NOVUM — Clinical Handouts

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Functional Decline & ADHD in Young Adults

Clinical handout for university students and young adults (16–30) presenting with disorganisation, academic decline, low mood, or concentration difficulties

Suggested clinical use: Print and walk through with the patient at a functional decline visit. The first three sections (differential, sleep-first principle, ADHD framing) anchor the explanation; the screening battery section sets expectations for the visit; the "What you can do right now" section seeds behavioural change before pharmacotherapy decisions. The parent/caregiver section is designed for collateral-history visits when the young adult is not present.

This handout is for university students and young adults (ages 16–30) who are struggling with disorganisation, academic decline, low mood, or difficulty concentrating — and for the parents or caregivers who are worried about them.

Three conditions that look identical

ADHD, depression, and sleep deprivation all produce the same symptoms: poor concentration, difficulty starting tasks, forgetting things, low motivation, and disorganised living spaces. This makes them genuinely difficult to tell apart — even for experienced clinicians.

Condition	Key clue	Most important question
ADHD	Symptoms present since childhood (before age 12)	"Did you struggle with focus, homework, or sitting still as a child?"
Depression	Low mood, anhedonia, sleep changes, came on in the past months or years	"Have you lost interest in things you used to enjoy?"
Sleep deprivation	Most common mimic — 56% of poor sleepers look like ADHD on screening tests	"How many hours of sleep are you getting? Do you use your phone in bed?"

The most important finding: Treating sleep first is the highest-yield, lowest-risk intervention. A 2025 clinical trial showed that sleep treatment alone reduced ADHD-like symptoms significantly — meaning many students who appear to have ADHD actually have a treatable sleep disorder.

When it might be ADHD

ADHD in university students is now diagnosed at 14–15% prevalence — significantly higher than a decade ago. An important finding: many students who were "fine" in high school develop problems at university because the structure of home life was compensating for undiagnosed ADHD. When that structure disappears, the difficulties become visible for the first time.

Difficulty starting tasks even when you want to do them
Constantly losing things, forgetting appointments, missing deadlines
Room and belongings chronically disorganised despite wanting to be organised
Difficulty reading or sustaining focus for more than 20–30 minutes
These symptoms were also present in primary/secondary school — even if you managed

ADHD is highly heritable. If a parent, sibling, or first-degree relative has ADHD, your probability of having it is significantly higher.

What your doctor will check

At a functional decline assessment, your doctor will likely use a brief screening battery. All of these tools take less than 15 minutes total:

ASRS-5 — 6 questions about ADHD symptoms (2 minutes)

PHQ-9 — 9 questions about depression (3 minutes)

GAD-7 — 7 questions about anxiety (2 minutes)

ISI — 7 questions about sleep quality (3 minutes)

AUDIT-C — 3 questions about alcohol use (1 minute)

What you can do right now — before your appointment

These five interventions have evidence behind them and are safe to start immediately, regardless of what your doctor later diagnoses:

Phone out of the bedroom at night. Sleep deprivation is the most common cause of ADHD-like symptoms in university students. Charge your phone in another room. This single change improves sleep quality, morning concentration, and mood.

Fixed wake time every day (including weekends). Irregular sleep schedules destabilise circadian rhythm and worsen every mental health condition.

Open your window for 15 minutes daily. VOCs from food waste, stale air, and poor ventilation directly impair concentration and are linked to depression.

30 minutes outdoor activity daily. The strongest protective factor against executive dysfunction in university students. Even a walk counts.

Reduce nonacademic screen time to 2 hours or less per day. Smartphone use impairs the exact cognitive skills (task initiation, inhibitory control) needed to overcome disorganisation.

For parents and caregivers

If your young adult won't come to an appointment, you can still be helpful:

Book your own appointment and bring your observations — this collateral history is clinically valuable
Frame the visit to your young adult as "a check-up to help with focus and energy" rather than a mental health assessment
Parental support is statistically protective — a 3-year longitudinal study found it significantly reduces depression risk. Your concern matters and your engagement helps.
If you are worried about their safety, contact their university wellbeing service or their GP regardless of their consent

University student mental health services, crisis lines, and academic accommodation offices can all be accessed independently by students without parental involvement. If your young adult is struggling, encourage them to reach out to these services directly.

BC resources — available right now, no referral needed

Resource	What it provides	How to access
Foundry BC	Free integrated mental health, substance use, primary care, and peer support. Ages 12–24. Walk-in welcome — no appointment needed.	foundrybc.ca · 11 centres across BC + virtual
Here2Talk	Free 24/7 counselling and community referral for all BC postsecondary students. No appointment. Confidential.	here2talk.ca · phone or app
BC 988	National suicide and crisis helpline. 24/7 phone and text.	Call or text 988
ACCESS Open Minds	Youth mental health — accepts self-referral, family referral, peer referral. Ages 11–25. No diagnosis required to access.	accessopenminds.ca
University counselling	Free short-term counselling (typically 4–8 sessions). Student self-referral.	Your university website → Student Services → Counselling

PaRx — nature prescription: Your doctor can write you a formal prescription for time in nature and provide free access to Parks Canada national parks. Ask about PaRx at your next appointment. Evidence shows 20 minutes outdoors 3× per week reduces depression and anxiety symptoms. In BC this is free and available to any patient.

Educational reference for clinician use within NOVUM. Not medical advice. Based on: Gloger & Suhr Arch Clin Neuropsych 2020, van der Ham J Attention Disorders 2025, Agnew-Blais JAMA Psychiatry 2016, AAFP American Family Physician 2024, WHO ASRS-5 (Ustun et al. JAMA Psychiatry 2017). Generation Health Inc. · April 2026

AAFP 2024 · WHO ASRS-5 · JAMA Psychiatry 2017

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When Does My Child Need Antibiotics?

For parents of children aged 0–12 — protecting your child's gut microbiome while treating infections safely

Suggested clinical use: Review at any visit where antibiotics are considered, declined, or recently completed. Also valuable at well-child visits as anticipatory guidance. The gut microbiome section is the most important — parents respond well to understanding the long-term stakes of unnecessary prescriptions. The "what to do instead" section reduces the risk of parents feeling dismissed when a prescription is not given.

Most childhood infections are caused by viruses. Antibiotics kill bacteria — they have no effect on viruses. Using antibiotics when they are not needed does not help your child get better faster, and it causes long-term harm to their gut bacteria.

Illnesses that do NOT need antibiotics

These conditions are caused by viruses. Antibiotics will not shorten the illness, reduce symptoms, or prevent complications:

Common cold and runny nose — even when mucus is green or yellow
Most coughs and chest colds (bronchitis)
Most sore throats (only strep throat, confirmed by a swab, requires antibiotics)
Influenza (the flu)
Croup (the barking cough)
Bronchiolitis in babies (wheezing, usually caused by RSV)
Most ear infections in children over 2 years with mild symptoms

Green or yellow mucus does not mean your child needs antibiotics. This is a normal part of the body clearing a viral infection and does not indicate a bacterial infection.

Illnesses that may need antibiotics

Your doctor will decide based on examination and, where needed, a test:

Strep throat — confirmed by throat swab (not all sore throats are strep)
Ear infection — severe pain, fever above 39°C, or in babies under 6 months
Bacterial pneumonia — confirmed by examination or chest X-ray
Urinary tract infection — confirmed by urine test
Bacterial skin infection — spreading redness, warmth, pus

Watchful waiting — a safe and recommended option

For many ear infections and mild illnesses, your doctor may recommend monitoring for 48–72 hours before prescribing antibiotics. Research shows that 2 out of 3 children with mild ear infections get better without antibiotics. You may receive a “safety net” prescription to fill only if symptoms worsen — this is good medical practice, not uncertainty.

What helps while you wait: Paracetamol or ibuprofen for pain and fever. Plenty of fluids. Rest. Saline drops for congestion. Honey (1–2 teaspoons for children over 1 year) for cough. Patience — viral illnesses typically peak at days 3–5 and then improve.

Why unnecessary antibiotics cause long-term harm

Your child's gut contains trillions of beneficial bacteria that train the immune system, produce protective compounds, and support brain development. A large analysis of over 22 million children found that antibiotic use in the first two years of life was linked to:

Condition	Increased risk with antibiotic use
Asthma	Nearly double the risk (OR 1.96)
Eczema	40% higher risk (OR 1.40)
Food allergies	35% higher risk (OR 1.35)
Allergic rhinitis	66% higher risk (OR 1.66)
Obesity	21% higher risk (OR 1.21)

These effects increase with each additional course of antibiotics and are stronger with broad-spectrum antibiotics. A UK study of over 1 million children confirmed this with sibling-matched analysis — controlling for family factors — showing the effects are real, not just explained by sicker children receiving more antibiotics.

The first 2 years of life are the most critical window. Gut bacteria are still being established during this period. Disruption during this time can have lasting effects on immune development and allergy risk.

If antibiotics are truly needed

Complete the full course as prescribed — stopping early does not protect gut bacteria

Continue breastfeeding if applicable — breast milk actively helps restore gut bacteria

Offer fermented foods daily during and after the course (dahi, yogurt from 6 months, age-appropriate portions)

Increase high-fiber foods (lentils, oats, vegetables, fruit) to feed recovering gut bacteria

Ask your doctor whether a probiotic supplement is appropriate during the antibiotic course

When to go to emergency immediately

Call 911 or go to emergency if your child has any of these:
• Difficulty breathing or breathing very fast
• Cannot be woken up, is unusually drowsy, or is limp
• Fever in a baby under 3 months
• Stiff neck with fever
• Rash that does not fade when pressed (glass test)
• Signs of dehydration: no tears, dry mouth, no wet diapers for 6+ hours

Educational information for clinical use. Based on: Duong et al. J Infection 2022 (22.1M children meta-analysis), Beier et al. J Infectious Diseases 2025 (UK 1.09M sibling-matched cohort), Verbakel et al. Lancet 2025 (ARON trial), Spurling et al. Cochrane 2023 (delayed prescribing). Generation Health Inc. · April 2026

22.1M children meta-analysis · Cochrane 2023 · ARON Trial 2025

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Itching in Pregnancy: What You Need to Know

For South Asian, Southeast Asian, and Filipino patients — and any patient with unexplained itching in the second half of pregnancy

Suggested clinical use: Distribute at first prenatal visit for South Asian, Southeast Asian, and Filipino patients, and for any patient with a personal or family history of ICP. Also use reactively for any patient reporting unexplained itching in the second half of pregnancy. The urgent symptom box is the most critical element — patients often wait too long because they attribute itching to normal pregnancy changes.

One symptom that always needs same-day contact with your doctor or midwife:

Itching without a visible rash on your palms or soles — especially at night — in the second half of pregnancy.

This can be a symptom of intrahepatic cholestasis of pregnancy (ICP), a liver condition that is treatable but requires a blood test and monitoring. Do not wait for your next scheduled appointment.

What is ICP?

Intrahepatic cholestasis of pregnancy (ICP) is a liver condition where bile acids build up in the blood during pregnancy. It causes intense itching, usually in the last trimester, particularly on the palms of the hands and soles of the feet, often worse at night. ICP resolves after delivery but requires treatment and monitoring during the pregnancy.

Who is at higher risk?

ICP is more common in certain ethnic groups. UK data shows:

Background	Approximate ICP rate
Pakistani	1.46% (2.4× the rate in white women)
Indian	1.24% (2× the rate in white women)
Southeast Asian / Filipino	Elevated (exact rates vary by study)
White UK	0.62%

Other risk factors: previous ICP in a prior pregnancy, family history of ICP, multiple pregnancy (twins), and selenium deficiency.

Symptoms to watch for

Itching on palms and/or soles — the most distinctive symptom. Can be mild at first and intensify over days to weeks.

Worse at night — itching that disturbs your sleep is particularly significant

No rash — ICP itching has no visible rash (scratching marks may appear but are not a rash)

Sometimes mild jaundice — yellowing of skin or eyes. Seek care immediately if this occurs.

Itching in pregnancy can be normal — skin stretching causes itching on the abdomen in many women. ICP itching is different: it is specifically on the palms and soles, there is no rash, and it tends to intensify at night.

Why gut health is connected

Research now shows that gut bacteria play a direct role in ICP. Specific gut bacteria help regulate bile acids through an enzyme called bile salt hydrolase. When these bacteria are reduced — due to a low-fiber diet, antibiotic use, or dietary acculturation — bile acid processing in the liver can be disrupted. This is why the same dietary changes that support gut health also help reduce ICP risk.

What you can do

Omega-3 rich foods daily — salmon, mackerel, sardines, walnuts, flaxseed. Research shows higher omega-3 intake is linked to 31% lower ICP risk.

Fermented foods daily — dahi, lassi, kefir, miso, or other traditional fermented foods from your culture. These support the gut bacteria that regulate bile acids.

Selenium-rich foods — selenium deficiency is linked to ICP. Include: Brazil nuts (1–2 per day is enough), sardines, eggs, sunflower seeds.

High-fiber diet — lentils, whole grains, vegetables, fruit. Fiber supports the gut bacteria that process bile acids.

Reduce ultra-processed foods and refined carbohydrates — these deplete the gut bacteria needed for healthy bile acid metabolism.

Medical management (your doctor will advise)

If ICP is confirmed by a bile acid blood test, your doctor will likely prescribe ursodeoxycholic acid (UDCA) — a medication that reduces bile acid levels and relieves itching. Regular monitoring of bile acid levels and fetal wellbeing will be arranged. ICP typically resolves within days of delivery.

Tell your family members who have been pregnant: if they experienced unexplained itching in any pregnancy, especially on their palms or soles, this is important information for their daughters and daughters-in-law to know, as ICP has a family history component.

Educational information for clinical use. Based on: Ovadia et al. Lancet 2019 (UK ethnic disparities), Chiang et al. Hepatology 2023 (gut microbiome causal mechanism, Mendelian randomization), Wikstrom Shemer et al. (selenium), Nordic Cochrane ICP review. Generation Health Inc. · April 2026

Lancet 2019 · ICP gut microbiome MR evidence · UDCA trials

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Your Job and Your Cancer Risk

For patients in construction, agriculture, night shift work, or transportation — practical steps you can take while staying employed

Suggested clinical use: Use alongside the Workplace Exposure History intake form. Select the relevant section(s) for this patient's occupation. The most important clinical message for all groups is the same: smoking + occupational exposure multiplies risk dramatically — smoking cessation is always the highest-yield intervention. WorkSafeBC rights section is important for patients who may not know they can report safety concerns without being fired.

Certain jobs carry a higher risk of cancer due to regular exposure to carcinogens. A 2026 study analysed cancer death rates across 452 specific occupations. Construction, agriculture, night shift work, and transportation had among the highest rates. The good news: many of these risks can be meaningfully reduced with practical changes you can make right now.

Construction workers

Key exposures: silica dust (from cutting, grinding, or drilling concrete/stone), asbestos (in older buildings), diesel exhaust (from equipment), solvents and paints.

Wet cutting — always use water when cutting or grinding concrete, stone, or brick. This is the single most effective way to reduce silica dust. Your employer is required to provide this.

Properly fitted N95 respirator — must be fit-tested to work. An ill-fitting mask provides little protection.

Never dry sweep — use a HEPA vacuum or wet methods to clean up dust. Dry sweeping sends dust back into the air.

Change clothes before going home — do not bring dust into your car or house. Shower at the worksite if possible.

If you work around asbestos — your employer must provide full containment, decontamination, and respiratory protection by law. This is not optional.

Smoking + construction exposure = multiply, not add. Silica dust and tobacco smoke together produce a lung cancer risk far higher than either alone. Quitting smoking is the single highest-yield action you can take.

Agricultural workers and farmers

Key exposures: pesticides and herbicides (linked to leukaemia, colorectal cancer, pancreatic cancer, non-Hodgkin lymphoma), diesel exhaust, UV radiation from prolonged outdoor work.

Full PPE when spraying — chemical-resistant gloves, long sleeves, coveralls, boots, hat, and a respirator with organic vapour cartridges. This is the single most important step.

Wash hands and face with soap and water before eating or drinking — even during a brief break in the field. This is the most commonly missed protective behaviour.

Change clothes before entering your home — do not expose your family to pesticide residue on your clothing

Spray during calm weather — spraying in wind increases your exposure through drift and inhalation

Sun protection — wide-brimmed hat, long sleeves, SPF 30+ sunscreen. Schedule demanding outdoor work for early morning and late afternoon to avoid peak UV hours (10 am – 4 pm).

Pregnant family members — should avoid all direct pesticide contact. Prenatal pesticide exposure is linked to childhood cancers and developmental problems.

Night shift and rotating shift workers

The International Agency for Research on Cancer (IARC) classifies night shift work as a probable human carcinogen. Working at night disrupts your body's internal clock, suppresses melatonin (a hormone that repairs DNA), and is linked to higher rates of breast, colorectal, and pancreatic cancer with long-term shift work.

Blue-light blocking glasses on your commute home — amber or orange-tinted. Protects melatonin production and helps you fall asleep faster during daylight hours.

Blackout curtains and eye mask for daytime sleep — your bedroom must be as dark as possible for quality recovery sleep

Avoid eating between 1:00 am and 6:00 am — your digestive system is least efficient and most dysregulated during these hours. Eat your main meal before your shift.

Fermented foods daily — night shift work disrupts gut bacteria. Daily yogurt, kefir, or kimchi helps restore microbial balance.

Aim for 7–8 hours of uninterrupted sleep — even if this is daytime sleep. This is not a preference, it is cancer prevention.

The longer you work night shifts, the higher the risk — strongest evidence for cancer risk after 15–20 years. If you have worked nights for more than 15 years, discuss with your doctor whether additional cancer screening is appropriate.

Transportation and delivery workers

Key exposures: diesel exhaust (a Group 1 definite carcinogen), traffic-related air pollution (PM2.5), prolonged sitting (linked to colorectal cancer — sitting more than 14 hours per week raises risk by 68%), and often night shift work.

Windows closed, air conditioning on recirculation mode in heavy traffic, near diesel trucks, and in tunnels — reduces in-cabin PM2.5 by up to 37%

Movement breaks every 2 hours — get out of your vehicle, walk, stretch. This is the most important thing you can do for colorectal cancer prevention given your sitting time.

Pack your own meals — home-prepared food is lower in processed ingredients than fast food and truck stop options. Carry a cooler with yogurt, vegetables, and whole grain items.

Never idle in enclosed spaces — garages, loading docks, and enclosed depots concentrate diesel exhaust to dangerous levels

For all workers — your rights and your health

Your employer is legally required to provide a safe workplace, appropriate protective equipment, and training

You have the right to know what chemicals you are exposed to at work — ask for the Safety Data Sheet (SDS / WHMIS in Canada)

You cannot be fired for reporting a safety concern to WorkSafeBC

WorkSafeBC: 1-888-967-5377 — available in multiple languages

Tell your doctor about your occupational exposures — include past jobs, not just your current one

Universal cancer prevention that applies to every occupation: No smoking (not even “just a few”). No safe amount of alcohol. Eat a Mediterranean-style diet. Exercise at least 150 minutes per week. Maintain a healthy weight. Stay current on cancer screening.

Educational information for clinical use. Based on: Lesinski et al. Lancet Oncology 2026 (452 occupations), ACS Cancer Prevention 2025, IARC night shift Group 2A, Shen et al. Scand J Work Health 2026 (pancreatic cancer night shift). Generation Health Inc. · April 2026

Lancet Oncology 2026 · IARC Group 1 & 2A · ACS 2025

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Mold, Damp Buildings, and Your Health

What the evidence shows — what to test, what not to test, how to fix it, when to see a doctor

Suggested clinical use: Use when a patient presents with symptoms they attribute to mold or indoor air, when patients ask about mold testing, or after flood or water damage. The most clinically important section is “Tests that are not recommended” — many patients arrive having already ordered urine mycotoxin panels from online labs. This section helps redirect toward evidence-informed assessment without dismissing their concerns. The “When to see a specialist” section is important for patients with asthma.

Damp and mold in homes and workplaces are real health hazards. The evidence clearly links indoor moisture and mold to asthma, allergic rhinitis, and respiratory infections. Your symptoms are real and this is worth investigating. The question is how to investigate it properly.

What mold and dampness can cause (established evidence)

Asthma — new-onset asthma and worsening of existing asthma. Children in damp homes have 2–4 times the risk of developing asthma.
Allergic rhinitis — chronic runny nose, congestion, sneezing triggered by mold spores
Recurring respiratory infections — more frequent colds, chest infections, sinusitis
Worsening of existing respiratory and allergic conditions

What is less certain

Brain fog, fatigue, memory problems, depression, and non-specific multisystem symptoms are reported by people living in damp buildings. Observational studies find associations, but the evidence does not yet establish that mold directly causes these symptoms through toxin exposure. These symptoms can have many causes — and a thorough medical evaluation is more useful than testing for mycotoxins.

Tests that are useful

Specific IgE blood test to common molds (Alternaria, Aspergillus, Cladosporium, Penicillium) — identifies whether you are allergic to mold. This can be ordered by your family doctor without a referral.

Visual inspection of your home — look for visible mold growth, water stains, musty odor, leaks, and areas of persistent dampness. This is the most important step.

Humidity monitor (hygrometer) — costs $10–15. Mold cannot grow below 60% relative humidity. Target 40–60%.

Allergy skin prick testing and spirometry — if your doctor suspects asthma with mold allergy, referral to an allergist or respirologist may be appropriate

Tests that are NOT recommended

Urine mycotoxin tests (from online labs or alternative practitioners) are not validated by any medical society for diagnosing illness from indoor mold exposure. The American College of Medical Toxicology (ACMT 2025) states these tests are not appropriate and cannot distinguish normal dietary exposure from building exposure. They are costly and frequently generate alarming results that do not guide useful treatment.

Mycotoxin antibody panels, ERMI home dust tests for clinical decision-making, and “biotoxin illness” biomarker panels (C4a, TGF-beta, MMP-9, VEGF, MSH) are similarly not validated and are not recommended by any accredited medical organisation.

How to fix a mold problem

Fix the moisture source first. Mold will return within weeks if the underlying water problem is not addressed. Cleaning mold without fixing leaks, improving drainage, or repairing water ingress is temporary at best.

Small areas (less than 1 square metre): Clean with soap and water, or dilute vinegar, or 3% hydrogen peroxide. Wear gloves and an N95 mask. Ensure good ventilation.

Large areas, hidden mold, or HVAC contamination: Call a professional mold remediator. Large-scale disturbance of mold without containment spreads spores.

Sensitive individuals should not clean mold themselves — anyone with asthma, mold allergy, or weakened immune system should be out of the building during remediation

After remediation: Improve ventilation (open windows daily, bathroom exhaust fan), maintain humidity 40–60%, HEPA air purifier in bedroom

Research shows that repairing mold-damaged buildings significantly reduces asthma symptoms, medication use, and respiratory infections. The evidence is strongest for structural repairs that address the moisture source — not just surface cleaning.

When to see a specialist

Allergy / Immunology: Persistent allergic rhinitis or asthma not controlled with medication; to confirm mold allergy by skin prick testing; to discuss immunotherapy for mold allergy (effective for Alternaria)

Respirologist / Pulmonologist: Poorly controlled severe asthma — important to test for fungal sensitization and for a rare condition called ABPA (allergic bronchopulmonary aspergillosis) that requires specific treatment

Occupational Medicine: If symptoms appear related to your workplace rather than your home

If your landlord refuses to address mold

In BC, landlords are legally required to maintain rental properties in a state that does not endanger health. Mold from unaddressed moisture is a habitability issue. Contact the BC Residential Tenancy Branch (gov.bc.ca/tenants) or your local health authority if your landlord does not respond to written requests for mold remediation.

Educational information for clinical use. Based on: ACMT Position Statement 2025 (urine mycotoxin testing), AWMF guideline 2017 (medical diagnostics for mold), Sauni et al. Cochrane 2015 (remediation outcomes), Fernandez Perez et al. CHEST 2021 (HP guidelines), Denning et al. Lancet Infect Dis 2017. Generation Health Inc. · April 2026

ACMT 2025 · AWMF 2017 · Cochrane 2015

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Probiotic Prescription

Which probiotic, which dose, for which condition — and what to look for when buying

Suggested clinical use: Print and review when prescribing a specific probiotic, or when a patient asks which over-the-counter probiotic to buy. The most critical section for patient safety is the red warning box for pregnancy. The food-first principle at the bottom is the most important message for patients who are not taking a prescribed probiotic — fermented foods are safer, cheaper, and more broadly beneficial than supplements.

The key principle: Benefits are strain-specific. A probiotic that works for one condition does not necessarily work for another, and a different strain of the same species may have completely different effects. Look for the exact strain name on the label (e.g., Lactobacillus rhamnosus GG, not just “Lactobacillus”).

Probiotic recommendations by condition

Condition	Recommended strain(s)	Dose and duration
Eczema prevention (prenatal + postnatal)	L. rhamnosus GG or HN001	10&sup9;–10¹⁰ CFU/day. Start at 35 weeks pregnancy, continue through 6 months if breastfeeding.
IBS — abdominal pain	L. plantarum 299v (DSM 9843)	10&sup9;–10¹⁰ CFU/day · 4–8 weeks
IBS — general / constipation-type	B. longum 35624	10⁸ CFU/day only (higher doses are less effective — dose matters)
Ulcerative colitis — active	De Simone Formulation (8-strain blend)	900 billion bacteria/day · 8–12 weeks. Requires specialist involvement.
Pouchitis prevention and maintenance	De Simone Formulation (8-strain blend)	900 billion/day · up to 12 months. 85% remission vs 3% placebo.
Antibiotic-associated diarrhoea prevention	Saccharomyces boulardii CNCM I-745	250–500 mg twice daily. Start with first antibiotic dose; continue 7 days after completing course.
C. difficile infection (adjunct)	S. boulardii CNCM I-745	500 mg twice daily alongside vancomycin. Reduces recurrence from 13% to 2%.
Sleep quality / night shift support	B. animalis subsp. lactis BLa80	10¹⁰ CFU/day · 8 weeks minimum
Metabolic / T2D support	Akkermansia muciniphila (pasteurised)	10¹⁰/day · 3 months. Only effective in patients with low baseline levels; limited commercial availability.

Safety warnings

PREGNANCY — mandatory risk discussion before prescribing:
A Cochrane systematic review (high-certainty evidence) found that probiotics during pregnancy may increase the risk of pre-eclampsia (RR 1.85, 95% CI 1.04–3.29). A large umbrella meta-analysis (83,817 participants) confirmed this signal (RR 1.23).

Action: Discuss this risk explicitly with the patient before prescribing. Document the conversation. Monitor blood pressure at every prenatal visit if prescribed. Consider starting later in pregnancy (35 weeks) to minimise exposure window while preserving eczema prevention benefit (if that is the indication).

ACUTE PANCREATITIS — contraindicated: Probiotics are contraindicated in acute pancreatitis. The PROPATRIA trial found increased mortality with probiotic use in critically ill pancreatitis patients.

Saccharomyces boulardii — never with a central venous catheter: Rare but documented risk of fungemia (yeast bloodstream infection) from airborne contamination during administration.

How to choose a quality product

Exact strain name on the label — must include species AND strain designation (e.g., “Lactiplantibacillus plantarum 299v”). If it just says “Lactobacillus blend,” you cannot verify it is the right strain.

CFU count guaranteed at expiration date — not at manufacture. Look for “CFU at time of expiry” or “guaranteed through expiry date.” CFU counts drop significantly over time.

Third-party tested — look for USP, NSF, or ConsumerLab certification

Appropriate storage conditions — most live-culture probiotics require refrigeration. Check the label.

Food first — the principle that matters most

For most patients who do not have a specific clinical indication for a prescribed probiotic, daily fermented foods are safer, cheaper, more diverse, and more broadly beneficial than supplements.

Food	Approximate live bacteria	Key strains
Homemade dahi / yogurt (live cultures)	10⁸–10⁹ CFU/mL	L. helveticus, L. delbrueckii, S. thermophilus
Kefir	10⁹–10¹⁰ CFU/mL	30+ species including L. kefiranofaciens, Bifidobacterium
Kimchi (refrigerated)	10⁷–10⁸ CFU/g	L. plantarum, Leuconostoc mesenteroides
Sauerkraut (refrigerated, unpasteurised)	10⁵–10⁷ CFU/g	L. plantarum, L. brevis
Miso (dissolved in warm water)	Variable but significant	Aspergillus oryzae, Lactobacillus spp.

A Stanford University trial (10 weeks, 36 adults) found that eating 6+ servings of fermented foods per day increased gut microbiota diversity and significantly decreased 19 markers of inflammation. No probiotic supplement has produced this result.

Educational information for clinical use. Based on: AGA Clinical Practice Guidelines on Probiotics 2020, Cochrane (prenatal probiotics/pre-eclampsia), Maslennikov et al. J Clin Med 2026 (IBS strain meta-analysis), Wastyk & Sonnenburg Cell 2021 (Stanford fermented food trial), Surviving Sepsis Campaign 2026. Generation Health Inc. · April 2026

AGA 2020 · Cochrane pre-eclampsia · Stanford MIDAS 2021

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Eye Health & Nutrition

Patient handout for individuals with age-related macular degeneration (AMD), cataracts, dry eye, diabetic retinopathy risk, or a general eye-health focus

Suggested clinical use: Print and review with the patient during a NOVUM consult when eye health is a focus area (C7 cluster). Walk through the food-first section with every patient. The AREDS2 section is clinician-directed — discuss eligibility and the beta-carotene safety gate before the patient leaves. The smoking and environmental sections anchor modifiable risk.

This handout is for people who want to support their eye health through nutrition and lifestyle. It covers foods that may help protect vision, supplements that your doctor may recommend for specific conditions, and environmental steps you can take.

Food first — the foundation of eye-health nutrition

Research suggests that dietary patterns rich in certain nutrients are commonly associated with better long-term eye health. A food-first approach is recommended for everyone, regardless of whether supplements are also discussed.

Food group	Why it may matter	Examples
Dark leafy greens	Rich in lutein & zeaxanthin — pigments that concentrate in the macula	Spinach, kale, collards, broccoli, orange peppers, palak, bok choy, gai lan, callaloo
Oily fish (2×/week)	DHA is a structural component of retinal photoreceptors	Salmon, sardines, mackerel. Algae-based omega-3 for vegetarian/vegan diets
Colourful vegetables & fruit	Broad antioxidant support	Carrots, sweet potato, berries, citrus, tomatoes
Mediterranean-style pattern	Mulpuri 2023: plant-based/Mediterranean pattern associated with decreased AMD progression. Appleby 2011 EPIC-Oxford: vegetarians had 30% lower cataract incidence (IRR 0.70)	Whole grains, legumes, olive oil, nuts, abundant vegetables

A 2023 meta-analysis (Cirone) found that a pescatarian dietary pattern was associated with lower odds of age-related eye disease (OR 0.70). Red and processed meat intake was associated with higher odds (OR 1.41).

Cultural food sources of lutein & zeaxanthin: palak paneer and saag (South Asian), stir-fried gai lan or bok choy (East Asian), callaloo (Caribbean), collard greens (Southern/African American). These traditional dishes are naturally rich in the same protective nutrients found in research studies.

AREDS2 supplementation — when your doctor may recommend it

Important: AREDS2 supplements are indicated for intermediate AMD or advanced AMD in one eye only. If you have early AMD or no AMD, your doctor will likely recommend the Mediterranean-pattern diet and lutein/zeaxanthin food sources above rather than supplements.

The AREDS2 formulation studied in clinical trials contains:

Lutein 10 mg + zeaxanthin 2 mg
Vitamin C 500 mg
Vitamin E 400 IU
Zinc 80 mg + copper 2 mg

The AREDS2 trial (JAMA 2013) confirmed that lutein and zeaxanthin are a safe and effective substitute for beta-carotene in the original AREDS formulation. The beta-carotene arm was associated with more lung cancers (2.0% vs 0.9%), predominantly in former smokers. Your doctor will advise which formulation is appropriate for you.

Safety information — beta-carotene: The original AREDS formula contained beta-carotene, which was associated with increased lung cancer risk in current and former smokers. AREDS2 replaced beta-carotene with lutein/zeaxanthin. If you are a current or former smoker, always confirm with your doctor that your supplement uses the AREDS2 (lutein/zeaxanthin) formulation, not the original beta-carotene version.

Smoking and eye health

Smoking is considered one of the most significant modifiable risk factors for AMD. A 2021 Mendelian randomisation study (Kuan, JAMA Ophthalmology) found:

Smoking initiation was associated with advanced AMD (OR 1.26)
Cessation (former vs. current smoker) was associated with reduced risk (OR 0.66)
Alcohol consumption was associated with geographic atrophy (OR 2.70)

If you smoke, quitting is likely to be the single highest-yield action for your eye health. Ask your doctor about cessation support (nicotine replacement therapy, behavioural programs, quitlines).

Environmental protection

UV-protective eyewear — UV400 sunglasses and a wide-brim hat outdoors. Delcourt 2014: upper-quartile lifetime UV radiation exposure was associated with higher cataract risk (OR 1.53).

Indoor air quality — if you live in an area with high air pollution (PM2.5), consider a HEPA air purifier in your main living space. Long-term PM2.5 exposure has been associated with retinal microvascular changes.

Blue-light glasses — a Cochrane review (Singh 2023) found that blue-light filtering glasses may not reduce digital eye strain, and sleep effects were indeterminate. These are not recommended as an eye-health intervention.

Outdoor daylight (children) — outdoor time is protective for pediatric myopia (He 2015, JAMA, children mean age 6.6). This finding applies to children, not adults.

Key points to remember

1. A Mediterranean-style diet rich in leafy greens, oily fish, and colourful vegetables is the foundation of eye-health nutrition.
2. AREDS2 supplements are for specific AMD stages only — your doctor will advise if they are appropriate for you.
3. If you smoke, quitting may be the most impactful step you can take.
4. Protect your eyes from UV light with quality sunglasses and a hat.
5. Blue-light glasses are not currently supported by evidence for eye-health benefit.

Educational information for clinical use. Based on: AREDS2 primary trial (PMID 23644932), Mulpuri 2023 (PMID 36866844), Cirone 2022 (PMID 36102832), Appleby 2011 EPIC-Oxford (PMID 21430115), Kuan 2021 MR (PMID 34734970), Delcourt 2014 UV (PMID 25335979), Singh 2023 Cochrane blue-light (PMID 37593770). Generation Health Inc. · May 2026

AREDS2 · Mulpuri 2023 · Kuan 2021 MR · Cochrane 2023