Why Is It Low? The Root-Cause Approach to Nutrient Deficiencies and Supplementation

What’s Inside This Episode?

• Low nutrients: why they’re a clue, not a diagnosis
• Six hidden drivers: the real causes of many deficiencies
• Absorption problems: why adding more often fails
• Activation issues: when nutrients can’t convert to active forms
• Cellular transport: the overlooked signaling problem
• Increased demand: how stress, toxins, and inflammation drain nutrients
• Functional deficiency: when labs look normal but cells aren’t
• Supplement decisions: when they help and when they miss the root cause

Resources and Links:

• Download the full transcript here
• Download our FREE Smart Supplementation Matrix
• Join the Next-Level Health Practitioner Facebook group here for free resources and community support.
• Visit INEMethod.com for advanced health practitioner training and tools to elevate your clinical skills and grow your practice by getting life-changing results
• Check out other podcast episodes here

 

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Transcript

 

Dr. Ritamarie Loscalzo 

You run labs and a nutrient comes back low. What's your first move? 

 

If your reflexes replace it, this episode may challenge you, because we're living in the most over-supplemented era in human history. People are taking 10, 15, 20 capsules a day, magnesium for sleep, B12 for energy, iron for fatigue, adaptogens for stress, creatine for cognition, but very few are asking the important question. Why is the nutrient low in the first place?

 

The difference between a protocol prescriber and a clinical thinker is one question. And that's why, my favorite question of all time, why is it low? Why is it high? Why is it out of range? 

 

In episode 207, we used creatine as a case study in discernment. Today, we expand that conversation, because deficiency is not a diagnosis, it's a clue. And until we understand the mechanism behind that clue, we're not practicing healthcare, we're reacting.

 

Today we're unpacking how to determine when supplementation is actually indicated and when it's not. 

 

If you'd like a structured clinical tool that walks you through this exact reasoning process, I created something I call the Smart Supplementation Matrix. It's a root cause framework for clinical nutrient decisions, and it's available for free. Just go to the show notes and click on the link to download it. 

 

Before we ever ask what to supplement, we have to ask why does this nutrient appear low? 

 

Dr. Ritamarie Loscalzo (02:18)

There's at least six primary mechanisms that create the appearance of deficiency, and each one demands a different response. 

 

Number one is lack of supply. This can be due to dietary insufficiency, restrictive eating patterns, low protein intake, low mineral dense foods, or caloric restriction, and this is one of the simplest scenarios. Here, supplementation may make sense for the short term, but even here we should be looking at food quality and dietary patterns and correcting those as well. 

 

Number two is impaired digestion and absorption or one or the other. The nutrient is in the diet, but it's not being absorbed properly. Probable causes of this are low stomach acid, pancreatic insufficiency, low bile flow, gut inflammation, dysbiosis, celiac disease, and any number of things. If absorption is broken, more intake doesn't fix the root cause problem, does it? You must fix the underlying terrain. 

 

Number three is impaired activation or conversion. The nutrient is present in the diet, it's being absorbed, but it isn't being converted into its active form. This is where genetics and enzymatic efficiency matter.

 

So let's look at some examples of that. Well, it could be that folate is not converting efficiently to methylated folate, right? This could be due to genetics or lack of specific nutrient cofactors. 

 

Vitamin B6 is not converting to pyridoxal 5-phosphate. The food form and the supplement form is usually pyridoxine hydrochloride. Vitamin D may not be activating properly because of some impairment in the liver or kidneys. Thyroid hormone conversion can be inefficient. So in this case, the form matters and more of the inactive form is not going to solve the problem, right? 

 

Number four is impaired cellular uptake. The cells have to take the nutrient in for it to be utilized. And this is one of the most under-discussed mechanisms. Serum levels can look normal, yet cells can be deficient. 

 

Insulin resistance can impair nutrient transport. Inflammation can impair receptor signaling. Membrane dysfunction can affect uptake, and this can be related to fatty acids and all kinds of other things. You can't supplement your way past a broken signaling pathway. You need to restore the signaling. 

 

And number five is increased demand, right? Sometimes the nutrient is low, because usage is accelerated. This person, because of various things, may be needing more of a particular nutrient. Maybe there's chronic inflammation, or oxidative stress, or infection, or increased athletic load, or pregnancy, or trauma, even detoxification burden, extra exposure to things like mold in the environment, or chemicals in the environment. 

 

All of these things are places where we have an increased need and utilization of this particular nutrient. It may be temporary, but it may be permanent. It may be due to a current environment, or a current trauma, or a specific acute situation, but it might be more of a long-term thing, and there may be some genetics involved. 

 

Here, temporary supplementation is going to be appropriate, but you need to be addressing the driver. 

 

Number six is increased loss, and this one is almost always forgotten. Things like taking diuretics or having high cortisol, or blood loss, kidney losses, chronic diarrhea, heavy sweating. Again, these might be short-term acute things, or they may be long-term, and we need to be looking at these things. If the loss exceeds retention, the intake alone isn't going to correct the issue. 

 

If you want a visual decision tool that walks you through these six drivers step-by-step, I laid it out clearly in the Smart Supplementation Matrix. So check out the show notes for the link. 

 

So let's look at lab values versus functional deficiency. And I want to also stress that we don't just look at labs to figure out if somebody's deficient in nutrients. We're looking at their history. We're looking at their symptoms. We're looking at the big picture. 

 

When we look at lab values, when we look at serum levels of nutrients, they're not usually very accurate. Sometimes when we look at the value in the serum, it's not even low.

 

For example, vitamin B12 might look perfectly normal, but methylmalonic acid is elevated, and that's a functional marker. Homocysteine might be elevated, again, a functional marker. MCV, mean corpuscular volume, may be high. When these things are high, it suggests a possible B12 deficiency, even when the serum is normal. And that's a functional deficiency. It's because of any number of reasons, but one common one is we're not activating that B12, and it's not able to get into the cells. 

 

Another example is magnesium. It could look normal in the serum, but low in the red blood cells and in red blood cells is indicative of the cellular levels, right? So we need to be looking at all these things, before we slap a bunch of supplements on people. 

 

I've had people say, well, why is my magnesium coming back so low? I'm taking 500, 800 milligrams a day. Any one of those reasons could be an increased need. They have some genetic factors, an increased need because of exposures, environment,

interfering substances in their diet, any number of things. And this is where we as functional practitioners need to address this differently than standard medical. We have to be looking at these pathways. 

 

Another example is ferritin. A lot of doctors just look at ferritin, or they just look at serum iron. The old way was to look at serum iron and then people heard about ferritin. So they look at that. Well, ferritin is an iron store. So if the ferritin is good, but the serum iron is low, that suggests a very different mechanism than iron deficiency anemia and vice versa. We see that go both ways. So if the ferritin is normal or elevated, there could be inflammation. It could be liver inflammation and other kinds of inflammation. And so we're not going to have a bioavailability of iron. 

So all of these things need to be taken in. We can't just respond to numbers. We have to interpret the physiology. Low lab values doesn't automatically mean take more, give them a supplement. It means we need to investigate the mechanism. 

 

So let's just quickly address the synthetic question. We'll go more into this in the next episode, but many nutrients used clinically are synthesized, right? They're not extracted from a specific whole food. There are some examples like vitamin C. Most vitamin C is synthetic, but you can get rose hips, extracted vitamin C from rose hips. Those are usually going to be very low dosages. 

 

So you'll know whether it's synthetic, or you'll know whether it's actually from real food. 

 

Most B vitamins, and especially the activated forms like P5P, and R5P, and all that, those are usually going to be synthesized.

 

Dr. Ritamarie Loscalzo (09:50)

A lot of the concerns people raise are about industrial origin. So a lot of these vitamins, these substances, are derived from petroleum products and coal-based intermediates, and chemical synthesis, and all that. And I personally don't want to be taking things like that. 

 

I prefer whole food forms of things, but sometimes we need to take higher doses and need those synthetic forms. Here's the thing though, the body doesn't really evaluate a molecule based on its story, based on its origin, it evaluates based on the molecular function, or the molecular structure.  

 

So the final compound is chemically identified to the endogenous molecule, although vitamins aren't synthesized endogenously, so we can't compare it that way. But if it's exactly identical to the food form, for example.  When it comes to vitamins, and if it's properly purified, like there's no remnants of those petroleum products still left in there, it's free from residual solvents, and heavy metals, and contaminants, then the body really doesn't discern between it, it recognizes it. The issue might be that the dosages that we take are much higher than in food, and that might overstress the liver and the organs. 

 

So those are all things we need to take into consideration, right? Ultra high doses of things, they throw the body into a tailspin. But the real questions are, is it bio identical or is it food identical? Or is it third party tested? Is there any remnant of any of those petrochemicals or any of the solvents used to create it? Are there any remnants still in there? Are there heavy metals? Are they screened for heavy metals, right? These are all things that we need to look at. And are there excipients added? A lot of them, most supplements, have excipients added to them. 

 

So I'm really discerning about the whole brands that I use and the quality, because I don't want all these extra excipients that get in the way and that change the absorption and the usability, but also add some toxicity to the mix. 

 

So this is a purity discussion. It's not a physiologic one, or it's not a philosophical one, right? 

 

Just because a vitamin B6 supplement is derived from a synthetic process, if it's pure, and it doesn't have all kinds of additives, and we know that it doesn't have traces of solvents still in there, then it could be just fine, right? Although I'm a big food first person, I really like to do it that way. 

 

We're going to look more at excipients and binders and things like that in our next episode, right? Flow agents, right? They're always added, because it's cheaper. It makes it easier for the manufacturer to flow it through the machinery and get it into the capsules. I'm not a big fan of capsules. We'll talk more about that in my next episode.But all of this influences the absorption, and the usability, and the tolerability, quite frankly, of these supplements. 

 

I find a lot of people have reactions when they start to take certain supplements, and a lot of it may be that they're just a sensitive system. It may be that their body is more reactive to those doses, or they're reacting to whatever's added to them. That's why I'm a big fan of using powders in small doses. I'm a low and slow type of person, and that's how I work with all clients, not just the ones that tell me that they're sensitive. 

 

So we don't want to fear supplementation. We want to think carefully about supplementation, and we'll go more deeply into that in the next episode. 

 

When does supplementation make sense? It may be appropriate when, number one, intake is insufficient. So while we're working on the food, we get them up to speed. If somebody's been deficient in a specific nutrient for a long time, we can get them, of course, to eat the foods that contain those nutrients. The repletion of that nutrient might take a while. So in that meantime, we're supplementing. We want to get them back up to function while we're addressing the harder part, which is getting them to change their diet and lifestyle. 

 

They may have a temporary demand, a trauma, or blood loss, or anything like that, or a pregnancy. They may have activation that's impaired. Genetics increases the requirement. They may just genetically not process as well, and they just may need more of it and more than they can actually get in food. 

 

We find that they have an absorption problem and that has led to this deficiency, but it's not going to get immediately resolved. So while we're working on improving the absorption using stomach acid stimulators like bitters, and enzymes, and getting the probiotics, and the microbiome up to speed, we may need to supplement in the meantime. 

 

I look at supplementation, the ideal way of supplementing, as a minimal effective dose for a minimum length of time while we work on a diet that's full of nutrients or concentrated foods. 

 

Now, a lot of the argument is we have to supplement, because the soils are depleted and the food supply is not replete with these minerals and vitamins. That may be true. So we always have to be discerning what we need to do with people and not just throwing supplements at them willy-nilly. 

 

So a lot of times, functional testing is going to confirm their need. Say they have an MTHFR genetic SNP, and their homocysteine is elevated, the best and easiest way that usually works really quickly to get that homocysteine level down into a safe level, is to supplement with B vitamins and magnesium and the cofactors, right? 

 

So even then, we have to make sure we're using the right form in the right dosing, not just like throwing 15 milligrams of B12 at somebody, which I've seen happen, believe it or not. When somebody comes in, and it throws off other pathways, and they end up anxious and all kinds of things. 

 

We have to be careful with supplementation and not over-assess, but also have a plan in place for reassessing to make sure that our repletion is working. 

 

So when supplementation won't work is if somebody has poor digestion, and you just supplement. They may not absorb or utilize those supplements while their digestion is impaired, right? If they have insulin resistance, we have to get them over these things so that they can actually use this. If they have a chronic inflammatory burden, yes, supplementation is going to be maybe something that works short term, but long term, it's not going to work unless we get the inflammation down, unless we get them sleeping properly, unless we get them off the ultra processed food, and slow down the stress, right? No capsule replaces changing the physiology. 

 

What concerns me more than any single supplement is the culture around them. Influencers are pushing supplements stacks. They're pushing supplements that people may or may not need. And when you combine all these things without a smart practitioner who knows the physiology, knows the biochemistry, and does a complete history with the person, you can get people into trouble. And a lot of times, fear is driving people's purchases, and they're spending a lot of money, and then they're getting more stressed, because their finances are messed up, and they're not getting better. 

 

I think it's just really important that we as good functional practitioners look at the big picture and help people make smart decisions about supplementing. Supplementing just what they need in the minimum effective dose and make sure they're not taking 15 to 30 capsules a day without really optimizing their fundamentals. Their food, their exercise, their stress, their sleep.

 

So before you supplement, these are the questions we started out with that you should be asking.

 

Is it supply? Is it absorption? Is it activation? Is it transported into the cells? Is it excess demand? Is it a loss? 

 

If you don't know the answer, pause. That pause is your ability to be clinically mature, and if you want a structured way to walk through that reasoning for any nutrient, download the SMART Supplementation Matrix. It's free, and it's a root cause framework for clinical nutrient decisions. It's in the show notes. 

 

The body isn't fragile, it's adaptive, it's intelligent, and it deserves decisions grounded in real physiology and biochemistry, not fear. That's a big shift that we all need to make. That's how we rethink and reinvent healthcare. 

 

In our next episode, we're going to go deeper. We're going to look at genetics related to nutrient absorption and utilization. We're going to look at active forms, excipients, and how to make truly precise supplementation decisions. 

 

Together, let's continue rethinking what healthcare can be. And until next time, shine on.