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Podcast

Guest Bios:

Dr. Lara Zakaria is a pharmacist, nutritionist, and adjunct professor specializing in functional medicine and personalized nutrition. She began her career in pharmacy community practice, noticing that her patients’ chronic conditions were advancing, year-to-year accumulating new diagnoses and a longer list of medications instead of getting healthier. This was the “aha” moment that the pharmaceutical-based guidelines she was trained in were intended to manage chronic disease, not prevent progression. That led her to functional medicine and the power of nutrition. Dr Zakaria is passionate about prevention and reversal of metabolic, allergic, and autoimmune disease. She splits her time between clinical practice, teaching, and mentorship in service of expanding awareness and access to functional medicine and personalized nutrition.

Dr. Melody Hartzler has developed a passion for functional medicine and treating the underlying causes of disease. Her focus areas are functional gastrointestinal disorders, nutritional deficiencies, metabolic conditions, and autoimmune conditions. She is also a nationally recognized speaker on diabetes and functional medicine. She is board certified in ambulatory care pharmacy, advanced diabetes management, and integrative and functional medicine. She specializes in endocrinology and functional medicine and loves combining her passions, teaching about root causes of metabolic syndrome. She is the owner of PharmToTable, LLC, where she develops continuing education for pharmacists at FxMedCE.com and provides a platform for functional medicine telehealth visits at PharmToTable.Life, and is a graduate of Ohio Northern.

Transcript:

Kalea Wattles, ND:
In recent years, more pharmacists have been receiving functional medicine training with the goal of becoming integrated into an expanded functional medicine collaborative care team. These professionals have direct interactions with patients when dispensing pharmaceuticals and are able to provide information on potential drug or drug supplement interactions, timing and dosing specifics, tips for adherence, and potential side effects. As part of this role, pharmacists can also provide information about the potential for drug-induced nutrient depletion and strategies to correct the issue.

Dr. Lara Zakaria
I look at it as we’re speaking the same language. And so if you are a functional medicine provider, you wanna be speaking to a pharmacist who understands what your priorities are and how you’re assessing or arriving at a conclusion.

Dr. Melody Hartzler
Most people think they get started on a drug, “I’m gonna take this for the rest of my life,” when it’s related to a chronic disease. And so they’re always, you know, fearful of that decision because they feel like whatever decision they’re making in the office today means that this is the decision they’re making forever. And I think helping them understand that that’s not necessarily the case either. So understanding that, you know, while we work on these lifestyle things, like, our goal is to de-prescribe these drugs if we can.

Kalea Wattles
On today’s episode of Pathways to Well-Being, we welcome functional medicine pharmacists Dr. Lara Zakaria and Dr. Melody Hartzler to talk about drug-induced nutrient depletions and the role of pharmacists on the functional medicine collaborative care team. Welcome to the show, Lara and Melody.

Melody Hartzler
Hi.

Lara Zakaria
Thanks for having us. Hello.

Melody Hartzler
Yes. Thanks for having us.

Kalea Wattles
Well, I think the listeners of this show know that I love an origin story, so I wanna get to know you both a little bit and talk about how you came to find the functional medicine model of care. So Lara, maybe let’s start with you, and I wanna know, when you went into pharmacy school, did you know that you wanted to practice through the lens of functional medicine or is this something you found later?

Lara Zakaria
I have to admit, I did not even know that functional medicine was an option when I went to pharmacy school eons ago. In fact, when I started pharmacy school, I really had a limited scope of understanding beyond obviously the scope around medication and safety and making sure that the right medication got to the right person and that they took it the right way. Honestly, beyond that, I think I even was naive in terms of what pharmacists could potentially bring to the table. Fast forward, I spent the first part of my career in community pharmacy doing a lot of exactly that, getting the right medication and the right bottle to the right person at the right time. And it wasn’t until I started to see cracks in the system and I, myself, started to see my own health decline, I started to see the health of my colleagues decline. All of us were really struggling in a high-stress environment dealing with, you know, what it is to be a healthcare provider and constantly changing, like, requirements and metrics and having to meet these demands. Meanwhile, it wasn’t doing my patients any good. They weren’t necessarily safer, better off, or healthier, for that matter.

And I think the more I saw my patients over the course of those years, like, not necessarily doing better, they’re coming in, they’re getting more prescriptions, more and more new medications are being thrown on their list, but their actual health is not improving. They’re talking to me and they’re telling me, “I don’t feel good, but, hey, doctor says that I gotta start this new medication.” And I think that’s where it starts to crack a little bit for me. That’s where I start exploring these other avenues. Long story short, I realize I’m obsessed with nutrition, and I’m really, really fascinated by the way that nutrition interacts with our biochemistry and how that then changes our health. And that’s when I end up going down the slippery slope of functional medicine, nutrition education. I get my master’s in nutrition, I become a CNS, and we come full circle to really understanding not only the value that nutrition brings to the table but all those lifestyle factors that can really make the difference when it comes to improving our patients’ health. And I think that’s why we’re all here.

Kalea Wattles
That’s why we’re here. Functional medicine found you as it finds many of us.

Lara Zakaria
It sure did.

Kalea Wattles
So how about you, Melody? How’d you discover?

Melody Hartzler
Yeah, so my background from a pharmacy standpoint, I’ve done a little bit of dispensing more as a side job to sort of stay in the community role, cause I really feel like that accessible healthcare professional in the community was there, but also to pay off my crazy student loans. But my main career path has been primary care. So I did a residency in a VA facility that was an ambulatory care facility. I was on a primary care diabetes team. We were managing patients’ drug therapy as well as providing some nutrition guidance surrounding carb counting and helping them understand the relationship to carbs and their blood sugars. We did all kinds of different things, renal home-based primary care, things like that. So I’ve always been integrated on a primary care team. I’ve worked in post-residency, FQHCs, so federally qualified healthcare centers and eventually a private practice family medicine office. I still practice one day a week in a family medicine office. So our state allows us to have a collaborative practice agreement with both physicians, nurse practitioners, PAs, and we’re allowed to help manage chronic disease and order labs, be able to assess the patient and make sure that they’re getting their, you know, disease management done. So certainly that’s, like, from the conventional standpoint.

And then from the functional standpoint, as far as where that came into play, part of it was my own health journey. So I had a baby and had sort of a traumatic birthing experience. I have a whole podcast episode where I discussed that with another functional medicine provider. But that I think was, like, the nail on the head. Sort of that thing that, you know, drove me into, you know, being, and then the lack of sleep of having, you know, a new infant that was colicky, figuring out why that was happening, what foods were causing her to be like that that I was eating, and then realizing how connected gut health was as she started to develop food allergies, and that my gut health sort of started to go down the tubes. I probably had SIBO or SIFO, you know, sort of figuring that out along the way with various different providers, and then hormone imbalances that came from all the stress of all of that. And so me just learning about that for myself. And then I was caring for people that had diabetes, a lot of metabolic syndrome. And I started to connect the dots between the gut health piece and the nutrient depletion piece and those patients that I was taking care of. So I started to, you know, on my diabetes patients that I would see, they were all these women coming in with diarrhea, constipation, they had their gallbladders removed. And so starting to do stool testing and also, you know, addressing, like, your vitamin D level is really low and your zinc level is, you know, really low, and how all that goes into play. So I started probably… I don’t even know. When my son was born was when I was really… He was, in 2017 is when I started my blog. But then that sort of, you know, kick started my interest in functional medicine and starting researching all this stuff. So yeah, so now we have a team of pharmacists doing this across the country, and I’m helping educate more pharmacists to do it because I can’t, and Lara is helping me with that as well, but I can’t be the only… You know, we try to, you know, multiply ourselves instead of, you know, try to fill our own schedules with people. So trying to make sure that more patients have access to this type of care.

Kalea Wattles
Wow, you both have such diverse and robust backgrounds, and I think so many of us, we have a clinical interest that then is ignited by a personal experience. You know, cracks in our own health and understanding that we’re not serving our patients in the way that makes us feel the most proud and the most satisfied. So I commend you both for honoring that call to action. And Melody, you mentioned that there are so many different aspects of healthcare that a pharmacist can participate in. And I wanna dive into that a little bit more, because I think we’re all really familiar with pharmacists and their expertise in dispensing medication like you both mentioned. But there’s so many other skills and so many other areas where we can have engagement. So my first question is, are all pharmacists trained… I imagine everyone gets trained in drug-drug interactions, but is everyone trained in the interaction between pharmaceuticals and nutraceuticals that someone, you know, a functional medicine primary care doc like me might really need to understand?

Melody Hartzler
Yeah, that’s a great question. So we certainly are trained in where to find the information about those things, and we talk about some of the high ones like St. John’s wort or ones that we know have significant interactions that… And there’s always levels of interactions, right? You’ve got the, like, you know, level A, B, C, you know, evidence type things. So it’s definitely a part of curriculum. It’s not something that I think, like, every pharmacist that you talk to that’s graduated pharmacy school is gonna remember all of those things off the top of their head because often they’re not faced with them every day. So there’s certain people that are using more supplements in their practice and are, you know, more aware of those things. But we definitely have resources that we can, you know, plug in the drugs and plug in, you know, the supplements that someone’s using to be able to determine what those are. But I think it takes, like, because we also, there’s one thing about just looking at that information in the database, because any provider could pull up that database, but having our background in drug therapy and being able to look at it and say, “Okay, well, basically this is just maybe gonna reduce the effectiveness based on what I’m reading with this data. So I think it’s still safer for you to use, and we just need to monitor that,” or “No, this is gonna significantly increase the drug concentration and that could be at risk for serious adverse events.” So it’s really that, you know, using our skillset as that drug expert to determine is this, you know, just a mild reaction that we can just monitor for or is it something more significant and serious that we wouldn’t even advise someone to use the medication for? Cause I think, I mean, you can plug in things all day long and there’s a laundry list of potentials, but sometimes it’s just, like, well, this drug can potentially lower blood sugar and so can this supplement. Well, that’s why we’re using both of them, right? So some of those things are just, you know? But I think a lot of providers, especially maybe some of our other mid-level providers that are, you know, looking at these things for the first time are just, like, a little nervous about, you know, even those minor interactions that they might see in the database.

Kalea Wattles
Yeah, that makes great sense. I’m thinking for myself when I’m sitting at my desk and typing in these interactions and I might see something, like, well, this, you know, nutraceutical is going to enhance the metabolism of this drug in the liver. And so then I’m sitting there like, okay, well, is that fine? Do I increase the dose of the pharmaceuticals so that I can still give this nutrient? And then I could really use some support there. But what kind of clinical setting is this type of collaboration happening? Is it in a hospital system? Can I call up my local pharmacist and say like, “Hey, I’m sending this person over, and I have them on these supplements and they’re on these medications.” Where does that kind of work happen?

Melody Hartzler
Right, so unfortunately, like, in the traditional retail setting that is run by the big three, you know, organizations or even some of the big grocery store chains, a lot of times the pharmacists there, as much as they would love to have conversations with you about that, don’t necessarily have the time in their day to do that because they’re focused on that dispensing process that Lara talked about. We have some amazing pharmacists across independent pharmacies. So I would say if you’re looking for someone, or consultant pharmacists, so our team, we practice as clinical consultant pharmacists, but we are doing that in the telehealth fashion. So we actually have a couple practices that are, you know, PA, at one practice here in Ohio is a PA nurse practitioner practice, but they have a pharmacist that is on our team that goes and spends time with them in a huddle once a month and answers their drug medication questions. But then she also is a resource that they have additional things pop up throughout the month.

So that’s an easy way, is to find that pharmacist in your community, whether it’s through the IFM directory or whether it’s through, you know, other sources like our team or somewhere else that you can say, “Hey, I wanna, you know, use you for an hour a month to join on this call with us so we can discuss these de-prescribing cases.” Or whatever, you know, that looks like. But having someone sort of tagged as your resource person. But that could also be the pharmacist down the street if there is someone that is in an independent setting that has the ability to make those decisions and say, “Yes, I’m gonna, you know, be able to commit time to working through these cases with you.” Not to say that someone in a chain retail setting wouldn’t be a person that could help you with that. It’s just that their time, I think, in this era of, you know, the vaccines happening to the pharmacy and all of the other things they’re being asked to do at the pharmacy just makes that a little bit more challenging. But now, Lara, do you wanna add anything to that?

Lara Zakaria
No, that’s a great point that you make. And I’ll say that the IFM website is a great resource. Find a practitioner and look specifically for pharmacists who have either training, some level of training or membership within IFM, and that will at least guide you towards a pharmacist who understands those principles. Cause I look at it as we’re speaking the same language. And so if you are a functional medicine provider, you wanna be speaking to a pharmacist who understands what your priorities are and how you’re assessing or arriving at a conclusion. And so I think it’s helpful that we do our best to network amongst each other to find other practitioners that are like-minded. And I think that’s a great starting point for finding a pharmacist, to Melody’s point, that can do the drug information research for you that is dedicated to it and understands the language that you’re speaking when you’re trying to arrive at a decision about safety or even about, like, just trying to enhance a pathway, right? I think so often we think of drug-herb interactions or drug-nutrient interactions as being potentially harmful, but we can actually use them synergistically and get an even better outcome than we would’ve gotten with medication or even with the nutraceutical alone.

Melody Hartzler
The other thing I would add is there’s pharmacy schools across the country, so part of my background is in academia, and so there’s plenty of faculty that are also doing, whether it’s research, or normally there’s someone teaching drug information at that school, and they normally have students, interns. And so there’s other resources, you know, that people might have in their community if there is a school of pharmacy there or a faculty that teaches the nutraceutical component that is able to be a resource for your practice as well.

Lara Zakaria
Can I use this as an opportunity to call to action any of said clinicians that are in those positions? Because we desperately need research and more information on this topic. So if you are in that kind of position, please, let’s work together to get more research and get more eyes on these interactions, both the synergistic as well as the potential safety concerns.

Kalea Wattles
Yeah, mobilize the functional medicine community to get more data. I love that. Lara, you and I have talked over the last couple years about having a pharmacist buddy, and I really like the idea of that, because I am the primary care doc who is guilty of writing my prescription. I send it off and then the pharmacist calls me if there’s an issue, but other than that, there’s not a lot of communication between us. And I had this example come up the other day. I’m sitting at my computer and I’m refilling this prescription, and it’s giving me options, like, do you want a tablet, do you want a capsule? And I just have my go-tos. But I’m thinking in my mind, “Am I even choosing the right thing? Like, maybe I should be considering absorption and this patient’s gut health and all these different things.” For things like that, you know, choosing the best route of administration, is that something that I could work with a functional medicine pharmacist on to decide what’s right for my patient?

Lara Zakaria
Somebody was asking me the other day about training for pharmacists and what exactly it entailed, and I was telling about one course that I had that was literally two semesters worth, by the way, of just learning how things break down in the body. And so to answer your question, that’s exactly what we’re here for. I think so often because the way the healthcare system is set up, our role has been relegated to just getting, again, the right medication to the right person at the right time. And that’s incredibly important. Like, I cannot stress enough that that is an important role, but there’s so much that we are taught about the pharmacokinetics of a drug that we can translate to nutraceuticals. And I think you’ll see, like, the smartest nutraceuticals that we’re using, the ones that we really love as functional medicine providers tend to have what? Good absorption. We trust that they are doing what they’re supposed to do, and we trust that there’s data about how they work, right? And so I think if we can merge that idea, if you have a question on how something would be best used in a patient, and I understand the way that something breaks down, and I can guide you to the right solution and take that off your plate, I feel like I’ve really, at that point, done my job as a pharmacist, cause at the end of the day, you could write the most perfect prescription, perfect dose, really follow the guidelines. But if the person can’t take it, won’t take it, it doesn’t work for them because of something else that’s going on in their body, then frankly, it’s just not effective. It doesn’t matter how ideal that prescription was. So at the end of the day, I see pharmacists as problem solvers, right? Like that’s essentially what we’re doing. We’re trying to make sure that whatever solution the prescriber has in mind, whatever that plan is supposed to look like, we’re trying to remove every obstacle that there is to make sure that that patient gets the outcome that was intended for them, right? That means making sure it’s in the right formula, making sure that it’s in a formula that’s not only gonna improve their absorption, but they’re actually gonna take it.

I don’t know how many times you’ve had this where I’ve recommended a supplement and they’re like, “I hate powders, I hate capsules, I can’t take that many pills.” Right? “I don’t like the smell of that,” right? These are the kinds of things that are part of compliance and adherence that pharmacists are very used to working with patients. Making a list of supplement timing. Like, creating a chart for a patient so that they can take their supplements consistently, right? And that they’re remembering what to take when and why they’re taking it. Remembering what they have to space away from pharmaceuticals and what they have to space away from certain other supplements or away from meals, for example, or with meals, right? Those are the kinds of solutions that we could provide that ultimately make your prescription better.

Kalea Wattles
Can I just say how impactful that would be for me to have someone help? Especially with the timing. I’m thinking of all of our patients who are on levothyroxine and they’re on DHEA, and they’re on all these things that need to be taken away from food and need to be taken in the morning, but they have low blood sugar. So it’s, like, it’s a whole thing. And having someone to create that schedule for them, I cannot even imagine how relieving that is to everyone involved. Melody, any additions for strategies that you use to really support patients with the adherence piece? Because like we said, the best treatment plan is gonna be the one that the patient can actually implement.

Melody Hartzler
Yes, I mean, I’ll echo Lara’s comments about, like, if asking the patient for their preference, like, do they want to put on this cream every day, you know, from a hormone therapy standpoint, or do they want to take a pill or do it in a different way? So, or the powders, you know, some people are like, “Oh, my goodness, I’ll never take something that I have to mix up in water,” or they do, and, “I just wanna swallow the capsules.” So making sure that you understand what the patient preference is. Also, like challenges at home. I mean, from a medication standpoint, if I have an elderly patient, you know, are they gonna be able to take this every day by themselves or are they expecting that, you know, can we do a twice daily dose of something? Like, is that even realistic when they have a pill box that’s set up for once a day or what are their, you know, methods that they’re using at home to remember that right now? Some medications can’t be taken out of the bottle and can’t be put in a pill box. So how is that gonna be incorporated if they are using some type of technology to help them get their, you know, making sure they’re taking it if they’re living alone. So especially in geriatric medicine, I think it’s even more important to understand what their support system looks like and figuring out, you know, is a nurse coming in once a week? Are they coming in every day? Are they helping fill up the pill box? Is a patient doing that themselves? But even, like, when we’re talking about, you know, some drugs come in injectable versus oral, so is an injectable once a week option for certain things better than somebody trying to take it every day? So the more we can give patients the ability to communicate and be part of that plan and creating the plan, the better the adherence piece is gonna be. So the more they’re the ones making a decision and not me making a decision is the win on the adherence end, from what I’ve seen.

Kalea Wattles
Yeah, I just wanna recognize after hearing you both talk about this that these things that you were thinking of, these specific and precise questions, I was not trained to ask. I would not think to ask about a lot of these things just in my intake or in my follow-up visit with a patient. So I’m really starting to see even more clearly how important it is to have a pharmacist on the collaborative care team, because these are skills that I don’t have.

Lara Zakaria
Thanks, Kalea. I appreciate you saying that. And I wanna also add that pharmacists not only are trained to think this way, but we have systems in place in order to evaluate for these things. So one of the things I talk about a lot is the medication therapy management or the MTM, and this has been an opportunity, it’s a specific type of encounter that has been created to ensure medication safety with patients. And it’s, essentially, it’s a Medicaid-approved and paid service. And within that service, we have the ability to take a look at everybody at a patient’s medication list and make sure that one, they’re taking the correct medication at the correct dose. A lot of times, this is an opportunity for us to discontinue unnecessary medications or to clarify on medications. I’ve seen cases where a patient’s taking two of the same medication, not realizing they’re both in the same class. And so now they’re doubling down on, like, two ACE inhibitors, for example, without even realizing it. Or I’ve seen this a million times, where they were discharged from the hospital on a PPI, and two years later are still taking it, not realizing they actually needed to stop it after they were discharged. So we are able to sort of find these very low hanging fruit opportunities to discontinue these medications, but that also becomes, from a functional lens, an opportunity for us to assess for drug-induced nutrient depletions. It’s an opportunity for us to ask about their supplements. There is an interesting statistic that I came across that about 40% of patients don’t disclose to their healthcare provider that they are actually taking any supplements, which means now as a healthcare provider, you don’t have the opportunity to tell whether or not it’s impacting or interacting with their medication or if it’s safe for them to take with their particular health condition. So I think that opportunity to have a conversation when they trust the pharmacist, when they know that pharmacist is not gonna be judgmental around their choices of nutraceuticals, and what they may have self-initiated, and can have a clear conversation about what’s safe and how to more effectively take those supplements, and maybe even find a better solution for them, and then communicate that back to their physician, I think that’s when we can really see a powerful way where pharmacists can step in and not only, you know, get rid of the low hanging fruit but potentially, like, make this an even better, more therapeutic interaction.

Kalea Wattles
And everyone benefits when that happens. The pharmacist is utilizing their strengths and specialized skills. The patient is certainly benefiting from more precise and specific care. And the primary care doc is able to kind of let the pharmacist take over that area that is their expertise. So I think everybody really benefits when we work in that collaborative care team. And, Lara, I wanna continue on this train of drug-induced nutrient depletion because I think this combines your love of pharmacy and nutrition. Will you just give us some common examples of medications that are associated with nutrient depletions?

Lara Zakaria
Absolutely. So let me start by saying that this area is what I’m advocating that we need more research in. So first and foremost, I think we all realize that when it comes to this particular intersection, we don’t have enough high-level, high-quality research to really make definitive clinical decisions. And this is what we’ve been alluding to in saying, well, this is where the pharmacist can really shine, because we can use sort of our algorithmic brain and our training, our understanding of the pharmacology, the therapeutics and the indications, to help clinicians make better decisions on the value or the extent of the concern that we would have around interactions and drug-induced nutrient depletions. So with that said, I think, let me define also drug-induced nutrient depletion, drug-nutrient interactions, and drug-herb interactions. Drug-nutrient interactions, I put in this, like, larger umbrella category. That’d be any interaction with any nutrient, food, beverage, et cetera that could potentially change or offset the way a medication acts. And that’s a neutral statement. It makes it better, it could make it worse, it just changes the way that that drug would act. Under that umbrella would be drug-induced nutrient depletions. As the term implies, it means that that drug induces a depletion of a particular nutrient, right?

So classic example here I think that we can all get on board with is that statins induce a depletion of CoQ10. It’s well established. We know it’s part of its adverse reaction profile, and we know this is a common nutrient depletion that we see very often. So in that case, we would say, okay, well, the simple solution would be to add CoQ10 to an individual’s supplement routine so that we can try to offset that drug-induced nutrient depletion. From there, we can get a little bit deeper in what we can talk a little bit about drug-herb interaction. So that, as the name implies, is when an herb alters the way that a drug acts, but sometimes drugs also alter the way herbs act. So that’s a bidirectional relationship that can occur as well. And sometimes we can use an herb to purposely interact with a drug to enhance the benefit of the drug. So I might use something like berberine alongside somebody that’s using a statin, for example, because I know that berberine not only helps to improve metabolic function, it has been shown to improve insulin resistance. So it’s especially useful in somebody that has that overlap in their physiology. But it can also improve the quality of LDL particles while that statin is reducing that LDL number. So it’s a way for us to improve some of those advanced lipid markers while we also try to achieve a lower LDL, which hopefully can help to improve that whole cardiovascular risk picture to begin with. Now we often think of drug-herb interactions as being this, like, scary thing. St John’s wort, I literally have nightmares about that particular herb. I think all of us who have heard about those drug interactions, rightfully so, are sort of terrified of using that herb. It can be a really effective herb on its own. The challenge is that it has so many different points at which it interacts with the same mechanisms where drugs could potentially be metabolized. Not just the CYP450 enzymes, P-glycoproteins, absorption mechanisms. There’s just multiple ways that it can interact with other medications. So we tend to be really cautious about avoiding it with those medications, and I think there’s places for us to really use that concern, especially if there’s a better option out there. I don’t necessarily have to use St. John’s wort. I could use saffron. There are probiotics that can help with depression and mood. I can use 5-HTP, right? There’s so many other mechanisms for me to support serotonin. I don’t necessarily have to resort to that in a patient that I might be concerned about their drug interactions. So I think that hopefully starts to paint a picture how there’s various ways that we can look at it, and I really try to emphasize the positive, right? The ways that we can rather than look at this with fear and really lean into our bias in terms of safety concerns. But can we flip that conversation around to start to use this to improve the way that we actually prescribe both the pharmaceuticals and the nutraceuticals and find a good way to use them together?

Kalea Wattles
This sounds fun. Piecing all these pieces together and reviewing all these things and making sure that these things are working either synergistically or complementary or even just safely. That actually sounds like great fun to me. Melody, you mentioned that your team is kind of working in a clinical setting to review these medications. Is this the type of thing they’re looking for? They’re reviewing medication lists, looking at supplement lists and identifying these areas of either synchronicity or areas where things need to maybe be separate.

Melody Hartzler
Yeah, yeah. So we have a couple different patient populations. I mean, some of the patients we’re doing a traditional MTM encounter like Lara was talking about. So that program that Medicare says, “Hey, these are your list of patients that are either coming to your practice or coming to your pharmacy that we would like you to meet with and review a drug list for.” And so certainly sitting down with those patients and doing the medication review but also incorporating the conversation about, you know, okay, you’ve got a PPI on board. Likely, you’re depleted in iron. When is the last time that you’ve had any kind of anemia panel checked? And having that conversation because this person is likely fatigued or, you know, they might have osteopenia and they’re not absorbing calcium because of that medication. So that’s probably one of the most common things I see in primary care is PPI use. And then also metformin and, like, our B vitamins. And so we’re having those conversations continually. A lot of our population is also more of a traditional functional medicine population that may not be on drugs because they are trying to avoid drugs by use of functional medicine. So we sort of have both sides of the coin but definitely something that we can do and are equipped to do.

Kalea Wattles
Okay, I have to ask a follow up question about this, because you highlighted something that is so prominent in my practice. People find functional medicine because they’re so excited about it being lifestyle-focused and nutrition-focused. And oftentimes they are specifically trying to avoid having to use a medication. But they might come in, they have hypertension, they have something that actually would really benefit from pharmaceutical treatment. How do we talk to them about the potential nutrient depletions in a patient that’s already not super excited about…

Melody Hartzler and Lara Zakaria
Right, yeah.

Kalea Wattles
Pharmaceuticals. And making it, you know, approachable and having them feel confident that we have the skills to kind of balance these issues.

Melody Hartzler
Yeah, you know, I always talk about things as tools in our toolkit. You know, we have a tool of this drug therapy, we have a tool of the nutraceutical, and we also have risk, right? So we have a risk of if your blood pressure remains high and you increase your risk for kidney disease or, you know, other, you know, cardiovascular complications. And I also, you know, normally probably bring in the conversation of, you know, the earlier we get your blood pressure controlled, the earlier we get your blood sugar controlled, we also have better outcomes because we don’t have this metabolic memory piece. And so sometimes we frame it as we’re gonna use this tool, this drug therapy tool for this period of time while we work on the lifestyle modifications. Because yes, weight loss can bring down your blood pressure, but do I wanna wait six months to a year for you to bring down your weight enough to affect your blood pressure? So when I think when we frame use of drugs in that way, especially for chronic disease, we’re not talking about rare disease or acute things that need treated like infections with medications. But I think helping them understand that drugs aren’t always, like, the evil thing. Like, there’s a reason that we have this modern information, and sometimes the use of drugs, it can be really helpful to them. Bringing in, like, when we’re talking about side effects of drugs, I also bring up there’s side effects to nutraceuticals too. So it’s not always just, you know, a side effect or a nutrient depletion related to a drug. There can be things that happen if we take too much zinc, we get our copper imbalance. And so that also is sort of, and not that it’s necessarily a depletion, but there are ways we can throw the body out of balance. We can methylate too much and cause issues there with people throwing all kinds of methylated B vitamins. So I just try to explain that they’re not, like, these opposing things all the time, and that, you know, they’re probably pretty more similar. We got drugs derived from a lot of plant-based things.

So we’re really just using a different tool and, you know, and when we’re talking about statins, I think, you know, that conversations with the CoQ10, you know, we know that we need to supplement with CoQ10. So that’s one thing we’re gonna be asking, like, someone, okay, if we are recommending you take a statin, we’re gonna recommend that you take 100 milligrams, or at least maybe 200 milligrams of CoQ10 a day. But it also depends on the risk. Are they a primary prevention patient? Have they had a heart attack before? Did their dad die at 50 of heart disease? Like, so there’s so much other nuance to I think the whole conversation with a patient and helping them understand, like, why drug therapy may be your best option right now. And also, I think helping them understand that drug therapy isn’t always a forever thing. Most people think they get started on a drug, I’m gonna take this for the rest of my life when it’s related to a chronic disease. And so they’re always, you know, fearful of that decision because they feel like whatever decision they’re making in the office today means that this is the decision they’re making forever. And I think helping them understand that that’s not necessarily the case either. So understanding that, you know, while we work on these lifestyle things, like, our goal is to de-prescribe these drugs if we can. But again, like, safety and efficacy conversations and you know, what’s the risk/benefit. I mean, there’s always a risk to everything we do. There’s a risk walking across the street, there’s a risk if I decide to travel or I don’t decide to travel, or if I take a car or I take a plane. Like, so anything they choose to do, you know, whether it’s a nutraceutical or a drug, is always gonna come with some conversation. So trying to make them not, like, opposing things, but sort of like both options in our toolkit, I think, has been my approach to things.

Lara Zakaria
I love using that analogy of a toolkit, because it truly is just another option, right? And we have data that helps guide some of those decisions. And then there’s personal, like, needs and family history and genetics that are really gonna shift for one person or another. I like to give some specific examples. Like, antibiotics is my go-to example of just the vast change that we’ve seen in public health with the advent of antibiotics. Now could they be overprescribed? Absolutely. Can they create unintended consequences in terms of disrupting the microbiome and the gut health? And yeah, that’s all absolutely part the conversation, but sometimes we have to use that tool in order to save somebody’s life, right? And that is going to then mean, okay, well, that’s step one. Step two is now how do we reverse some of the adverse reactions that we saw as a result of needing that particular intervention? The other example that I give is in hormone replacement therapy, specifically thyroid. I find too often my patients assume that having to take thyroid medication means that they lost the battle somehow. That needing to take it or not being able to discontinue it means that they’re not doing a good job in terms of managing their thyroid condition. And that’s one of the first, you know, goals that a lot of people share with me when they’re working with me on their thyroid health. And part of it is, well, you know, you need thyroid hormone. It’s kind of the master metabolite. She is very important in terms of every single function that we have in the body. So if you are not able to make enough thyroid, that is a life-threatening condition, in my opinion. It starts off with superficial things, like losing your hair, changing your skin texture, changing your nail beds, and it just very quickly evolves into being more and more serious if we don’t actually address that deficiency. And there’s no shame in actually needing to take a replacement.

The other myth that I hear around this is around levothyroxine somehow being inferior to bioidentical hormones or T3/T4 compounds. And I don’t think that’s true for everybody. I think some people do really well on levothyroxine, and we’ve done an amazing job in public health of being able to get a cheap medication out to the masses to help to supplement their thyroid function. But what we can do if you are not indicated for a bioidentical or a T3/T4 combination is actually improve the conversion of T4 to T3. And I think that’s a missing conversation that you actually need certain nutrients, particularly zinc, vitamin A, vitamin E, antioxidants to help to improve the conversion from the inactive T4 to the active T3. And then from there making sure that T3 interacts well with the cell receptor so that it goes on to open that door and do the job that it’s supposed to do metabolically. And I think this really starts to open the conversation about empowering the patient with things that they can actively do. They can seek out foods that have these particular nutrients in them. If needed, we can supplement them with supplements, right? We can talk about the lifestyle prescription and how stress impacts that conversion and impacts that interaction with the cell receptor. We could talk about an anti-inflammatory diet and the role of antioxidants, right? We could start talking about how other hormones start to impact thyroid function, like insulin resistance and estrogen levels and things like that. And of course, we could talk about the foundational gut health component so that all of these things are functioning synergistically. And I think to me that conversation starts to shift from, “I have to take this HRT,” to, “How do I make this HRT work best for me?”

Kalea Wattles
There’s such a strong undercurrent of motivational interviewing here. Like…

Melody Hartzler
Yes, I would…

Kalea Wattles
Helping the patient figure out what is your goal? Let’s anchor into that, and then we have a million tools to help you get there, medication being one of those.

Lara Zakaria
Exactly.

Melody Hartzler
Yeah, I was gonna say, I mean, and also the blame factor, like so many people are thinking, like, they failed, whether it’s with thyroid or with diabetes or hypertension, and they’re, like, thinking that this is, like, the punishment, like, is taking the medication. And sometimes, historically, physicians have used things like insulin, like, as a threat. Like, if you don’t get your act together, you’re gonna need to be on insulin. And so many patients have told me that. And so when they do need insulin and then we’re having this conversation, they’re like, “Well, I failed. You know, it was my fault.” Or even now that we have injectable agents that aren’t insulin, they think even that medication is a failure because they associate the injectable with other historical injectables. So just helping people understand we live in a terrible environment. Like, we have all of these toxins around us, like, we have our nutrition. You know, it’s not our fault what has been put into our nutrition system, and we can make the good choices now that we know. But did our parents know a lot of this information when we were growing up about the microbiome and what we shouldn’t have been eating from the school lunch and all of those kinds of things? No, and so all that you can do…

Lara Zakaria
Let alone have access to, right?

Melody Hartzler
Right.

Lara Zakaria
Like able to even choose…

Melody Hartzler
Exactly.

Lara Zakaria
What they eat.

Melody Hartzler
Exactly. Exactly. Yeah, so I think it’s just that helping, the motivational interviewing, the coaching is so important in these conversations of, like, you did not fail. This is, like, you know, you’re here now, and we have this knowledge now, and these are our options to move forward.

Kalea Wattles
I think you both have made a strong case that we need more functional medicine pharmacists. And one way that you are increasing this access to this type of care is with your new online course, “Functional Medicine for Pharmacists, Root Cause Approaches to Medication Therapy Management.” Will you tell us a little bit about this new online course? It’s really exciting.

Lara Zakaria
Yeah, this was such, honestly, a dream to be able to collaborate on producing this course. We have been sort of envisioning an opportunity for pharmacists to not only learn the basics of functional medicine, not only start to understand the framework because let’s, you know, let’s break that down a little bit. Functional medicine is not just one type of medicine, right? It is the way that we take all of our collective specialties, the way that we have been trained, and we apply a filter on it based on this functional medicine approach. And I think when we all speak that same language and we’re able to understand the differences in assessment, the systems medicine component and the interconnectedness of the various systems, when we start to understand the interaction with the gut microbiome and gut health, and we start to put all of those pieces together, we start to see our patients’ health concerns from a different lens. And that’s what I call sort of putting that lens on, putting that filter on to view the condition from this functional medicine perspective. So we wanted to do that for pharmacists. We felt like there wasn’t enough specific training for pharmacists to really step into the functional medicine framework and say, “Hey, here we are. Here’s the skills that we have, and we wanna apply it within this lens.” And so what we did was we took the basics of the functional medicine framework, the assessment strategies, the GOTOIT model, the matrix, the timeline, we pulled it in to use that as the foundation to then layer in the basics of MTM that helped to support the lifestyle interventions, diet, nutraceuticals, motivational interviewing, meeting the patient where they’re at, and helping to find solutions to both support that patient as well as to support the busy practitioners that could use the help.

Melody Hartzler
Absolutely. I think we, you know, we are using tools from the IFM Toolkit as well. So there’s great resources that people who participate in this course have access to, to be able to implement into practice afterward as well, which I think is key, is being able to take what you’re learning and actually use it in those medication therapy management encounters or in the clinical consultations that you’re doing as a pharmacist.

Kalea Wattles
Well, I wanted to thank you both for giving us this inside scoop about how functional medicine pharmacists can work in a collaborative care team and really benefit all areas of healthcare delivery. I’m really excited to see the evolution of functional medicine pharmacy, and it’s just been such a pleasure to spend time with you both today. Thank you so much for being on the show.

Melody Hartzler
Thank you for having us.

Lara Zakaria
Yeah, it’s been a pleasure. Thank you so much for this fun conversation.

Kalea Wattles
To join the conversation on this topic, visit IFM’s pages on Facebook and Instagram. For more information about functional medicine, visit ifm.org.