Is Folic Acid Toxic? What the Research Really Says

Intro:

Welcome to Dr. Ruscio radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

DrMichaelRuscio:

Hey everyone. Welcome back to another episode of Dr. Ruscio radio. This is Dr. Ruscio and today let’s discuss a case study, conservative functional medicine, and the appropriate use of antibiotics. Also a critical clinical review exploring a recent Medscape article on MTHFR, polymorphism, and folic acid. And some of this misinformation on both sides of the argument and at least our best attempt to provide a dispassionate overview on it. Finally, we’ll do a review of a study looking at the effect of modified citrus pectin on urinary excretion of toxic elements. Another way of saying this is how can binders help pull toxins out of the body? So this is what we will jump into here in a second. I just want to cue you in on the fact that this information has been taken from the Future of Functional Medicine Review clinical newsletter. During the month of April, you can sign up for $1 to have a full month of access.

DrMR:

It doesn’t matter when you enact that month, you will have a full 30 days of access to every back issue, going back for a few years with case studies, research study reviews, and practice tips. So again, to make it easy for you, if you’re a clinician or enthusiast, a health coach, really the newsletter could be used and viewed by anyone. We’re making it as easy as possible here periodically by opening up this $1 for a full month of access. So I hope you will go over to DrRuscio.com/review, give it a look, sign up. If you like what you learn, continue to receive that newsletter on a monthly basis so that we can stay attuned with what we are doing in clinical practice and what research we are looking at and how that’s informing what our clinical model is. So let’s go into this case study.

Oral Antibiotics for Peri-Menopausal Women

DrMR:

This was published in the February, 2021 FFMR (Future of Functional Medicine Review). This was a case study by Dr. Rob titled: Conservative Functional Medicine and the Appropriate Use of Oral Antibiotics for a Peri-Menopausal Woman. Key points: Stacy is a 48 year old, outgoing and active female. Previous diagnoses: infertility, endometriosis, and arthritis. She is on no prescription medication and she complains of being overweight, vertigo, hot flashes, insomnia, joint and muscle pain. Historic findings: In May of 2020 during a stressful life period she noted her last menstrual cycle and has been experiencing hot flashes, increased fatigue, insomnia, dizziness, or vertigo, some brain fog and just generalized neural cognitive challenges. Over the last three months, she recently completed a course of antibiotics for a concerning “sinus type infection” as she termed it. Fairly straightforward presentation thus far. One thing I’ll point out that is probably obvious with the way we’re framing it, this is a female hormone imbalance case.

DrMR:

This is one of the main facets that we’d want to focus on. However, I will see in the clinic, a number of previous doctors looking at a very nuanced, meticulous analysis of a thyroid panel and not going after or queuing in on foundationally the gut, but then also keeping the female hormones in mind. So the basic point there is, look to the female hormones as something that can cause thyroid hormone like symptoms. So let’s continue forward. Some of the notes and the differential diagnosis. For Stacy we are suspecting perimenopausal, hormonal fluctuations, a sub optimal diet insomnia, or inadequate sleep and underlying gut dysfunctions as the primary drivers of her symptoms.

DrMR:

We also want to be aware of potential cardiometabolic dysfunction, given her weight and cardiovascular disease reported in her family history. Her initial lab work found a fasting blood glucose of 103. So that’s something. White blood cells were normal. Differential is normal. Thyroid panel was normal. Again, this is according to the conventional diagnostic criteria. If we were to overlay this against the functional criteria, I’m sure an imbalance would have been found and hence the red herring that leads us down a usually unfruitful rabbit hole. Her cholesterol and fractions were normal except for an elevated LPA. A1C was normal and B12 was low. Folate, magnesium, copper, normal. Zinc was low. She had an elevated CRP and elevated homocysteine and also an elevation of her FSH and LH signaling molecules for estrogen and progesterone, but her estradiol was normal. What’s noteworthy here, oftentimes we want to assess the end hormones in this case, estrogen and progesterone. However, if you suspect peri-menopause, you could look at pituitary signaling.

DrMR:

I wouldn’t say that’s essential because you’re not really going to do anything about that process, but if you’re already having someone go to Lab Corp or Quest, those are fairly inexpensive markers. Depending on the financial wherewithal of the patient, perhaps you run these. Looking at someone’s symptoms, in my opinion, is probably the best way to go here, especially when considering that we’re using symptoms to say yes or no on frontline therapy of herbal adaptogens so to speak, to balance out the female hormones. So we don’t really need to get this meticulous lab read on the front end. In any case, some of the notes on the lab and lab interpretation, Stacey appears to be in perimenopause, moving into the menopausal state with rising LH/FSH, but normal Estradiol. She has a few nutrient deficiencies that could be from a combination of decreased dietary intake, maldigestion or malabsorption, and potentially increased utilization. Given some of her recent stress infection and inflammatory status. She appears acutely elevated with high levels of CRP that could be related to her soft tissue skin infection that appears to have both bacterial and fungal elements to it. Her blood sugar markers are optimal, but could be influenced acutely because of the suspected skin infection.

DrMR:

She appears to have a genetically elevated LPA that could be contributory toward her cardiovascular disease risk and explain some of her reported family history. However, her APO B is within normal limits. The recommendations at this point: A zinc supplement, a magnesium malate supplement, a B complex, a lactobacillus and bifidobacterium blend, a Saccharomyces boulardii, curcumin and an adaptogen. This would be an adrenal adaptogen, not a female hormone adaptogen like Estro harmony as an example, and for the soft tissue skin infection, a combination Lotrisone, amoxicillin, and Bactrim. These were used for 10 to 14 days. The clinical outcomes: Hot flashes and female hormone symptoms, improved without any hormone replacement or even female hormone supporting supplements. Really important to underscore that. I discussed that in Healthy Gut, Healthy You. Oftentimes digestive imbalances co-occur with female hormone imbalances. Oftentimes by improving foundational aspects of diet and lifestyle, plus gut supports, you will see improvements in those female hormone symptoms.

DrMR:

Then you consider escalating to herbal therapy second to that. In this case, just some basic nutritional foundational dietary lifestyle and anti-inflammatory support plus gut support. We see a nice improvement in her symptoms. Her skin condition improved with the antibiotics. Important to note that her gut was not hindered by this. I think patients tend to, and partially rightfully so, be wary of using antibiotics. I think antibiotics have been typified to be more detrimental than they actually are. Now, if we’re talking about indiscriminate use, especially in infants and children, that’s a big deal. If we’re talking about routine, repeat indiscriminate use in adults, that’s also problematic. But for an adult who is eating a healthy diet tending to their lifestyle and especially using probiotics, then the side effects or any ill effects from the antibiotics is attenuated quite strongly. It’s rare that we’ll see a patient in the clinic who is using an antibiotic, outside of Rifaxamin, that actually report GI problems.

DrMR:

It does happen on occasion, but as we reviewed in the past, the data are pretty compelling when looking at probiotic co-administration with antibiotics, reducing antibiotic associated diarrhea and other antibiotic associated side effects. I also want to make people aware of the one study that was mechanistic in nature, that decried that probiotics delayed the microbiota from returning to normal. Important note to point out there, how we define normal. The testing that is used, and the fact that the stool tests will assess the colonic and not the small intestine microbiota, makes that so incredibly difficult to extrapolate any useful information from. Rather what we should be looking to is a clinical outcome data. We take a cohort of people who are receiving antibiotics, half of them receive probiotics, the other half does not and we look at these hard clinical subjective endpoints, diarrhea and abdominal pain.

DrMR:

So any case this person did well with the antibiotic. Final note here, she was initially challenged with weight loss and we then moved to a more ketogenic diet with some rigorous fasting. That helped to kind of get her over the edge. Just to frame this, we’ll typically start with diet, lifestyle and gut health first, before we really push more into nuanced interventions for anthropomorphic measures. Whether they be waist/hip ratio, waist girth so to speak or weight. So that is a case study from the Austin Center for Functional Medicine published in the Future of Functional Medicine Review in February of 2021.

SponsoredResources:

Hey everyone, this is Dr. Ruscio with a quick note about immunoglobulins. If you haven’t yet tried immunoglobulin therapy, I hope you will try our Intestinal Support Formula. To make it a little easier for you to do so, we are running a promotion of 10% OFF if you go to our website, DrRuscio.com/isf, you can use the code, TryISF. What’s novel and unique about immunoglobulins is they seem to attenuate immune system overzealousness in the gut by glomming onto and kind of deactivating, almost like taking a shard of glass and covering it with wax, against toxins and bacterial fragments like LPS. What ends up happening is instead of these fragments triggering an overzealous immune system, causing inflammation, exacerbating leaky gut, leading to a whole array of different things like dysbiosis, food reactive brain fog or bloating, that cascade is attenuated by the immunoglobulins. Perhaps the best study looking at this was the one by Weinstock that found a 75% response rate, albeit uncontrolled, in patients who did not respond to diet, who did not respond to Rifaximin, who did not respond to antispasmodics. Certainly an exciting and novel therapy. If it’s not one that you’ve tried, or if you want to try it again, go and check out our Intestinal Support Formula, use the code, TryISF for 10% OFF.

MTHFR Debate

DrMR:

All right. So continuing over to what I’m sure people are curious to hear the consensus on, the MTHFR debate. This gene mutation is one that, a few years ago, was of such interest to clinicians that seminars on this topic would sell out. For whatever reason, it really caught wind and likely because clinicians were hoping that this would offer a key insight for patients who are otherwise non-responsive. This is something that clinicians are always grappling with. We may be able to loosely approximate that a third of patients are strong and quick, easy responders. Another third are moderate, kind of the meat of the Gaussian curve, normal pace responders.

DrMR:

Then the third are challenging. They’re reactive, and they don’t respond to the therapeutics that help the other 2/3. Because of that, clinicians, myself certainly included, are always curious and hunting and searching for what else could help these patients. Unfortunately, that curiosity is oftentimes preyed upon and to be sensitive and careful here, I don’t think it’s preyed upon with poor intent, but there’s this marketplace of ideas where various healthcare providers, doctors, gurus, supplement companies and lab companies all have hypotheses that they care about, that they’re passionate about, and that they’re trying to champion. There are some who really just care about making money. In trying to give everyone the benefit of the doubt, I’m going to assume that most people may have what they feel to be a good argument, but perhaps are making an attractive argument out of poor evidence.

DrMR:

I think the analogy I’ll use here and it’s been used in the past is that it’s like building a ship out of rotting wood. Building a yacht, an impressive vehicle out of rotting wood, or in this case a poor quality argument, or poor quality material. This is important for the field to be aware of because these specious arguments that are attractive on the surface should be exposed to due scrutiny, to make sure that they fact check and they withstand these probes. MTHFR is one of these that was attractive. Approximately five years ago I was running an MTHFR assay on pretty much every patient for a year to a year and a half. What I observed was little to nothing. Some patients had a little more energy likely just due to the vitamin therapy as we’ll talk about here in a moment. Folic acid supplementation versus folate supplementation seem to have similar effects on serum levels of either fully or homocysteine.

DrMR:

So that kind of supports my suspicion that all this song and dance and telling a patient that they have another thing wrong with them, because that is how patients’ are going to interpret this most likely, to obtain little to no clinical effect. Pardon my editorializing here, but part of what allows a clinician to piece these things together is a clinical model, which is why having a stepwise process where you intervene minimally and focus on only making one or a couple changes at a time allows you to get a gauge for how much a certain line of therapy moves the needle. That’s important because if you have a multi interventional model that you’re administering for all patients, you’re likely going to see effect. If you’re already, let’s say, making a dietary change, three lifestyle changes, supporting hormones, supporting adrenals, supporting the gut and supporting inflammation with antioxidants or anti-inflammatory nutrients or herbs.

DrMR:

Then you’re adding on top of that, a folate supplement, it’s going to be darn near impossible to tease out the Delta impact from plus or minusing the folate. So let’s unpack some of this. The article appeared in Medscape and the title of this article as it appeared Medscape: Online Misinformation Fuels a Fight Over Folic acid. So let’s go into an objective review and we published our review of that article on the topic more broadly in the February, 2021 FFMR. Key points here are that the Medscape article appear to be overall well-written, balanced and brought up some important points to consider for clinicians across all scopes of practice. Testing for MTHFR variants as a routine clinical practice in all patients may have many pitfalls. This form of genetic testing does not appear to readily change clinical practice with regards to nutritional supplementation and is likely unnecessary in the care of most patients.

DrMR:

Remember these are our key points that we’ve come away with after fact checking the claims from the Medscape piece and then this topic more broadly. Both the potential benefits of folic acid supplementation and folic acid fortification, and the risks from folic acid supplementation – so kind of both sides of this argument pro and con – appear overstated. Individuals from both traditional and functional medicine may be proporting degrees of benefit and or risk that do not correspond to population level data. That’s a shock. People would cherry pick to support their preconceived notion? I can’t believe that. It’s not to say that we are above this, but I like to think the way we operate is we are so sick of people having a bias that we kind of don’t care. We approach this stuff as neutrally as we can because we care more about what the signal from the scientific evidence is then does this fit within our preconceived philosophical construct. Which is a starting place. The philosophical construct of this kind of ancestral stressors foundations up approach, definitely including gut as foundation is a starting point, but it’s not something that we are unwilling to be flexible regarding and make modifications to.

DrMR:

Okay. The next bullet point here from our summary: clinical data suggests on average that individuals can achieve similar blood folate and homocysteine levels with equivalently dosed, folic acid, or folate supplements. That is the key point. There was also a good article by, I believe it’s Michael McGregor at nutritionfacts.org. I like some of Michael’s work. I find it to be a bit dogmatic in the vegan, vegetarian plant-based direction, but I appreciate his commitment to evidence. While I do think there is a bit of a selective showcasing of only the evidence that supports that hypothesis within what he’s evaluating, he does evaluate things fairly well and in a somewhat objective evidence-based way. He recorded a very interesting video, really confirming something I had come across a year or two ago from a quick search and had in the back of my mind to go back and do this more thoroughly. He did, which was to show that if someone is struggling to get their serum levels of B12 up, people will often argue that, well, you can have a deficiency of intrinsic factor.

DrMR:

So you need injections instead of the oral vitamin B12 supplement or a sublingual supplement. What I had found and what he kind of reaffirmed in a more comprehensive review was that you do not need to use injections to have that impact on the levels. A simple, higher dose of the oral B12 supplement, which is much cheaper and much less invasive than injections, will get you to the same place. This is what is being showcased here. Folic acid supplementation versus folate supplementation, it’s often said that if you have this MTHFR variant hetero or homozygous, doesn’t really matter. They’ll have slightly different levels of impact, but they’ll have the same direction of impact. It does not appear that that’s the case. We’ve talked about studies in the past. Most notably was the large population based study in Asia, finding a marked reduction in stroke risk when giving folic acid to MTHFR positive patients.

DrMR:

This may be because, pulling from a conversation with Dr. Tommy Wood, the magnitude of effect, I believe here, it could be slightly off on my number, but I believe it registers according to Woods analysis squarely at 1%. The impact of MTHFR on the ability to process folic acids compared to folate is 1%. Don’t quote me too critically on that, but I’m fairly certain that’s what Tommy had mentioned with regards to the impact of the gene polymorphism on folic acid. So I just pause the recording and look this up and here is the full statement. “The impact that the MTHFR polymorphism has on homocysteine levels is, at most, 1%”. According to Dr. Tommy Wood, this is less than normal acceptable lab error. This is a brief tangent here but I’m trying to do a better job of always discussing not only what the finding is, in this case, MTHFR impacts folic acid metabolism, but also, what is the magnitude of the effect or effect size?

DrMR:

It is inconsequential. This is important because if this was more robustly fact checked at the time that the gene seminars were selling out, and again, I think everyone was doing their best, but what I’m trying to continually point to without trying to be critical, just for the sake of being critical, I’m trying to be critical about the thought process. So before rushing into this, and I include myself in that criticism. Me five years ago was not doing as good of a job as me today. And that’s okay. I share this so that we can be progressing as a field, not so that people can dig in their heels and say, Oh, Ruscio doesn’t know what he’s talking about. What I care mostly about is that the field is doing a good job in bringing the patients things that can help them.

DrMR:

So if we can start just trying to quickly fact check what the effect size is of an intervention or the impact of a lab marker on a given outcome that can help prevent us from getting swept into one of these arguments. That’s attractive in what it promises, but actually quite disappointing in what it delivers. So coming back to the review here. The other point here is folate supplements are more expensive than folic acid. Also that third party testing does not suggest rampant fraud or poor manufacturing practices for most common consumer brand B complex vitamins, folate or folic acid supplements. This is always a balance because on the one hand, we should be open to where the field and the supplement companies used and intertwined into the field are trying to pioneer better products.

DrMR:

I think, to some extent, we are doing that. On the other, we want to be careful because, in any organization there tends to be two extremes. An academic and ultra cautious, nuanced and not wanting to say too much or promise too much. Then on the other side, where we need to get the word out to people. We need to give people an argument that’s simple enough for them to wrap their heads around. This natural tension sometimes falls too far toward the simple messaging of, let’s give people something to be excited about an opportunity to improve maybe your multivitamin with a methylated folate. It sounds good. This is where, if the fact checking mechanism is running, we’ll eventually catch these things. I hope I’m swaying the opinions or at least peaking the curiosity enough for an audience to actually read our full write-up with supporting references so they can see this for themselves.

DrMR:

I do not care if folic acid is better than folate. What I care about is, whether one of these is demonstrably better than the other. Just because people can say, you had this gene and insert a 30 minute lecture of the mechanism and how that mechanism ties to a hundred ways in which this is going to decrease your health. What I care about is the actual outcome data. Apologies if I’m monologuing here a little bit, but it’s the underlying thought process. I was having a dinner last night with Anthony Gustin, the owner of Perfect Keto. We talked about how the deepest layer is the operating system. The actions are just a superficial layer that are an outgrowth of what’s happening at the operations systems level. In this case, the thought process is part of the operating system. So I’m trying to get at the thought process because that will change all of these superficial actions that we’re taking. I don’t mean superficial in a vanity way. I just mean the deepest root cause is the operating system and the thought process. Superficial to that are actions. So if we can change the thought process, one thought process, in this case fact checking and effect size, we can change a whole array of secondary actions that we take.

RuscioResources:

Hi everyone. This is Dr. Ruscio. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to drruscio.com/Resources, you will see a few links you can click through for more. Firstly, there is the clinic, which I’m immensely proud of. The fact that we deliver, cost-effective, simple, but highly efficacious, functional medicine. There’s also my book, Healthy Gut, Healthy You, which has been proven to allow those who’ve been unable to improve their health, even after seeing numerous doctors, to be able to help them finally feel better. There’s also our store where there’s a number of products like our Elemental Heal line, our probiotic line, and other gut supportive and health-supportive supplements. We now offer health coaching. So if you’ve read the book or listened to a podcast like this one, or are reading about a product and you need some help with how or when to use, or how to integrate with diet, we now offer health coaching to help you along your way. And then finally, if you are a clinician, there is our clinicians’ newsletter, the Future of Functional Medicine Review. I’m very proud to say, we’ve now had doctors who’ve read that newsletter, find challenging cases in their practices, apply what we teach in the newsletter and be able to help these patients who were otherwise considered challenging cases. Everything for these resources can be accessed through drruscio.com/Resources. Alrighty, back to the show.

Questioning Genetic Testing Results

DrMR:

Okay. So let’s see here. What else? A few reflective notes. As anecdotes of what we’ve seen at the center, there have been patients who’ve had conflicting results for the same gene or genes from different consumer based testing companies, as well as academic laboratories. So this begs the crucial question, should we, as clinicians put full faith into genetic testing results and create entire treatment protocols based on a genetic result that may not be accurate.

DrMR:

When we look at that in juxtaposition to my earlier comments of consistently achieving positive results without the use of consumer-based genic testing, this really starts to build a case for this is probably something that we can get out of the model. The search should continue. We should continue to look for the rocks underneath which improvements for our patients reside. As we’ve been discussing, and will continue to discuss, I have a growing suspicion that a sizable number of people have mild to moderate sleep apnea who don’t know it. Raising my hand. I was just diagnosed via two different home sleep tests with mild sleep apnea. Now I’m still trying to make up my mind on how much that means, because I want to be careful not to just chase a lab value. However, my suspicion is with some simple myofunctional therapy said more simply tongue, neck, mouth, and lip exercises, I’ll be able to improve the resting tone of the musculature in the throat, and no longer have these apneic events at night. So if we’re going to talk about, well, why do you have this fatigue and maybe brain fog? It could be that you’re toxic. We live in a toxic world. You have the MTHFR gene heterozygous. That’s a hypothesis that’s worth consideration. I feel it’s now had due consideration and the case has not been made. The evidence that has been brought forth has demonstrated lack of benefit. It’s not that there’s lack of evidence. There is evidence and the evidence demonstrates lack of benefit, but let’s keep looking. Perhaps the area that we can redirect that energy and that passion for helping patients too, is boy, 20 to 40% of people snore. That is a huge red flag for apnea. And I don’t mean you snore so loud that you hear them from the next room.

DrMR:

That’s a bulls-eye the size of a cruise liner. But if 20 to 40% of the population snores then that is a fairly prominent red flag to raise for apnea. Apnea can be treated with things like mouth taping and myofunctional therapy and a temporary use oral appliance that, that are all corrective in nature. All these interventions and Apnea has been associated with hypertension, cognitive impairment, and more broadly sleep impediments have been associated with nearly everything from cancer to cognitive decline. Maybe this is the rock underneath which there are some solutions. So just to try to paint this in the perspective of just because one facet of practice is not showing promise, it doesn’t mean we’re putting up a roadblock and saying, don’t keep digging on behalf of our patients. The search must go on. In this case, it seems that it’s now time to divert attention into a different realm and a few concluding remarks from our writeup, our understanding of methylation MTHFR variations in the effects of folic acid and folate supplementation is constantly evolving consensus on best practices with regards to the role of MTHFR genetic testing and folic acid versus folate supplementation remains controversial. Educating individuals about whole food anti-inflammatory diets containing folate rich foods is encouraged and supported.

DrMR:

Basic blood chemistry, such as RBC folate, serum folate and homocysteine should be run before genetic testing and likely in place of at least for MTHFR. For conceiving mothers with marginal folate status, be mindful that supplementation with either folic acid or folate take upwards of nine months to get a sufficient level. So don’t fall into the trap after three months on folic acid that you have to spend significantly more money now on a methyl folate supplement. For cost conservative patients choosing a folic acid supplement over methylated folate is reasonable and appears to achieve similar effects as folate supplementation without harm. So that is the controversial topic of MTHFR.

Modified Citrus Pectin’s Effect on Urinary Excretion

DrMR:

Then moving on to the final piece here, a review of a study entitled: The Effect of Modified Citrus Pectin on Urinary Excretion of Toxic Metals.

DrMR:

This paper kind of comes down to a key idea for heavy metal detox. Do you really need EDTA, this kind of powerful binder? Is there evidence that anything natural actually has an impact or is clinically meaningful in that impact? So the study purpose here was to undertake an evaluation of the effect of modified citrus pectin on the urinary excretion of toxic elements in healthy individuals. The intervention: subjects ingested 15 grams of modified citrus pectin each day for five days and 20 grams on the sixth day, a 24-hour urine sample was collected on day one and on day six for comparison with baseline. The urinary samples were analyzed for toxicant essential elements. The results: in the first 24 hours of modified citrus pectin administration, the urinary excretion of arsenic increased significantly, 130%. On day six, urinary excretion was increased significantly for cadmium 150%. In addition, lead showed a dramatic increase in excretion of 560%. The author’s conclusion, this pilot trial provides the first evidence that oral administration of modified citrus pectin increases significantly the urinary excretion of toxic metals in subjects with a normal body load of metals. It is suggested that systemic chelation of toxic metals by modified citrus pectin may, in part, be attributable to the presence of certain binding compounds, which have been shown previously to chelate metals.

DrMR:

So the take home idea here, there may be a role for natural agents to support elimination of heavy metals in the urine. Utilization of chelating agents and elaborate detox regimens is very unlikely to be necessary. More research and information about modified citrus pectin and other binders would be helpful to guide clinical practice. So hopefully this is showcasing that another area that’s a bit controversial, detox,and something that we discussed a few years ago with Dr. Bryan Walsh. There’s evidence supporting, moving more in direction of the standard natural, functional and alternative medicine party line. Per the usual, how I approach these topics and how we at the clinic are integrating this into our care is an evolution based upon what the evidence is showing.

Episode Wrap-Up:

Reminder, all of this comes from the Future of Functional Medicine Review our monthly publication that contains a case study and either select research study reviews or mini topic reviews, and also occasionally some practice tips. During the month of April, you can sign up for your first 30 days of all access for only $1. And I really hope you will join because it’s these conversations that we’re having in that newsletter, especially for clinicians that I’m hoping will continue to guide practice. I have to say that doctors, Joe and Rob came across my work in part from that newsletter and started applying the concepts and their practices and writing in case studies about how application of the concepts from the FFMR was helpful with their patients. That snowballed into a beautiful partnership now at the Austin Center for Functional Medicine and much more to follow with various research initiatives. So it’s really now our attempt to share good information so as to help provide a stream of data to guide, practice and thinking in the field. So again, I hope you will head over to Dr. ruscio.com/review and sign up for your first month if it’s something that interests you. All right, I hope everyone is doing fantastic. I look forward to our next episode.

Outro:

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