The Role of Stress and Nutrient Availability in Circadian Metabolism

BY THOMAS G. GUILLIAMS, PHD

In the last several years, I dove into the research exploring the intersection between circadian rhythm and the HPA axis. As most of you probably know, normal cortisol production follows a predictable circadian output, which rises sharply upon awakening (the cortisol awakening response, or CAR) and then drops quickly over the next few hours, gradually declining and reaching its nadir late at night. What many may not know is that glucocorticoid receptors (i.e., cortisol receptors), found in almost every tissue, are vital in helping to maintain peripheral circadian rhythm, which can greatly influence cellular metabolic function.
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The Breakfast of Functional Medicine Champions

BY SHILPA P. SAXENA, MD

When I first began my foray into functional medicine, I was pleasantly surprised to hear of this thing called functional foods. As someone who doesn’t like to eat solids for breakfast, who loves the concept of eating but feels it gets in the way of more pressing matters, and who surely needs some daily nutrient therapy for existing and future medical issues, I found functional foods deserved that heavenly operatic “Ahhhhhh” when I began enjoying all the benefits they provided me in my day-to-day life.
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Simplifying SIBO: Case Study + Treatment Plan

By Vincent Pedre, MD

You have a new patient coming in to see you. As you peruse her intake forms, you see she has already been treated for small intestinal bacterial overgrowth (or SIBO, for short) several times, and she comes in complaining of recurring symptoms. As you prepare to see her, you feel a rivulet of sweat down your back, knowing this is going to be a tough case. What is the most effective strategy for a patient like this? In this blog post, we’ll use this sample case study to examine the challenges and pitfalls of diagnosing and successfully treating SIBO.
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Resetting Circadian Rhythms of the HPA Axis

By Christopher Mote, DO, DC

After nearly 20 years of clinical practice, I have found one concept makes all the difference between partial and significant clinical effectiveness: understanding and harnessing the power of circadian rhythms.
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Pain, Addiction and the Opioid Crisis: A Fresh Perspective for a Growing Epidemic

By Adrian den Boer, ND, DC and Shilpa P. Saxena, MD

From the pages of medical journals to the worried minds of family members watching loved ones suffer, the opioid crisis continues to permeate our society. Whether in chiropractic, allopathic or physical therapy offices, clinicians must focus on bringing awareness and solutions to patients concerned about physical pain and the very-real risk of addiction.
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Strategies to Move Patients from Acute Injury to Long-Term Wellness

By Adrian den Boer, DC, ND

If patients are experiencing low back pain, they’re not alone. About 80% of adults experience low back pain at some point in their lifetimes, and it is one of the most common reasons patients seek out medical care. Most causes of low back pain are not acute broken bones or traumatic accidents, but subacute/overuse injuries in which increased mechanical stress accumulates and degenerates body tissues over time, resulting in tissue failure. Any injury, whether categorized as a micro or macrotrauma, results in biomechanical dysfunction and is commonly characterized by both pain and inflammation.
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4 Ways to Make Your Functional Medicine Clinic More Profitable

By Christopher Mote, DO, DC

Profitability: A concept few want to talk about and just about all of us are concerned about.
Whether you are just starting out in practice or have reached a point of fatigue and burnout, “how” as well as “how much” you are compensated for your considerable efforts helping patients is extremely important. Regardless of our motivations for entering the medical profession, all of us have some expectation for personal income we can or should attain.
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Mitochondrial Dysfunction: Key Indicators You Might be Overlooking

By Angela Lucterhand, DC

How many patients walk through your door with a chronic disease diagnosis? If you answered, “almost all of them,” then you see mitochondrial dysfunction daily. In cell physiology, you learned that mitochondria are the powerhouses of cells; they are responsible for creating cellular energy, known as ATP. However, we often forget how mitochondria are negatively impacted by HPA axis and metabolic stressors, certain medications, and poor lifestyle habits.
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Ketogenic Diets for Cardiometabolic Outcomes: What is the Evidence?

by Thomas G. Guilliams, PhD.

While the ketogenic diet (KetoDiet) may have had its roots as a treatment modality for epilepsy as far back as the 1920s, variations of this diet are now mostly popular for their metabolic outcomes (e.g., weight loss, improved glycemic control, etc.) or for cognitive support/neurological conditions (e.g., Alzheimer’s disease, malignant glioma, migraine headache, and other neurologic disorders).
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Microtrauma: The Little Things Matter

By Adrian den Boer, DC, ND

It was a typical Monday morning. I walked into one of our treatment rooms and encountered a fit, 53-year-old female patient in severe pain. She had severe right cervical pain that radiated into her right arm and hand. Her debilitating pain drastically limited her ability to move her neck in all directions and perform simple daily activities.
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Gastrointestinal Lab Markers That May Be Telling You to Use Immunoglobulins

By Angela Lucterhand, DC

In the world of functional medicine, testing has come a long way. Not only do we have more types of tests that can be performed, but the analysis has evolved, too.
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New Frontiers in Cardiovascular Medicine: Vitamin K2 as MK-7, Part 3

Jeffrey Bland, PhD, FACN, CNS and Leon Schurgers, PhD

As scientists continue to find evidence that interfering with vitamin K may have unintended effects like vascular calcification, they also hope to research how calcification can be prevented.
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New Frontiers in Cardiovascular Medicine: Vitamin K2 as MK-7, Part 2

Jeffrey Bland, PhD, FACN, CNS and Leon Schurgers, PhD

When the body uses vitamin K in blood clotting, the vitamin K is recycled through a redox reaction. Warfarin prevents clotting by blocking the recycling enzyme in this reaction. But this inhibition of vitamin K in the vasculature by warfarin may be detrimental.
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New Frontiers in Cardiovascular Medicine: Vitamin K2 as MK-7, Part 1

Jeffrey Bland, PhD, FACN, CNS and Leon Schurgers, PhD

Vitamins have captured the attention of health-conscious people ever since the term “vitamin” was coined in 1912. Named “vita” for life or life-giving and “amin” for amine compounds, scientists now know much more about these crucial dietary components, including the fact that not all vitamins contain amine groups. There is still more to learn about how vitamin intake from our diets prevents or causes disease, or how diseases may cause vitamin deficiencies. But some experts are raising a new concern: that the common drug warfarin is actually contributing to disease by interfering with vitamin K.
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Nailing and Scaling the 80/20 Rule in Cardiometabolic Disease Treatment

By Shilpa P. Saxena, MD

If you talk to non-clinicians in the health care industry, you may not be surprised to find they are not overly impressed with the average clinician’s understanding of business philosophy. Who would blame us clinicians? We focus on patient care, and the most important thing we may learn about the “business” of conventional medicine is how to optimize billing and coding.
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The Missing Piece in the Autoimmunity Puzzle

By Angela Lucterhand, DC

It’s no secret that so many Americans suffer from chronic disease, especially autoimmunity. We have done a great job making the connection to leaky gut; however, sometimes healing leaky gut can be a conundrum, and new evidence supports the idea of endotoxins playing a role in patients that seem to stall in their treatment.
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Strategies for De-Stressing Your Practice

By Christopher Mote, DO, DC

We usually discuss stress and its effects on our patients, but today I’d like to discuss the impact of stress on the physician.

Physicians, and all health care practitioners, face innumerable stressful conditions every week. In my 18 years of clinical practice, some of the “biggies” have been related to documentation and electronic medical records, technology glitches, staffing and staff-related concerns, maintaining CE requirements, malpractice costs (and ALL costs in general) among others. Over the same time period, it seems these have intensified or even multiplied, and the cumulative effects are significant.
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Lifestyle Medicine’s Approach to Tackling the Chronic Pain Problem

By Adrian den Boer, DC, ND

According the CDC, NIH, and Institute of Medicine, more than 30% of Americans are living with some form of chronic or severe pain. To put this in perspective, 116 million Americans live in pain, compared to the 30.3 million who suffer from diabetes, 25.4 million who suffer from cancer, and 14.7 million who suffer from heart disease. More people have chronic pain than suffer from major chronic diseases, and the economic burden and complexity of chronic pain are of epidemic proportions—and growing. Musculoskeletal pain is the number one presenting complaint in clinicians’ offices, and most are ill-equipped to handle it.
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Neurotransmitters, Mood and the Perception of Stress, Part 3

By Thomas G. Guilliams Ph.D.

The hypothalamus is directly innervated by neuronal systems that produce neurotransmitters, such as serotonin (5-HT), dopamine and norepinephrine (NE), that are involved in mood regulation and play various other roles in cognitive health. During the acute stress crisis, the mesolimbic dopaminergic reward system is stimulated to help maintain morale. However, during chronic stress or depression, the reward system is down-regulated by stress mediators, resulting in anhedonia.
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Neurotransmitters, Mood and the Perception of Stress, Part 2

By Thomas G. Guilliams Ph.D.

When we talk about “stress,” or allostatic load, in terms of the perception of an event, we must realize that these “events” must first be translated into neurochemical signals before they trigger the HPA axis. Therefore, the sensitivity and outcome of translating these events (whether they are ongoing events, memories of past events, or stressful anticipation of unrealized events), is highly dependent upon signaling from other neurotransmitters. In fact, the signaling neurotransmitters that manage mood and affect often overlap with measures of HPA axis activation, and cannot be easily distinguished in some subjects.
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Neurotransmitters, Mood and the Perception of Stress, Part 1

By Thomas G. Guilliams Ph.D.

When we talk about “stress,” or allostatic load, in terms of the perception of an event, we must realize that these “events” must first be translated into neurochemical signals before they trigger the HPA axis. Therefore, the sensitivity and outcome of translating these events (whether they are ongoing events, memories of past events, or stressful anticipation of unrealized events), is highly dependent upon signaling from other neurotransmitters. In fact, the signaling neurotransmitters that manage mood and affect often overlap with measures of HPA axis activation, and cannot be easily distinguished in some subjects.
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Setting Successful Treatment Expectations for Your Patients in the New Year

By Vincent Pedre, MD

You’ve created an amazing A–Z plan for your patient. You’re excited to apply all your functional medicine knowledge. They walk out the door with pamphlets, instructions, and a bag of supplements you’re sure will alter the course of their chronic illness. The patient gets home and realizes, “Oh, oh…I can’t do all this!” Two to four weeks later at follow-up, the patient tells you they only did one or two things on the list of 10 perfectly planned interventions for their condition. You feel like you failed, but really, you set your patient up for failure.
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A Scientific Turn of Mind

By Christopher Mote, DO, DC

“It’s all in your head.”
This is the last thing a patient with stubborn symptoms wants to hear from their doctor. I recently said this to my 40-year-old female patient with chronic insomnia, fatigue, depression and pain, not because I couldn’t find the root cause for her health concerns, but precisely because the brain had become the primary initiator and perpetuator of her symptoms.
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The Challenges and Pitfalls of PPI Withdrawal

By Vincent Pedre, MD

Proton pump inhibitors (PPIs) are among the most widely prescribed drugs worldwide, accounting for a profit in the billions for the pharmaceutical industry. They are the leading Western treatment for GERD, dyspepsia, and peptic ulcer disease. But the problem is that PPIs are not used judiciously for the short-term, such as healing a gastric ulcer; instead, patients are prescribed PPIs, then kept on them indefinitely without regard to the long-term potential harm of these medications.
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Using Community to Motivate Patient Movement

By Shilpa P. Saxena, MD

Let’s face it. Advising patients to exercise and engage in regular physical activity is a prescriptive no-brainer. The case for movement as medicine continues to solidify as journal after journal elucidates the anti-inflammatory powerhouse that exercise is. Whether for the reduction or reversal of obvious cardiometabolic diseases like diabetes and heart disease or of lesser-known chronic complex conditions like autoimmunity, cancer and dementia, exercise should be a foundational strategy to reduce inflammation and change epigenetic signaling for a healthier future for all patients.
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Autoimmunity: Common Protocols to Consider for Every Case

By Angela Lucterhand, DC

Fifty million Americans suffer from at least one autoimmune condition. Comparatively, 12 million suffer from cancer and 25 million from heart disease. This statistic cannot be explained with genetics, as genes don’t change or evolve that quickly.
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The Emergence of Autoinflammatory Syndromes

by Thomas G. Guilliams, PhD

Most clinicians are familiar with autoimmune disease mechanisms. Typically, these define situations where effectors within the adaptive immune system (i.e., immunoglobulins or T-cell receptors) bind inappropriately to a host molecule which subsequently recruits an immune response against those tissues. Processes of self-tolerance, whereby naïve B and T lymphocytes are exposed to self-antigen in a controlled environment, are used to find cells producing cross-reactive antibodies or T-cell receptors so they can be eliminated before they circulate in the body.
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The question in cardiometabolic disease is not what are you eating, but who are you feeding?

by Todd R. LePine, MD

Cardiometabolic disease is rampant in the United States and our current approach to treating it is broken. For years, doctors and patients have been taught that cholesterol is the underlying cause of heart disease. The American Heart Association has recommended a low-fat, low-cholesterol diet based on the guidelines of the USDA food pyramid. Unfortunately, following this pathway has led to increased obesity and diabetes, thanks to a calorie intake of mostly sugar and high glycemic carbohydrates.
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MTHFR: Treating Genes or Patients?

by Thomas G. Guilliams, PhD

In the discussion about nutrition, genetics and genomics, invariably the topic of methylation and genes related to methylation will find their way into the discussion. Chief among the genes mentioned in such conversations is MTHFR, the gene encoding one of the key enzymes responsible for “re-charging” the activated form of folate (5-MTHF), called methylenetetrahydrofolate reductase, along with a few of its well-known polymorphisms (e.g., C677T). If you have been following the MTHFR discussion over the past few years, you know how complex and confusing it has become.
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Mapping the Cardiometabolic Patient Journey

by Shilpa P. Saxena, MD

Mapping the Cardiometabolic Patient Journey
As of 2015, the combined prevalence of diabetes and prediabetes was 45.4% among adults in the United States. Approximately 11% have diabetes and 33.9% have prediabetes, representing 84.1 million people who could develop type 2 diabetes within five years, according to the CDC in the 2017 National Diabetes Statistics Report.
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Cardiovascular Disease: New Clinical Options for Expanding the Therapeutic Target, Part 3

by Jeffrey Bland, Ph.D., FACN, CNS and Thomas G. Guilliams, Ph.D.

A New Pleiotropic Path
From early ideas about dietary fat, to a complex array of genetic risk factors and biomarkers, the arc of scientific discovery is pointing to cardiovascular disease being a pleiotropic condition. It follows, then, that one agent against a cluster of diseases will not produce favorable outcomes. The old “a pill for an ill” model will be outdated.
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Cardiovascular Disease: New Clinical Options for Expanding the Therapeutic Target, Part 2

by Jeffrey Bland, Ph.D., FACN, CNS and Thomas G. Guilliams, Ph.D.

Vector of Truth: Medical Research is an Arc of Discovery
Anyone who devotes their career to scientific research is likely a seeker of truth. But this can sometimes mean taking the road less traveled. Even in medicine, it can be tempting to take the path of not seeking the hard and difficult questions about a disease, but to seek the expedient answers.
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Cardiovascular Disease: New Clinical Options for Expanding the Therapeutic Target, Part 1

by Jeffrey Bland, Ph.D., FACN, CNS and Thomas G. Guilliams, Ph.D.

Functional medicine can sometimes clash with the broader healthcare industry, which focuses on treating specific systems or diseases. In functional medicine, practitioners offer a more holistic and preventative approach to care, often recommending lifestyle, diet, and nutritional supplements. However, the norms of pharmaceutical research don’t necessarily translate into effective supplement research. Moreover, nutritional supplements often fall into gray areas in drug regulation, making the safe and effective use of supplements difficult for many functional medicine clinicians.
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The Gym Inside Your Door

by Ralph LaForge, MSc

The Gym Inside Your Door program was initially developed to increase daily physical activity in prediabetic and diabetic Alaska Natives in 2007, but has since gained widespread use in primary and secondary prevention programs. Diverse forms of physical activity have been shown to improve health outcomes and reduce risk for cardiometabolic disease. One means of prescribing exercise is by recommending specific physical activities by their frequency, duration and relative intensity. Read more

Exercise: The Ultimate Anti-Inflammatory

by Jonathan Cannizzo, MSc

Do you talk about the importance of nutrition and prescribe a personalized diet to every patient, regardless of health status, who walks into your clinic? Of course, you do. Every functional medicine clinician understands the importance of nutrition. What you eat matters. It plays a role in your long-term health, wellness and ability to prevent chronic disease. No one would argue that. Now, let me ask you this: Do you talk about the importance of physical activity and prescribe a personalized exercise program to every patient, regardless of health status, who walks into your clinic? Read more

Beyond Bacteria: How Antibiotics Impact Mitochondria

by Angela Lucterhand, DC

According to the Centers for Disease Control and Prevention (CDC), at least 30% of antibiotics prescribed in the outpatient setting are unnecessary—meaning no antibiotic was needed at all. With that, would it shock you to know that five out of six people are prescribed an antibiotic in outpatient care? Read more

Managing the Exposome

by Thomas G. Guilliams, Ph.D.

Two related fields of study, both owing to the emerging science of genetics and genomics, are beginning to help us discover the role toxins play in human health and disease. The first is toxicogenetics, which describes how the genetic differences between certain individuals allow for varying susceptibility to different toxins. Since there are hundreds of different enzymes involved in our detoxification pathways, many individuals carry gene variants (polymorphisms) that allow for more efficient conversion and removal of toxins than others. Those individuals with slower detoxification pathways for a given toxin will show signs of toxicity at much lower doses than those with normal detoxification capacity. These differences often complicate “cause-and-effect” studies in large populations that carry over into the clinic. That is, just because a large epidemiological trial does not find a statistically significant relationship between exposure to a particular toxin and a particular health outcome (the average of all genetic variants), does not mean that such a relationship does not exist in the genetically-susceptible patient. Read more

Be Worth It! Value Your Care and Improve the Financial Wellbeing of Your Patients

by Jeff Gladd, MD

This post correlates to a presentation delivered by Dr. Gladd at The Evolution of Cardiology Functional Forum (March 2017). Click here to view the presentation.

The most common criticism of direct-pay practices is that the services are too expensive and only accessible by patients with the means to afford them. As practitioners, we can all agree that health care should not cost an arm and a leg, but are we advocating for the financial wellness of our patients as much as their physical wellness? If we believe the services and guidance we provide are worth it, then we must become health care “financial advisors” and demonstrate how our care can be worth it to our patients. The first step is identifying challenges in the current health care system. Read more

How to Keep Patients from Sabotaging Their Exercise Programs

by Jonathan Cannizzo, MSc

A recent publication in PeerJ documented compelling evidence that exercise might not be the key to controlling body weight. This study found that over a three-year period, total weight gain was greater among participants who met the physical activity guidelines of two and a half hours a week, compared to those who did not. Read more

How to Make Your Practice Stand Out in a Crowded Field

by Mark J. Tager, MD

No matter the terminology—Integrative, Functional, Holistic, Wellness or Anti-Aging—a growing cadre of clinicians are now competing for the cash dollars of patients seeking a more personalized, root-cause health care experience. Don’t just take my word for it; let’s do the math: In this case, a simple LinkedIn search (February 2017) shows the following number of practitioners: Read more

Group Visits? My Patients Love Them and So Do I!

by Randi Mann, WHNP-BC, APNP, NCMP

It's my hope that this article inspires you to offer Group Visits to your patients. With the tools, support and coaching offered by the Lifestyle Matrix Resource Center, I know every practitioner can do this!!Read more

3 Steps to Eradicating Cardiometabolic Disease

by Shilpa P. Saxena, MD

Cardiovascular and cardiometabolic disease continue to devastate the lives of patients, families, communities and the US healthcare system at large. The sad truth is, a solution already exists. If healthcare systems could figure out how to implement therapeutic lifestyle change, nearly 80% of the world’s medical problems would either be prevented or reversed. Over the last 10 years, I have seen this solution play out in my office and other Functional and Integrative offices around the world. So, why isn’t this already happening? Three things: 1) Provider training, 2) Patient engagement, and 3) Cost. Read more

Understanding the Pathology of Autoimmunity Through the Prism of the Gut

by Kara Fitzgerald, ND

Dr. Alessio Fasano catapulted the understanding of GI involvement in immune diseases to center stage with his seminal research on zonulin and intestinal permeability. Notably, his 2008 Scientific American piece got the attention of almost every clinician I know. When his concepts were introduced at the Institute of Functional Medicine’s Annual International Conference that year, we were collectively awestruck that a scientist finally, solidly, put on the map what we, as integrative and functional clinicians, have observed clinically for years. Read more

What Can You Learn From a Salivary Hormone Test?

by Christopher Mote, DO, DC.

You know whether your patient has high cortisol, normal cortisol, or low cortisol—so what? Cortisol and DHEA can be high, low or within range and be perfectly appropriate depending on the patient’s physiologic condition. How do these markers change your medical decision-making? Read more

Re-assessing the Notion of “Pregnenolone Steal”

by Thomas G. Guilliams, Ph.D.

When clinicians measure salivary cortisol and DHEA (DHEA-S) to assess stress and HPA axis function, it is common to find DHEA levels below the reference range in a number of individuals. A common explanation for the depletion of DHEA and other hormones (e.g., progesterone, testosterone) due to chronic stress is the phenomenon known as “pregnenolone steal.” This notion basically states that since all steroid hormones use pregnenolone (derived from cholesterol) as a precursor, the elevated secretion of cortisol caused by acute or chronic stress will inevitably result in less available pregnenolone to serve as a precursor for the production of DHEA and other down-stream hormones.
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Exercise Adherence Starts with an Exercise Prescription

by Jonathan Cannizzo, MSc

The statement, “Exercise is an important part of lifestyle medicine,” seems rather obvious. Studies indicate relative risks for cardiovascular disease are up to three times higher for inactive persons as compared to active. In fact, physical inactivity is as harmful as other conventional risk factors, such as blood pressure and cholesterol levels, in predicting chronic disease. Yet, only 10% of Americans meet the recommended level of 150 minutes of exercise per week. Read more

Dysbiosis or Adaptation: How Stable is the Gut Microbiome?

by Thomas G. Guilliams, Ph.D.

One of the greatest paradigm shifts in medicine over the past few decades has been the unfolding discoveries revealing the metabolic influence of the human microbiome, especially that which resides within the gastrointestinal tract. Indeed, it is difficult to find a medical discipline that is not actively investigating the potential role played by the gut microbiome in human health and disease. Read more

The Twofold Path to Practice Success

by Mark J. Tager, MD

Every health care business has a major goal. You want to get noticed, known, and remembered so you can attract the types of patient you’d like to treat. In the process of caring for your patients, you must also create an experience that meets or exceeds their expectations. The better the patient experience, the more likely you will gain a good reputation and be the recipient of positive referrals. Read more

Assessing Immune Dysfunction: What You Need to Know

by Kara Fitzgerald, ND

Inflammation is the body’s natural, protective response to a harmful stimuli, be it a pathogen, an injury, a noxious compound, damaged tissue or cellular debris and more. A remarkably elegant and complex symphony of immune cells and associated compounds are released that quickly and powerfully contain the offending agent(s) and restore order. Our immune system is ever-active, constantly monitoring and clearing potential dangers with astonishing efficacy. Read more