Latest / Nutrition Connection by Dr. Kristen Hicks-Roof / 56: Dr. Dean Elbe PharmD, BCPP - PHARMACIST / DRUG-NUTRITION INTERACTIONS
Transcript
- Kristen Hicks-Roof PhD, RD: Hi and welcome back to the Nutrition Connection podcast, the show where science meets storytelling. I'm your host, Dr. Kristin X Ruef, dietitian, researcher, and lifelong advocate of the role of nutrition, health, and wellness. Each episode, I sit down with dietitians and nutrition experts all across the food and healthcare landscapes. Leaders whose work touches nearly every aspect of our lives. So whether you're a student, a seasoned professional, or someone simply curious about food, nutrition, and health, this podcast is just for you. The views, thoughts, and comments on this podcast do not reflect those of my employer nor the employers of my guests. So let's go ahead and get connected. Y'all, I'm so excited to bring on, we have Dr. Dean Elb. He is the clinical pharmacy specialist at Child and Adolescent Mental Health in Vancouver, British Columbia, but he's also the president and owner of Drug Nutrition Interactions. Welcome to the show, Dean. Dean Elbe: Thanks so much for having me on today. Great to be here. Kristen Hicks-Roof PhD, RD: So I was super excited to find out that you have revised and created a new version of our old school book, Food Medication Interactions, which I know you have a copy of that old school book that I use all the time when I was a dietetic intern. And so I was really excited to bring you on because that was such a critical resource for us as clinical dietitians. And so you're my first pharmacist on, but I can't wait to talk about. Dean Elbe: This one right here. Kristen Hicks-Roof PhD, RD: your journey in becoming a health professional and then how that's gotten integrated with nutrition to help nutrition experts all over the globe. So let's get, let's get started from the beginning, Dean. What inspired you and made you want to become a health professional and specifically intertwined with nutrition? Dean Elbe: Yeah, so for sure, ⁓ growing up, chemistry was sort of my favorite subject and that sort of led into my pharmacy career. ⁓ But this connection with nutrition happened really early on. was actually even when I was an undergrad, ⁓ I applied for, I get most of my jobs when nobody else applies. I don't know why that is, but ⁓ I applied for a job that was posted at our faculty to work on a diet manual, work on the drug nutrition interaction section in that diet manual. This was 1991, okay. Kristen Hicks-Roof PhD, RD: ⁓ yeah. Dean Elbe: And during that time, that happened to be right around the time when grapefruit drug interactions were first discovered. And so it was like so off the wall, so bizarre. It was really fascinating to me. And that led me to continue to follow it even after that manual was completed and published. I decided to teach myself web design by creating a grapefruit drug interactions webpage. And I thought like six people might look at it, but it would be like a way to teach myself web design and, uh, have a resource online for myself in this area. And after that discovery, like the field of grapefruit interactions just kind of exploded as they started testing a whole bunch of different medications and trying to figure out what the mechanism was. ⁓ Dr. Zinitta Pronsky found me ⁓ through that website in about 1995 or so and asked me to contribute to food medication interactions. They did a table on grapefruit drug interactions. And that went well and I started editing her manual and I started speaking with her, traveling around the US. I've been to 25 different states, ⁓ DPG meetings, even presenting at Fency with her. And then I started making software for Palm Pilots, if you can believe it, ⁓ back in the day. Yeah, back in the day and ⁓ even ⁓ after Zendida passed away in 2011. ⁓ Kristen Hicks-Roof PhD, RD: ⁓ You're dating yourself a little bit there, Dean. Dean Elbe: her husband was the publisher, they still did two more editions. So I ended up authoring the content in the last two editions of the manual. And then they stopped publishing altogether in 2019. So I decided to create my own company. This was kind of my COVID project, believe it or not. And so to develop the drug nutrition interactions database, finally launching in 2024 with over 1,150 different medications in it. really trying to keep the spirit of the food medication interaction handbook, but bringing it into the 21st century with ⁓ the technology, having it online, always having it available with you wherever you go on your phone, right, on your mobile device. Kristen Hicks-Roof PhD, RD: is so fun. mean, I remember my lab coat pocket, I kept that book with me everywhere and you'd be looking up but I think now I mean, clinicians across the board are so much more fortunate to have technology at their fingertips, especially with AI and using some of these digital tools to be the most up to date on clinical recommendations. So what really drove you in that space? I mean, you're a practicing pharmacist, right? So like what? Why was it that Dean Elbe: Yeah. Kristen Hicks-Roof PhD, RD: that you really wanna do understand and the grapefruit example, it sounded like was a little bit of your in, but did you always have a little bit of an interest in the nutrition overlay? And then also I'm curious, in your day-to-day role, do you have a nutrition overlay in that role as well? Dean Elbe: ⁓ So certainly in my day-to-day role as a clinical pharmacist in child mental health, one of the big things we look at is monitoring for metabolic adverse effects of antipsychotic medications. And unfortunately, we know it's woefully under monitored and kids can get fairly significant metabolic complications if they're not monitored properly. So we do a whole bunch of different projects and ways to encourage our treatment team and providers to make sure the proper monitoring is done. We're doing a project looking at the rates of monitoring prior to hospitalization right now. And that's a very, very big aspect. We work with a dietician and present with them here at our children's hospital on that regard. But yeah, just I think really the entree to this really was that project on the diet manual and then just the fascination with it and wanting to ⁓ explore it more. then as I started working with Sunita, realizing the scope. of how much ⁓ and how closely pharmacy and nutrition are intertwined. And ⁓ like I said, I've collaborated with dietitians throughout my entire career because of that aspect. Kristen Hicks-Roof PhD, RD: I mean, as someone who came from academia myself and all my whole PhD and all my research was on integrating nutrition care across health professions. I mean, that was the crux of it. So I just, I think it's awesome when we get continue to get more health professionals across disciplines to not only work with, but also show that there is this synergy and there's this crossover that your pharmacy technical language also has crossover with the nutrition technical language. Because what I saw and I don't know if you've seen it too is sometimes we get caught up in our own technical language that we don't speak the same lingo as the other health professions on our team and maybe that's different in Canada. What do you think? Dean Elbe: No, I think we're stronger when we collaborate, right? And that's proven out throughout my career and continues to this day, working with physicians, with nursing, with dieticians and other professionals. ⁓ And you have that slightly different lens of viewing things, but together it's a team effort to recognize and then manage the impact of those medications on people's nutrition and health. especially over the long run, right? Because the number of medications people take is growing, ⁓ even amongst the child and mental health population, never mind in older adults. And so the complexity goes up and we need that collaboration to be able to best manage these. So really, really cool to hear that that was your PhD focus. Yeah. Kristen Hicks-Roof PhD, RD: So, ⁓ well, that was part of the reason I'm like, ⁓ I gotta bring Dane on this show. Anytime that we can showcase this cross-professional interaction, I think it means so much more for the patient, right? Because the patient doesn't necessarily understand the drug nutrient interactions. And although you have training in that, pharmacists may not have the full depth and breadth. I think just like dieticians may not have the full depth and breadth. And that's why you having these kind of crossover connections among disciplines can really weed out some things that might easily get overlooked. Dean Elbe: Yeah, and like, you even though I worked on this manual for 20 some years with Sunita, when I went to create drug nutrition interactions, I sought out ⁓ Mary Litchford, who's a PhD dietitian, to be the dietitian, senior dietitian expert, revising the nutritional recommendations, like I can identify the interactions, but I relied on her guidance and advice of, what is the relevant guideline for nutrition in this area? What are the recommendations that are evidence-based? for diet and nutrition ⁓ for this particular, if you're taking this particular medication, right? So again, it remains a collaborative effort. Kristen Hicks-Roof PhD, RD: when as you, ⁓ it has to, when as you mentioned, like people are on more and more medications because every medication may have some sort of side effects. So then you may take another medication to offset that side effects, right? And so, or there's, yeah, or there's multiple comorbidities that you may need a variety. And, you know, I think the grapefruit was so fascinating. I wish I was really there in that time period where they explored that because I think for a long time, Dean Elbe: unfortunately sometimes. Kristen Hicks-Roof PhD, RD: Maybe they didn't realize that. And that's where I think research is so imperative to be able to match what happens in the data to say like, mechanistically, what is happening? Like, why is there this interaction? So I think your guide will be super useful. And I wanna talk a little bit about what do you do in your day to day? Not only as a pharmacist, but then how do you interact with clinical nutrition experts? Dean Elbe: Exactly. Right, so in my day to day as a pharmacist, I'm a consultant, 100 % of my time is child and adolescent mental health. So I've really been able to specialize in ⁓ consulting with psychiatrists and the nurses on our team for our patients. We see a range of children from five years old up to age 19, excuse ⁓ me, with a variety of mental health conditions. So depression, anxiety, psychosis, OCD, bipolar mania, personality disorders, eating disorders. So the broad spectrum of that. And so I do a lot of consulting with the treatment team. I do a lot of patient counseling. We've been starting to talk about pharmacogenetic testing now and those results and how they impact choice of drug therapy. That's becoming more and more a part of my ⁓ day-to-day role. And as I mentioned, like the metabolic monitoring of antipsychotic drugs that are used not only for psychosis, but for bipolar disorder. for autism and as an augmentation and OCD as well as other uses. ⁓ And so a lot of kids are on those medications and making sure we're doing our best to mitigate and limit the metabolic harm that can come from them while still getting the most benefit out of those medications. So a lot of drug interaction checking, ⁓ referrals to dieticians when appropriate to advise. We have a metabolic mental health monitoring clinic. at our hospital and it's staffed with a pediatrician, a dietician and an endocrinologist. We frequently refer to that team when kids are on those medications to make sure they're properly monitored. Kristen Hicks-Roof PhD, RD: I love that. mean, I think if more health profession, just the landscape, if it was more integrated and you had this like pre-built teams, right, with consultants and other support parties, because not every patient may need an endocrine expert or may need whatever, a mental health counselor or whatever additional service, but I do think that that unit would allow for best care. So I think that's awesome. Now, how does... Dean Elbe: Exactly. Kristen Hicks-Roof PhD, RD: scientific data and evidence impact what you do in your day to day, not only as a pharmacist, but then even being able to update the drug nutrition interactions. Dean Elbe: Yeah, it's everything. It really is. ⁓ So I do pride myself on trying to be as evidence-based as possible. Although sometimes, as I say to my residents that I teach, sometimes the road of evidence runs out and turns into this gravel road that you're kind of bumpy, not really sure what's going on. So you have to be able to go back to first principles and think about what's happening with that medication and how can we use it even if we don't have a full set of randomized controlled trials to guide you on that. that journey, but we'd like to have those and we are getting more of them. So I certainly keep a large roster of curated evidence. I sort of am known for, you know, when a medication question comes up, I'm known for like Here's the summary of the trial and sort of before the psychiatrist is back at their desk, they've got a copy of the article in their inbox that is pertinent to that discussion, right? So that's one sort of method I use to really sort of say, okay, yes, here's your question, here's the evidence, this is the paper, here you go. You can't really argue with that evidence. And then as far as. as maintaining drug nutrition interactions, that's one of the beauties of it being an online resource as opposed to a book that we edit every three or four years. I can keep it up to date as the FDA and Health Canada release new ⁓ warning labeling and as new medications are put on the market. over, well, it's been a little slow right now at the FDA, but usually about 50 years, ⁓ 50 new medications per year are approved by the FDA, 30 or so of which are. used in common clinical practice and 20 or a bit more orphan low usage, but With 30 new medications or so coming out ⁓ being able to stay up to date on those Those trials and the research and the labeling under them and then putting that into the resource so ⁓ users have an updated ⁓ Reference list at all times and that's you can only do it when you're online. You can't do it in print. Yeah Kristen Hicks-Roof PhD, RD: One, things change. mean, science changes, but you're right. That's crazy. 30 new medications a year. I mean, that's unreal. Like, yes, that you also have commonplace, but then you have a lot of smaller diagnosed conditions that I'm sure some of those additional medications are, but that's a lot to be updated. this is totally my curiosity because I'm a science nerd and I just think it's really cool. now when FDA does... ⁓ accept a new medication to then go on market. Does that align directly with Health Canada when you go in it cross international borders or do they have different regulatory approvals? Like when you have drug nutrition interactions, is it potentially used more worldwide universally or is it more of a North American market? Dean Elbe: ⁓ Right now it's North American, but I've built it in mind of looking at worldwide English speaking countries like European Medicines Agency, Australia for example, could be things we bring into it eventually. I have built it so that you can change the setting for Canada and the US because our labeling differs between the two countries a little bit. There is a separate regulatory body, although the studies that the regulatory labeling is based on tend to be done in either the US or internationally. ⁓ Canada's smaller, we don't have as many people to do these clinical trials, so we do look at others' evidence. But maybe a little bit more conservative, a bit slower, ⁓ just because it comes out in the US does not necessarily mean it's gonna come out in Canada just due to ⁓ market size, due to pricing, and then Health Canada being a little more conservative. So some bigger meds will come very quickly and other ones take a few years and others don't show up at all, just because the company doesn't see the... market for it for example. Yeah so it is not in lockstep automatically. Kristen Hicks-Roof PhD, RD: Yeah, so. Well, that's why I was asking, like, you know, sometimes these digital tools are so nice because they can have broader reach, but especially when you talk about regulatory and what's allowable and not allowable ⁓ with the medication space, which is very tightly regulated across every individual country. There is not just like a one level ⁓ approval body per se. So I was curious how that works. Dean Elbe: Yeah, and the labeling does not match identically, let me tell you. Having reviewed, again, over 1,150 different medicines, ⁓ adverse effects can appear in one country and not the other. Warnings can be different. ⁓ Ages that they can be used in can be different. It's quite interesting. Kristen Hicks-Roof PhD, RD: Huh? So talk to me if you have a clinical nutrition expert or dietitians who are sitting in and listening to this podcast, like talk about drug nutrition interactions. If they're not maybe a little bit more old school like I am by the paper, what is it? What does it offer? How would I use that in my practice? And maybe it's not just clinical, maybe it's private practice or other industries. Dean Elbe: You Yeah, for sure. if you're a dietitian, chances are the patients you're seeing are taking medications and those medications can have, often do have impacts on nutrition and it's a bi-directional interaction, right? Nutrition can affect the medicine, medicine can affect the nutrition, it can go both ways. And so being aware of those implications when you're assessing a patient, taking that into account to make your final nutritional recommendations for them has to depend on. sometimes on the medications they're taking. So having an up-to-date resource that has got all of the currently used medications that are common and being up-to-date with all the warnings, adverse effects, nutritional impacts, and then guidelines from our dietician ⁓ for how to treat that condition, what the nutritional recommendations are, ⁓ is very important to have. And to have that with you all the time, essentially, on your mobile device, knowing... that it's up to date ⁓ and in a format that is laid out specifically created for dieticians. So one of the things in food medication interactions that I've preserved going forward, Zanita used to break out the adverse effects that go by oral cavity, GI tract, overall nutritional impact, and she'd have those separated out. And so I've maintained that. in DNI. So all the adverse effects are separated out that way. We've got interactions with, of course, grapefruit, ⁓ but also alcohol and selected natural products. We've got the monitoring guidelines, all the lab testing that should be done. And we've got like cited lists of product monographs and relevant guidelines that are curated that you can link to, not just like here's the citation, but tap it and there you go. There's your full full guideline, essentially, if you've never treated a person with, I don't know, whatever condition before, and you've never seen it, click, there's the guidelines for the nutritional recommendations for that condition. So it really is a robust resource and it really should stress that it's created for dieticians. You're not hunting through up to date or a product monograph that's 50 pages long looking for that nugget. I've done that. I've already hunted through it and extracted it. And so on one screen, you can see what a drug is all about. ⁓ at a glance and get up to speed really quickly. So I think it's a really valuable resource for dieticians to have in practice wherever they were. Kristen Hicks-Roof PhD, RD: super valuable and like I said, there's more and more people on more medications and not only just medications, but you're also talking about supplements and herbals and things like that, right? Like there's many, many different types of interactions. So I know that I use it when I was in practice, like don't see patients anymore. So I don't, I don't use it right now, but I think if you see patients on a one-on-one or a group basis, I mean, this tool is super helpful. So make sure you check it out, drugnutritioninteractions.com. So that way you can learn. Let's say Dean, what's been your favorite or something you're most proud of so far? And maybe it's this book and this endeavor that you've really taken on, but maybe it's something else related to just your pharmacy. Dean Elbe: ⁓ Yeah, for sure. Getting this up and launched was an ordeal, but so happy to have it up and launched. And I think what I'm most proud of is that it's being incorporated now by over 50 schools across the US as part of their training. So I've gone from creating this website 30 years ago that I thought six people might see to having at least a little part in the training across the profession. And so that reach and that scope and that influence is I feel really proud about. Another thing I do is I train pharmacy residents where I work, but I also train psychiatrists in psychopharmacology. And so they come and literally walk in the shoes of a pharmacist for a month during their psychopharmacology rotation with me and get to do all the things we do and have that different lens. Again, that cross-professional collaboration, like I say, it's been there. wherever I've gone, I've really tried to bring that in. And so they get to walk in the steps of a clinical pharmacist for a month and they find it's really valuable and helps with their training and confidence with prescribing medications after they graduate. Kristen Hicks-Roof PhD, RD: So what suggestions or tips would you have for someone who maybe doesn't currently or not frequently work with pharmacists, but you would encourage them to work with pharmacists? Like what sort of value add would you have in this bi-directional clinical relationship ⁓ working in between pharmacists and dieticians? And yes, in drug nutrition interactions, but then what about beyond? Dean Elbe: Ahem. Yeah, for sure. think so being aware that there can be interactions pretty much every time your patient's going to be on a medication, that there are DNIs to be identified. They may not be clinically relevant right then and there, but a lot of patients take these medications chronically, so they may not show up. in the first month or two that they take him, but after five years there can be nutritional alterations. And so being aware for that, monitoring for that. And then you can like have that conversation with the pharmacist on your team and like, hey, I noticed they're on drug X and it depletes vitamin D and calcium. Should, I was thinking of supplementing that. Is this still the best medicine for them if they still need it or is there an alternative? And if they still need it, I was thinking of the supplement. What do you think? And having that. that conversation and ⁓ most pharmacists that I know anyway would be like very open to, know, having that interface and discussion about how to proceed because they want what's best for the patient too. Kristen Hicks-Roof PhD, RD: And that's just that we all have the same mission for the patient, right? The same mission is to get the patient happier, healthier, and have a more fulfilling life. And in order to do that, you have this shared medical decision making. And I think sometimes I know I've seen it in a lot of my health profession work is kind of like, well, that's my domain. I don't know if you've ever seen this. It's like, well, that's my domain and this is my domain. Like don't take my job. And it's like. Dean Elbe: you Mm-hmm. Kristen Hicks-Roof PhD, RD: I've always been so fascinated by that because I'm like, they're not trying to take your job. They're trying to better understand how these puzzle pieces fit together. So that way, right, nutrition and pharmacy can work together because both of you have your independent unique roles, but then you have this synergistic overlap. Have you ever seen that in your practice? Dean Elbe: Yeah, think it really depends on the team and the setting that you work in and that it comes from management and it comes from the physicians and prescribers too that they need to be open to having that discussion. ⁓ But you get better results when you do have that. And so being well-versed in ⁓ the clinical language and talking about these things. being able to identify them and say confidently, I think this is a potential concern, should we check this? ⁓ You need to speak their language, but if you do, ⁓ you're gonna have great results. ⁓ again, collaboration, it's always better. Kristen Hicks-Roof PhD, RD: Yeah, well, I think I love your example of like, sometimes you just may need to approach, right? I think sometimes in the hierarchy of medicine, we think that it's like a dictated down, but I used to love to teach with health professionals of it's really this bi-directional process. know, a physician may detect something different than a pharmacist, which may detect something different than a dietician. And it's important for us to go in this bi-directional space. I loved your example of like, the dietician can go and say to the pharmacist, like, hey, I see they're on this medication, but they are deficient in X or Y, can we maybe reconsider or supplement? Like, I think that's a really good example to showcase this bi-directional communication. And I think ultimately you're right. Like, we wanna be able to help the patient in general. Dean Elbe: Yeah, and I think that happens a lot and we don't think too too much of it, like just a general day to day interaction, but it's really important. And ⁓ if that synergy and that connection isn't there, it may not happen, right? So ⁓ to have somebody looking, you you find things when you look for them, when you're aware and you look for them, you find things that can need clinical attention. Kristen Hicks-Roof PhD, RD: One, think drug nutrition interactions would also be a really good home base and a research hub to be able to share, here's the evidence of these art interactions. So that way, in case someone who may not be familiar, let's say if a pharmacist is not directly on the team and maybe they're a consultant ⁓ or an outside stakeholder. So super interesting. I love that you were able to bring that paper version, which if you're old school dietitian like myself, we loved the paper version. Dean Elbe: Hehehehehe Kristen Hicks-Roof PhD, RD: but I love that it's now online. I'm curious, Dean, have you seen this pulled in with any sort of AI inputs or outputs? I don't know if, it sounds like this was your COVID pet project and COVID was a little bit before AI boom. So have you been able to optimize the website to try and make sure that it goes into some of those large language models? Dean Elbe: Yes. ⁓ No, I mean right now it's our terms of service say that it can't be used to train LLMs, but what I'm thinking of ⁓ doing is putting an AI agent inside our content so you can chat with the content of DNI. And so that's still under development, let's say, but certainly a thought that you could have an AI agent sitting on the face of DNI and Kristen Hicks-Roof PhD, RD: Mmm! Dean Elbe: And you could search yourself or you could actually chat with the agent with the curated content. But it's really important that all of the content in DNI is important for people to know has been, it's 100 % human, so it's gone through myself and pharmacists reviewers and Dr. Litchford for their review. So it's not AI generated content. But having the AI agent sit on top of that is the way to go in my view. Kristen Hicks-Roof PhD, RD: That's it. Yeah, no, I agree. mean, like I said, as a researcher, sometimes the AI generate content is a little scary, but I also think that it is useful to make sure that we have experts such as yourself and your team to be able to generate content. If people are just going on and AI saying, Hey, what's this interaction? Well, it may not pull the most useful. So drug nutrition interactions if you need it. So Dean Elbe: Yeah, especially in the medical space, there can, you you you need that higher rate of ⁓ quality and accuracy compared to help me write this email. You need that higher rate for medical professions. One of my students recently, she's developing a whole ⁓ program looking at AI and pharmacy and that that's their struggle rate is getting that accuracy rate up to where ⁓ you're not having it generate a hallucination of a of an of an interaction or a citation or a study that doesn't exist. So that's an important sort of extra step you need for the medical aspect of AI. Kristen Hicks-Roof PhD, RD: Yeah, I mean, I think it's super scary that they're pulling maybe some blogs for research content. It's like, no, that's not a peer-reviewed research article, right? To be able to actually say, ⁓ okay, that is a trial and that would make sense to be as part of the hierarchy of evidence. So yeah, it's gonna be really interesting to see how that continues to lay out, but I'm curious. This is one of my favorite questions. And Dean, I can't wait to hear your response because you are... this like kind of dual overlay, but if you add a crystal ball, what do you think is coming next in nutrition? Dean Elbe: Yeah, so I'm thinking about that a couple of things. So certainly learning how to use AI, not just to replace mundane tasks, but certainly what I'm thinking about for my profession, I think would encourage dietitians to think about is how can we create something special that we don't have today with AI, not just replace sort of the routine, but how can we do more? ⁓ So as an example, I'm looking at taking some of the consults I've done and having ⁓ an LLM process them, de-identify them and have it process them and seeing if I can chat with that sort of shared stored knowledge that I've developed over like 15 years of consults kind of thing. ⁓ But can we do something special? Can we do medication charting? Can we identify drug nutrition interactions through AI? ⁓ Doing something beyond the routine with it. I think that's one thing you'll see and then people learn how to use AI to do this work. are going to be very successful. And then the other one that's interesting, I've seen sort of hints of, I'd love to hear your comments on is clinical nutrigenomics. Because pharmacogenomics has really exploded in the last five years, especially in the child mental health space, actually, adult mental health too. ⁓ And if that's any indication of the interest, ⁓ I know there are some nutrigenomic tests, I've seen them advertised at FENCY. ⁓ But interesting, interested to hear where you think that's going. for your profession. Kristen Hicks-Roof PhD, RD: Yeah, I mean, I definitely think when I was a faculty member, we were co-developing a nutrigenomics course. I mean, that was, what, six years ago? I think with the large language model, and just as you said, how you could maybe take de-identified patient charts to better educate the model, to be able to understand what are commonalities or what are some uniqueness about certain conditions or cases. think... Dean Elbe: Okay. Kristen Hicks-Roof PhD, RD: what you're gonna need for Neutrogenomics to be able to move forward at scale is really a comprehensive amount of data. And that's things like, right, like all your biomarker data, not only your general lipid panels and stuff, but looking at metabolomics and looking at some of these much more in-depth markers to really say from clinical trials. Like if we had a clinical trial hub where you had to put in all your data, I mean, how fascinating would that be? Because then you would actually start to see, you could use the large language models to start to see, people with this, you know, SNP polymorphism, for example, react differently to this food than other foods. So I think we have a long way to go to really be optimized in nutrigenomics. ⁓ I think there's a good opportunity, both from the supplement and from the whole food side, to be able to go that direction. I just don't think we're quite there yet, but now with machine learning going so fast that you can hardly keep up, right? It's like, you can't keep up with how fast that technology can run through data and output something that would have taken a year and a half previously. So I think it's maybe on the horizon and I'm sure it would be helpful for both clinicians and patients because if clinicians, just like in drug nutrition interactions, If I know that there's this interaction, then I can either find a different medication or advise the patient to omit or reduce certain foods or supplements. If we knew with nutrigenomics that this person, their body responds better to soluble fibers and this person responds better to meat protein, then maybe that would actually modify some of our recommendations that we would be able to give because they're responding different. I've always been fascinated too by it because like in clinical trials, I don't know if you've ever sat in clinical trials where it's seen like raw data. In human nutrition clinical trials, you always have this whole gamut of how people respond, right? And that, and whether that's a... Dean Elbe: Yeah, absolutely. Mm-hmm. Kristen Hicks-Roof PhD, RD: metabolomic or it's a cholesterol panel or whatever, you always have this variation. So something's happening at the nutrigenomic level of why you'd have such wide variation, right? Dean Elbe: Yeah, yeah, I use that analogy often. like, I'll talk to my students. I'm like, OK, when there's adverse effects or things don't go as planned, OK, well, like the drug does what it does and the nutrient does what it does. So what's the difference in that equation? It's you. You're the difference. Yeah, the drug binds at whatever constant and efficiency rate to every receptor. Kristen Hicks-Roof PhD, RD: Yeah. Dean Elbe: The same. So the difference is you have more or less of those receptors or there's something different about you, the patient, that's causing that difference in reaction. You're the difference. Kristen Hicks-Roof PhD, RD: Exactly one and every human is not only genetically different, but then all of a you talk about all the different foods that they eat. How much sleep do they get? Stress management, external, ⁓ you know, environmental lifestyles. And so now you have all these different co-factors. And that's why sometimes I struggle with some epi data because I'm like, how do you say that it's this one correlation when there's a billion co-factors that are really coming into play that you're not accounting for? Dean Elbe: Yeah, and another part with pharmacogenomics and nutrigenomics as well is it may not be the whole story, right? There's only certain things that have been identified through research as being clinically relevant. There may be factors that are yet uncovered or don't meet that threshold for statistical significance, so therefore they didn't include as a marker, but it sometimes doesn't tell the whole story. It's a clue. It's a piece of the puzzle, but it's not the whole story. Kristen Hicks-Roof PhD, RD: You know, but that's challenging. Right. Yeah, but I think that's where AI may be able to put that piece in the larger context, right? To be able to say, OK, well, this is the output related to this particular. like you said, receptor, this may be the, this is the process, but this is maybe the output and how that differentiates across patients. So yeah, it's super fascinating. I'm sure we could get on tangents for forever, but ⁓ Dean, thank you so much for coming on the show and really giving us some of your insights. Thank you for what you do with DNI. I think that's such a useful resource and I really hope all the dieticians on the call are able to think about this and look into it, drug nutrition interactions, because it's really so important that we. stand for the expertise of dieticians, but then also recognize that this is a cross-professional collaboration. It's not a one party over the other. It's a cross-professional. So it was great to have you on. If you liked the show, make sure you like, subscribe, leave a review, but most importantly, check out the next episode because every episode I bring on a different dietician and nutrition expert to share their story and give you tips on advice on how to be successful.