Are We Setting Patients Up to Fail?

 

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Fresh faced students, new graduates and seasoned practitioners alike, are forever reminding me of the challenge we experience as practitioners when it comes to instigating real change in our patients health related behaviours … the change we KNOW will make a difference to their health and wellbeing.  ‘If only they actually listened to us!?!’ has been screamed by the novice and seasoned practitioner alike. With an overwhelming desire to share our wealth of knowledge, the discovery that information ≠ change can lead us to despair at times.

In a recent interview with Dr. Azita Moradi (Consultant Psychiatrist) as part of our Access the Experts webinar series, I was quite surprised (and pleased) to hear that Azita sometimes spends a whole session with a patient discussing the possibility of change, before even touching on the reality of change. Azita’s discussion surrounding the neuroscience of change and the challenges this may pose in the therapeutic relationship was fascinating, and certainly resonated with the practitioners taking part in the webinar.  Azita’s interview was full of clinical gems reminding us that just as in other settings, if we give a man a fish he eats today but if we teach a man to fish we feed him for life.  Hand and in hand with this, we need to have a strong understanding and appreciation of how to engage clients in making positive changes to their lives, often when it seems most difficult to do, such as in mental health patients.

Knowing how to improve behavioural change in patients generally, is integral to everyday practice, and its value cannot be underestimated. (more…)

The Bugs are Biting Back!

microbe-1279146_960_720All health professionals are aware of increasing resistance in bacteria as a result of our overuse of broad spectrum antibiotics in both prescriptions and our livestock industry but increasingly we’re hearing about evidence of resistance in microbes of a variety of flavours – take the recent report on head lice that featured in the national news just this week.   I am also frequently hearing from mentees about patients being affected by bugs that traditionally have been relatively easy to resolve e.g. helminths, candida spp, tinea spp, that are proving in some clients very hard to budge!  A praccie  said to me just yesterday, when discussing a patient with recurring resistant oral thrush who was otherwise young, fit and well (!) – ‘Is it possible that these pathogens are actually getting harder to treat.’?..Absolutely! (more…)

With or Withania You?

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Cheesy I know! 😉  However, recently the issue of knowing when to use Withania somnifera & when not to, came up again in mentoring so I thought it’s probably a good one to share.  Withania, aka Aswagandha or Indian Ginseng, has become a favourite adaptogenic prescription for many practitioners, myself included.  I remember learning specifically (about a million years ago!!) that this herb is ‘warming’ & ‘nourishing’, thanks in part to its iron content. In a traditional medicine context, it’s used for those particularly vulnerable populations such as children, the pregnant, the elderly and the malnourished, boiled in milk as a tonic.  These ideas always stayed with me, and lead me to only use Withania in similar patients and presentations with good results. (more…)

Ten Quick Tips for Identifying High Oestrogen & its Causes

Feb Update under 30

During mentoring sessions over the last week I’ve been prompted to ask a few practitioners if their patient had any signs, either clinically or in their pathology results, of high oestrogen.  Each time it kind of caught the practitioner off guard because their patients weren’t presenting with conditions overtly related to an oestrogen excess and they hadn’t specifically ‘tested’ for this.  However, in each instance the information was already there in the case, it was just a matter of knowing what markers to look for.

So some patients scream ‘high oestrogen’ right from the minute they enter the room? But often others present with health problems that don’t necessarily appear related at first glance.  Regardless, their condition absolutely could be being compounded by this background imbalance – think thyroid & other autoimmune conditions for example.  

There are plenty of patients who don’t have the exaggerated clinical presentation but still have this imbalance as a significant compounder or perpetuating issue in terms of their pathology.  

Relax – I am not suggesting salivary hormones or any form of expensive testing all round (!) – in fact what I am saying is before you even consider yet another pay out of pocket test, costing your patient more time and money, we should look to the clues that are already there, in standard blood tests.  Amazingly, you can infer a lot not just about the overall oestrogenic load but also pick up some clues as well about where the excess might be coming from. 

In this Update Rachel brings together her 10 quick tips on how to recognise either high oestrogen and/or the potential underpinning reason behind the excess, in a range of easily accessible markers.  A great refresher and synthesis of ideas on this important aspect of diagnosis and clinical management.  This Update in Under 30 is now available to purchase as a download, click here to find out more or if you’re interested in a 12mo subscription click here

The Beauty of the Basics

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Howdy practitioners – I’ve had an inspiring month of clients.  Not because I cured anyone, answered some major riddle previously unsolved by modern medicine or any of these enormous tasks we or our patients often set ourselves but rather because I got back to basics.  Many of you will know that I spend most of my practice time working at the pointy end of complex chronic multi-system disease and while it is deeply satisfying when you have a breakthrough with someone’s health, it is challenging.  Often I am the last bastion, my clients have been referred to me and therefore typically have already addressed their diet and other health behaviours to a certain extent.  So unlike perhaps many naturopaths, I don’t spend most of my time in practice talking about food and doing the grassroots education that is at the core of naturopathic medicine (in my humble opinion) 😉

This month was different.  I had a bunch of clients who, while they did have pointy end (that’s a technical term!) multi-system disease, e.g. one client alone had retinal detachment, coronary stents, a genetic bone disease, NAFLD and a liver abscess, they clearly hadn’t been educated about food in the way that we do so well and which can make such a huge impact on a person’s life and health.

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When I Would Give Withania A Miss

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We kicked off mentoring this year with some great cases last week.  One was a pregnant hyperthyroid client.   During the session the wonderful practitioner mentions that the client is using Withania somnifera as required for anxiety.

Insert sound of brakes screeching to a dangerous squealing crash!  Here’s a situation where I would give Withania a miss.  (more…)

Turning the Spotlight on the Low Dopamine Depressive

 

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Low dopamine as an underpinning cause of depression, anxiety and even addiction (illicit drugs, sex, gambling) has been gaining increased recognition in research.  In spite of this there are no antidepressants currently on the Australian market that address dopamine specifically and therefore patients with this pathophysiology often fall through the gaps, failing to get efficacy from pharmaceuticals.  Many of these patients are subsequently diagnosed with ADHD as well, which has disordered dopamine as part of its aetiology, and are prescribed dexamethasone as well.  The dexamethasone, being a stimulant that helps significantly to improve dopamine, is typically the drug that has more of a positive impact than the anti-depressants on these patients however, still fails to really solve the issue and can come with many side effects.

Since the 1990s the term ‘Reward Deficiency Syndrome’ was coined to describe a subset of these individuals whose brains are effectively under-equipped with dopaminergic activity in certain key areas.  This is the result of a less common genotype coding for our D2 receptor in the brain.  Far from being rare, this genotype is reported to be present in 30% of Americans, however, the magnitude of problems associated with it can vary from mild to severe depending on many other genetic and environmental factors.

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A Duck Called Homer? (HOMA-IR)

Duck called HomerMost of us know that measuring a fasting blood glucose to assess how well someone is managing their glucose levels is about as crude and insensitive as waiting for the smoke detector alarm to tell you your dinner is cooked!  If we wait to see an abnormal result here we’ve missed a prime opportunity for patient education and prevention long ago.  Much the same story if you’re looking at HbA1c results.

To explain this I always use the analogy of a duck.  A duck will always be able to swim but the question is how much effort does it have to exert to swim the same distance?  If your blood glucose is within range after an overnight fast that’s as good as saying, ‘this duck can swim the length of the pond’.  What it doesn’t tell you is how fast its little legs are paddling in order to achieve that.  Measuring a fasting insulin at the same time, however, tells us some additional important information.  It tells you how fast the duck’s legs are paddling just to keep its head above water!  The more insulin you’re having to secrete to just maintain normal blood glucose levels, the more alarmed we should be! (more…)

Bali Beauty Beware!

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I’ve just come across yet another woman who has developed an unprecedented fungal nail infection  (Onychomycosis) in her toenails following a trip to Bali.  This infection is usually due to a species of tinnea that has managed to infiltrate the nail structure.  According to good old naturopathic theory we might wonder about what has made this individual susceptible e.g. high sugar diets and dysbiosis however my experience tells me that often these infections are directly the result of exposure to the fungi and don’t necessarily point to a bigger story.

In several patients recently who have presented with these, each one had recently returned from Bali where…yes you guessed it…they had a pedicure or ten!  Multiple uses of nail scissors, clippers or any other pedicure equipment without proper disinfection in between will frequently lead to infection subsequent clients.

These infections are extremely difficult to treat due to poor penetrance of any remedies through the nail in which the fungi is thriving.  Effective treatment needs to be started very quickly and necessitates vigilant daily administration of a topical anti-fungal (be that herbal, essential oils or otherwise).  Patients also need to understand the basic ways to prevent the spread of infection to other nails which includes using a separate pair of nail scissors for infected nails only.  Commonly these acute nail infections progress over weeks to months leading to loss of the entire nail and typically regrowth of a permanently infected and deformed nail – hence why treatment needs to taken so seriously early on.  At that stage surgery, laser therapy and pharmaceutical oral antifungals become the only treatment options.

Just thought it was worth spreading the word on this one as it seems to be increasingly a case of Bali (or any other Asian country offering cheap pedicures) Beware! 🙁

Correcting Urinary Iodine Results – A Newsflash!

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Howdy hard working praccies 🙂  well I received a very interesting email this week from someone asking me if I thought her urinary iodine result was accurate or if, as I have written about previously (https://rachelarthur.com.au/concentrating-concentration-getting-urinary-iodine-right/),  it needed to be corrected for the creatinine content of her urine.  Her raw iodine result was 24ug/L which suggests severe iodine deficiency.  Her referring doctor however had also asked for creatinine and applied the creatinine correction formula I have previously described:

Iodine (mcg) ÷ Creatinine (mmol) X 8.85 = Corrected Iodine  – which changed her result to 265 mcg/gCR which suggests she is NOT iodine deficient at all

She then asked another doctor to review the result who had told her 24ug/L was correct in the first place as ‘pathology companies automatically correct for the concentration of the urine’. Naturally the individual found the difference in opinions and results absolutely striking and ultimately disconcerting so she thought she’d ask me.

It was good to get this email because it made me go and check my facts, get in touch with all the major mainstream pathology companies we deal with and ask their labs ‘Do you or do you not automatically correct for creatinine when you report urinary iodine results?’  I was worried I had given you guys some bad advice 🙁  …here’s what I found out: (more…)

New Insights into Vulvovaginitis: Getting Species Specific & Sex Hormone Savvy

 

No matter how long I am in practise there is always a group of patients for whom ‘vaginal thrush’ is a major problem.  Most of us have some fabulous tricks up our sleeves to help resolve these issues & reduce their susceptibility – intravaginal lactulose is one of mine thanks to Jason Hawrelak.  And then you come across those clients who vigilantly do every thing you ask them to and yet you fail to completely resolve the issue. Doh!

One of the most important things to do with all clients presenting with ‘thrush’ sooner rather than later is send them STAT (!) for a vaginal swab.

Not only does this clarify if it is in fact actually thrush (2/3 of self-diagnosed women get it wrong according to research!)  but better again it names the actual culprit.  It may come as a surprise but not all vulvovaginitis is due to Candida albicans – increasingly they are the result of other Candida species and this is something you absolutely need to know.

During a recent mentoring session, a practitioner wanted to better understand why she had a group of patients whose thrush seemed so resistant to her usually successful treatment.   Here’s my initial response in a nutshell… (more…)

Is Your Rep a Good Rep?

 

Recently a practitioner lamented that because of her clinic location she didn’t see company reps very often & felt this was a barrier to her staying current with her clinical knowledge.  Of course, I had to beg to differ.

We’re quick to judge the medical profession for their reliance on commercial sources of CPD, overwhelmingly provided of course by the ‘drug reps’ but it seems we’re less fazed or concerned about ourselves being equally reliant, unduly influenced and misguided (might I add) by the people employed by the CAM manufacturers expressly to encourage us to sell more of their products! How does that make sense? 

I go back to my very repetitive mantra: always be mindful of who delivers you the message/information etc. and what their agenda is.

By promoting their company’s products to us, focusing on the products’ strengths, ignoring or simply not making it a priority to know the limitations or weaknesses of the products or the evidence, ignoring or again simply not making it their business to know when superior products are being produced by competitors or when new evidence comes to light that puts into question their products, reps are only doing what they’re employed to do.  But is it helpful and is it ok? (more…)

Dump The Dairy But Not the Calcium?

 

It’s not sexy but it is one of my favourite deficiencies. Favourite because it’s incredibly common…make no bones about it (tee hee)!  Favourite because a deficiency is actually reasonably easy to recognise once you know how (watch increasing phosphate levels especially over 1.2 mmol/L in particular in adults) rather than wait for a recognisable clinical deficiency picture because if you wait for this your patient will have probably had osteopenia if not osteoporosis for a decade already! Favourite lastly, but most importantly, because correction of a calcium deficiency has led to some of the most diverse but impressive improvements in people’s health that I have seen – from better menstrual regularity and less luteal phase symptoms (see the fascinating research on this also by Thys-Jacobs 2007 https://press.endocrine.org/doi/full/10.1210/jc.2006-2726) to improved pain control in fibromyalgia. (more…)

The Inclusive Specialist?

 

Lots of great conversations with practitioners following my recent post on the need to specialise – really thought provoking & clarifying ones which makes me think it’s been a good conversation starter. Key things that have come up for people are:

  • How do I choose my area of speciality…e.g. is a spin the bottle approach required?
  • Is specialisation sensible when you’re only just starting out or should you be taking everyone and anyone to begin with?
  • Is specialising even naturopathic given we have a holistic approach to health?? …e.g. I might say, I only do gut but for my IBS patients there’s a whole lot of stress management & mental health stuff that needs addressing along the way

Great questions 🙂 Now remember, all I’m offering here is my opinion, I don’t think there is a definitive answer to these but I think we should keep the conversation going as a way of keeping us thinking about the way we choose to practice rather than assuming there’s only one way to be a naturopath in clinic. (more…)

Why I wouldn’t use Vitex

 

 

We had a great case in one of our graduate mentoring sessions the other day (thanks Kate 😉 ) , about a 40 something mum of 3 who reported to have cyclical mood and depression.  Further investigation of the case, however, revealed that some of the key characteristics of the mood disorder were actually anger, aggression, irritability, hyperactivity, vivid nightmares etc.  This particularly came to light with her responses to a mood survey that the practitioner had asked her to complete.  I think validated tools like this (esp. DASS), when used appropriately, can give us enormous insight – often revealing things we might not have thought to ask about or that the client might not have voluntarily offered up, particularly if they are not socially accepted or attractive qualities.

If you practice anything like me, then Vitex is an absolute reflex response (think the very funny reflex paper ad – that’s me in my clinic!)  & godsend for most cyclical mood issues. However, apart from the fact that this woman’s key period of mood aggravation, although clearly related to her menstrual cycle, was day 5-14 rather than during the late luteal phase, there was another stand out reason for me why I definitely wouldn’t use Vitex. (more…)

Want Help With Your Grave’s Patients? Recording Available

So…a 55 year old female walks into your clinic only recently diagnosed with Graves disease but when you look through her old blood work it looks like actually she has had hyperthyroidism (or at the very least suppressed TSH) for some time prior.  She is experiencing a lot of the common features with stinging eyes, thinning hair, shortness of breath, broken sleep, as well as fatigue and depression.  Problem is you’ve done all the right things (Selenium, Rhemannia & Hemidesmus etc.) and yet you’re not seeing significant improvements.
Your mind starts going further afield… worrying about what you might have missed…she has lots of amalgams, parietal cell antibodies and very high ESR and copper levels.  What are you missing??

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Money and Meaning?

I had one of those conversations with a friend recently in which he was wondering out loud about what the point of it all is.  Now don’t panic…this is not ‘suicidal ideation over a cuppa’ kind of stuff … no this is the regular existential crises that many of us experience about what it is we’re doing with our lives as opposed to what perhaps we should be doing, or as a good psychologist might frame it asking ourselves the question, ‘do my values align with my actions & choices in life?’.  Maybe it’s my age, maybe it’s where we live but I find this is a conversation that’s coming up increasingly regularly amongst friends, colleagues and clients.

The wrestle between being V doing, earning V giving  and perhaps money V meaning is such an age-old one and I think particularly pertinent to people in our profession. We’ve chosen the road less travelled, we’ve opted for a career that (chances are..) we knew was likely to earn less (money, respect, fame! 😉 ) than a lot of other paths we could have chosen and yet most of us hold the almost endangered position of being able to say, “I love what I do”.  (more…)

Avoiding Overwhelm In Clinic

So…a 40 something female walks into your clinic with depression & anxiety…sounds common enough right?  But here’s the twist: she’s already seen another practitioner who ran a range of investigations revealing she has pyrroles, high copper levels & is homozygous for the C677T MTHFR mutation. Her medical history includes significant use of Ecstasy and a partial thyroidectomy due to nodules & she has persistently high TSH.  But wait there’s more!…The first practitioner upon discovering all of this put the patient on 12 different products which included zinc, B6, evening primrose oil, vitamin D, thyroid support etc etc.  And guess what…the patient feels worse!

Frequently our patients are just as complex as this case & sometimes our attempts to narrow the treatment focus through thorough investigation instead leaves us feeling we now have even more things we need to deal with than before! Feeling overwhelmed?? Often! At risk of completely overwhelming the client as well?  Definitely!  And a reflex to throw your whole dispensary at a client never ends well. (more…)

Iodine Excess in Action

 

I’m only human & there are some questions that do make me silently groan & invisibly (I hope!) roll my eyes.  One is the old chestnut:  “but the Japanese consume on average 7mg of iodine a day!” which is typically offered up as a rationale for the need for mega dosing of iodine in everyone.  This is of course only a partial truth & the missing bits make all the difference!  The Japanese have some of the highest rates of thyroid disease in the world & this is in part, attributed to their high iodine exposure.  Secondly, it’s simplistic & flawed to isolate one characteristic of a whole diet & not appreciate that its effect or impact is mitigated by the context of the entire diet & lifestyle of that population.  In the case of the Japanese, for example, this includes relatively intake of isoflavones, key goitrogens which will reduce the bioavailability of the iodine both within the gut & at the thyroid. Harrumph!  I love iodine & am frequently suspicious of a deficiency in my clients, however, like many nutrients feel that our ultimate objective is for optimal nutrition…not excessive.

Am I just a conservative scaredy cat perpetuating fear around this topic in the industry?  Well…..no.  There is accumulating international evidence of big spikes in autoimmune thyroid disease diagnoses following the introduction of iodine fortification programs in previously iodine deficient countries such as Greece, Turkey & Brazil.  There is of course evidence as well that iodine supplementation in Grave’s & Hashimoto’s disease can lead to delayed recovery or worsening of the condition. (more…)

Bad Patient Days (BPDs)

I was chatting with a colleague today about a complicated & interesting case of hers, severe hypothyroidism coupled with overt hypercortisolemia (salivary cortisol up to 230!).  This is a distance patient & she’s sharing care with a couple of other health professionals with conflicting ideas…tricky!!

So when my friend received an email last week to the tune of… “things are bad, everything is terrible if not worse”, then naturally she starts worrying: What has she missed? What’s gone wrong?  What more could/should she have done? Is this some sort of aggravation to the treatment she’s recommended?

This is the place our minds naturally go when faced with these scenarios however one of the things I have really learned over years in clinic is that patients, like me, like everyone else I know, are labile, in the moment kind of creatures & we’re all vulnerable to having BPDs. (more…)

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