Season 4, Episode 9: Integrating Pharmacy and Functional Medicine with Lara Zakaria

Evelyne: Absolutely. What is lighting you up this week?

Lara Zakaria: Ooh, that’s such a good question. We’re recording this, and as we’re transitioning kind of the last days of lazy summer and going into fall, and fall for me is the time of year that I start to take account and take assessment of different things. My birthday happens to also be in the fall, so it’s just like a perfect time to reset, see what maybe bad habits I might’ve picked up in the summer, what I want to readjust, reset, changes I want to make at home and changes I want to make going into fall, transitioning foods, eating more seasonally, changing up my supplement routine, so all that good stuff. It just happens to be this time of year for me.

Evelyne: I love that. Happy early birthday and I can’t believe we’re already this far into the year. It’s truly crazy.

Lara Zakaria: It feels like it went by very fast, but also very slow at the same time. I don’t know how that’s possible.

Evelyne: Yeah. Today we are talking about the role of the independent pharmacist, drug nutrient interactions and depletions, and Lara’s passion about both the prevention reversal of metabolic allergic and autoimmune disease, and for teaching about the practical application of nutrition and supplements into community pharmacy practice.

And, Lara, I’m also excited to talk to you because my parents are both PharmDs by training, though they always worked in regulatory affairs, and my grandfather was a pharmacist and he owned his own pharmacy, and my uncle still owns and runs it to this day in Belgium.

Lara Zakaria: Wow, that is so cool. Your pharmacy roots run deep. I would call that probably apothecary roots at this point.

Evelyne: I love that, and I do have training in herbal medicine. I trained with Dr. Tieraona Low Dog who we had on the podcast, so yeah, I do feel that connection, so I have a soft spot for pharmacists.

Lara Zakaria: Oh, that’s amazing. Oh my gosh. I bet we could nerd out at the dinner table at your house.

Evelyne: We definitely could. Definitely with my parents, that’s for sure. So Dr. Zakaria is a pharmacist and nutritionist with a focus on implementing solutions for functional medicine and personalized nutrition. A graduate of the Ernest Mario School of Pharmacy at Rutgers and the University of Colorado, Skaggs College of Pharmacy, she spent 20 years in community pharmacy practice. After developing an interest in nutrition, she earned her master’s in nutrition from the University of Bridgeport, and subsequently qualified as a certified nutrition specialist, as well as an Institute for Functional Medicine certified practitioner. She’s faculty at the Integrative Medicine Program at George Washington University, as well as a guest instructor for functional medicine at LECOM College of Pharmacy.

She is passionate about power in community, working with pharmacy professionals, nutritionists and other clinicians to leverage their unique expertise to amplify the message of personalized nutrition and functional medicine.

So, Lara, very interesting background. You even worked at CVS when you initially got out of pharmacy school, right? So I’m curious about your transition from working at CVS as a pharmacist, which is then very different from working at a community pharmacy. And then, what was that transition like? What was that moment of inspiration for your transition into functional medicine and nutrition?

Lara Zakaria: Yeah, I actually worked at almost all the major chains,

Evelyne: Oh you did?

Lara Zakaria: Not to date myself, yeah. Because either as an intern or as part of my rotations during my training when I was at Rutgers, or after I graduated, I’ve worked at three of the top chains that are still in existence today, Rite Aid, CVS and Walgreens. And I ended up, after I graduated, going with CVS. So in order to answer that question, I think I have to paint a little bit of a picture, because pharmacy has changed dramatically from the time that I graduated, from my undergrad, to now. And when I entered pharmacy, I entered pharmacy, we were all told that we were going to graduate, we’re going to get our license in one hand, and that we’re going to be able to jump into a career, that we are going to be able to make good money coming out, pay back our student loans, and that, essentially, coming out the gate, we would be set and that there were always going to be a need for pharmacists and pharmacy professionals.

At the same time, there was a growing interest in expanding the scope of pharmacy and pharmacists, meaning, we were seeing a decline in the number of primary care clinicians that were available to serve the growing need and the growing population. And that’s where you started to see a surge of physician assistants and nurse practitioners become mid-levels and to be able to meet that demand, and pharmacists were on track, at the time, to become providers and to be able to also provide primary care services to their communities.

That’s why you see a shift. If you talk to an older pharmacist, you might see that they only have a bachelor’s degree, a bachelor’s of science, five years, in pharmacy. And then, at some point in the early 2000s, late ’90s, we started to see a drastic transition to graduating pharmDs because they were trying to prepare the pharmacists for this change in profession, for the change in role where we would inevitably start picking up and supporting the community with primary care services.

And you could still see some of that today. You could still see that pharmacists started doing rotations. Most of us have doctorates. A lot of us have inpatient clinical experience as well as outpatient experience. We do ambulatory care pharmacy, that’s our version of primary care pharmacy. And you have pharmacy specialists that do things like diabetes education and work in co-ag clinics and things like that. So we can kind of see that. The thing is, we never saw the transition to pharmacists as provider in both states. And so as a result of that, we have a lot of pharmacists that still do the really important work of community and dispensing and in the retail space.

So when I graduated, there was so much demand for pharmacists to do that role, to do retail pharmacy. And so they were like throwing money at us. Anybody that graduated in the late ’90s probably remembers that. Early 2000s, there was a big demand, and especially in communities that had shortages of pharmacists. The big box chains were expanding in those areas, and they were meeting a demand of not enough pharmacy services, not enough places where people could get their medication. So that was a really easy sell for a kid who graduated college broke, you need a place to go. The money was good. And so a lot of us transitioned into that role, into that position.

Fast forward a few years, we see a major shift. We didn’t get provider status as promised. We start seeing a shift in the way insurance companies start reimbursing. We see a shift towards mail order pharmacy. We see the way that the big retailer started to purchase the third-party payers, and in that way, sort of created a smaller and smaller environment. And at the same time, a lot of acquisitions of the community pharmacists.

So as all of this is happening, I’m going through my own healthcare stuff. I am stressed out at work. If anybody in healthcare could probably relate, long hours, not enough breaks, not enough time to eat, not enough time to really take care of yourself. And even in my twenties, my health started to suffer. So in that transition, I started to explore ways for me to get healthier for myself. And in that, I discovered functional medicine. I found that I was really interested in nutrition, and that’s sort of what started me on that journey to transition over, and find a way to connect what I had learned in allopathic healthcare, to what I started to learn and understand from a functional perspective and from a nutritional perspective. And that would eventually pull me down the line to shifting over to community setting, and then eventually going back, getting my master’s degree in nutrition and embarking on this new chapter.

Evelyne: I love that. And thank you for describing the landscape of what pharmacy looks like and what it used to look like. I mean, I see it too. It’s just constantly changing with insurance reimbursement, and so I think it’s more important than ever for pharmacists to become educated in nutrition, in herbal medicine, in supplements.

And I think that pharmacists especially, because of your training, you are very well-equipped to be that person to help patients with this. Can you talk a little bit about some of those parallels?

Lara Zakaria: Yeah, absolutely. When I started to go down this road, herbal medicine was one of the things I first started to become interested in. And I think, at first, a lot of people said, oh, nutrition and herbal, it’s so the opposite of pharmacy. And I think people don’t realize that actually the root of pharmacy is herbalism.

Pharmacognosy, it’s one of my favorite words, pharmacognosy. It is the science of studying the mechanisms of plants in order to derive medicine. Now, originally, that was because we wanted to understand how the mechanisms work so we could use that plant more effectively, and eventually, we would develop pharmaceuticals that mimic those mechanisms. Classic example, red yeast rice. Once we figured out what that mechanism was with the HMG-CoA reductase inhibition, we then were able to develop multiple statins that mimicked that mechanism. Same with Willow’s bark and aspirin and NSAIDs. So there’s a lot of innovation that happens, because once we understand the mechanisms from plants, we can replicate that in pharmacy.

I think what’s really interesting is, not only finding that connection in the mechanism and understanding herbals from that perspective, but also being able to layer in. So we don’t have to think of it as pharma or herbalism. We don’t have to think pharmaceutical versus nutraceutical, but rather, how do we combine the two to improve safety and to improve efficacy? So number one, can we sometimes replace a pharmaceutical with a nutraceutical for better safety and better efficacy? And can we sometimes combine them safely to improve somebody’s outcomes? Or, can we avoid the combination in order to improve safety? So I think that is the real role of pharmacists right now.

I see patients are asking for, demanding, frankly, more holistic interventions. And I think pharmacists, particularly those in the community, have the best opportunity, not only because they’re accessible, not only because they’re knowledgeable, but they’re natural problem solvers. So if you’ve got a patient that is looking for a more holistic solution, I’d rather they come to you and have that conversation with their community pharmacist who knows them, knows their medications, knows their needs, knows their financial requirements, and can then solve that problem for them, in a way that really feels good to them and they feel taken care of.

Evelyne: Yeah, very interesting. And I love that too, even in compounding. You’re making medications just the same way that you would in making an herbal tincture or a salve or something like that.

Lara Zakaria: Absolutely. And again, solving a problem, because very often, we’re compounding things that aren’t available or they have a special requirement, like they’re not available in a dose that is appropriate for a specific individual’s needs, or we need it to be administered in a route that’s not commercially available. We’re doing the same thing. Again, that apothecary tradition just comes through to how we do pharmacy now, and we’re just building on that knowledge.

Evelyne: I saw that you recently spoke at a Cardinal Health event for the National Community Pharmacists Association, right?

Lara Zakaria: Yeah.

Evelyne: And you talked about the practical application of nutrition and supplements into community pharmacy practice. I’d love to delve deeper into this. What do you think is the way for community pharmacists to implement nutrition and supplementation, and also, knowing that, a lot of times, these patients are already working with possibly a functional medicine provider or with a nutritionist? Can you talk about some of those nuances?

Lara Zakaria: Absolutely. So first, I want to say that I think the opportunity starts with collaboration. I think it starts with working with the other nutritionists, functional medicine providers in your community. And I think working together collaboratively, putting our heads together, so that we can figure out the best way to serve our patients and our community. So that’s, I think, number one. I think, once you figure out what that is, there’s then different ways that the pharmacy can support.

To me, the lowest hanging fruit is drug-induced nutrient depletion. That’s the absolute basic place that I think any pharmacy can start out with. You have a medication. You know the list of nutrients that could potentially be compromised as a result of that medication, or the physiological impact or side effect that it might cause, and then you mitigate it using a nutraceutical. I’m going to pick on statins today. Statins is a really easy one. It’s a very uncontroversial opinion that statins deplete CoQ10.

So an easy thing to do, especially you know a patient’s going to be on a satin for a long time. We also understand the implications of CoQ10 in terms of mitochondrial health, heart function, vascular health, antioxidant capacity, et cetera. It’s a really easy decision to say, “Okay, you’re going to be on statin for a while. Now let’s couple that with a CoQ10 so that we can increase the efficacy of that statin.” Right?

Another easy one, antibiotics. We know antibiotics are going to change the microbiome. They’re going to alter the balance of our flora. We know it can lead to things like yeast infections and diarrhea and GI issues, a lot of which could be at least reduced, if not avoided, by using a probiotic. And we can also start thinking about longer-term therapy, things like prebiotics and polyphenols and postbiotics and things like that, to help offset, especially if we’ve got somebody who has a history of recurrent use of antibiotics. So that, to me, that’s the lowest hanging fruit.

And there’s usually resources. You don’t have to have them all memorized. There’s resources and tools that you can use to implement. And I would say the easiest thing to do is to pick those top movers in your pharmacy, even if it’s just 1, 2, 3, and start focusing on those. And as that becomes second nature, just watch how fast your patients start to send people over because they’re like, “Oh, that pharmacist doesn’t just give me a pill, they are really making sure that I’m taken care of. And hey, my side effects are better with this, or I feel a lot better because I started XYZ because my pharmacist suggested this.” So that’s, I think, number one, low hanging fruit, great place to start.

Number two is taking it to the next level, picking it up and starting to do consultations, or even quick little recommendations for OTC. We already do this. We already get asked, you’re behind the counter, you’re doing your work, you’re juggling a million things at the same time, and somebody shoots out a question and says, “Hey, what’s your favorite B12?” Or, “Hey, I’m having trouble sleeping. What do you recommend?” “Oh, hey, I’ve got these headaches. What do you think I should do? Allergies are really kicking my butt this year.” Whatever that is, we’re already used to shouting out that recommendation. What if you took that opportunity and you said, “Okay, here’s an OTC. This could work. If you’re looking for something a little bit more holistic, you’re looking for something a little bit more natural, I’d recommend you do this. Or do this while you do that, and let’s see if this doesn’t help together.” You could start making recommendations that way.

And then third, the next level would be to either rent out a space to another clinician, if you have the room in your pharmacy, hold community events for certain health topics and invite the community in to have those conversations. You could definitely include fellow clinicians, nurse practitioners, physicians, nutritionists, et cetera, in those conversations, and really build a reputation around that and start doing consultations as well with your community. One-on-ones.

There are also ways to bring this into the MTM model if you need to bill insurance. So there’s a lot of creative ways, but we don’t have to complicate it, and we could definitely use our space wisely, and most importantly, really be of service to our patients and our community.

Evelyne: Interesting. And, Lara, where are you located?

Lara Zakaria: I’m in the Tri-State area. I’m in New Jersey.

Evelyne: Okay. So I feel like, I’m in California, I’m in San Diego, and there are some community pharmacies, but it feels like, to me, different areas of the US, the community pharmacist is more that person. Maybe in smaller towns versus in the cities where, here, I mean, it’s like all CVS, Walgreens, Rite Aid, and then compounding pharmacies, and I find that pharmacists don’t often have the time to do a full consult with somebody. Since you’re speaking all over the US and talking to different pharmacists, do you feel like that’s true, that in certain areas it’s more like that?

Lara Zakaria: Yes and no. Time is definitely a challenge. That’s, I mean, the number one commodity for all of us. So I want to acknowledge that time is a factor.

I have seen pharmacists make it work in so many creative ways. I have seen… So I worked in Manhattan for a long time. I worked in New Jersey. I’ve worked in upper income communities. I’ve worked in lower income communities. The only place I haven’t worked is in a rural community, but I have quite a few friends that have educated me on the needs within the rural community. And what I find, the common denominator is that most patients who are coming to a community pharmacy are coming there because they value the added services that a community pharmacist can provide. And that’s what they’re coming for. They’re coming for the added benefits. They’re coming for delivery services. They’re coming because they know when they walk in, you know who they are, and that you could provide that extra level of care for them. And I don’t take that job lightly. I think that’s a really important role that we play. Whether you’re in a big city or in a small town, I think it’s really important for us to take care of each other in our community.

And very often, folks are coming to you because they don’t feel that care from their physician who are also really short on time and really probably would love to spend more time with you, but don’t have that luxury either. So I think, finding creative ways to provide those services can be useful. And it doesn’t always have to be one-on-one time. I often encourage folks to train their staff. Get your staff certified as health coaches, for example. Low-hanging fruit, and a great way for them to start engaging and really providing some of that foundational support for your patients.

I have some pharmacists that will hire a pharmacist for a few hours a week to come relieve them from the bench, and then they open those hours for consultations. Some will charge time, some won’t. Some will hold group sessions. Some will do after hours community calls, like a Zoom call with folks whoever wants to call in and ask questions, or they’ll hold coaching sessions or something like that to support a particular population. So there’s a lot of creative ways to use your time wisely.

And sometimes, you have the luxury of being able to charge out of pocket and got a community that’s more affluent, has the financial resources that wants to invest in their health, and they’re going to be more able to pay for higher cost items, to pay for consultations and things like that.

Then you’re going to have the communities that don’t have access to that, and that’s, I think, where we start to borrow from some of the leaders in our space or doing things like group coaching programs and creating mentorship groups using virtual sessions as a way to reduce costs and overhead and then using insurance billing. So one of the creative ways I’ve seen that done is you bring in a provider that could bill insurance, and they rent out the space and/or you do a barter, and then they are able to then bill insurance for their services and that sort of helps to compensate for the time and for the cost of those services.

There’s so many creative ways to do it and I wish there was one simple solution, but to your point, Evelyne, every community has its unique needs. Every community has its unique challenges, and I think most of us came into pharmacy, again, we’re problem solvers. We want to solve for that, and we want to meet the community’s needs and their expectation for a professional that can create those services, that can really meet those demands in a way that’s going to improve their health, that’s going to add and is going to just enhance the benefits.

Evelyne: Not that we advise on insurance billing on this podcast, but I have a clarifying question. So can pharmacists bill insurance when they do group programs or only other providers?

Lara Zakaria: It depends. It’s very different from state to state. So again, I’m going to speak very broadly and very generally. It’s very different from state to state.

In some states, pharmacists are able to bill as providers, and there’s some nuances to that. Depending on your state, you might be able to bill for certain services. You might be able to bill under a specific provider like a collaborator, and in other states, you don’t have that option at all, so those are collaborative practice agreements that vary, again, from state to state and how that might work out, so check with your state on that.

In other cases, you could bill it under what’s called a medication therapy management or a disease state management billing code. And in those settings, you’re essentially performing an MTM or a DSM, but you are integrating aspects of more holistic or integrative care. I’m seeing some clinicians, some pharmacists incorporating that. That’s a federal law, so that’s usually acceptable from state to state. It’s just whether or not it fits into your community and their insurance and the time that you have allotted to be able to manage that.

Evelyne: Interesting. And you mentioned in the beginning that so much has changed with insurance reimbursement with third party payers. Can you speak a little bit more about some of those changes?

Lara Zakaria: Yeah. This one is anxiety inducing because it really is changing the face of pharmacy, and what I’m about to say is probably not going to be very popular amongst my traditional pharmacists, but hear me out here when I say that the changes that are coming to pharmacy, in my opinion, are inevitable. As with any profession, I think we’re seeing a very dire and immediate need for us to respond and to do so in a way that preserves our profession. And again, pharmacy profession runs deep. So I’m very passionate about this because we are one of the first medical professions to arise. Right next to physicians, actually, there’s an argument whether physicians were first or pharmacists were first. If you go back and, say, the ancient teachings, very often, pharmacists and physicians perform very similar tasks. So this is, we’re talking a profession that is hundreds of years old and steeped in a lot of culture and tradition and ancient wisdom. So I don’t take lightly that we’re changing things in the way that pharmacy is being done.

But I do believe that we have to evolve, because at this point, pharmacy, in the United States at least, is based on providing a service and not providing a… Providing goods, not providing a service, excuse me. So in other words, we bill based on what we dispense. And what’s happening right now is that, we normally would bill for a medication. You come in and you fill, we’re going to pick on statins again, you fill your statin medication. There’s a cost to acquire that statin medication, and usually, there’s a margin that we add to that because we’re providing that just like any over the counter product that you might buy. And then there’s usually a fee to dispense it because we have to do the actual billing through an electronic software.

The third party biller is supposed to take that transaction and pay us those service fees. And what they’re doing is that they’re skimping on those service fees. And so you’re seeing a shift in how much we’re actually getting reimbursed for our services. And very often, we’re not getting even paid what we paid the retail cost of what we are dispensing. So this is why you’re seeing a lot of pharmacies, especially independent pharmacies, that are much more disproportionately impacted by these reimbursement rates, just trying to figure out other ways to start to create revenue so they keep their doors open and they can continue to serve their community. So compounding is one way to do that, for sure.

Another avenue is really leveraging OTCs, leveraging nutraceuticals, providing other services. And so you see a lot of diversification. In fact, I was just having a conversation the other day with somebody and saying, you’re going to see a resurgence in pharmacies of the old-fashioned, 1950s, where you had little fountain drinks and the ice cream parlor inside the pharmacy, because you’re seeing these combinations of coffee shops and gift shops and fountain shops inside the pharmacy as a way to diversify revenue and to be able to, again, keep providing services to that community and keep their doors open.

I believe that this is the time for us to start evolving and changing the way that we do pharmacy, but at the same time, meeting the needs of our patients in our community. So going back to the idea of problem solving, getting more creative in the way that we provide integrative healthcare, holistic healthcare, nutraceuticals, changing the game in terms of the expectation of, hey, I need a fish oil supplement, instead of going to the big box store, instead of going to Amazon, go to your local pharmacist that could tell you, one, which is the most effective and which is going to be the safest, and if it’s okay for you specifically to be taking that, because what’s good for your neighbor, what’s good for your brother, uncle, mother, whatever, may not necessarily be what’s best for you, and I think that’s where a pharmacist can really shine.

Evelyne: Yeah, and I think that pharmacists also have direct contact with patients, more so than maybe their doctor who they only see once a year.

Lara Zakaria: That’s a good point. Yeah, absolutely. Right, we usually go for our annual, unless we get sick, then we might go see our doctor more frequently, so maybe once a year, twice a year at best. Whereas the pharmacist, you have the opportunity to see every month if you’re refilling a monthly medication, or anytime that you go in to pick up an OTC or a nutraceutical. So those are always opportunities.

And again, some pharmacists are starting to now create hours in which they can actually exclusively make appointments, and you have that option to have a longer visit with them. And they’re setting up different financial ways to make that possible to meet the needs of their community.

Evelyne: I’d love to talk a little bit more about drug nutrient depletions and interactions. And I’d also love to mention that Designs for Health just released a drug nutrient interaction and depletion checker on the website, designsforhealth.com, and this includes supportive and negative interactions, as well as genetic SNPs that may affect the metabolism of those drugs, so of the top 25 most commonly prescribed medications, and we often hear about the depletions and the interactions, but not as much about supportive interactions. Can you talk a little bit more about those?

Lara Zakaria: That’s actually my favorite thing to talk about because it really gives it a positive spin. Because again, I think we’ve gone so far into this conversation of pharmaceutical versus nutraceutical, this like, it has to be one or the other. And I really think it lives on a continuum. There are some medications that are absolutely lifesaving. They’re effective, they work, they can be life-changing for people. And at the same time, we acknowledge that everything has a side effect, everything has a negative. And, we can also, just because you have to take a pharmaceutical for something, doesn’t mean that you can’t do all the other lifestyle interventions to also support that health condition. So we could do them at the same time. So I think that this brings us a little bit closer to starting to talk about the potential synergy and the place where we can really enhance people’s health.

So one example, one of my favorite examples, pain management is such a huge topic, and it could be so debilitating for people. It could be distracting. It could really take people out of their body literally, and they’re not really able to be present and fully enjoy the time with their family. It makes working harder. It often disables people. And so if we can make a nudge in people’s pain without having to resort to opioids or without having to resort to using too many NSAIDs that could potentially damage the gut and cause GI impacts and alter the microbiome and potentially have kidney or liver impacts, I think that’s a huge opportunity and a huge win.

And one of the ways that we could do that is by either using herbals that have anti-inflammatory properties, or using polyphenols, or combining them either to replace the NSAID, to reduce the need for the NSAID, or to reduce the side effect of the NSAID. So one example, there was a study on osteoarthritis specifically, that was looking on the NSAID… It was looking at Mobic specifically. So Mobic, we know, is actually a selective COX-2 inhibitor. So in theory, has reduced side effects, but they found that… Well, reduced side effects compared to the classic ibuprofen, for example.

What they found was when they combined resveratrol with the Mobic, they reduced the need for rescue pain management, which means that just by combining the Mobic with the Mobic, they were able to reduce the need for them to grab another NSAID to fill in when the pain broke through their primary management. They also found that more of the patients with osteoarthritis were able to tolerate 7.5 milligrams versus 15 milligrams of Mobic, without breakthrough pain.

So that combination on its own tells me two things. It tells me that it is possible, not only to safely use a nutraceutical in combination with an NSAID, but you potentially, think long-term, put that on a long-term scale, if that person’s osteoarthritis is not going to necessarily improve on its own, and they have to stay on a Mobic, we usually expect them to have to go up in dose or to need more aggressive anti-inflammatories. What we can protract that timeline by adding a nutraceutical at the same time.

Another study looked at ibuprofen with curcumin, and what they did was they had two groups. One group used the ibuprofen on its own, and the second group used ibuprofen with curcumin, and they both had the option to reach for an H2 antagonist, so the gastric pain as a side effect. The group with the curcumin not only experienced lower overall pain, but they also noted that they did not need to reach for that acid blocker nearly as often. And the thing I left out, in both of those studies, they measured the inflammatory profiles on the patients before and after, and the groups that had access to the polyphenols and the curcumin, they had actually lowered all their inflammatory markers. And the group that didn’t, didn’t have that benefit. So you could see, from both a clinical perspective and from an outcomes perspective, that they thrived with that combination. So that’s one example.

We have a lot of different anti-inflammatories that we can use. Fish oils, for example, SPMs. We can use things like EGCG, I mentioned resveratrol, curcumin, boswellia, cat’s claw. There’s so many different compounds, and finding that right combination for somebody that really helps to reduce their pain, not only are you going to reduce the potential impact of those NSAIDs, but I think, long-term, you can see all the various benefits, because that inflammation benefit is going to also protect their heart. It’s going to protect them from other chronic diseases, and I think can have a much broader impact as well.

Evelyne: I think something that steers people away, and when I say people, I mean maybe conventionally trained pharmacists, doctors, et cetera, from using supplements or even wanting to become educated is, A, some of the myths in the supplement industry, which I addressed on a recent podcast with Élan M. Sudberg from Alkemist Labs. But also, when you go and check some of these interaction checkers… I’ve been using the natural medicines database, which I think is great, and they list the levels of evidence from A to D, but a lot of those are theoretical. And so, I’d love for you to speak to that and speak to, as an example, it might say, oh, if somebody is on metformin or, I didn’t check this, but on GLP-1 drugs, maybe don’t take berberine because then they have the additive effect of lowering blood sugar. But sometimes you might want that, right? Can you speak to that a little bit more?

Lara Zakaria: Yeah. You are singing to my professor heart right now because you’re asking us to be a little bit more critical of the research that we are basing our recommendations on.

So first, if you could all just… If I can implore everybody to come on board with me for advocating for more clinically relevant research when it comes to drug nutrient interactions and drug-induced nutrient depletions, because to your point, Evelyne, the information that we have right now, much of it is theoretical. A lot of it is mechanism-based, so we’re making assumptions based on mechanisms and saying, well, if this has this mechanism and this has this mechanism, then put it together, then that’s probably going to be bad, right? Question mark? And we have very few RCTs, and when we do, they’re smaller. And when we have larger meta-analysis, they’re imperfect because there’s not enough RCTs to draw data from.

So I think one of the things that we have to do is kind of put our clinical thinking hat on, approach it more as an art. And again, this is where, not to keep tooting the horns of pharmacists, but this is where I think pharmacists can really shine. Being able to take the information that we have, and essentially translate it and say, okay, this is a risk I think we can take, and this is a risk I am not willing to take. And very often, the data, yes, it is graded, but even when you look at the grading of the data, it’s quite low. And then you look at it and you say, okay, you made a great example of berberine and metformin. Okay, well, what happens if somebody takes too much metformin? Not much. Their blood sugar does drop, but we don’t see hypoglycemia episodes, like dangerous hypoglycemia episodes when it comes to metformin.

So in that case, I would say, okay, probably adding a little bit of berberine, maybe let’s taper it. Let’s be very slow, slow and gentle with it, and see how somebody responds. This is, again, where being able to have quick contact with that healthcare professional to say, hey, how are you feeling today, I feel fairly confident that we can do that. We can add 250 or 500 milligrams and see what happens and maybe raise it up a little bit. Do a CGM on them and see how they’re doing. Monitor them closely, number one.

Take something like insulin, I’m not going to take that chance, because we know you can have hypoglycemic episodes with insulin, particularly with short-acting insulin. So we’re not going to take that chance. Same with hypertension. I discourage aggressively shifting blood pressure with people. So we were going to go nice and slow. We’re going to add things that are going to be supportive first. We’re going to add things that are the essential nutrients are needed to manage blood pressure. We’re going to add the nutrient depletions that we might be expecting. But we’re not going to aggressively try to get their blood pressure down while they’re on 2, 3, 4 different antihypertensives because I don’t need them fainting and hurting themselves.

So again, this is where the clinical thinking cap comes on and we go, okay, what’s the potential risks to the patient, and what’s the potential benefit? And what kind of monitoring do we need to employ in order to make sure this is safe and effective for them? Do I need to make sure that they have a blood pressure machine at home? Do I have to advocate for CGM for them? Do we need to get them in for some blood work before we try this experiment? And I think this is, again, where if you have the ability to add these extra services to your pharmacy, they can not only be a great way to create revenue, but they’re, frankly, a really important and needed service for your community.

Evelyne: Interesting. I also find it fascinating that there isn’t as much research on herbal medicine here, but I saw that you shared something about, in places like Eastern and South Asia and the Middle East and parts of Europe and South America, they have done a lot more research on herbal medicine, but sometimes, we don’t even see that published here on PubMed. Can you speak a little more to that?

Lara Zakaria: Evelyne, you really have been scouring my LinkedIn. Thank you very much.

Evelyne: I have.

Lara Zakaria: I work very hard on that, so thank you.

Yeah, absolutely. So I am always trying to advocate for the traditional roots of herbalism. Very often, myself, when I started to enter herbalism, I was very much approaching it from my allopathic western lens. What’s the mechanism? What’s the evidence? How many RCT trials are on it, et cetera? I think that’s one way to approach it. However, as I started to immerse myself a little bit more with herbalism, and traditional herbalism in particular, I started to see the intersection with making sure that we’re preserving the cultural roots of where those herbs came from. And I think one of the most important things, my aha moment, that really helped to crystallize, for me, the relevance of that was when I realized that what we’re trying to do is compare an allopathic approach to looking at pharmacology that’s maybe a couple of hundred years old, if I’m being generous, to something that has hundreds of years of wisdom, generation to generation to generation to generation, that’s been passed down. And there is not a single clinical trial that we have, on pharmaceuticals, on nutraceuticals, on anything, that can surpass that level of evidence.

And when you start to look at the numbers and think of it that way, and you sort of start to realize that these ancient civilizations, that didn’t have a microscope, that didn’t have the ability to extract compounds, were able to observe and intuitively understand how mechanisms worked. We’re finding out now are accurate and true, and we’re almost finding using science now to validate them. So to me, that opened up my eyes in a way to looking to more cultures that valued the root of herbalism.

So when you look at the Far East, you look at Japanese and Chinese traditions, you look at Ayurvedic traditions in India and South Asia, you look at Middle Eastern traditions, and even in Europe, you see that there is a heavy emphasis on those traditions, and that those are being studied in their universities, and that there because the culture values them, you see more emphasis on the scientific research to validate them and to learn more about them.

Whereas in the United States, we have more of a tradition of pharmaceuticals and emphasis on science and advancement from that perspective, and that’s essentially where our funding goes. So if you go into PubMed, you’re not going to see the research from external universities. You’re going to see everything that’s done here, with a few exceptions, but largely, it’s US universities or Canadian universities at best. Whereas if you start to search outside of that and you start to look through Google Scholar or you start to cast a wider net, you start to see more and more universities funding and producing evidence that really helps substantiate, one, mechanism type trials, understanding how things work, and two, clinical trials, and then three, meta-analysis and reviews that really help us to put the data together.

So I think just from that, opening ourselves up and realizing, hey, who out there, what universities, what cultures, what traditions can we learn from, and start truly integrating it into what we’re doing. Again, it’s not this versus that, but more so respecting the roots of that tradition.

Evelyne: I always thought it was interesting, and I learned this from Dr. Low Dog, that across different cultures, they use the same plants for the same thing, even if those cultures never interacted before. That’s fascinating to me.

Lara Zakaria: She is truly one of my idols slash mentor slash… She is actually part of the reason I started to change my perspective. Listening to her explain those traditions, that sort of seeded in me a different outlook. So I’m a huge fan of her work, and she’s clearly the GOAT in this.

Evelyne: Oh, I’m a huge fan too. I was definitely a fangirling over her when I interviewed her.

Lara Zakaria: Oh my God. Yeah, I can’t even imagine. That would be so exciting.

Evelyne: I’d love to ask you a little bit more about your teaching and also your volunteer work. In your teaching, you are teaching pharmacy students, and we’ve had some other guests on the show who teach newer doctors about functional medicine and how it opens their eyes, and it’s exciting, that this is starting to be talked about in conventional medicine. Do you feel like the same is happening in pharmacy? Or is it still sort of limited?

Lara Zakaria: Absolutely. Oh my gosh. So first, I’m seeing a huge surge in pharmacists, like active pharmacists, again, I think in response to their own interests, as well as their patient’s needs. But the students, oh my God, they are so lit up.

So I have the opportunity to guest teach at a pharmacy school, LECOM in South Florida. One of my colleagues, Vanessa Lesneski started a course on functional medicine, an introductory course for students on functional medicine, as well as a rotation for students in functional medicine, which is absolutely amazing. And she says that, ever since she started the course, she has a waiting list, almost immediately as soon as registration starts. The demand has been so high. They’re actually doing a part two to that curriculum.

Evelyne: That’s awesome.

Lara Zakaria: It’s so awesome. Number one, I love seeing the interest of students and their questions. They just get really lit up on these topics. And number two, I sit here and I imagine, if this seed is planted now, this interest is planted in them now, I’m so optimistic about the future of our profession and where we’re going to go, because they’re already starting to come up with creative ways to integrate it. They’re already learning it alongside their pharmacy curriculum. They are going to be these amazing clinicians that not only hold space for their patient’s needs, and they’re also going to hold space for this holistic, integrative and functional approach, and I just think that’s so cool.

Evelyne: So you’re also on the board at the Ocular Wellness and Nutrition Society, so can you talk a little bit more about that?

Lara Zakaria: Yeah, absolutely. So OWNS, as you said, Ocular Wellness and Nutrition Society, is really dedicated to increasing awareness and education around the role of nutrition in ocular healthcare. And one of my really good friends, actually, my fellow Rutgers alumni, Dr. Neda Gioia, she is currently serving as president, so she brought me in to help bring, one, the pharmacy voice in, as well as additional nutrition, the CNS voice as well. And I got to tell you, it’s been such an amazing opportunity to learn. I think, a lot of us, if we’re not specialists in eye health, see the eye as its own thing, an important and vital organ for us to maintain and keep healthy. And certainly, there are some risk factors with eye disease and other chronic health conditions.

But one of the things that really opened my eyes up to the potential role of learning more about eye health was that it’s literally a window to the brain, and it’s a way to really understand brain function, neurological function, vascular health. I was taught that you can actually predict and measure insulin resistance and metabolic disease, years in advance, quite accurately, by looking at oxidative stress in the eye.

So there’s just so much potential, again, from this lens of really truly collaborative work of bringing clinical professionals together to learn from each other and to work together to really optimize the health of our patients. Can you imagine a truly holistic approach where you’re using the eye to help to predict and preserve, not only eye health, but neurological health and metabolic health? And using that as a segue to really encourage more lifestyle changes and bringing in a nutritionist to really optimize their nutrition and lifestyle, and bringing in a pharmacist to really optimize their pharmaceuticals and nutraceuticals, and then working with their primary healthcare provider to ensure that we’re managing and monitoring them properly? I mean, it really is. It can be this really cool way for us to really start thinking about holistic care, and again, community care in a really proactive way.

Evelyne: Absolutely. And we actually did a very interesting episode with an ophthalmologist, Dr. Rani Banik in New York.

Lara Zakaria: She’s awesome. I had the pleasure of briefly meeting her at the IHS Conference, I think, last year in New York. She’s very cool.

Evelyne: Yeah. So, Lara, where can practitioners or pharmacists learn more about you?

Lara Zakaria: Yeah. So the number one place I would say is on social media, so come visit me, either on Instagram or LinkedIn is where I’ve been most active recently, and you could find me either by searching my name or looking for “foodie farmacist”. So that’s two F’s, foodie farmacist, not with a PH, but with an F. And you can also come to my website, larazakaria.com. But I really enjoy meeting other clinicians that are interested in this integrative space in health and wellness, whether pharmacists, nutritionists, or other healthcare professionals that are really looking to find a way to create community and work collaboratively. So please don’t hesitate to say hi.

Evelyne: And where can pharmacists learn more about functional medicine specific to their profession? I know that at Designs for Health, for example, we have the dietary supplement specialist program that they can take. What are some other resources?

Lara Zakaria: Absolutely. What a great resource that is. So outside of the academic sources, we already mentioned Natural Meds Pro. You can go there to look specifically at drug interactions, and as we said, where they’re graded, the level of evidence that’s available. You can go get resources like examine.com, which is a great resource for just looking at nutraceuticals and the level of evidence available and how to use them.

But if you’re looking for something specifically training, specifically for pharmacists for continuing education that is going to help you with implementation, I would recommend Functional Med CE. I do teach very often there, and I do often advise on the curriculum, so just for full transparency, but that is created by Melody Hartzler, a fellow pharmacist, functional medicine pharmacist, endocrinology background. And she has done a really great job of curating continuing education content for pharmacists specifically interested in accessible content, to teach you about functional medicine and to help you start to implement some of that education into your practice.

And then one more resource for pharmacists, especially if you’re looking for community support and other pharmacists that might be on a similar journey as you trying to explore ways to bring in more nutrition or nutraceuticals or functional medicine into your practice, would be FMPHA, Functional Medicine Pharmacists Alliance, which is a professional group organization started by Lauren Castle, fellow pharmacist, functional medicine pharmacist, nutrition expert, and that is a great, I think, community for additional support and opportunities for education.

Evelyne: Great resources. Thank you. I’d love to just ask you some rapid fire questions that we ask every guest. Number one, what are the top three supplements that you take?

Lara Zakaria: Oh, that’s a good one. Okay. Number one non-negotiable is vitamin D. Most of us need vitamin D and I personally take vitamin D every day, and I try to get my vitamin D levels checked, if not annually, twice a year ideally, that doesn’t always happen, to make sure that I’m getting the right amount of vitamin D, so I dose adjust based on that from summer to winter.

Number two would be magnesium, also, in my opinion, a non-negotiable. I may not be great about taking it every single night, but I do try to incorporate that as often as possible, particularly the glycinate form. Because of the absorption, it helps with sleep, so some good benefits there.

Number three these days for me has been maca, a combination of the fact that it’s an adaptogen, so great for stress management, adrenal support, and also because of its benefits on hormone balance as well. So those are probably my top three. My actual farmacy with an F is a lot bigger than that, but those are my three non-negotiables, I’m going to take them.

Evelyne: Yeah, mine too. So many products. What are your top health practices to keep you balanced?

Lara Zakaria: Can I say sleep, sleep and sleep?

Evelyne: Sure.

Lara Zakaria: No. So number one is definitely sleep. I have learned to prioritize sleep above all else, and I do everything that I can to make sure that, even if I can’t necessarily always get to bed as early as I’d like, or I have to wake up earlier than I’d like, I try to, over the course of the week, really balance it out as much as I can. And I give myself a little extra time in the morning so that I can get the extra rest if I need it and get a good start to my day. So I have the luxury to do that, thankfully. Doing what you can, I think, to set your circadian rhythm, wake up at a regular time, go to bed at a regular time, get light exposure in the morning, try to minimize blue light exposure in the evening, I think is such a powerful tool in terms of a foundational health set.

Two would be movement. So trying to, throughout the day, keep moving. I have a standing desk, I’m actually standing at it right now with a little balance board under me, so that keeps me a little bit mobile as I’m sitting in meetings or typing something up. I use that as a way to keep myself moving throughout the day. But I try to go for a walk in the morning, or if I can’t get it in the morning, at the end of the day, and just in general, try to put in little bits of movement, shorter verse of exercise throughout the day.

And number three, I’m going to go back to community, just making sure I’m prioritizing my connections, my family, the people that are important in my life, my friends, making sure I’m keeping tabs on those relationships and that I’m really nurturing them. When we look at the longevity research and we look at the impacts in the blue zones, for example, the number one thing that always comes up, yes, diet is important. Yes, sun exposure can be helpful. Yes, movement is important. But community and how we do those health activities together is probably one of those esoteric benefits that is really hard for us to measure.

Evelyne: Absolutely. And last question for you, what is something you’ve changed your mind about? I feel like you’ve kind of already addressed this, but maybe something else, maybe more recently?

Lara Zakaria: One of the things I think I’ve learned from my experience as a clinician over the years has been that, you don’t want to hold on to something too tightly because any theory, any research that comes up is inevitably going to pendulum swing back the other way. So if you’ve been around long enough, you’ve seen the swing from low fat to high fat, high carb to low carb, vegan to carnivore. These ongoing debates are always happening and I think that is what science is about. Science is about being flexible and finding the truth in something.

I think that, if I had to say, if I had to pick one thing, when I first started doing nutrition consulting, counseling and stuff was at the height of elimination diets and autoimmune diets, and really trying to figure out what trigger foods were and the beginning of the rise of gluten-free diets and things like that. And although I believe that there’s a place, still therapeutically, for elimination diets and for therapeutic diets that might be more exclusionary, the biggest swing I’ve had was in rather trying to present it as an inclusionary diet. So how do I, instead of villainizing foods, villainizing components of foods, rather think about what we can add into a diet, what’s missing from a diet, so that even if I have to remove something, I am actually not just removing it, I’m replacing it with something that is going to be as good as, if not better in some way. And that to me has opened up, sort of pulled on a string of thinking about how food naturally is.

When I think about eliminating things that make diets too restrictive, I think of, again, ancestrally, culturally how we’ve always eaten those anti-nutrients or things that are possibly bad for us or bad for some of us. I don’t think we culturally could have thrived on them if there wasn’t some benefit to them. So I think just becoming a little bit more nuanced in my approach when I’m prescribing therapeutic diets, and again, thinking about things as inclusionary rather than exclusionary.

Evelyne: Great. I love that. Thank you so much for sharing. And thank you, Lara. This was such a great conversation. Really enjoyed talking with you today.

Lara Zakaria: Thank you, Evelyne. I really appreciate this. Such a fun conversation and definitely can see those apothecary roots in your questions.

Evelyne: Well, thank you so much for tuning in to Conversations for Health. Check out the show notes for any resources from today’s show, and check out our website for the new drug nutrient depletion and interaction checker. Please share this podcast with your colleagues. Follow, rate, or leave a review wherever you listen, and thank you for designing a well world with us.

Voiceover: This is Conversations for Health with Evelyne Lambrecht, dedicated to engaging discussions with industry experts, exploring evidence-based, cutting-edge research, and practical tips.