed for acne support
• Biotin, vitamin B12, and acne concerns
• Practical skincare strategies for adult women

Dr. Mamina Turegano is a board-certified dermatologist with expertise in medical, surgical, and cosmetic dermatology. She is known for translating complex skin science into practical, patient-centered guidance and frequently speaks about acne, skin aging, hormone-related skin concerns, and integrative approaches to dermatologic care.

00:00 Introduction

02:04 Why adult acne develops during perimenopause

04:01 Adult acne versus teenage acne

05:00 Topical treatment approaches

07:22 Supplements and acne support

09:47 Biotin, vitamin B12, and breakouts

14:32 Acne in men versus women

15:35 Diet, dairy, fiber, and blood sugar

17:04 Final thoughts and resources

Practitioners, what if your supplement dispensing, patient education, and treatment planning all lived in one powerful platform built for whole person care? Meet Fullscript—the comprehensive care delivery platform designed to reduce administrative burden and enhance clinical impact. From automated refills and lab ordering to evidence-based protocols and adherence support, Fullscript helps streamline care while keeping the focus where it belongs: on patients. In a recent survey, 74% of providers reported saving up to three hours per week using Fullscript to create treatment plans. Visit fullscript.com to learn more.

1. Alexandre, M., Saint Aroman, M., Mengeaud, V., Carballido, F., Doat, G., Coutinho, A., & Bagatin, E. (2024). Unveiling the nuances of adult female acne: A comprehensive exploration of epidemiology, treatment modalities, dermocosmetics, and the menopausal influence. International Journal of Women’s Health, 16, 663–678. https://doi.org/10.2147/IJWH.S431523
2. Bagatin, E., de Freitas, T. H. P., Rivitti-Machado, M. C., Ribeiro, B. M., Nunes, S., & da Rocha, M. A. D. (2019). Adult female acne: A guide to clinical practice. Anais Brasileiros de Dermatologia, 94(1), 62–75. https://doi.org/10.1590/abd1806-4841.20198203
3. Bowden, A., Ekeh, O., Brownstone, N. D., & Hsu, S. (2023). Acneiform eruption secondary to over-the-counter vitamin B12. Cureus, 15(8), Article e43275. https://doi.org/10.7759/cureus.43275
4. Dréno, B., Layton, A., Zouboulis, C. C., López-Estebaranz, J. L., Zalewska-Janowska, A., Bagatin, E., Zampeli, V. A., Yutskovskaya, Y., & Harper, J. C. (2013). Adult female acne: A new paradigm. Journal of the European Academy of Dermatology and Venereology, 27(9), 1063–1070. https://doi.org/10.1111/jdv.12061
5. Meixiong, J., Ricco, C., Vasavda, C., & Ho, B. K. (2022). Diet and acne: A systematic review. JAAD International, 7, 95–112. https://doi.org/10.1016/j.jdin.2022.02.012
6. Reynolds, R. V., Yeung, H., Cheng, C. E., Cook-Bolden, F., Desai, S. R., Druby, K., Freeman, E. E., Keri, J. E., Stein, L. F., Tan, J. K. L., Tollefson, M. M., Weiss, J. S., Wu, P. A., Zaenglein, A. L., Han, J. M., & Barbieri, J. S. (2024). Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology, 90(5), 1006–1030.e30. https://doi.org/10.1016/j.jaad.2023.12.017
7. Shields, A., Ly, S., Wafae, B., Chang, Y.-F., Manjaly, P., Archila, M., Heinrich, C., Drake, L., Mostaghimi, A., & Barbieri, J. S. (2023). Safety and effectiveness of oral nutraceuticals for treating acne: A systematic review. JAMA Dermatology, 159(12), 1373–1382. https://doi.org/10.1001/jamadermatol.2023.3949

Hair loss can feel deeply personal, especially when it happens after illness, stress, rapid weight loss, postpartum changes, or a hormonal transition. In this episode, Dr. Mamina Turegano joins Dr. Kate Kresge to unpack the most common patterns of hair shedding and thinning, including telogen effluvium and androgenetic alopecia.

Dr. Turegano explains why hair loss is often multifactorial and why the timing matters: shedding may appear months after a physiologic or emotional stressor. She walks through the root-cause workup she considers in practice, including thyroid function, ferritin, vitamin D, B12, zinc, sex hormones, inflammation, scalp health, and medication history.

The conversation also covers postpartum hair loss, dandruff and scalp inflammation, protein intake, GLP-1-related weight loss, birth control changes, and evidence-informed options such as minoxidil, red light therapy, scalp massage, and PRP. Throughout the episode, Dr. Turegano brings a practical, compassionate approach to helping patients understand what may be driving hair loss and when a dermatology referral matters.

Clinical Takeaways from This Episode

• Telogen effluvium timing matters: Diffuse shedding often appears two to four months after a stressor such as illness, surgery, childbirth, hemorrhage, crash dieting, low protein intake, thyroid dysfunction, or medication changes. (Malkud 2015)(Hughes 2024)
• Pattern recognition guides the workup: Telogen effluvium, androgenetic alopecia, alopecia areata, traction alopecia, and scarring alopecias can look different clinically, which is why scalp exam and referral are important when diagnosis is uncertain. (Mubki 2014)
• Nutrient status can inform care: Ferritin, vitamin D, B12, zinc, and thyroid markers may help identify contributing factors in selected patients, though deficiencies are not the only explanation for shedding. (Ahmed 2026)(Durusu 2024)
• Postpartum shedding is common but still deserves context: Hormonal shifts, delivery-related stress, sleep disruption, breastfeeding, and blood loss may all contribute, and persistent or patterned loss should be evaluated. (Hirose 2023)
• Treatment should match the diagnosis: Topical minoxidil, low-level laser therapy, and PRP have evidence for androgenetic alopecia, but protocols, response, safety considerations, and patient context vary. (Adil 2017)(Perez 2024)(Yao 2024)

Guest Bio: Mamina Turegano, MD, is a triple board-certified dermatologist, internist, and dermatopathologist based in New Orleans. She specializes in medical, cosmetic, and integrative dermatology, blending conventional and holistic approaches to skin health. With over 2 million followers across social media, she shares dermatologist-backed skincare and wellness insights with a broad audience. She also co-hosts a podcast, called Skin Deep MDs, has been published in leading medical journals, and frequently contributes her expertise to major press outlets, TV, and beauty publications.

Frequently Asked Questions

What is telogen effluvium?

• Telogen effluvium is a form of diffuse, nonscarring hair shedding that often follows a physiologic or emotional stressor. The shedding commonly appears a few months after the trigger rather than immediately. (Malkud 2015)(Hughes 2024)

What labs may be useful for hair shedding?

• Depending on the patient’s history and exam, clinicians may consider CBC, ferritin, thyroid markers, vitamin D, B12, zinc, and selected hormone testing. Lab results should be interpreted in context rather than used as a stand-alone explanation. (Malkud 2015)(Durusu 2024)

Can postpartum hair loss be normal?

• Postpartum shedding is common and often related to hormonal shifts after delivery, but persistent, severe, patterned, or scarring hair loss should be evaluated. Blood loss, low iron stores, thyroid changes, and sleep disruption may also matter. (Hirose 2023)

Does washing hair make shedding worse?

• Not necessarily. Infrequent washing may make shedding look more dramatic because shed hairs accumulate between washes. Scalp inflammation or seborrheic dermatitis may also contribute to ongoing irritation and should be addressed when present.

When should a patient see a dermatologist for hair loss?

• Referral is especially important for patchy hair loss, scalp pain, itching, redness, scaling, shiny or scarred areas, rapid progression, frontal hairline recession, or hair loss that does not fit a clear trigger pattern. Scarring alopecias can cause permanent loss if not recognized early. (Mubki 2014)

Timestamps

00:00 — Why hair loss and shedding deserve a root-cause conversation

06:44 — Telogen effluvium vs androgenetic alopecia

10:31 — Ferritin, vitamin D, thyroid, B12, zinc, hormones, and ANA

15:09 — When to refer for scarring alopecia or autoimmune causes

17:54 — Hair washing, dandruff, scalp oil, and local inflammation

24:03 — GLP-1 medications, birth control, beta blockers, statins, and SSRIs

29:18 — Protein, calorie restriction, vegetarian diets, and nutrient status

35:42 — Postpartum shedding, hemorrhage, breastfeeding, and recovery

38:55 — Minoxidil, breastfeeding considerations, red light therapy, and PRP

44:15 — Scalp massage, circulation, and realistic supportive strategies

Want to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

Disclaimer: The views expressed on this podcast are those of the hosts and the guests, and they don't necessarily reflect the views of FullScript or any affiliated organizations. This podcast is for informational and educational purposes only, and it's not intended to be medical advice. For your safety, always check with your healthcare provider before making any changes to your healthcare routine.

Citations

1. Adil A, Godwin M. The effectiveness of treatments for androgenetic alopecia: A systematic review and meta-analysis. J Am Acad Dermatol. 2017 Jul;77(1):136-141.e5. doi: 10.1016/j.jaad.2017.02.054. Epub 2017 Apr 7. PMID: 28396101.
2. Ahmed A, Alali A, Alahmadi M, Alghamdi S, Khawaji Z, Humedi A, Alqurashi S. Association between Serum Trace Elements and Telogen Effluvium: A Systematic Review and Meta-Analysis. Skin Appendage Disord. 2026 Mar 18. doi: 10.1159/000550921. Epub ahead of print. PMID: 42077991; PMCID: PMC13134860.
3. Durusu Turkoglu IN, Turkoglu AK, Soylu S, Gencer G, Duman R. A comprehensive investigation of biochemical status in patients with telogen effluvium: Analysis of Hb, ferritin, vitamin B12, vitamin D, thyroid function tests, zinc, copper, biotin, and selenium levels. J Cosmet Dermatol. 2024;23:4277-4284. doi:10.1111/jocd.16512 
4. Hirose A, Terauchi M, Odai T, Fudono A, Tsurane K, Sekiguchi M, Iwata M, Anzai T, Takahashi K, Miyasaka N. Investigation of exacerbating factors for postpartum hair loss: a questionnaire-based cross-sectional study. Int J Womens Dermatol. 2023 Jun 16;9(2):e084. doi: 10.1097/JW9.0000000000000084. PMID: 38323220; PMCID: PMC10846762.
5. Hughes EC, Syed HA, Saleh D. Telogen Effluvium. 2024 May 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan–. PMID: 28613598.
6. Malkud S. Telogen Effluvium: A Review. J Clin Diagn Res. 2015 Sep;9(9):WE01-3. doi: 10.7860/JCDR/2015/15219.6492. Epub 2015 Sep 1. PMID: 26500992; PMCID: PMC4606321.
7. Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss patient: part I. History and clinical examination. J Am Acad Dermatol. 2014 Sep;71(3):415.e1-415.e15. doi: 10.1016/j.jaad.2014.04.070. PMID: 25128118.
8. Perez SM, Vattigunta M, Kelly C, Eber A. Low-Level Laser and LED Therapy in Alopecia: A Systematic Review and Meta-Analysis. Dermatol Surg. 2025 Feb 1;51(2):179-183. doi: 10.1097/DSS.0000000000004442. Epub 2024 Oct 15. PMID: 39404126.
9. Yao J, Zhu L, Pan M, Shen L, Tang Y, Fan L. The additive value of platelet-rich plasma to topical Minoxidil in the treatment of androgenetic alopecia: A systematic review and meta-analysis. PLoS One. 2024 Aug 28;19(8):e0308986. doi: 10.1371/journal.pone.0308986. PMID: 39197003; PMCID: PMC11356437.

New research is raising important clinical questions about the long-term effects of GLP-1 receptor agonist therapy during significant weight loss. A recent five-year observational study reported associations between GLP-1 use and higher rates of osteoporosis, osteomalacia, and gout in some adults with obesity and type 2 diabetes, particularly in the setting of rapid weight reduction (Wajahath et al., 2026). While GLP-1 therapies may support glycemic control, cardiometabolic health, and surgical outcomes, these findings highlight the importance of proactive monitoring and individualized patient support.

In this episode, we explore practical clinical considerations, including:

• How clinicians may approach bone health monitoring more proactively during significant weight loss
• Which patients may warrant closer nutritional or musculoskeletal assessment
• Symptoms that may merit further evaluation during GLP-1 therapy, including fatigue, weakness, diffuse bone pain, or mobility-related concerns

We also discuss another emerging area of research: the role of exercise in mental health care. Drawing from a large umbrella review involving nearly 80,000 participants, we examine how aerobic exercise, walking, resistance training, and group-based movement may support depression and anxiety outcomes when implemented consistently and tailored to patient capacity (Munro et al., 2026).

This conversation focuses on practical, evidence-informed strategies clinicians can integrate into care plans immediately - from resistance training and hydration strategies to helping patients build sustainable movement habits during periods of stress, fatigue, or overwhelm.

Clinical Takeaways From This Episode

• Rapid weight loss may increase the need for nutritional and musculoskeletal support: Emerging observational evidence suggests GLP-1 therapy during significant weight loss may be associated with higher rates of bone- and uric acid-related complications in some patients, highlighting the importance of muscle preservation, hydration, and nutritional status monitoring (Wajahath et al., 2026).
• Some musculoskeletal symptoms may warrant additional evaluation: Fatigue, weakness, diffuse bone discomfort, and mobility changes may justify further clinical assessment in patients experiencing rapid weight loss or reduced nutritional intake (Wajahath et al., 2026).
• Exercise may support both mental and metabolic health: Research suggests moderate-intensity aerobic exercise, resistance training, walking, and group movement may support mood, resilience, and long-term metabolic health outcomes when patients can engage consistently over time (Munro et al., 2026).

FAQ

Do GLP-1 medications affect bone health?

• Some emerging observational evidence suggests GLP-1 receptor agonist therapy may be associated with increased rates of osteoporosis and osteomalacia during rapid weight loss in certain populations. Additional research is still needed to better understand causality, mechanisms, and which patients may be at greatest risk (Wajahath et al., 2026).

What labs may help clinicians monitor patients on GLP-1 therapy?

• This episode discusses clinical considerations that may include alkaline phosphatase, vitamin D, calcium, phosphate, parathyroid hormone (PTH), and other markers of bone or metabolic health when clinically appropriate and individualized to the patient context (Wajahath et al., 2026).

Can exercise support anxiety and depression symptoms?

• Research suggests aerobic exercise, walking, resistance training, and mind-body movement practices may support improvements in mood and anxiety symptoms when practiced consistently over time as part of a comprehensive care plan (Munro et al., 2026).

Timestamps

00:00 — Clinical questions emerging around GLP-1 therapy and rapid weight loss

03:00 — Osteomalacia symptoms that may overlap with fatigue and chronic pain presentations

10:33 — Why rapid weight loss may influence gout risk in some patients

15:29 — The large exercise and mental health review clinicians are discussing

20:50 — How to help patients build sustainable movement habits

Want to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

Disclaimer: The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.

Citations

1. Wajahath M, et al. GLP-1 Receptor Agonist Use Is Associated with Increased Risk of Osteoporosis, Gout, and Osteomalacia in Adults with Type 2 Diabetes and Obesity. 2026.
2. Munro NR, Teague S, Somoray K, et al. Effect of exercise on depression and anxiety symptoms: systematic umbrella review with meta-meta-analysis. British Journal of Sports Medicine. 2026;60:590–599.

In this episode, Dr. Kate Kresge speaks with Mosaic Diagnostics CEO Scott Mattivi and Chief Medical Officer Dr. Kurt Woeller to explore how specialty laboratory testing is used in functional and integrative medicine. Mosaic Diagnostics offers tests such as organic acids, environmental exposure biomarkers, and microbiome assessments, which may help clinicians evaluate complex, multi-system presentations. These tools are typically used as part of a systems-based clinical framework, supporting pattern recognition rather than serving as standalone diagnostic tests. The discussion also explores how clinicians interpret multi-system lab data, the role of practitioner education, and how emerging technologies—such as AI-assisted tools—may support clinical efficiency and decision-making.

Mosaic Diagnostics provides specialty lab testing commonly used in integrative and functional medicine, including:

• Organic acids testing (OAT)
• Environmental toxin and mycotoxin testing
• Microbiome and gastrointestinal assessments
• Metabolic and immune-related biomarkers

These tests are designed to provide insight into biochemical pathways, microbial activity, and environmental exposures. Results are generally interpreted alongside clinical history, symptoms, and conventional labs to support individualized care.

Organic acids testing evaluates urinary metabolites involved in intermediary metabolism. It may provide insight into:

• Mitochondrial function
• Nutrient metabolism (e.g., B vitamins, amino acids)
• Oxidative stress patterns
• Microbial activity

When interpreted within clinical context, OAT may support identification of metabolic patterns and inform clinical hypotheses (Gallagher, 2018).

Environmental exposure testing evaluates biomarkers associated with compounds such as:

• Mycotoxins
• Heavy metals (in some panels)
• Industrial chemicals

These tests may help characterize exposure patterns, though interpretation can be complex due to variability in exposure timing, metabolism, and elimination. Clinical relevance should be assessed cautiously and within the broader evidence base (Warth, 2013; Owolabi, 2024).

• Organic acids testing may offer a systems-level view of metabolism and support pattern recognition when interpreted in context (Gallagher, 2018).
• Environmental testing may help identify exposure patterns, though clinical actionability varies (Warth, 2013; Owolabi, 2024).
• Specialty lab testing is most effective when used to evaluate patterns across systems, rather than isolated biomarkers.
• Practitioner education plays a key role in appropriate interpretation and application of these tests.
• AI tools may enhance data interpretation and workflow efficiency but should be used alongside clinical expertise.

Who Should Listen to This Episode?

This episode is designed for healthcare providers who:

• Use or are considering functional or integrative lab testing
• Work with complex, chronic, or multi-system conditions
• Want to better understand organic acids testing or mycotoxin testing
• Are interested in clinical data interpretation strategies
• Are exploring AI tools in clinical practice

FAQ: Mosaic Diagnostics and Specialty Lab Testing

Mosaic Diagnostics is known for specialty laboratory testing used in functional and integrative medicine, including organic acids testing, environmental exposure assessments, and microbiome analysis.

Timestamps

00:00 – Introduction to Mosaic Diagnostics

03:22 – Origins of organic acids testing

08:26 – Expansion into environmental and microbiome testing

23:41 – Environmental exposures and clinical applications

31:57 – Overview of testing portfolio

42:09 – Organic acids testing in practice

47:41 – Innovation and AI in clinical workflows

This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

The views expressed on this podcast are those of the hosts and the guests, and they don't necessarily reflect the views of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only, and it's not intended to be medical advice. For your safety, always check with your health care provider before making any changes to your health care routine.

1. Gallagher RC, Pollard L, Scott AI, Huguenin S, Goodman S, Sun Q; ACMG Biochemical Genetics Subcommittee of the Laboratory Quality Assurance Committee. Laboratory analysis of organic acids, 2018 update: a technical standard of the American College of Medical Genetics and Genomics (ACMG). Genet Med. 2018 Jul;20(7):683-691. doi: 10.1038/gim.2018.45. Epub 2018 Mar 15. PMID: 29543224.
2. Warth B, Sulyok M, Krska R. LC-MS/MS-based multibiomarker approaches for the assessment of human exposure to mycotoxins. Anal Bioanal Chem. 2013 Jul;405(17):5687-95. doi: 10.1007/s00216-013-7011-1. Epub 2013 Jun 18. PMID: 23774829; PMCID: PMC3695324.
3. Owolabi, Iyiola & Siwarak, Kawisara & Greer, Brett & Rajkovic, Andreja & Dall’asta, Chiara & Karoonuthaisiri, Nitsara & Uawisetwathana, Umaporn & Elliott, Christopher & Petchkongkaew, Awanwee. (2023). Applications of Mycotoxin Biomarkers in Human Biomonitoring for Exposome-Health Studies: Past, Present, and Future. Exposure and Health. 16. 1-23. 10.1007/s12403-023-00595-4.
4. Muñoz JP, Bleak TC, Calaf GM. Glyphosate and the key characteristics of an endocrine disruptor: A review. Chemosphere. 2021 May;270:128619. doi: 10.1016/j.chemosphere.2020.128619. Epub 2020 Oct 19. PMID: 33131751.

When OCD, anxiety, or food restriction appears overnight in a child, that’s a different clinical problem—and it requires a different lens.

In this episode, we sit down with Dr. Lindsey Wells to walk through how to recognize and approach PANS and PANDAS in practice. We focus on the hallmark presentation: abrupt-onset neuropsychiatric symptoms, often with a clear “before and after” that families can describe in detail. From there, the conversation shifts to what may be driving that change—whether that’s infection, immune activation, inflammation, or broader system vulnerability.

We also get practical. What does an initial workup look like? How do you think about common triggers like strep or other infections? When do you stay with foundational labs versus expanding further? And how do you support families who are often dealing with a sudden and destabilizing shift in their child’s behavior?

This episode is for clinicians who want a clearer, more grounded way to recognize PANS and PANDAS—and to start thinking through these cases without overcomplicating or overinterpreting limited evidence.

• Abrupt-Onset OCD in Children: Sudden onset OCD, food restriction, or severe anxiety should immediately shift your differential toward PANS/PANDAS
• Clinical Diagnosis Over Lab Reliance: There is no confirmatory test—history, timing, and symptom clustering drive diagnosis (AAP, 2025)
• Infection–Immune Connection: PANDAS is associated with streptococcal infection, while PANS includes broader potential triggers (Swedo et al., 1998; AAP, 2025)
• Practical Lab Workup: Foundational labs (CBC, inflammatory markers, autoimmune screening, nutrients) can help inform clinical direction (Vitiello, 2026)
• Relapsing–Remitting Course: These conditions often follow a flare-based pattern, requiring longitudinal care planning (Johnson et al., 2019)

Dr. Lindsey Wells is a naturopathic physician specializing in pediatric PANS and PANDAS. Her clinical work focuses on identifying potential infectious and immune contributors to abrupt-onset neuropsychiatric symptoms while supporting long-term stabilization. She is also the author of Super Sam and the Battle Against PANS/PANDAS, a children’s book designed to help families, siblings, and educators better understand these conditions.

• What is PANS? PANS (Pediatric Acute-onset Neuropsychiatric Syndrome) is defined by the sudden onset of OCD or severe food restriction, along with at least two additional neuropsychiatric symptoms such as anxiety, regression, tics, sleep disruption, or urinary changes. It is a clinical diagnosis without a disease-specific biomarker (AAP, 2025).
• What is PANDAS? PANDAS is a subset of PANS associated with group A streptococcal infection, characterized by abrupt-onset OCD and/or tics with a relapsing-remitting course linked to infection (Swedo et al., 1998).
• What causes sudden OCD in children? In some cases, abrupt-onset OCD may be associated with post-infectious immune activation or neuroinflammatory processes, although mechanisms remain under investigation (Snider & Swedo, 2004).
• How is PANS diagnosed? PANS is diagnosed clinically based on symptom onset, pattern, and exclusion of other neurologic or psychiatric conditions. Laboratory testing supports—but does not establish—the diagnosis (AAP, 2025).
• What labs should be considered? A phased approach may include CBC, inflammatory markers (CRP, ESR), metabolic panel, and autoimmune screening, with additional testing guided by presentation (Vitiello, 2026).

00:00 – PANS/PANDAS overview

02:03 – How to explain PANS/PANDAS to families

06:33 – What is PANS? What is PANDAS? Diagnostic criteria and symptom clusters 

10:20 – Why PANS/PANDAS is often missed

14:06 – How is PANS diagnosed?

18:37 – What causes PANS/PANDAS? Infection triggers, immune response, and neuroinflammation explained

24:55 – PANS/PANDAS treatment approaches: antimicrobials, anti-inflammatories, and symptom support

27:11 – Using anti-inflammatory trials in PANS: when ibuprofen response may inform clinical direction

34:02 – Can teens or adults have PANS/PANDAS?

41:38 – Long-term management of PANS/PANDAS: preventing flares and supporting immune resilience

This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.

1. American Academy of Pediatrics. Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Clinical Report. Pediatrics. 2025;155(3):e2024070334.
2. Johnson M, Fernell E, Preda I, Wallin L, Fasth A, Gillberg C, Gillberg C. Paediatric acute-onset neuropsychiatric syndrome in children and adolescents: an observational cohort study. Lancet Child Adolesc Health. 2019 Mar;3(3):175-180. doi: 10.1016/S2352-4642(18)30404-8. Epub 2019 Jan 29. PMID: 30704875.
3. Sigra S, Hesselmark E, Bejerot S. Treatment of PANDAS and PANS: a systematic review. Neurosci Biobehav Rev. 2018 Mar;86:51-65. doi: 10.1016/j.neubiorev.2018.01.001. Epub 2018 Jan 6. PMID: 29309797.
4. Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry. 1998;155(2):264–271.
5. Vitiello B. Clinical Utility of Medical Investigations in Pediatric Acute-Onset Neuropsychiatric Syndrome. JAMA Netw Open. 2026;9(3):e262624. doi:10.1001/jamanetworkopen.2026.2624
6. Snider LA, Swedo SE. PANDAS: current status and directions for research. Mol Psychiatry. 2004 Oct;9(10):900-7. doi: 10.1038/sj.mp.4001542. PMID: 15241433.

There’s a category of patients every clinician recognizes immediately.

They’re exhausted.

Their hair is thinning.

They’re getting sick more often than they used to.

Their focus isn’t what it was.

And their labs?

“Normal.”

This episode is about what gets missed in that gap.

We sit down with Lara Zakaria to discuss some of the least commonly tested for (but most commonly occuring) nutrient deficiencies that can help to explain symptoms like fatigue, hair loss, impaired immune function, and reduced resilience.

We walk through how a structured nutrition panel combining familiar markers like CBC and iron studies with underutilized ones like vitamin B6, folate, zinc, and RBC magnesium can reveal patterns that standard interpretations often overlook.

Because the future isn’t more testing - it’s running the right labs and using smarter interpretation to uncover what’s been hiding in plain sight.

• Pattern recognition is the clinical upgrade: Interpreting CBC, iron studies, and nutrient markers together - rather than in isolation - helps connect symptoms to physiology and identify contributing drivers earlier.
• Iron deficiency can exist before anemia: Hemoglobin is often a late marker; early depletion may only be visible through ferritin and iron transport patterns (Dhurde, 2025).
• Intracellular status matters:  Serum values alone may miss functional deficiencies—markers like RBC magnesium offer insight into cellular availability and physiologic demand (Razzaque, 2018).
• Underutilized nutrients complete the picture: Vitamin B6 and zinc play roles in neurotransmitter pathways, immune signaling, and metabolic function—but are rarely assessed together in standard workflows.

Dr. Lara Zakaria is an integrative pharmacist, nutritionist, and professor specializing in Functional Medicine and Personalized Nutrition. In addition to clinical practice and teaching, her work focuses on translating complex science—spanning nutrition, natural products, diagnostics, and health technology—into clear, clinically relevant frameworks that support education, implementation, and informed decision-making. You can sign up for the Journeys webinar series with Dr. Zakaria here. 

• What types of symptoms should prompt nutrient testing? Fatigue, brain fog, hair loss, reduced exercise tolerance, and frequent illness are common presentations where nutrient patterns may play a role.
• Why isn’t hemoglobin enough to assess iron status? Hemoglobin changes occur later in the course of deficiency. Ferritin, transferrin saturation, and TIBC provide earlier insight into iron availability and storage (Dhurde, 2025).
• Why include markers like B6 and zinc? These nutrients are involved in neurotransmitter production, immune response, and metabolic pathways. They are often under-assessed but may contribute to overlapping symptom patterns.
• What’s the benefit of RBC magnesium vs serum magnesium? Serum magnesium reflects a small, tightly regulated portion of total body magnesium, while RBC magnesium offers a better proxy for intracellular status (Al Alawi, 2018).

• 02:36 – The new way to test for nutrient deficiencies
• 03:55 – Building a smarter, structured nutrition panel
• 10:54 – Vitamin D and why “adequate” isn’t always enough
• 17:34 – Iron deficiency and early clinical clues
• 24:43 – B vitamins and functional metabolism
• 30:53 – Zinc: the overlooked but essential nutrient
• 34:57 – Answering “Am I inflamed?” with data
• 43:31 – Fatty acids and inflammation patterns
• 48:33 – Making personalized care scalable and efficient

This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

The views expressed on this podcast are those of the hosts and the guests, and they don’t necessarily reflect the views of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only, and it’s not intended to be medical advice. For your safety, always check with your healthcare provider before making any changes to your healthcare routine. We’ll catch you next time on the Root Cause Medicine Podcast.

1. Dhurde VS, Patel AB, Locks LM, Hibberd PL. Diagnostic performance of red cell indices in detecting iron deficiency and iron deficiency anemia among rural adolescent girls aged 14-19 years in Nagpur District. PLOS Glob Public Health. 2025 Sep 29;5(9):e0005108. doi: 10.1371/journal.pgph.0005108. PMID: 41021630; PMCID: PMC12478879. 
2. Chaudhry, H. S., & Kasarla, M. R. (2026). Microcytic hypochromic anemia. StatPearls. Retrieved March 31, 2026 from https://www.ncbi.nlm.nih.gov/books/NBK470252/
3. Razzaque MS. Magnesium: Are We Consuming Enough? Nutrients. 2018 Dec 2;10(12):1863. doi: 10.3390/nu10121863. PMID: 30513803; PMCID: PMC6316205.
4. Al Alawi AM, Majoni SW, Falhammar H. Magnesium and Human Health: Perspectives and Research Directions. Int J Endocrinol. 2018 Apr 16;2018:9041694. doi: 10.1155/2018/9041694. PMID: 29849626; PMCID: PMC5926493.

Dr. Cheng Ruan is a fascinating physician on the leading edge of medicine, and in this episode we explore his story, how he thinks, and what he sees coming next in healthcare. What I loved most about this conversation is how it expands the way we think about practicing medicine - beyond protocols and productivity into something more human and sustainable. While we touch on integrative care, insurance models, and AI, the deeper thread is that physicians are being asked to evolve - not just clinically, but personally and systemically. Dr. Ruan reminds us that care isn’t just about what we prescribe, but how we listen, communicate, and design the environments we work in. It’s an invitation to step back and ask: what kind of medicine are we building, and does it truly support both our patients and ourselves?

Guest Introduction

Dr. Cheng Ruan, MD, is the founder of the Texas Center for Lifestyle Medicine, an integrative, insurance-based practice focused on chronic disease, mind-body medicine, and personalized care. He is also the co-founder of the Physician Transformation Institute, where he works with clinicians to address burnout, reconnect with purpose, and explore new ways of practicing medicine. His work sits at the intersection of clinical care, systems design, and emerging technology.

Key Moments from This Episode

• From transactional to transformational care: Dr. Ruan shares a pivotal moment early in his career that led him to rethink the purpose of clinical practice and move toward a more patient-centered, root-cause approach.
• Medicine as a system, not a set of diagnoses: He introduces the idea of viewing health through a systems-based “flowchart,” focusing on upstream drivers rather than isolated conditions.
• Reframing physician burnout: The conversation shifts burnout from a workload issue to something deeper—touching on identity, alignment, and meaning in medicine.
• Building an insurance-based integrative model: He walks through how he created a lifestyle medicine practice that operates within traditional reimbursement structures.
• Group care as a tool for chronic disease: Dr. Ruan highlights how cohort-based care models may support patient engagement, accountability, and long-term behavior change.
• AI as a support layer in clinical practice: The episode explores how AI can assist with education, workflows, and communication - while emphasizing the need for thoughtful implementation.
• Digital twins and patient experience: He introduces the concept of clinician “digital twins” as a way to extend communication and improve access while maintaining consistency in care delivery.
• Raising resilient kids in an uncertain world: The conversation closes on a personal note, focusing on how to support the next generation through emotional safety, curiosity, and critical thinking.

Timestamps

• 00:00 – Introduction to Dr. Cheng Ruan and his work
• 02:29 – Early life and integrative medicine background
• 05:21 – Systems thinking and reimagining clinical care
• 09:20 – Behavioral observation and patient insight
• 20:54 – Physician burnout and meaning in medicine
• 24:31 – Community, retreats, and clinician support
• 42:42 – AI in healthcare and patient communication
• 47:40 – Safety considerations and AI guardrails
• 58:16 – The future of medicine and education
• 01:06:23 – Inside his clinical model and practice design

Want to elevate your practice? 

This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

Disclaimer

The views expressed on this podcast are those of the hosts and the guests, and they don't necessarily reflect the views of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only, and it's not intended to be medical advice. For your safety, always check with your healthcare provider before making any changes to your healthcare routine.

Citations

• West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281.
• Zhang X, Li L, Zhang Q, Le LH, Wu Y. Physician Empathy in Doctor-Patient Communication: A Systematic Review. Health Commun. 2024 May;39(5):1027-1037. doi: 10.1080/10410236.2023.2201735. Epub 2023 Apr 16. PMID: 37062918.
• Tang MY, Graham F, O'Donnell A, Beyer F, Richmond C, Dhami R, Sniehotta FF, Kaner EFS. Effectiveness of shared medical appointments delivered in primary care for improving health outcomes in patients with long-term conditions: a systematic review of randomised controlled trials. BMJ Open. 2024 Mar 7;14(3):e067252. doi: 10.1136/bmjopen-2022-067252. PMID: 38453205; PMCID: PMC10921542.

Magnesium is one of those nutrients clinicians think they understand—until they take a closer look. In this episode, we sit down with Dr. Robert Fredrickson, author of Magnesium Answers, to unpack why this foundational mineral continues to create confusion in modern practice. We explore the gap between what standard lab testing shows and what may be happening intracellularly, how lifestyle factors like stress may influence magnesium balance, and how to think more precisely about selecting the right form for the patient in front of you. This conversation is a reminder that advancing patient care isn’t always about adding more complexity—it’s about seeing the fundamentals more clearly.

Why serum magnesium may not reflect total body or intracellular magnesium status

• Serum magnesium represents a small fraction of total body stores, which may limit its utility as a standalone marker; intracellular measures like RBC magnesium may offer additional insight (NIH, 2022).

Magnesium’s foundational role in ATP production and metabolic processes.

• Magnesium is required as a cofactor in ATP synthesis and numerous enzymatic reactions, supporting energy metabolism and overall cellular function (Gröber et al., 2015).

Magnesium as a cofactor in vitamin D metabolism and nutrient synergy.

• Magnesium participates in multiple steps of vitamin D activation, highlighting the importance of evaluating nutrient interactions in clinical planning (Uwitonze & Razzaque, 2018).

Dr. Robert Fredrickson is a clinician, educator, and author of Magnesium Answers: Unlocking the Secrets of Magnesium. With a background in sports medicine and functional medicine, he focuses on helping clinicians better understand mineral balance, metabolic health, and evidence-informed supplementation strategies. He also works with Fullscript, supporting providers with clinical decision support and access to professional-grade supplements and nutraceuticals. Dr. Fredrickson also has his own podcast, the Fredrickson Health Show.

• Not always. Serum magnesium reflects a small percentage of total body magnesium
• Intracellular markers, such as RBC magnesium, may provide additional context
• Interpreting trends alongside clinical presentation may support decision-making (NIH, 2022)

• Dietary intake and food quality
• Malabsorptive disorders like celiac and IBD
• Alcohol intake
• Insulin resistance or type 2 diabetes
• Vitamin D deficiency (NIH, 2022)



• Magnesium acts as a cofactor in enzymes required for vitamin D metabolism
• Inadequate magnesium status may influence how vitamin D is processed in the body (Uwitonze & Razzaque, 2018)

• 00:00 – Why magnesium remains overlooked in modern clinical care
• 02:20 – Dr. Fredrickson’s shift from sports medicine to functional medicine
• 05:32 – Limitations of serum magnesium testing in clinical practice
• 07:27 – Understanding intracellular magnesium and RBC testing
• 09:51 – Magnesium’s role in ATP production and metabolic function
• 13:25 – Dietary patterns, food quality, and nutrient density challenges
• 15:55 – How to select the appropriate form of magnesium
• 18:33 – Magnesium citrate and GI motility considerations, including GLP-1 support
• 20:46 – Common clinical patterns associated with low magnesium status
• 22:09 – Safety considerations and when to individualize magnesium use

This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.

1. Gröber U, Schmidt J, Kisters K. Magnesium in Prevention and Therapy. Nutrients. 2015 Sep 23;7(9):8199-226. doi: 10.3390/nu7095388. PMID: 26404370; PMCID: PMC4586582.
2. Rosanoff A, Weaver CM, Rude RK. Suboptimal magnesium status in the United States: are the health consequences underestimated? Nutr Rev. 2012 Mar;70(3):153-64. doi: 10.1111/j.1753-4887.2011.00465.x. Epub 2012 Feb 15. PMID: 22364157.
3. Uwitonze AM, Razzaque MS. Role of Magnesium in Vitamin D Activation and Function. J Am Osteopath Assoc. 2018 Mar 1;118(3):181-189. doi: 10.7556/jaoa.2018.037. PMID: 29480918.
4. National Institutes of Health. “Magnesium.” National Institutes of Health, 2022, ods.od.nih.gov/factsheets/Magnesium-HealthProfessional/.

• How to use a hormonal matrix approach to connect thyroid, adrenal, and reproductive hormone patterns
  • The HPTA axis reflects interconnected signaling between endocrine systems, and dysfunction in one axis may influence others through neuroendocrine and immune pathways (Tsigos & Chrousos, 2002).
• Why cortisol rhythm - not just a single value - may support more nuanced HPA axis assessment
  • Disruptions in diurnal cortisol patterns have been associated with fatigue, sleep disturbance, and stress-related conditions, supporting the value of rhythm-based assessment (Adam et al., 2017).
• How thyroid antibodies may offer early signals of immune activity and nutrient considerations
  • Thyroid peroxidase (TPO) and thyroglobulin antibodies are markers of autoimmune thyroid activity and may appear before overt dysfunction. Dietary interventions such as gluten removal have been studied for their potential to reduce antibody levels in some populations (Piticchio, 2023).
• How even small menopause-related hormone shifts may influence cognition and brain health
  • Changes in estrogen and gonadotropins during menopause are associated with alterations in mood, cognition, and neurological function. We now have new tests like ultra-high sensitivity analysis of estrogen to detect these changes in post-menopausal patients (Lang, 2025).
• How the gut-thyroid axis may inform integrative hormone support strategies
  • The gut microbiome plays a role in immune regulation and thyroid hormone metabolism, with emerging evidence supporting a bidirectional relationship between gut health and thyroid function (Shi et al., 2024).

• Do hormone systems need to be evaluated together?
  • Endocrine systems are interconnected through the hypothalamic-pituitary axes, and dysregulation in one system may influence others via shared signaling pathways (Tsigos & Chrousos, 2002; Chrousos, 2009).
  • A systems-based approach may help clinicians identify patterns in patients with complex or persistent symptoms.

• Is there evidence that cortisol rhythm matters clinically?
  • Yes—cortisol follows a diurnal rhythm that influences metabolic, immune, and neurological processes. Altered cortisol slopes have been associated with fatigue, poor sleep, and adverse health outcomes (Adam et al., 2017).

• Why assess thyroid antibodies if thyroid labs are normal?
  • Thyroid antibodies such as TPO and thyroglobulin antibodies can indicate autoimmune activity prior to changes in TSH or thyroid hormones (Fröhlich, 2017). Interventions including dietary modification have been studied for their potential to influence antibody levels, though results vary across individuals (Piticchio, 2023).

• Is there a proven connection between gut health and thyroid function?
  • Yes - research supports a bidirectional relationship between the gut microbiome and thyroid function, mediated through immune and metabolic pathways. Gut dysbiosis has been associated with autoimmune thyroid conditions and altered thyroid hormone metabolism (Shi et al., 2024).

• How are menopause and cognitive changes connected?
  • The menopause transition involves changes in estrogen and gonadotropins that are associated with shifts in mood, cognition, and brain health. Estrogen also plays a role in neuronal function and vascular health, which may contribute to cognitive changes (Lang, 2025).

• What integrative strategies are supported for HPTA Axis support?
  • Nutrient status (e.g., zinc, selenium) has been associated with thyroid hormone metabolism and immune function (Wang, 2023). 
  • Gut health interventions may influence inflammation and endocrine signaling (Shi et al., 2024).
  • Lifestyle factors such as sleep and stress management impact HPA axis regulation (Adam et al., 2017).

• 00:00 – The “normal labs, not normal patient” clinical gap
• 00:39 – The hormonal matrix: understanding endocrine cross-talk
• 02:20 – Why this framework matters in clinical practice
• 04:40 – ART panel: integrating adrenal, reproductive, and thyroid markers
• 06:29 – Thyroid antibodies and early immune signals
• 09:19 – Menopause hormones and cognitive patterns
• 11:32 – Adrenal adaptation and hormone transitions
• 13:13 – The gut–thyroid connection explained
• 16:29 – Cortisol rhythm and the evidence base
• 19:28 – Practical strategies for complex hormone cases
  
  

1. Adam EK, Quinn ME, Tavernier R, McQuillan MT, Dahlke KA, Gilbert KE. Diurnal cortisol slopes and mental and physical health outcomes: a systematic review and meta-analysis. Psychoneuroendocrinology. 2017;83:25-41. doi:10.1016/j.psyneuen.2017.05.018
2. Wang F, Li C, Li S, Cui L, Zhao J, Liao L. Selenium and thyroid diseases. Front Endocrinol (Lausanne). 2023 Mar 24;14:1133000. doi: 10.3389/fendo.2023.1133000. PMID: 37033262; PMCID: PMC10080082.
3. Lang XL, Huang CC, Cui HY, Zhong HX, Shen MY, Zhao F. From physiology to psychology: An integrative review of menopausal syndrome. World J Psychiatry. 2025;15(11):108713. doi:10.5498/wjp.v15.i11.108713 
4. Chrousos GP. Stress and disorders of the stress system. Nat Rev Endocrinol. 2009;5(7):374-381. doi:10.1038/nrendo.2009.106
5. Shi C, Chen J, He S, Zhang Y, Zhang Y and Yu L (2024) Cross-talk between the gut microbiota and hypothyroidism: a bidirectional two-sample Mendelian randomization study. Front. Nutr. 11:1286593. doi: 10.3389/fnut.2024.1286593
6. Jiang T, Yang X, Wu B, Tao R, Chen R, Jin L, Sun D, Weng H. Gut microbiota in hypothyroidism: pathogenic mechanisms and opportunities for precision microbiome interventions. Front Microbiol. 2025 Oct 1;16:1661211. doi: 10.3389/fmicb.2025.1661211. PMID: 41103764; PMCID: PMC12521424.
7. Tsigos C, Chrousos GP. Hypothalamic–pituitary–adrenal axis, neuroendocrine factors and stress. J Psychosom Res. 2002;53(4):865-871. doi:10.1016/S0022-3999(02)00429-4
8. Fröhlich E, Wahl R. Thyroid Autoimmunity: Role of Anti-thyroid Antibodies in Thyroid and Extra-Thyroidal Diseases. Front Immunol. 2017 May 9;8:521. doi: 10.3389/fimmu.2017.00521. PMID: 28536577; PMCID: PMC5422478.
9. Piticchio T, Frasca F, Malandrino P, Trimboli P, Carrubba N, Tumminia A, Vinciguerra F, Frittitta L. Effect of gluten-free diet on autoimmune thyroiditis progression in patients with no symptoms or histology of celiac disease: a meta-analysis. Front Endocrinol (Lausanne). 2023;14:1200372. doi:10.3389/fendo.2023.1200372
10. Handelsman DJ, Gibson E, Davis S, Golebiowski B, Walters KA, Desai R. Ultrasensitive serum estradiol measurement by liquid chromatography–mass spectrometry in postmenopausal women and mice. J Endocr Soc. 2020;4(9):bvaa086. doi:10.1210/jendso/bvaa086

• Botanical powders can carry microbial risk if supply chain controls fail
  • Plant-derived supplements are grown in open agricultural environments where contamination from soil, water, or wildlife can occur. Without appropriate processing and testing, pathogens such as Salmonella may persist (Lin et al., 2024).
• Salmonella can survive in dry foods for long periods
  • Low-moisture products—including spices, flour, and powdered botanicals—can allow Salmonella to remain viable for extended periods despite appearing shelf-stable (Lin et al., 2024; Flock et al., 2022).
• Manufacturing standards are a key safeguard in supplement safety
  • Systems such as supplier verification, microbial testing, pathogen-reduction steps, and lot traceability—required under Current Good Manufacturing Practices (cGMP)—are designed to reduce contamination risk in dietary supplements (Bailey, 2020; Ma et al., 2025).

• Is Salmonella infection from supplements common?
  • Salmonella is one of the most common causes of foodborne illness globally, though infections linked to dietary supplements are relatively uncommon compared with traditional foods (Shane et al., 2017). However, outbreaks involving powdered foods and botanical ingredients have been documented.
• What symptoms should clinicians watch for?
  • Symptoms typically begin 6 hours to 3 days after exposure and may include diarrhea, abdominal cramps, fever, nausea, and vomiting (Eikmeier et al., 2018; Butt et al., 2004). Most healthy adults recover within several days without antibiotics
• How can clinicians help patients choose safer supplements?
  • Encourage patients to choose products from manufacturers that follow Current Good Manufacturing Practices (cGMP), perform microbial testing, and maintain transparent sourcing and quality control systems (Bailey, 2020).

1. Bibi N, Rahman N, Ali MQ, Ahmad N, Sarwar F. Nutritional value and therapeutic potential of Moringa oleifera: a short overview of current research. Nat Prod Res. 2024;38(23):4261-4279. doi:10.1080/14786419.2023.2284862
2. Camilleri E, Blundell R. A comprehensive review of the phytochemicals, health benefits, pharmacological safety and medicinal prospects of Moringa oleifera. Heliyon. 2024;10(6):e27807. doi:10.1016/j.heliyon.2024.e27807
3. Lin Z, Jiang S, Zwe YH, Zhang K, Li D. Glycogen plays a key role in survival of Salmonella Typhimurium on dry surfaces and in low-moisture foods. Food Res Int. 2024;175:113714. doi:10.1016/j.foodres.2023.113714
4. Flock G, Richardson M, Pacitto-Reilly D, et al. Survival of Salmonella enterica in military low-moisture food products during long-term storage at 4, 25, and 40°C. J Food Prot. 2022;85(4):544-552. doi:10.4315/JFP-21-321
5. Bailey RL. Current regulatory guidelines and resources to support research of dietary supplements in the United States. Crit Rev Food Sci Nutr. 2020;60(2):298-309. doi:10.1080/10408398.2018.1524364
6. Ma C, Monagas M, Bronstein L, Cadwallader A, Goldman V. Dietary supplement adulteration: laboratory approaches to risk mitigation. J Nat Prod. 2025. doi:10.1021/acs.jnatprod.5c00456
7. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017;65(12):e45-e80. doi:10.1093/cid/cix669
8. Eikmeier D, Medus C, Smith K. Incubation period for outbreak-associated, non-typhoidal salmonellosis cases, Minnesota, 2000–2015. Epidemiol Infect. 2018;146(4):423-429. doi:10.1017/S0950268818000079
9. Butt AA, Aldridge KE, Sanders CV. Infections related to the ingestion of seafood: part I—viral and bacterial infections. Lancet Infect Dis. 2004;4(4):201-212. doi:10.1016/S1473-3099(04)00969-7
10. Marchello CS, Birkhold M, Crump JA; Vacc-iNTS Consortium Collaborators. Complications and mortality of non-typhoidal Salmonella invasive disease: a global systematic review and meta-analysis. Lancet Infect Dis. 2022;22(5):692-705. doi:10.1016/S1473-3099(21)00615-0
11. Falowo AB, Mukumbo FE, Idamokoro EM, et al. Multi-functional application of Moringa oleifera Lam. in nutrition and animal food products: a review. Food Res Int. 2018;106:317-334. doi:10.1016/j.foodres.2017.12.079
12. Fernandes Â, Bancessi A, Pinela J, et al. Nutritional and phytochemical profiles and biological activities of Moringa oleifera Lam. edible parts from Guinea-Bissau (West Africa). Food Chem. 2021;341(pt 1):128229. doi:10.1016/j.foodchem.2020.128229
13. Hassan MA, Xu T, Tian Y, et al. Health benefits and phenolic compounds of Moringa oleifera leaves: a comprehensive review. Phytomedicine. 2021;93:153771. doi:10.1016/j.phymed.2021.153771
14. Ramesh B, Chauhan R, Don PMU, et al. Moringa oleifera: a comprehensive review of its nutritional benefits, functional applications, and future potential in food science. J Sci Food Agric. 2025. doi:10.1002/jsfa.7038

• Supplement quality directly affects clinical decision-making
  If a product does not contain the labeled ingredient or dose, clinicians may struggle to determine whether a therapy is supporting patient outcomes.
• Botanical supplements can vary widely in active compounds
  Factors such as plant sourcing, harvest timing, and extraction methods may influence the concentration of active constituents like hypericin (Butterweck, 2007).
• Quality verification systems help reduce risk
  Third-party cGMP certification, validated laboratory testing, and transparent supply chains may help clinicians identify supplements with stronger quality controls (FDA, 2024).
  
  

• Extracts are commonly standardized to 0.3% hypericin, a marker used to estimate potency.
  
  

• Certificates of Analysis (COAs) verifying ingredient identity and potency
• Third-party cGMP certification for manufacturing facilities
• Testing for contaminants such as heavy metals, pesticides, microbes, and solvents
  
  

• High-performance liquid chromatography (HPLC)
• High-performance thin-layer chromatography (HPTLC)
  
  

1. Butterweck V, Schmidt M. St. John's wort: role of active compounds for its mechanism of action and efficacy. Wien Med Wochenschr. 2007;157(13-14):356-61. doi: 10.1007/s10354-007-0440-8. PMID: 17704987.
2. Barnes J, Anderson LA, Phillipson JD. St John's wort (Hypericum perforatum L.): a review of its chemistry, pharmacology and clinical properties. J Pharm Pharmacol. 2001 May;53(5):583-600. doi: 10.1211/0022357011775910. PMID: 11370698. 
3. Izzo AA. Interactions between herbs and conventional drugs: overview of the clinical data. Med Princ Pract. 2012;21(5):404-28. doi: 10.1159/000334488. Epub 2012 Jan 11. PMID: 22236736.
4. NOW Tests St. John’s Wort Supplements Sold on Amazon. NOWFoods.com October 29, 2025. https://www.nowfoods.com/healthy-living/articles/now-tests-st-johns-wort-supplements-sold-amazon
5. USFDA. Current Good Manufacturing Practices (CGMPs) for Food and Dietary Supplements. Published 04/24/2024. https://www.fda.gov/food/guidance-regulation-food-and-dietary-supplements/current-good-manufacturing-practices-cgmps-food-and-dietary-supplements 

Anyone Can Order Labs Now: Who Interprets?

In this episode of the Root Cause Medicine Podcast, we explore a growing clinical reality: patients now have immediate access to advanced bloodwork but not necessarily interpretation with a clinician. In this conversation, we introduce Fullscript Journeys, the provider-led answer to direct-to-consumer lab platforms. With lab testing, AI-supported interpretations and wellness plans, and seamless follow-ups, Journeys empowers providers to deliver a modern patient experience — without compromising clinical guidance.

What is Fullscript Journeys? Fullscript Journeys is a provider-led lab-to-plan solution that enables clinicians to deliver a modern, digital care experience while maintaining clinical oversight and individualized judgment.

Patients can:

• Order labs through a branded storefront curated by their provider
• Complete a simple intake to power a personalized wellness plan
• Schedule a blood draw
• Access structured, provider-reviewed labs results
• Receive a personalized wellness plan from their clinician
• Stay on track with retesting and follow-ups

Providers can:

• Choose or customize lab panels (including 20 ready-made templates)
• Launch and share a Journeys storefront to grow their practice
• Keep current patients engaged by adding a Journey to their care plan
• Review and edit AI-assisted draft interpretations before release
• Approve and personalize wellness plans
• Monitor lab orders, results, and follow-ups within one dashboard

Fullscript Journeys is designed to reduce repetitive administrative work – such as creating first drafts of interpretations and coordinating follow-up lab orders – while preserving provider authority, individualized care planning, and appropriate clinical review.

Importantly, Journeys functions as clinical decision support. It does not replace medical judgment, diagnosis, or individualized patient assessment.

Key Episode Themes

• More patients have lab results in hand—but not clear answers. The bottleneck is interpretation, not access.
• AI can help draft and organize information, but it supports clinical judgment—it doesn’t replace it.
• Preventive, long-term care can scale with better systems—while keeping trust and the provider–patient relationship at the center.

Fullscript Journeys gives providers a scalable way to deliver personalized care that keeps patients engaged and under their guidance between appointments. Patients order labs through a personalized storefront, receive AI-powered interpretations, and follow a wellness plan built around their results. Automated follow-ups keep patients engaged over time, and providers stay in control of every care decision without taking on additional administrative work.

Disclaimer The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.

On this episode of Root Cause Medicine, we’re honored to share the story of Dr. Emlah Tubuo, PharmD, MS, an integrative pharmacist who came to the U.S. in 2003 with $300 in her wallet and built what many of us wish existed in every community: a pharmacy designed around whole person care. Dr. Emlah explains how growing up around infectious disease in Cameroon shaped her prevention-first mindset, and how arriving in the U.S. revealed a different challenge: chronic disease that silently progresses for years before symptoms demand urgent intervention.

Creatine is one of the most extensively researched nutrients in sports, metabolic, and brain health, yet parents and practitioners alike have questions about its use in children and adolescents. In this episode, Dr. Kate Kresge speaks with Jeff Gladd, MD, Chief Medical Officer at Fullscript, to clarify how creatine functions in normal physiology, what the research shows about pediatric safety, and how clinicians can guide families with confidence. Together, they explore growth-related energy needs and practical clinical considerations—offering an evidence-informed framework for responsible conversations about creatine use in youth.

• Creatine Supports Pediatric Energy Metabolism: Creatine is synthesized endogenously and obtained through diet, primarily from meat and fish. Average turnover is estimated at 2–4 g/day in adults, with children excreting approximately 14–15 mg/kg/day, reflecting ongoing metabolic demand during growth (Wang, 2018).
• Available Evidence Supports Safety in Healthy Youth: Although long-term pediatric-specific trials are limited, existing studies and decades of clinical use report no serious adverse events in healthy children and adolescents at typical doses (Kreider, 2017)
• Creatine Status Is Associated With Lean Mass and Bone Health: Lower creatine availability has been linked to lower lean mass accrual, lower bone mineral content, and less favorable body composition in youth (Korovljev, 2021).
• Clinical Context and Product Quality Are Key: Caution may be appropriate for individuals with known kidney disease. Professional-grade, single-ingredient creatine monohydrate is preferred over blends, which may contain unintended additives (Kreider, 2017).

• Emphasize a nutrition-first framework, with supplements as adjunctive support
• Review total protein and animal protein intake, especially in low-meat or vegetarian diets
• Assess caloric adequacy during growth spurts and high physical activity
• Adequate sleep and recovery during growth and training
• Balanced training loads to reduce overuse and endurance-related stress (Kreider, 2017).

• Creatine monohydrate is the most studied and evidence-supported form of creatine
• Professional-grade, third-party tested products, including NSF Certified for Sport® options for athletes. Practitioners can prescribe these through Fullscript (Kreider, 2017).

• Basic metabolic panel to assess renal function and electrolytes
• Body composition tracking when relevant
• Additional evaluation only when rare creatine synthesis or transport disorders are suspected (Kreider, 2017).

• 00:00 – Why creatine raises concerns for kids and teens
• 03:28 – How the body produces and uses creatine
• 05:39 – Low creatine availability and body composition
• 07:18 – Safety data and common side effects
• 09:07 – Addressing the “gateway supplement” myth
• 10:48 – Labs clinicians may consider for patients taking creatine
• 12:44 – Why supplement quality matters
• 13:45 – Choosing NSF Certified for Sport® creatine monohydrate
• 14:47 – Practical takeaways for families and clinicians

• Kreider RB, Kalman DS, Antonio J, Ziegenfuss TN, Wildman R, Collins R, Candow DG, Kleiner SM, Almada AL, Lopez HL. International Society of Sports Nutrition position stand: safety and efficacy of creatine supplementation in exercise, sport, and medicine. J Int Soc Sports Nutr. 2017 Jun 13;14:18. doi: 10.1186/s12970-017-0173-z. PMID: 28615996; PMCID: PMC5469049.
• Wang W, Du C, Lin L, Chen W, Tan L, Shen J, Pearce EN, Zhang Y, Gao M, Bian J, Wang X, Zhang W. Anthropometry-based 24-h urinary creatinine excretion reference for Chinese children. PLoS One. 2018 May 23;13(5):e0197672. doi: 10.1371/journal.pone.0197672. PMID: 29791502; PMCID: PMC5965866.
• Korovljev D, Stajer V, Ostojic SM. Relationship between Dietary Creatine and Growth Indicators in Children and Adolescents Aged 2-19 Years: A Cross-Sectional Study. Nutrients. 2021;13(3):1027. Published 2021 Mar 23. doi:10.3390/nu13031027
• Antonio J, Candow DG, Forbes SC, Gualano B, Jagim AR, Kreider RB, Rawson ES, Smith-Ryan AE, VanDusseldorp TA, Willoughby DS, Ziegenfuss TN. Common questions and misconceptions about creatine supplementation: what does the scientific evidence really show? J Int Soc Sports Nutr. 2021 Feb 8;18(1):13. doi: 10.1186/s12970-021-00412-w. PMID: 33557850; PMCID: PMC7871530.
• Jagim AR, Stecker RA, Harty PS, Erickson JL, Kerksick CM. Safety of Creatine Supplementation in Active Adolescents and Youth: A Brief Review. Front Nutr. 2018 Nov 28;5:115. doi: 10.3389/fnut.2018.00115. PMID: 30547033; PMCID: PMC6279854.
• Geyer H, Parr MK, Mareck U, Reinhart U, Schrader Y, Schänzer W. Analysis of non-hormonal nutritional supplements for anabolic-androgenic steroids - results of an international study. Int J Sports Med. 2004 Feb;25(2):124-9. doi: 10.1055/s-2004-819955. PMID: 14986195.

In this Root Cause Medicine podcast episode, we explore emerging concerns around ashwagandha-associated drug-induced liver injury (DILI). While ashwagandha remains one of the most widely used adaptogens in integrative medicine, recent international case reports have highlighted rare but clinically meaningful hepatic adverse events. This episode equips clinicians with a mechanistic understanding of potential risk factors, extraction methods that may increase vulnerability, and practical strategies for patient screening, education, and monitoring—without dismissing the therapeutic value of this foundational herb.

• Ashwagandha-Associated Drug-Induced Liver Injury (DILI) Is Rare but DocumentedCase reports from Japan, Iceland, and the U.S. describe hepatocellular injury typically occurring within 2–12 weeks of initiation, often resolving after discontinuation (Björnsson, 2020).
• Withanone and Oxidative Stress as a Proposed MechanismThe withanolide withanone may contribute to genotoxic and oxidative stress, particularly in states of depleted glutathione, potentially impairing hepatic detoxification capacity (Siddiqui, 2021).
• Withanolide Concentration MattersProducts standardized to high withanolide content may pose greater theoretical risk compared to traditional whole-root or aqueous preparations (Björnsson, 2020).
• Patient Vulnerability Influences Risk ProfileIndividuals with pre-existing liver concerns, polypharmacy, high oxidative stress burden, or impaired phase II detoxification may warrant closer consideration and monitoring (Siddiqui, 2021).
• Clinical-Grade Supply Chains Support Risk MitigationPractitioner-dispensed platforms with transparent sourcing, certificates of analysis, and clear extract documentation may help reduce exposure to adulterated or mischaracterized products.
• Patient Education and Monitoring Remain Frontline ToolsCounseling on symptom awareness and considering baseline and follow-up liver enzymes may support safer use when ashwagandha is clinically appropriate.

• Comprehensive Metabolic Panel (CMP)
• ALT
• AST
• Total and direct bilirubin
• Alkaline phosphatase, as clinically indicated  (Björnsson, 2020)

• Adequate dietary protein to support glutathione synthesis (Siddiqui, 2021)

• Review of total supplement and medication load with attention to polypharmacy
• Patient education on early symptoms of liver stress such as fatigue, pruritus, dark urine, and jaundice (Björnsson, 2020)

• Prefer transparent, clinically vetted supply chains with clear extract specifications and quality documentation.
• Screen for liver history and medication/supplement load.
• Educate patients on early warning symptoms.
• Consider baseline and follow-up liver enzymes (e.g., ALT, AST, bilirubin) in higher-risk individuals or if symptoms develop.
• This framing supports safer use without implying the product is universally unsafe or “detoxifying,” and keeps claims within educational and clinical-monitoring boundaries (Björnsson et al., 2020; Siddiqui et al., 2021).

1. Björnsson HK, Björnsson ES, Avula B, Khan IA, Jonasson JG, Ghabril M, Hayashi PH, Navarro V. Ashwagandha-induced liver injury: A case series from Iceland and the US Drug-Induced Liver Injury Network. Liver Int. 2020 Apr;40(4):825-829. doi: 10.1111/liv.14393. Epub 2020 Feb 11. PMID: 31991029; PMCID: PMC8041491. 
2. Siddiqui S, Ahmed N, Goswami M, Chakrabarty A, Chowdhury G. DNA damage by Withanone as a potential cause of liver toxicity observed for herbal products of Withania somnifera (Ashwagandha). Curr Res Toxicol. 2021;2:72-81. Published 2021 Feb 16. doi:10.1016/j.crtox.2021.02.002

Nearly one in three adults will experience a voice disorder at some point in their lifetime, often without realizing it may be connected to their overall health (Stachler et al., 2018). In this episode, we sit down with integrative otolaryngologist Dr. Linda Dahl to unpack how subtle changes in vocal tone, stamina, and clarity can serve as early clues to what’s happening systemically - from inflammation and hormonal shifts to nervous system stress, reflux, and microbiome changes - and what to do next depending on what you hear. From simple in-office listening strategies and targeted questions to appropriate referrals, lab considerations, and integrative support options, this episode helps clinicians effectively resolve common voice issues using a whole person approach.

• Inflammatory and metabolic markers as clinically appropriate (Stachler, 2018).
• Hormonal assessment as clinically indicated (Yalim, 2025).

• Hydration assessment and counseling (Verdolini, 1994).
• Address reflux holistically if present (Stachler, 2018).
• Support the microbiome as clinically indicated and consider candidiasis overgrowth in patients with a history of oral corticosteroid use (Pinto, 2013).

• Consider humidified air and environmental support for laryngeal tissue health (Levendoski, 2014).
• Vocal hygiene education, including pacing and rest—even in non-performers.
• Referral to voice therapy when functional misuse or strain is suspected (Wolfberg, 2024).

1. Stachler, R.J., Francis, D.O., Schwartz, S.R., Damask, C.C., Digoy, G.P., Krouse, H.J., McCoy, S.J., Ouellette, D.R., Patel, R.R., Reavis, C.W., Smith, L.J., Smith, M., Strode, S.W., Woo, P. and Nnacheta, L.C. (2018), Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Otolaryngology–Head and Neck Surgery, 158: S1-S42. https://doi.org/10.1177/0194599817751030
2. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, Self-Regulation. Stephen W. Porges. W.W. Norton & Company:  New York, NY,  2011.
3. Yalim SD, Bayram S, Bayar Muluk N, Cingi C. Association Between Menopause and Voice. Ear, Nose & Throat Journal. 2025;105(2):91-98. doi:10.1177/01455613251395924
4. Levendoski EE, Sundarrajan A, Sivasankar MP. Reducing the negative vocal effects of superficial laryngeal dehydration with humidification. Ann Otol Rhinol Laryngol. 2014 Jul;123(7):475-81. doi: 10.1177/0003489414527230. PMID: 24690983; PMCID: PMC5441306. 
5. Verdolini K, Titze IR, Fennell A. Dependence of phonatory effort on hydration level. J Speech Hear Res. 1994 Oct;37(5):1001-7. doi: 10.1044/jshr.3705.1001. PMID: 7823546.
6. Pinto CR, Almeida NR, Marques TS, Yamamura LL, Costa LA, Souza-Machado A. Local adverse effects associated with the use of inhaled corticosteroids in patients with moderate or severe asthma. J Bras Pneumol. 2013;39(4):409-417. doi:10.1590/S1806-37132013000400003
7. Wolfberg J, Whyte J, Doyle P, Gherson S, Muise J, Petty B, Tolejano CJ, Hillman RE, Stadelman-Cohen T, Van Stan JH. Rehabilitation Treatment Specification System for Voice Therapy: Application to Everyday Clinical Care. Am J Speech Lang Pathol. 2024 Mar 7;33(2):814-830. doi: 10.1044/2023_AJSLP-23-00283. Epub 2023 Dec 19. PMID: 38101322; PMCID: PMC11001165. 

In part two of our SIBO series, we’re joined again by Dr. Allison Siebecker to focus on what often determines whether patients stabilize or relapse: nutritional management and supportive care during and after SIBO treatment. We explore how to use prokinetics to support migrating motor complex function, when digestive aids like bile acids and enzymes may be appropriate, and how to apply SIBO dietary frameworks as personalized, flexible tools—not rigid rules. We also cover practical approaches to suspected yeast/dysbiosis overlap, how to support gut barrier integrity without worsening fermentation, and the key myths that can derail outcomes. This episode helps clinicians move from “eradication mode” to sustainable, integrative SIBO care.

• When used: between rounds and for remission maintenance (often at least ~3 months, individualized).
• Options discussed: prucalopride, low-dose erythromycin, LDN (adjunct), ginger and ginger-based blends, Iberis amara–containing multi-herbal combinations.

• Bile support may be considered when clinical suspicion of low bile flow exists; enzymes may support digestion during symptom management and re-expansion.

• Stool testing (colonic yeast), urine organic acids (yeast metabolites), Candida immune markers (reactivity patterns), and symptom questionnaires as pragmatic adjuncts.

• Trial cautiously: marshmallow, aloe, comfrey (may aggravate symptoms for some).
• Often better tolerated options discussed: IgG/colostrum, zinc carnosine, non-fermentable anti-inflammatory supports.

• Physical medicine, acupuncture, chiropractic when appropriate.

1. Camilleri M, Atieh J. New Developments in Prokinetic Therapy for Gastric Motility Disorders. Front Pharmacol. 2021;12:711500. Published 2021 Aug 24. doi:10.3389/fphar.2021.711500
2. Deloose E, Janssen P, Depoortere I, Tack J. Redefining the functional roles of the gastrointestinal migrating motor complex and motilin in small bacterial overgrowth and hunger signaling. Am J Physiol Gastrointest Liver Physiol. 2015;309(9):G649-G661.
3. Knez E, Kadac-Czapska K, Grembecka M. The importance of food quality, gut motility, and microbiome in SIBO development and treatment. Nutrition. 2024 Aug;124:112464. doi: 10.1016/j.nut.2024.112464. Epub 2024 Apr 5. PMID: 38657418.

The research around SIBO is evolving, and 2026 has brought more subtypes, testing and treatment options than ever before. Our guest this week, Dr. Allison Siebecker, is an expert in conventional and natural approaches to SIBO, helped to open one of the first integrative SIBO centers in the nation, and frequently teaches physicians about how to effectively treat even the toughest cases of SIBO, ISO, IMO and more. Today, we explore how hydrogen, methane (IMO), and hydrogen sulfide–associated (ISO) pattern-typing can help us choose treatment options that help to decrease SIBO symptoms effectively. We discuss how impaired motility - particularly dysfunction of the migrating motor complex - can impact symptom persistence and relapse in addition to microbial type and load, and why we should address it in treatment plans. Dr. Siebecker also reviews the newest advances in SIBO testing, breath test interpretation, and how long to test depending on what you’re looking to discover. If SIBO has felt like a guessing game in your practice, or if you’re just looking to stay on the leading edge, this episode offers a clearer, physiology-driven framework grounded in education that will help your clients get and stay well.

• Learn more about Optimizing SIBO Diagnosis with Testing 
• Order SIBO testing for patients through Rupa Health and Fullscript with a free account

1. Pimentel M, Saad RJ, Long MD, Rao SSC. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol. 2020;115(2):165-178.
2. Rezaie A, Buresi M, Lembo A, et al. Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus. Am J Gastroenterol. 2017;112(5):775-784. 
3. Serra J, Azpiroz F, Malagelada JR. Impaired transit and tolerance of intestinal gas in the irritable bowel syndrome. Gut. 2001;48(1):14-19. 
4. Park H, Lee K, Park S, et al. The effects and mechanism of action of methane on ileal motor function. Neurogastroenterol Motil. 2017;29(9):e13067. 
5. Losurdo G, Leandro G, Ierardi E, Perri F, Barone M, Di Leo A. Breath Tests for the Non-invasive Diagnosis of Small Intestinal Bacterial Overgrowth: A Systematic Review With Meta-analysis. J Neurogastroenterol Motil. 2020;26(1):16-28.
6. Tansel A, Levinthal DJ. Understanding Our Tests: Hydrogen-Methane Breath Testing to Diagnose Small Intestinal Bacterial Overgrowth. Clin Transl Gastroenterol. 2023;14(4):e00567. Published 2023 Apr 1. doi:10.14309/ctg.0000000000000567
7. Birg A, Hu S, Lin HC, et al. Reevaluating our understanding of lactulose breath tests by incorporating hydrogen sulfide measurements. JGH Open. 2019;3(2):228-233.
8. Lakhoo, Krutika MD1; Liu, Xiaochen MSc1; Lentz, Greg2; Lin, Eugenia BS1; Chang, Bianca W. MD3; Pimentel, Mark MD1; Pichetshote, Nipaporn MD1; Rezaie, Ali MD, MSc1. Phenotype and Antibiotic Response in Patients With Flat Line Breath Test Results: A Large Scale Database Analysis: 448. American Journal of Gastroenterology 113():p S261, October 2018. 
9. Soliman N, Kruithoff C, San Valentin EM, Gamal A, McCormick TS, Ghannoum M. Small Intestinal Bacterial and Fungal Overgrowth: Health Implications and Management Perspectives. Nutrients. 2025;17(8):1365. Published 2025 Apr 17. doi:10.3390/nu17081365 
10. Rao, Satish & Bhagatwala, Jigar. (2019). Small Intestinal Bacterial Overgrowth: Clinical Features and Therapeutic Management. Clinical and Translational Gastroenterology. 10. e00078. 10.14309/ctg.0000000000000078. 
11. Kim YJ, Jo IH, Paik CN, Lee JM. Efficacies of prokinetics and rifaximin on the positivity of a glucose breath test in patients with functional dyspepsia: a randomized trial. Rev Esp Enferm Dig. 2023 Mar;115(3):121-127. doi: 10.17235/reed.2022.8735/2022. PMID: 35748472.

This episode of the Root Cause Medicine Podcast features host Dr. Kate Kresge, ND in conversation with Dr. Jeff Gladd, MD, Chief Medical Officer at Fullscript and an integrative primary care physician. Together, they unpack three timely topics for whole-person clinicians: emerging human data on urolithin A as a mitophagy-activating postbiotic that may support mitochondrial function and immune aging; how to help patients engage with the “fiber maxing” trend in a safe, sustainable way that supports metabolic health, GI function, and diet adherence; and a new industry survey showing that 94% of pharma leaders are running or exploring direct-to-patient (DTP) programs, with implications for GLP-1 therapy access, continuity of care, and the clinician’s central role in guiding treatment decisions. (Nature)

• Emerging human data on urolithin A as a mitophagy-activating postbiotic that may support mitochondrial function and immune aging
• How to help patients engage with the “fiber maxing” trend in a safe, sustainable way that supports metabolic health, GI function, and diet adherence
• A new industry survey showing that 94% of pharma leaders are running or exploring direct-to-patient (DTP) programs, with implications for medication access, continuity of care, and the clinician’s central role in guiding treatment decisions. 

• Urolithin A postbiotic and mitophagy support for immune agingUrolithin A (UA) is a gut-derived postbiotic produced from ellagic acid–rich foods (e.g., pomegranate, walnuts, raspberries) by specific microbiome profiles. Only a minority of patients appear to generate robust amounts endogenously, making it a candidate for targeted supplementation in select cases (Kuerec, 2024).
• Randomized controlled trial of urolithin A and “younger” immune phenotypes
  A 4-week randomized, double-blind, placebo-controlled trial in 50 middle-aged adults (1,000 mg/day UA) found favorable shifts in T-cell subsets (more naïve, fewer exhausted CD8+ cells) and improved mitochondrial activity in immune cells, suggesting UA may help support a more “youthful” immune profile and mitigate aspects of inflammaging (Denk, 2025).
• Mitophagy, mitochondrial fitness, and healthspan-focused care
  UA may act as a mitophagy inducer, potentially enhancing removal of dysfunctional mitochondria and supporting mitochondrial biogenesis; this aligns with broader healthspan strategies aimed at maintaining immune competence, muscle function, and cardiorespiratory fitness across the lifespan, without framing UA as a standalone longevity cure (Keurec, 2024).
• Integrating urolithin A within comprehensive mitochondrial and metabolic health plans
  Rather than “hero-ing” a single ingredient, Dr. Gladd underscores that any consideration of UA belongs alongside foundational lifestyle medicine: resistance training for muscle preservation, VO₂-max–oriented movement, nutrient-dense diets, sleep, stress regulation, and microbiome-supportive nutrition.
• Evidence-informed high-fiber nutrition to support metabolic and GI health
  Only about 5% of the U.S. population meets daily fiber intake recommendations, with average intakes around 17 g/day compared to suggested ranges of roughly 21–25 g for adult women and 30–38 g for adult men (Dahl, 2015). Clinicians can frame fiber not as restriction, but as “nutrition by addition” for metabolic health, GI regularity, cholesterol balance, and satiety.
• Coaching patients through the ‘fiber maxing’ trend safely
  Social media trends promoting 30–40+ g/day of fiber can be beneficial in concept but may trigger gas, bloating, or bowel changes if patients increase too quickly or consume large bolus doses; gradual titration across meals, adequate hydration, and movement can improve tolerability and outcomes (McRae, 2020).
• Whole-food fiber strategies pair protein, polyphenols, and GI support
  The episode highlights simple upgrades—adding berries, flax, or psyllium to yogurt; spinach and lentils to egg scrambles; swapping regular pasta for lentil pasta; and building soups and stews around beans and lentils—allowing patients to hit fiber goals while supporting blood sugar steadiness, microbiome diversity, and adherence to higher-protein diets.
• Supplemental fibers: powders, liquids, and gummies in integrative GI care
  When diet alone is insufficient, blended soluble/insoluble fiber powders (e.g., psyllium, FOS, apple pectin) and pediatric-friendly liquids or travel-ready gummies can help bridge gaps. The conversation emphasizes quality sourcing, gradual introduction, and pairing supplements with water and movement to reduce GI side effects (McRae, 2020).
• Direct-to-patient pharma programs and the future of GLP-1 therapy access
  A recent ixlayer/DHC Group survey found that 94% of pharma leaders are running, planning, or exploring direct-to-patient programs, which may bundle telehealth, diagnostics, and medication fulfillment—including access to GLP-1 therapies for obesity and metabolic disease (Park, 2025). While this may reduce wait times for some medications, it also risks further fragmenting care.
• Preserving the provider–patient relationship in a DTP landscape
  Dr. Gladd frames this shift as a “rallying cry” for clinicians and platforms like Fullscript to double down on coordinated, whole-person care—ensuring someone is monitoring polypharmacy, side effects, risks, and lifestyle interventions, rather than allowing care to be driven solely by DTP marketing pipelines.
• Leveraging digital tools to scale integrative, whole-person care
  The episode closes with an invitation for clinicians to lean on practice-support tools (e.g., supplement quality curation, lab testing support, interaction checkers, AI-assisted plan-building) so they can stay at the center of patient care while reducing administrative burden and burnout.

• Urolithin A
• Fiber powders
• Fiber liquids
• Fiber gummies

1. Bischof-Ferrari HA, et al. Effect of the mitophagy inducer urolithin A on age-related immune decline: a randomized, placebo-controlled trial. Nature Aging (2025).https://www.nature.com/articles/s43587-025-00996-x.pdf 
2. Slavin JL et al. Position of the Academy of Nutrition and Dietetics: Health Implications of Dietary Fiber. J Acad Nutr Diet. 2015;115(11):1861–1870.https://www.jandonline.org/article/S2212-2672(15)01386-6/abstract 
3. Park, A. DHC Group / ixlayer industry survey reporting that 94% of pharma leaders are currently running, planning, or exploring DTP programs, including telehealth and at-home diagnostics. 2025. https://www.fiercepharma.com/marketing/direct-patient-programs-are-works-94-pharmas-set-become-standard-practice-survey 
4. Kuerec AH, Lim XK, Khoo AL, Sandalova E, Guan L, Feng L, Maier AB. Targeting aging with urolithin A in humans: A systematic review. Ageing Res Rev. 2024 Sep;100:102406. doi: 10.1016/j.arr.2024.102406. Epub 2024 Jul 11. PMID: 39002645. 
5. Denk, D., Singh, A., Kasler, H.G. et al. Effect of the mitophagy inducer urolithin A on age-related immune decline: a randomized, placebo-controlled trial. Nat Aging 5, 2309–2322 (2025). https://doi.org/10.1038/s43587-025-00996-x 
6. Dahl, Wendy J. et al. Position of the Academy of Nutrition and Dietetics: Health Implications of Dietary Fiber. Journal of the Academy of Nutrition and Dietetics, Volume 115, Issue 11, 1861 - 1870
7. McRae MP. Effectiveness of Fiber Supplementation for Constipation, Weight Loss, and Supporting Gastrointestinal Function: A Narrative Review of Meta-Analyses. J Chiropr Med. 2020 Mar;19(1):58-64. doi: 10.1016/j.jcm.2019.10.008. Epub 2020 Aug 29. PMID: 33192192; PMCID: PMC7646157. 

In this episode of the Root Cause Medicine Podcast, Dr. Kate Kresge is joined by Dr. Eric Viegas, a leader in supplement safety at Fullscript, for a timely and evidence-informed discussion on lead exposure in protein powders and nutritional supplements. Amid rising media attention and consumer concern, the conversation unpacks how and why trace amounts of lead can appear in supplements, how different regulatory thresholds (Prop 65 vs. USP/ICH) should be interpreted clinically, and what toxicologically relevant exposure actually means. Clinicians will gain practical insight into cumulative lead exposure, patient risk stratification, and how Fullscript is advancing supplement quality through enhanced testing, transparency, and practitioner-facing safeguards.

• Blood lead testing for evaluating current exposure (CDC, 2024)
• Environmental assessment of drinking water and occupational or environmental exposure (PEHSU, 2025)

• Preference for brands with third-party cGMP certifications
• Review of batch-specific Certificates of Analysis (COAs) (CHPA, 2010)
• Awareness that organic certification does not eliminate heavy metal risk (Ramakrishnan, 2021)

• Clean Label Project. Heavy Metals in Protein Powders. Retrieved October 2025 from https://cleanlabelproject.org/protein-study-2-0/ 
• Consumer Reports. Protein Powders and Lead Levels. October 2025. https://www.consumerreports.org/lead/protein-powders-and-shakes-contain-high-levels-of-lead-a4206364640/ 
• United States Food and Drug Administration. FDA Draft Guidance on Lead in Food Intended for Babies, Children, and Adults. Updated January 2025. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/guidance-industry-action-levels-lead-processed-food-intended-babies-and-young-children 
• EFSA. EFSA scientific report on dietary exposure to lead in the European population. June 30, 2025. https://efsa.onlinelibrary.wiley.com/doi/10.2903/j.efsa.2025.9577 
• World Health Organization. Lead Poisoning and Health. September 2024. https://www.who.int/news-room/fact-sheets/detail/lead-poisoning-and-health 
• Centers for Disease Control. CDC Updates Blood Lead Reference Values. April 2024. https://www.cdc.gov/lead-prevention/php/news-features/updates-blood-lead-reference-value.html
• US Pharmacopeia. USP 232 Elemental Impurities - Limits. https://www.usp.org/sites/default/files/usp/document/our-work/chemical-medicines/key-issues/c232-usp-39.pdf 
• International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) Harmonised Guideline: Guideline for Elemental Impurities Q3D(R2). 26 Apr. 2022. https://database.ich.org/sites/default/files/Q3D-R2_Guideline_Step4_2022_0308.pdf 
• Consumer Healthcare Products Association. Certificate of Analysis for Dietary Supplement Components. Consumer Healthcare Products Association. Apr. 2010, www.chpa.org/public-policy-regulatory/voluntary-codes-guidelines/certificate-analysis-dietary-supplement 
• Hasan, G. M. M. Anwarul, et al. “Accumulation of Heavy Metals in Rice (Oryza Sativa. L) Grains Cultivated in Three Major Industrial Areas of Bangladesh.” Journal of Environmental and Public Health, vol. 2022, 8 Mar. 2022, p. e1836597, https://doi.org/10.1155/2022/1836597 
• “Chemical Exposure Warnings (Proposition 65 Warnings).” Ca.gov, 2021, www.p65warnings.ca.gov/ 
• Ramakrishnan, Balasubramanian, et al. “Organic Farming: Does It Contribute to Contaminant-Free Produce and Ensure Food Safety?” Science of the Total Environment, vol. 769, 15 May 2021, www.sciencedirect.com/science/article/abs/pii/S0048969721001455 
• “Lead Exposure: Information for Health Professionals.” PEHSU - Pediatric Environmental Health Specialty Units, 7 Nov. 2025, pehsu.net/health-issue/lead-hcp/ Accessed 31 Dec. 2025.

In this “Health or Hype” rapid-fire episode, Dr. Kate Kresge teams up with Dr. Chris Sands, DPT, OCS, and Dr. Gabe Kresge, DPT, to sort running fact from fiction. They break down why strength training rarely “bulks up” runners and more often boosts efficiency, why single-leg strength better reflects the true demands of running than squats alone, and why minimalist shoes (and cushioning) should be chosen based on individual capacity and a gradual transition. They also address joint health—explaining why moderate, well-programmed running isn’t automatically “wear and tear”—and close with a practical prevention message: running assessments can catch issues before pain starts, and most injuries trace back to training load and under-recovery more than biomechanics.

• Strength Training as a Performance Amplifier (Not a “Bulking” Risk): The guests emphasize that most runners are unlikely to gain meaningful muscle mass that slows them down without a significant caloric surplus and bodybuilding-style programming. In typical runner programming, strength work more often improves running economy, stride efficiency, and neuromuscular coordination (Rønnestad 2014, Llanos-Lagos 2024). 
• Bilateral Strength Helps—But Running is a Single-Limb Sport: Squats can be useful for global strength, but running requires repeated single-leg force absorption and production. Unilateral patterns (split squats, step-downs, single-leg hinge work) better reflect the frontal-plane control, pelvic stability, and side-to-side comparisons that matter for durability and efficiency, particularly over long distances (Li, 2025).
• Minimalist Footwear is a Contextual Tool, Not a Universal Upgrade: Barefoot/minimalist shoes may nudge stride length and foot strike mechanics, but the guests stress that this is only helpful when the runner has adequate calf/soleus capacity and introduces changes gradually. Rapid transitions can increase injury risk (Altman 2015).
• Running and Joint Health: “Cyclic Loading” Can Be Supportive in Moderate Doses: Dr. Chris Sands frames the “running ruins your knees” claim as largely hype for recreational runners, noting that well-programmed, moderate running is not inherently degenerative and may correlate with better long-term joint outcomes compared with sedentary patterns—especially when recovery and cross-training are addressed.
• Running Assessments as Preventive Medicine for the Athlete: A running assessment isn’t positioned solely as an injury service. Instead, Dr. Gabe Kresge describe it as a way to identify subclinical deficits, asymmetries, or capacity gaps before they become pain-limiting—supporting performance, longevity, and more individualized programming.
• Most Injuries Track with Training Errors and Under-Recovery: Biomechanics can contribute, but the episode highlights a consistent theme in the literature: volume spikes, poor programming, and inadequate recovery (sleep quality, nutrition, chronic stress load) are common drivers of injury risk at the population level (Hamstra-Wright, 2021).

1. Rønnestad BR, Mujika I. Optimizing strength training for running and cycling endurance performance: A review. Scand J Med Sci Sports. 2014 Aug;24(4):603-12. doi: 10.1111/sms.12104. Epub 2013 Aug 5. PMID: 23914932.
2. Altman AR, Davis IS. Prospective comparison of running injuries between shod and barefoot runners. Br J Sports Med. 2016 Apr;50(8):476-80. doi: 10.1136/bjsports-2014-094482. Epub 2015 Jun 30. PMID: 26130697.
3. Llanos-Lagos C, Ramirez-Campillo R, Moran J, Sáez de Villarreal E. Effect of Strength Training Programs in Middle- and Long-Distance Runners' Economy at Different Running Speeds: A Systematic Review with Meta-analysis. Sports Med. 2024 Apr;54(4):895-932. doi: 10.1007/s40279-023-01978-y. Epub 2024 Jan 2. PMID: 38165636; PMCID: PMC11052887.
4. Prieto-González P, Sedlacek J. Effects of Running-Specific Strength Training, Endurance Training, and Concurrent Training on Recreational Endurance Athletes' Performance and Selected Anthropometric Parameters. Int J Environ Res Public Health. 2022 Aug 29;19(17):10773. doi: 10.3390/ijerph191710773. PMID: 36078489; PMCID: PMC9518107.
5. Huffer D, Hing W, Newton R, Clair M. Strength training for plantar fasciitis and the intrinsic foot musculature: A systematic review. Phys Ther Sport. 2017 Mar;24:44-52. doi: 10.1016/j.ptsp.2016.08.008. Epub 2016 Aug 18. PMID: 27692740.
6. Sun X, Lam WK, Zhang X, Wang J, Fu W. Systematic Review of the Role of Footwear Constructions in Running Biomechanics: Implications for Running-Related Injury and Performance. J Sports Sci Med. 2020 Feb 24;19(1):20-37. PMID: 32132824; PMCID: PMC7039038.
7. Willwacher S, Sanno M, Brüggemann GP. Fatigue matters: An intense 10 km run alters frontal and transverse plane joint kinematics in competitive and recreational adult runners. Gait Posture. 2020 Feb;76:277-283. doi: 10.1016/j.gaitpost.2019.11.016. Epub 2019 Dec 13. PMID: 31884254.
8. Li X, Mao L. Characteristics of Lower Limb Dominant and Nondominant Joint Load Changes After Long-Distance Running in Young Male Runners Under OpenSim Environment. Sensors (Basel). 2025 Oct 11;25(20):6301. doi: 10.3390/s25206301. PMID: 41157355; PMCID: PMC12567293.
9. Hamstra-Wright KL, Huxel Bliven KC, Napier C. Training Load Capacity, Cumulative Risk, and Bone Stress Injuries: A Narrative Review of a Holistic Approach. Front Sports Act Living. 2021 May 28;3:665683. doi: 10.3389/fspor.2021.665683. PMID: 34124660; PMCID: PMC8192811.

This episode of the Root Cause Medicine Podcast explores the Modern Running Assessment, an evidence-informed, data-driven framework for evaluating runners’ biomechanics, load tolerance, and performance capacity. Host Dr. Kate Kresge interviews Dr. Chris Sands, DPT, OCS, and Dr. Gabe Kresge, DPT, from Kinetic Physical Therapy to examine how modern tools—dynamometry, force plate testing, slow-motion gait analysis, cadence and vertical oscillation metrics, and single-leg endurance testing—provide objective information that visual observation alone may miss. These measurable insights help clinicians better understand strength-to-body-weight ratios, inter-limb asymmetries, foot-strike loading patterns, and fatigue-related movement changes, offering a clearer picture of the factors that may influence running efficiency, durability, and injury risk.

• Single-leg Bulgarian split squats
• Single-leg Romanian deadlifts
• Single-leg deficit calf raises
• Lateral band walks / hip abduction work

• Trial modest cadence adjustments and monitor symptoms and perceived effort.
• Teach foot strike as a load-distribution choice dependent on goals and physiology, not as a right-or-wrong pattern.
• Encourage shoe rotation and prioritize comfort and function over marketing claims.

1. Rønnestad BR, Mujika I. Optimizing strength training for running and cycling endurance performance: A review. Scand J Med Sci Sports. 2014 Aug;24(4):603-12. doi: 10.1111/sms.12104. Epub 2013 Aug 5. PMID: 23914932.
2. Altman AR, Davis IS. Prospective comparison of running injuries between shod and barefoot runners. Br J Sports Med. 2016 Apr;50(8):476-80. doi: 10.1136/bjsports-2014-094482. Epub 2015 Jun 30. PMID: 26130697.
3. Llanos-Lagos C, Ramirez-Campillo R, Moran J, Sáez de Villarreal E. Effect of Strength Training Programs in Middle- and Long-Distance Runners' Economy at Different Running Speeds: A Systematic Review with Meta-analysis. Sports Med. 2024 Apr;54(4):895-932. doi: 10.1007/s40279-023-01978-y. Epub 2024 Jan 2. PMID: 38165636; PMCID: PMC11052887.
4. Prieto-González P, Sedlacek J. Effects of Running-Specific Strength Training, Endurance Training, and Concurrent Training on Recreational Endurance Athletes' Performance and Selected Anthropometric Parameters. Int J Environ Res Public Health. 2022 Aug 29;19(17):10773. doi: 10.3390/ijerph191710773. PMID: 36078489; PMCID: PMC9518107.
5. Huffer D, Hing W, Newton R, Clair M. Strength training for plantar fasciitis and the intrinsic foot musculature: A systematic review. Phys Ther Sport. 2017 Mar;24:44-52. doi: 10.1016/j.ptsp.2016.08.008. Epub 2016 Aug 18. PMID: 27692740.
6. Sun X, Lam WK, Zhang X, Wang J, Fu W. Systematic Review of the Role of Footwear Constructions in Running Biomechanics: Implications for Running-Related Injury and Performance. J Sports Sci Med. 2020 Feb 24;19(1):20-37. PMID: 32132824; PMCID: PMC7039038.
7. Willwacher S, Sanno M, Brüggemann GP. Fatigue matters: An intense 10 km run alters frontal and transverse plane joint kinematics in competitive and recreational adult runners. Gait Posture. 2020 Feb;76:277-283. doi: 10.1016/j.gaitpost.2019.11.016. Epub 2019 Dec 13. PMID: 31884254.
8. Li X, Mao L. Characteristics of Lower Limb Dominant and Nondominant Joint Load Changes After Long-Distance Running in Young Male Runners Under OpenSim Environment. Sensors (Basel). 2025 Oct 11;25(20):6301. doi: 10.3390/s25206301. PMID: 41157355; PMCID: PMC12567293.

We’re launching a new series that brings the insights that Fullscript Chief Medical Officer Dr. Jeff Gladd normally shares only with our internal team—now open to the entire integrative and functional medicine community. This month, Dr. Gladd breaks down three emerging clinical priorities with immediate relevance to whole-person care. He covers why the American College of Cardiology is now recommending high-sensitivity CRP (hs-CRP) for universal cardiovascular screening, how grip strength paired with BMI is outperforming traditional biomarkers in predicting metabolic decline and all-cause mortality risk, and what new evidence tells us about saffron as supportive care for patients experiencing SSRI-related sexual side effects.

• Why the American College of Cardiology is now recommending high-sensitivity CRP (hs-CRP) for universal cardiovascular screening
• How grip strength paired with BMI is outperforming traditional biomarkers in predicting metabolic decline and all-cause mortality risk
• What new evidence tells us about saffron as supportive care for patients experiencing SSRI-related sexual side effects.

• hs-CRP (per ACC universal screening recommendation)
• Lipid panel and triglycerides
• Fasting insulin or HOMA-IR
• CBC, ESR, ANA when clinically indicated
• Oral health evaluation for periodontal inflammation
• Magnesium and B vitamins may warrant assessment in patients on SSRIs
• Handheld dynamometer in-clinic or at-home

This episode features Dr. Neda Gioia, OD, CNS®, IFMCP, a pioneer in integrative eye care who blends optometry, clinical nutrition, and functional medicine to advance preventive vision strategies. Clinicians will learn how gut-eye axis mechanisms, AI-driven oculomics, sex-hormone transitions, and nutrient patterns influence ocular inflammation, retinal biomarkers, and whole-system health. Dr. Gioia illustrates how modern imaging (including emerging AI models), stool and hormone testing, and nutrient evaluation can support earlier identification of risk patterns and more personalized, prevention-forward care for patients across the lifespan.

• Gut-Eye Axis and Systemic Inflammation Pathways: Dysbiosis may influence cytokine activity, intestinal permeability, and endotoxin load—factors that can contribute to ocular discomfort or inflammatory pathways affecting the uveal tract, conjunctiva, and retina. Clinicians may consider gut-driven contributors when chronic ocular symptoms persist despite standard care.
• AI-Driven Oculomics for Early Risk Detection: Retinal photography and OCT/OCT-A imaging combined with AI allow analysis of microvascular integrity, tortuosity ratios, nerve fiber patterns, and biological age metrics—supporting prevention-focused evaluation of cardiovascular, neurologic, metabolic, and longevity-related risk patterns.
• Hormone-Responsive Ocular Tissues and Midlife Vision Changes: Sex-hormone receptors in the lacrimal and meibomian glands, cornea, and retina help explain perimenopause- and menopause-related symptoms such as dry eye, fluctuating vision, and ocular-surface sensitivity. Hormonal transitions may influence lipid secretion, tear stability, and DHA metabolism.
• Preventive Vision Care as a Whole-Systems Touchpoint: Regular retinal imaging, nutrient status assessments, and symptom scoring may help clinicians identify early ocular patterns associated with metabolic or inflammatory changes. Annual eye exams remain essential—even when vision clarity appears stable.
• Nutrient Density and Ocular Resilience Across the Lifespan: Nutrients such as DHA, lutein, and zeaxanthin play supportive roles in retinal structure, macular function, and tear-film stability. Identifying nutrient insufficiencies or imbalances—especially in zinc and copper ratios—may help clinicians guide personalized nutrition strategies.
• Integrative Data Linking: Gut, Hormones, Labs, and Retinal Biomarkers: Combining stool markers (e.g., zonulin, calprotectin, SCFAs), hormone trends, nutrient analysis, and ocular imaging may offer a more complete preventive picture for chronic eye symptoms and systemic health mapping.

• Website: integrativevision.com
• Professional site: https://www.drnedagioia.com/

1. How strong is the evidence linking dysbiosis to ocular inflammation? Emerging research shows meaningful associations between gut dysbiosis and ocular inflammatory pathways, including effects on cytokines, permeability, SCFA signaling, and retinal immune activation. Mechanistic animal and human data continue to expand, though large interventional trials remain limited. Citation: Rowan S, et al. Front Cell Neurosci. 2024. Available at: https://www.frontiersin.org/articles/10.3389/fncel.2024.1468187/full
2. Which stool markers may be relevant when patients present with chronic ocular symptoms? Markers such as zonulin, calprotectin, and SCFAs may help clinicians understand permeability, gut-mediated immune activity, and microbial metabolite patterns that could interact with ocular-surface or retinal inflammatory pathways. Citation: Rowan S, et al. Front Cell Neurosci. 2024. Available at: https://www.frontiersin.org/articles/10.3389/fncel.2024.1468187/full
3. How does AI-enhanced oculomics fit into preventive medicine? AI-driven retinal imaging can identify subtle microvascular changes, nerve-fiber patterns, and tissue integrity metrics that may correlate with cardiovascular, neurologic, metabolic, and longevity-related risk. These tools expand prevention by extracting systemic biomarkers from retinal data. Citation: Keane P, et al. Theranostics. 2024. Available at: https://www.thno.org/v15p3223.pdf
4. Which hormonal shifts are most relevant to midlife changes in ocular comfort? Perimenopause- and menopause-associated fluctuations in estrogen and declines in androgen activity may impact meibomian gland lipid output, tear film stability, ocular surface sensitivity, and inflammatory thresholds.Citation: Jin, Xiuming, et al. “Hormone Replacement Therapy Benefits Meibomian Gland Dysfunction in Perimenopausal Women.” Medicine, vol. 95, no. 31, Aug. 2016, p. e4268, https://doi.org/10.1097/md.0000000000004268
5. Should clinicians routinely evaluate eye symptoms when initiating hormone therapy? Changes in ocular comfort—including dryness, irritation, or fluctuating vision—may accompany hormone transitions or therapy adjustments. Incorporating eye-symptom questions may help clinicians detect hormone-related effects on the ocular surface. Citation: Abelson MB, Lines L. Review of Ophthalmology. 2006. Available at: https://www.reviewofophthalmology.com/article/hormones-in-dry-eye-a-delicate-balance
6. Which nutrients are most essential for long-term ocular support? DHA, lutein, and zeaxanthin are well-studied nutrients supporting retinal function and macular pigment density. Balanced zinc and copper intake is also important for ocular and neural physiology. Citation: Age-Related Eye Disease Studies (AREDS/AREDS2): major findings https://www.nei.nih.gov/research/clinical-trials/age-related-eye-disease-studies-aredsareds2/about-areds-and-areds2 
7. How often should adults receive a comprehensive eye exam? Dr. Gioia explains that many adults benefit from annual examinations starting around age 40—earlier or more frequently for those with ocular symptoms or systemic risk factors—because asymptomatic conditions such as early glaucoma or macular changes may be detectable only through imaging. 
8. What’s the clinical advantage of combining gut, hormone, and retinal imaging data? According to Dr. Gioia, integrating these data streams can help clinicians observe multi-system patterns earlier—linking inflammatory load, hormonal fluctuations, nutrient availability, and microvascular integrity into a unified preventive strategy. 

In this inspiring episode of the Root Cause Medicine Podcast, Dr. Kate Kresge welcomes Dr. Cynthia Libert, a board-certified family physician, functional medicine expert, and creator of The Joy Prescription. Together they explore the biochemistry of joy, how gratitude reshapes brain connectivity, and how positive emotion can help to modulate inflammation, support neuroplasticity, and protect cognitive health. Clinicians will learn practical ways to integrate “joy prescriptions” into patient care, using evidence-informed tools to foster resilience and prevent burnout.

• Joy as a Measurable Biological State: Joy, positive affect and gratitude practices appear to increase activity in the ventral striatum and prefrontal cortex (Rueschkamp, 2019), and have some evidence for improving neuroplasticity, vagal tone, and immune resilience while reducing inflammatory cytokines like IL-6 (Dutcher, 2021).
• Gratitude Practices and Neurochemistry: Regular gratitude journaling boosts dopamine and serotonin, rewiring the reward pathways that reinforce positive affect and motivation. It may even help people to exercise more often over time (Emmons, 2003).
• Positive Affect and Cognitive Performance: Studies show that positive affect can enhance cognitive flexibility and attention-switching—even brief exposure to positive emotion improves executive function (Wang, 2017).
• Micro “Joy Prescriptions” for Busy Clinicians: Dr. Libert recommends short “Vitamin G” (gratitude) walks, deep-breathing practices, or quick notes of appreciation to activate joy and resilience in under 10 minutes per day.
• Integrative Cognitive Health Framework: Joy supports foundational systems—sleep, movement, nutrition, and connection—that underlie cognitive longevity, aligning with the Bredesen Protocol and functional medicine principles.

• High-sensitivity CRP, IL-6, and HbA1c for inflammatory and metabolic insight
• B12, vitamin D, magnesium, and thyroid panels for cognitive optimization
• Sex hormones, insulin resistance, and micronutrient status for personalized longevity mapping

• Anti-inflammatory protocols rich in omega-3s, polyphenols, and curcumin
• Supportive nutrients for neurotransmitter balance: B-complex, magnesium glycinate, phosphatidylcholine
• Gut–brain support through probiotics, fiber diversity, and fermented foods

• Daily gratitude or journaling rituals shown to reduce anxiety and depression by ~7 % (Diniz, 2023)
• Movement and strength training for muscle preservation and insulin sensitivity
• Structured rest—weekly breaks, retreats, or community connection for burnout prevention
• Group programs like Dr. Libert’s SoulCare circles to rebuild belonging and resilience

1. Emmons RA, Sefick, WJ, Froh, JJ. Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being. J Pers Soc Psychol. 2003.
2. Van der Stigchel S et al. Positive emotion and cognitive flexibility. Front Psychol. 2017.
3. Ochsner KN et al. Cognitive regulation of emotion: functional networks and mechanisms. Soc Cogn Affect Neurosci. 2012.
4. Cole SW et al. Eudaimonic well-being and gene expression: CTRA down-regulation. Proc Natl Acad Sci USA. 2013.
5. UC Braid Clinical Trials Registry: Ventral striatum activity correlated with decreases in IL-6 and CRP.
6. Diniz, et al. The effects of gratitude interventions: a systematic review and meta-analysis. PMC 2023.
7. Rueschkamp, Johanna M Grosse. “Neural Correlates of Up-Regulating Positive Emotions in FMRI and Their Link to Affect in Daily Life.” Social Cognitive and Affective Neuroscience, vol. 14, 2019

In this episode of The Root Cause Medicine Podcast, Dr. Kate Kresge interviews Dr. Chris Magryta and Dr. Erik Lundquist about Advanced Blood Labs 201—a course designed to help clinicians interpret metabolic and immune biomarkers across pediatric and adult populations. They explain how to use tests like C-peptide, adiponectin, leptin, and glutathione to identify early metabolic stress, and explore immune indices such as SII (Systemic Immune Inflammation Index) and SIRI (Systemic Inflammation Response Index) to uncover inflammation trends in both children and adults.

• Why early biomarker detection matters for identifying metabolic and immune imbalances before symptoms develop
• How to interpret C-peptide, adiponectin, leptin, fructosamine, LDH, and GGT for a clearer picture of metabolic and oxidative stress
• What advanced immune markers—cytokines, NK cells, T-cells, SII, and SIRI—reveal about inflammation and immune activation
• How to use affordable tests like a CBC to gain immunometabolic insights
• Why trend tracking and pattern recognition offer more clinical value than single lab snapshots
• How oxidative stress and mitochondrial biomarkers can guide chronic disease prevention and management

• Dr. Chris Magryta is a pediatrician at Salisbury Pediatrics and host of Women and Children First. His work centers on identifying the root causes of pediatric chronic illness through biomarker analysis, nutrition, and early intervention.
• Dr. Erik Lundquist is the founder of Temecula Center for Integrative Medicine and host of The Root Cause Business of Medicine Podcast. He specializes in integrative and functional medicine, teaching clinicians to bridge evidence-based practice with systems biology.
• Together, they lead the Blood Labs 101 and Advanced Blood Labs 201 courses—comprehensive programs helping practitioners translate complex biomarker data into actionable insights.

• Fructosamine
• Adiponectin
• Leptin
• LDH (Lactate Dehydrogenase)
• GGT (Gamma-Glutamyl Transpeptidase)
• 8-Hydroxy-D-Guanine
• MPO (Myeloperoxidase)
• CBC (Complete Blood Count)

• Glutathione (discussed for educational purposes only; not intended as a treatment recommendation)

• Advanced Blood Labs 201 November 2025

• 00:00 – Introduction and course overview
• 02:03 – Early biomarker detection and childhood metabolic health
• 04:07 – Evolution from Blood Labs 101 to 201
• 08:27 – Understanding C-peptide and insulin activity
• 11:08 – Fructosamine and short-term glucose trends
• 13:24 – Adiponectin and leptin in inflammation and metabolism
• 15:20 – Oxidative stress, LDH, glutathione, and DNA damage
• 17:20 – GGT and antioxidant balance
• 20:54 – Cytokines, NK cells, and the SIRI index
• 26:07 – Monocytes and immune pattern recognition
• 32:41 – Why each clinician chose medicine
• 50:52 – Personal growth and lessons beyond the clinic
• 54:00 – Final reflections

• Dr. Chris Magryta’s Podcast: Women and Children First
• Dr. Erik Lundquist’s Podcast: The Root Cause Business of Medicine
• Course Information: Advanced Blood Labs 201 at rupahealth.com
• Sponsor: Fullscript – Free platform for whole person care, lab ordering, and supplement management

1. Connecting the Spots: Serial Home C-Peptide Measurements for Assessing β-Cell Function. Diabetes Care, American Diabetes Association, 2025. https://diabetesjournals.org/care/article/48/9/1472/163233/Connecting-the-Spots-Serial-Home-C-peptide
2. Adiponectin as a Key Regulator of Inflammation and Metabolism. Nature Reviews Immunology, 2024.  https://www.nature.com/articles/s41577-024-01103-8
3. Changes in Adiponectin and the Leptin/Adiponectin Ratio During Lifestyle Intervention and Association With Metabolic Improvement in Obese Children. The Journal of Clinical Endocrinology & Metabolism, Vol. 93, Issue 8, 2008. https://pubmed.ncbi.nlm.nih.gov/18492759/
4. Systemic Immune-Inflammation Index (SII) and Systemic Inflammation Response Index (SIRI) as Markers of Metabolic Risk in Adolescents. Frontiers in Endocrinology, 2024. https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2024.1426404/full
5. Oxidative Stress Biomarkers and Mitochondrial Dysfunction in Cardiometabolic Health. Artery Research, 2024. https://arteryresearch.biomedcentral.com/articles/10.1007/s44200-024-00062-8
6. Evaluation of Fructosamine as a Short-Term Glycemic Marker in Diabetes. BMJ Open, 2015. https://bmjopen.bmj.com/content/5/5/e007689
7. Use of Fructosamine Test in Diabetic Children. Diabetes Care, Vol. 14, Issue 7, 1991. https://diabetesjournals.org/care/article/14/7/578/17573/Use-of-Fructosamine-Test-in-Diabetic-Children
   

James Greenblatt explores the evolving science of low-dose lithium as a neuroprotective intervention — highlighting its potential to prevent, slow, and even reverse cognitive decline associated with Alzheimer’s disease. He emphasizes that safe, nutritional lithium (2-10 mg) can support brain health by reducing neuroinflammation, promoting neuroregeneration, and stabilizing mood—without the risks associated with pharmaceutical doses. Clinicians are encouraged to assess lithium status through hair mineral analysis, monitor thyroid and kidney function, and consider environmental and dietary influences on endogenous lithium levels. By integrating low-dose lithium into a comprehensive, individualized care plan—including lifestyle modifications and targeted testing—practitioners can leverage this simple mineral to support mental clarity, impulsivity regulation, and long-term cognitive resilience.

• The Latest Harvard Research & Its Implications: The recent study showing that lithium naturally exists in the brain and diminishes early in Alzheimer’s, with animal models demonstrating that lithium orotate can reverse memory deficits.
• Mechanisms of Lithium in Brain Health: Its anti-inflammatory, neuroprotective, and neuroregenerative actions, including inhibition of GSK3, enhancement of neurotrophic factors, and support of myelin integrity.
• Differences Between Lithium Forms: Lithium carbonate (medication) vs. nutritional lithium orotate; why the latter is safer at microdose levels and less sequestered by amyloid plaques.
• Safety and Monitoring: Practical considerations for dosing, laboratory testing (such as hair mineral analysis), and monitoring thyroid and kidney function over time.
• Environmental and Dietary Lithium: The influence of water sources, diet, and geographic variations on lithium status, and implications for mental health and neuroprotection.
• Impulsivity, Mood, and Behavioral Regulation: How low-dose lithium may support impulse control, reduce irritability, and improve emotional stability across various psychiatric and neurological conditions.
• Future Therapeutic Directions: The potential for broader use of low-dose lithium as a public health intervention to reduce rates of suicide, neurodegenerative diseases, and mental health disorders.
• Hair mineral analysis (lithium marker)
• Thyroid function tests
• Kidney function tests
• Lithium orotate 
• Magnesium supplements
• Dietary sources of lithium (e.g., drinking water, herbs like thyme)
• Nutritional Lithium: A Cinderella Story 
• Lithium deficiency and the onset of Alzheimer’s disease 2025 paper
• 00:00 Introduction & episode overview
• 02:04 Harvard’s groundbreaking research on lithium and cognition
• 05:36 Historical context: lithium in psychiatry and nutrition
• 07:43 Lithium’s neuroprotective mechanisms: inflammation, neurogenesis, GSK3 inhibition
• 11:54 Differences between lithium carbonate and lithium orotate—clinical implications
• 13:35 Lithium sequestration by amyloid plaques and the unique properties of orotate
• 15:28 How lithium supports neurotransmitter balance and mood stability
• 19:21 Safety strategies: dosing, lab monitoring, and real-world practice
• 23:35 Assessing lithium levels: hair analysis and environmental factors
• 26:54 Geographic influences on natural lithium exposure and implications for mental health
• 29:03 Lithium’s role in impulsivity regulation and behavioral health
• 35:16 Clinical case examples: children to adults, mood stabilization, addiction, and cognitive decline
• 37:15 Treatment timelines and patient outcomes with low-dose lithium
• 42:50 Long-term management considerations and lab monitoring protocols
• 46:12 The preventive potential of low-dose lithium for Alzheimer’s disease and dementia
• 49:18 Industry influence, patent issues, and future directions in natural lithium therapies
• 55:05 Resources for clinicians and closing remarks

Rebalancing Bone Turnover: CTX, P1NP & Modern Protocols

In this episode of The Root Cause Medicine Podcast, Dr. Kate Kresge talks with Margie Bissinger, PT, CDCES, founder of the Bone Health Academy and host of the Happy Bones, Happy Life podcast, about modern, root‑cause approaches to osteoporosis and bone health in 2025. They cover advances in testing, nutrition beyond calcium and vitamin D, targeted exercise prescriptions (including LIFTMOR/ONERO‑style strength training), the role of hormones, and practical tools clinicians can use to help patients build stronger, safer bones.

You'll hear them discuss:

• New perspectives on exercise for bone: high‑intensity resistance, progressive loading, jumping protocols, balance work, and posture stabilization
• Blood markers of bone turnover: CTX and P1NP— how to interpret values and use them to guide treatment
• Micronutrients beyond calcium & D: magnesium, vitamin K2 (MK‑4 and MK‑7), boron, zinc, tocotrienols, B‑vitamins (homocysteine), and protein needs
• Gut health, malabsorption (including gluten sensitivity/celiac) and earlier screening for at‑risk patients
• Hormone replacement therapy (bioidentical estrogen) for fracture prevention and CTX improvement
• Practical use and limitations of interventions: strontium, weighted vests, vibration plates, and jumping programs
• Useful clinical labs and screenings: 25‑OH vitamin D, magnesium, homocysteine, hs‑CRP, parathyroid screening (total serum calcium & 24‑hour urine calcium), thyroid, micronutrient panels, and stool/microbiome testing
• Patient empowerment: reframing diagnosis as opportunity and combining lifestyle, supplements, testing, and when needed, medication

Guest Introduction

Margie Bissinger, PT, is a physical therapist with over 30 years’ experience specializing in bone health, nutrition, and rehabilitation. She co‑leads practitioner training (Restore & Rebuild / Bone Health Academy), hosts the Happy Bones, Happy Life podcast, and teaches integrative approaches to reduce fracture risk and improve bone quality.

Labs Mentioned

• 25‑hydroxy vitamin D
• CTX (C‑terminal telopeptide)
• P1NP (procollagen type 1 N‑propeptide)
• Total serum calcium
• 24‑hour urine calcium
• Magnesium
• Homocysteine
• hs‑CRP
• Thyroid labs
• Micronutrient/interstitial testing (specialty panels)
• Gluten/celiac testing
• Stool/microbiome analysis

Supplements Mentioned

• Calcium
• Vitamin D
• Magnesium (glycinate, dimalate, citrate, Mg‑threonate referenced)
• Vitamin K2 (MK‑4 and MK‑7)
• Tocotrienols (vitamin E subtype)
• Boron
• Zinc
• Omega‑3s
• B‑vitamins / folate (for homocysteine)
• Essential amino acids / protein formulations
• (Strontium discussed — concerns raised)

Guest and Sponsor Details

• Margie Bissinger — website: margiebissinger.com (free exercises, programs, Roadmap, Bone Health Academy) Podcast: Happy Bones, Happy Life (available on major podcast platforms & YouTube)
• Bone Health Academy — Certified Integrative Bone Health Practitioner Program (bonehealthacademy.com)
• Mentioned collaborators: Dr. Kim Millman; Dr. Keith McCormick; Dr. Belinda Beck (LIFTMOR research)
• Sponsor / platform referenced: Fullscript (clinician dispensary used by Margie)

Timestamps

00:00 Episode intro; topic overview (osteoporosis & bone health in 2025)

03:00 Exercise advances and empowerment through strength training

05:50 Nutrition overview: calcium, vitamin D, absorption & gut health

08:08 Vitamin K2: MK‑4 vs MK‑7 research and dosing discussion

11:50 Importance of magnesium and preferred forms

18:33 Protein needs updated: ≥1.1 g/kg and essential amino acids

24:22 Bone turnover blood markers: CTX and P1NP — interpretation & clinical use

31:05 Common drivers of elevated CTX: inflammation, hormones, parathyroid

36:43 Exercise prescription specifics, posture, stabilization, and BoneFit / BoneFit/PT resources

43:16  Weighted vests: when they help and when they hurt

45:35 Vibration plates: low‑intensity vs high‑intensity, safety considerations

49:01 Hormone replacement therapy: role in bone protection and CTX improvement

55:22 How Margie began focusing on bone health and integrative care

59:25 Strontium: effects on DEXA accuracy and recommendations

01:02:56 Jumping protocols and impact dosing for bone

01:07:05 Homocysteine and bone: thresholds and correction

01:13:33 Resources and recommended reading (Dr. Keith McCormick; Bone Health & Osteoporosis Foundation; BoneFit)

01:17:20 Closing: reframing diagnosis as opportunity; where to find Margie

Frequently Asked Questions

Q: Can strength training actually increase bone density in people with osteoporosis? 

A: High‑intensity, supervised resistance training (e.g., LIFTMOR/ONERO protocols) has been shown to increase bone density and improve bone quality.  

Q: Are CTX and P1NP blood tests better than DEXA for guiding osteoporosis treatment? 

A: CTX measures bone breakdown and P1NP measures bone formation, letting clinicians track turnover and treatment response long before DEXA changes.  

Q: Is vitamin K2 important for bone health — and which form should patients take? 

A: K2 (both MK‑4 and MK‑7) helps direct calcium into bone and research supports using both forms for fracture risk reduction and cardiovascular benefit.  

Q: Could an undiagnosed parathyroid tumor be causing unexplained bone loss? 

A: If total serum calcium is >10 mg/dL (especially over age 40), consider parathyroid evaluation because benign adenomas can drive significant bone loss.  

Q: Will jumping a few times a day improve bone density? 

A: Short daily impact protocols (e.g., 10 jumps twice daily) have produced measurable bone gains in studies when done with proper progression and posture.  

Q: Is homocysteine linked to fracture risk and is it reversible? 

A: Elevated homocysteine (>15 µmol/L) is associated with lower bone density and higher fracture risk, and levels often improve with targeted B‑vitamin repletion.

Disclaimer: The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.

True longevity requires metabolic flexibility, but how can we help our clients get there? This episode previews personalized metabolic health and longevity strategies from Dr. Rob Downey and Monique Class, presenters at Fullscript Forward 2025. Dr. Downey discusses how metabolic phenotyping, stress/HRV context, and GI patterns can inform evaluation, while Monique describes low-dose (microdosed) GLP-1 approaches, titration by response, and gradual tapering within lifestyle-first care model help them achieve impactful results for their clients. The conversation explores objective monitoring (labs, body composition), muscle-preserving movement, and structured workflows that may help patients sustain progress after medication changes. This episode is for informational and educational purposes only.

• Metabolic Phenotyping & Personalized Patterns in Longevity Care: Dr. Downey discusses using patterns such as body shape, lifestyle context, and lab trends to categorize presentations and organize evaluation, rather than applying one standardized protocol to everyone.
• “Body-Knows-the-Way” Framing & Foundational Inputs: Both Dr. Downey and Monique Class describe a model focused on reducing burdens (e.g., chronic stress, inflammation, dysbiosis) and adding supports (sleep, whole foods, movement) so adaptive pathways may function more effectively.
• Stress Physiology, HRV, Sleep & Behavior Change: Conversation covers the role of chronic sympathetic arousal and low HRV in metabolic challenges, and how breath work, meditation, or similar practices were used by some patients in their experience to shift autonomic balance.
• GLP-1 Microdosing, Titration & Slow Tapering: Monique explains her rationale for starting below common starter doses when appropriate, titrating to the lowest perceived effective dose to reduce “food noise,” and planning tapering from the outset—positioning medications as a potential bridge during lifestyle change.
• Side-Effect Themes & Constipation Workflow on GLP-1s: Both practitioners review proactive steps they consider before initiation of GLP-1s, such as addressing reflux/constipation and dysbiosis, and discussed tools often used in practice (hydration strategies; magnesium citrate/Cal-Mag; buffered vitamin C; ginger/bitters; gradual fiber; stool positioning) to manage common GI complaints.
• Nutrition Patterns, Endogenous GLP-1 Signaling & Glycemic Awareness: The dialogue highlights food-quality patterns (protein with meals; colorful produce; fermented foods/fiber) discussed in relation to satiety, SCFA production, and L-cell signaling, as well as interest in meal timing and CGM-based learning.
• Muscle Preservation & Body Composition Tracking: Monique and Dr. Downey discuss prioritizing resistance training, NEAT/micromovement, and tracking lean mass vs. visceral fat (e.g., Seca metrics, phase angle) as more informative than scale weight alone.
• Medication Reviews During Weight Loss: The guests emphasized reviewing other medications (e.g., blood pressure, lipid, glycemic, or psychiatric medications) as weight, intake, and vital signs change, with attention to orthostasis or hypoglycemia risk.
• Gut–Brain–Metabolic Axis Considerations: Guests describe empiric GI support and, in some cases, stool testing, as well as nutrients like glutamine and zinc (including zinc carnosine)in the context of comfort and barrier support.
• Metabolic Rebound & Relapse Prevention: The conversation covers reports of rebound with rapid dose escalation/high doses and abrupt discontinuation, and discussed slower titration, gradual tapering, and habit “scaffolding” (meal timing, movement, sleep, alcohol awareness) as strategies they consider to help maintain gains.

• Glycemic/insulin markers: Fasting insulin, fasting glucose, HbA1c, optional CGM patterns
• Lipid & metabolic context: Standard lipid panel; triglycerides; uric acid; waist circumference
• Endocrine/sex hormones: Thyroid panel; sex hormones as indicated
• GI & micronutrients: Stool testing where applicable; micronutrient analyses
• Body composition: Visceral fat and phase angle (e.g., Seca), lean mass vs. fat mass

• Gut/immune: Boswellia, bromelain, quercetin; probiotics (product/strain selection varies)
• Stress/adaptogens: Ashwagandha, cordyceps, phosphatidylserine; ginseng/licorice when appropriate
• Metabolic support: Chromium, bitter melon; glutamine, zinc / zinc carnosine, lecithin
• Constipation toolkit: Magnesium citrate or Cal-Mag, buffered vitamin C, ginger/bitters, aloe options, gradual fiber, hydration, stool positioning

• Fullscript Forward Summit – Oct 17 → https://www.fullscriptforward.com/

This episode of The Root Cause Medicine Podcast explores how the 2025 GLP-1 prescribing advisory from the American College of Lifestyle Medicine, the American Society for Nutrition, the Obesity Medicine Association, and The Obesity Society can act as a catalyst for whole-person metabolic care—rather than just symptom management. Lara Zakaria, IFMCP, pharmacist and functional medicine practitioner, breaks down the new consensus guidelines and highlights opportunities to integrate nutrition counseling, strength training, and lab monitoring to support muscle preservation, nutrient adequacy, and patient safety. You’ll hear Lara’s practical approach—starting with screening for eating disorders and nutrient status before prescribing—and learn how to design workflows that make guideline implementation realistic in busy clinical settings. Providers will leave with evidence-informed strategies to improve patient outcomes, minimize side effects, and support sustainable behavior change around GLP-1 therapy.

• GLP-1 Therapy as a Catalyst for Metabolic Health: How to use GLP-1 medications as a tool to initiate lifestyle change, reset eating patterns, and improve overall body composition rather than relying on medication alone.
• GLP-1 Nutrition Screening & Eating Disorder Risk Assessment: Why clinicians should screen for disordered eating and evaluate baseline diet quality—including fiber, protein, and phytonutrient intake—before initiating GLP-1 therapy.
• Protein Intake & Muscle Preservation During GLP-1 Treatment: Evidence-informed guidance on maintaining protein intake (0.4–0.5 g/kg/day) and combining GLP-1s with resistance training to reduce muscle loss and support long-term metabolic health.
• Micronutrient Monitoring for GLP-1 Patients: Recommended lab tests to monitor iron, vitamin D, RBC magnesium, zinc, and fat-soluble vitamins (A, D, E, K) to help prevent nutrient insufficiency and support patient energy and recovery.
• Managing GLP-1-Related GI Side Effects Naturally: Stepwise strategies for reducing nausea, constipation, and bloating with smaller meals, fiber, hydration, magnesium, ginger, and digestive bitters.
• Tracking Body Composition in GLP-1 Weight Loss: Why measuring visceral fat, lean mass, and muscle density provides a more complete picture of progress than weight alone—and how to use body composition scales effectively.
• Multidisciplinary GLP-1 Care Team Approach: How dietitians, physical therapists, trainers, mental health providers, and pharmacists can collaborate to create comprehensive, patient-centered care plans.
• Optimizing Clinical Workflows for GLP-1 Prescribing: How to build visit templates, lab panels, and follow-up systems to integrate guideline-based nutrition, exercise, and lab monitoring into everyday practice.

• CMP, CBC with iron studies
• RBC magnesium
• Vitamin D
• Full thyroid panel (TSH, free T4/T3, reverse T3, antibodies)
• Functional testing options: NutrEval, organic acids, stool test

• Targeted protein intake (0.4–0.5 g/kg/day)
• Multi-mineral or multi-nutrient powder, divided doses
• Vitamin D + K2, B-complex, and iron as clinically indicated
• Electrolyte support during titration

• Magnesium citrate or Cal-Mag combination for low magnesium constipation
• Buffered vitamin C (titrated to bowel tolerance) and hydration for osmotic constipation
• Triphala, ginger, digestive bitters as appropriate to support peristalsis
• Squatty potty and morning routines to activate parasympathetic tone and support optimal pelvic floor function

• Strength training 2–3x per week to protect muscle mass
• Walking, yoga, gardening, or functional movement on non-training days
• Sleep and stress hygiene support to balance circadian rhythm

• 00:00 – Episode introduction and overview of prescribing considerations for GLP-1s
• 03:28 – Historical context: GLP-1 development and off-label use for weight loss
• 05:54 – The recent consensus statement and its implications for practice
• 06:43 – Decision tree considerations: muscle loss, fat distribution, and diet quality
• 09:05 – The importance of nutrition counseling and the gut-brain axis
• 12:05 – Holistic assessment framework: screening, laboratory biomarkers, and functional testing
• 14:10 – The role of fiber and gut health in optimizing GLP-1 outcomes
• 17:50 – The significance of screening for nutrient deficiencies: iron, vitamin D, magnesium, B vitamins, zinc
• 22:07 – Prevention of sarcopenic obesity during weight loss interventions
• 25:51 – Importance of assessing micronutrient status before and after GLP-1 therapy
• 27:54 – Lab assessments for liver, thyroid, and metabolic health indicators
• 40:51 – Advanced testing considerations and personalized evaluation strategies
• 47:02 – Managing GI side effects proactively: counseling, lifestyle, herbal supports
• 50:56 – Gut motility, herbal supports, and the importance of lifestyle factors
• 54:43 – Titrating and off-boarding GLP-1 medications for long-term health
• 55:30 – Resources