There’s probably some poignant lines from a rap song everyone knows that I could insert here but, alas, Gold FM doesn’t play anything produced after 1999, so I’m none the wiser. What I’m trying to bring to mind, is the potential clash between our reality & our response: we’re not all gonna get instafamous, so the majority of us should probably curb the buy-now-pay-later spending and establish some contingency plans. And while it might seem like I’m just picking on the young folk, this can happen at any age and stage of life. These, in psycho-speak are called Positive Illusions, and are one of the concerns psychologists have about the potential impact of exclusively focussing on ‘the positives’, aka Positive Psychology (PP).
There’s a lot to like about this Gen Z offspring of psychology. And perhaps, as integrative health professionals, a ready-made romance, given both tribes (them & us) believe in health being something beyond the mere absence of disease. That and the fact they give due recognition to the role diet & exercise play in our mental wellbeing…how truly thrilling! Over the last 20 years PPIs (Positive Psychology Interventions not the other ones!) have become so pervasive: schools, workplaces, we’re in an age of the National Happiness Index, we’re overflowing with positivity, spilling over the lip of your coffee mug, emblazoned with ‘You’re Awesome!’ or ‘You’ve Got This!'(Just in case we forget momentarily) But we need to explore the science for and against, to better discern when these messages and tools are a help in clinic and in our patients, and when potentially a hindrance, worse still, a harm.
😁POSITIVITY😁
is extremely popular right now, but an obsession with it & rejection of all things negative (thoughts, feelings, experiences pasted over by something nicer and brighter!) is not necessarily a balanced recipe for mental wellbeing, according to the science.
PP has made a wonderful contribution to how we think and talk about our mental wellness as opposed to just our mental illness. However, there is a critical context in here that’s important for clinicians to understand, in order to use it well, and some thought-provoking criticisms and counter-balances that will help us all avoid becoming as (in)effective as a slogan on a coffee mug. Oh and guess what guys? Assessment first 🤓💪 this takes the guess work out of whether your patient is a good candidate for PPIs and we’ve included two in this latest Update in Under 30 – even a validated mental health screen that only uses positive language for those averse to those nasty negative thoughts and feelings!
UU30 Positive Psychology Its likability & limits
The ideas behind Positive Psychology may resonate deeply with integrative health professionals, for good reason. We have in common a belief that ‘the absence of disease’ does not constitute health & that prevention is better than cure. And PPIs have become so popularised they have permeated into schools, workplaces and most people’s therapeutic interactions, e.g. gratitude exercises, identifying our strengths via a strengths wheel, self-compassion. But do we know the limits of positive psychology? Do we know who it works for and what it means when it ‘doesn’t deliver’ mental wellness?
You can purchase Positive Psychology Its likability & limitshere.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.
I’ve been hatching this passion project for quite some time. In truth, I can probably trace its beginning back 2 decades, when I returned to practice, after working in psych meds for big pharma. I knew then I had something to say. Because even then I knew that we, as integrative health professionals, could see that food must matter, nutrition must play a part, in the difference between mental illness and wellness and that the solutions were unlikely to be all pharmaceutical, or even that the likelihood of a ‘pharmaceutical fix’ would be improved by adequate attention our nutrition. For those of you too young to know, this was about a decade before the ‘Inflamed brain’, as a model for mental illness, got wings. About 5 years before the psychiatrist, Michael Berk, first took NAC to the world & about 5 years after the first links between methylation & mental health were just being muttered. It was before this extraordinarily expanding field of research even had a name: Nutritional Psychiatry, circa 2015 (thanks in part to Jerome & Felice)
And now it has a name And the evidence is irrefutable But we still need to get the message out, further, louder.
Since then, I’ve mostly shared my ‘something to say’ with you. Entrusting you with passing on the message and the medicine further & it has been an honour and something I work to improve all the time. But every year or so along the way, I had the opportunity to speak to the uninitiated, the non-believers. At medical conferences, to doctors and pharmacists, via in-hospital training of psychiatrists, on large public platforms and each time I did, the same thing happened. The room went quiet, people listened, crossed arms before I began, unfolded by the time I finished, with even the staunch non-believers at the outset, approaching me afterwards, to speak to the impact, the revelations. I had hit a nerve & built a bridge, simultaneously.
So I decided it was time, to indeed ‘say something’ , to more people and more loudly than ever before & I created this video: How Could Nutrition Improve Your Mental Health?
This is something so many need to hear right now. I hope you might share it with your patients and save yourself some precious time in your already over-crowded appointments. Use it as an educational offering, a soil tiller, a ready rationale, maybe even, a ‘step 1: watch this’, for those you’re about to help. With the other health professionals you share these patients care with, so they can better understand the place and potency of your contribution. Family and friends – so they too can benefit and better understand. It doesn’t feature me, outside of my voice to carry the message & it refers them back to you – to ‘us’, those of us passionate about wellbeing, skilled-up in nutrition, who take the time and know that not all mental health solutions are outside of ourselves & an individualised approach that takes the best of each modality is ultimately best for the individual.
Introduction to Nutritional Psychiatry can be viewed here. This 30 min video is an introduction to Nutritional Psychiatry. It is especially beneficial for integrative health practitioners and people working in mental health related industries. We encourage you to use this engaging ‘visual’ presentation to educate your clients by giving them this link. Contact [email protected] if you would like to receive a digital copy to add it to your website or other online platforms.
THIS IS A NON-SERVING SUGGESTION!!! Supplements should not be chucked in together like this – clearly their stability testing Is based on being on their own in a closed bottle under controlled conditions – this is definitely a case of do as I say not as I do!!! 🙄
So, I’ve spent the break on a very long road trip. Some of you may have seen my happy snaps on socials, in particular, all the #natschats I was lucky enough to have along the way – either accidentally or ‘accidentally-on-purpose’ catching up with naturopaths across the eastern states! What can I say – we’re everywhere and tend to flock 😂
During this challenging time in our lives, with so much distance, disconnect and disorientation – I have felt so nourished through re-connecting with my professional community and reassured by the familiarity of these friends and colleagues: still fighting the good fight, providing extraordinary care for their patients, furthering our profession through delivering education to the public, mentoring practitioners, working from ‘within’ asking the ‘big’ questions about our training, our offering, representation, our voice, our responsibility.
I know not everyone reading this was lucky enough to have a restorative break, or in fact any kind of break this year but I hope that my travel tales, reconnect you in some small way & give you a little bit of hope. Here’s my take-home:
We are a profession filled with extraordinary individuals – diverse, granted – but overwhelmingly what links us all is that we care so deeply for our patients, we feel pride in our profession and we keep on keeping on, for as long as we can, in spite of adversity and look around – our message and model is definitely spreading.
Any way, ol’ lazy bones here knows when it’s time to head home…when the supplement stash runs dry 🙄
Lastly – it’s a new year full of resolutions – so when I saw this wonderful card by Rosie Made a Thing on my travels, I couldn’t resist sharing
Burning, tingling, crawling, buzzing, humming, zapping, pins & needles, numbness: our patients often tell us about strange sensations they have in various parts of their body. It’s typically not their major concern, but they mention it as an aside, a curiosity, ‘another weird thing I get’. While they may have trivialised this, relative to their ‘real issues’ [insert gut, hormonal, mental health] we should do the opposite and bring this concern to top of the list to correctly identify the cause.
If bilateral sensory nerves are mis-messaging it typically means 1 of 2 things: 1. Nerve damage is occurring – and if allowed to progress this can become irreversible or extend to motor and central deficits 2. Nerves are irritated or impaired – and this tells you something ‘systemic’ is out of whack and these sensations are often the only alarm bell
The top cause of paraesthesia, falls into the first category and is of course diabetes – and yes even now diabetics will walk into your clinic not knowing they have this (a good old HbA1c should be routine to rule this out). Second on the list is alcohol dependence. The third most likely explanation for the patient with paraesthesia is nutritional. And in contrast to what many of us might incorrectly think, there is a long list of nutritional imbalances that can be responsible for either, nerve damage or irritation, and B12 deficiency is not in fact the most likely.
That’s right all you nutritional ninjas🐱👤 – that makes the correct identification of the cause & the solution our bag, right? I mean who else is going to do this, accurately?
Asking the right questions about these sensations helps you to quickly confirm when a nutritional cause is likely. From there we need to know how each single micronutrient excess or deficiency or in the case of some, ‘sort of single’ nutrients (we all know people who sit in this category, right?! So why not nutrients 😂) are likely to present, via ‘easy-to-spot’ key characteristics that cover: pattern of distribution, speed of onset and progression, risk factors, accompanying features etc. In our final New Graduate mentoring session for 2021, a practitioner presented her patient who rated her concerns as 1) Fatigue 2) PMS 3) GIT issues & 4) Tingling & crawling sensations across limbs, face, lips and tongue…and I was like, whoa stop right there, you might just have given us the answer to all of the above~!~! Seriously. Here’s a clue: it wasn’t oral allergy syndrome and it wasn’t B12. Can you pick it?🤓
The Patient with Paraesthesia – Part 1 Patients often mention experiencing peculiar sensations: crawling, tingling, burning, as an aside, as a ‘oh and by the way’. But while it may not be their top priority – it should be ours. That’s because nutritional imbalances are the 3rd most common cause of these and timely treatment is essential to prevent progression to more serious issues. The list of potential nutrient deficiencies and excesses behind these, is long, but this recording, the first part of 2, will help you narrow the differentials, nail the diagnosis & the solution.
The Patient with Paraesthesia – Part 2 In this continuation of this topic, we discuss several less talked about nutrients whose deficiencies drive potent pathology for the nervous system & move onto a cluster group of minerals, whose imbalances create functional irritation rather than organic change. This episode includes a range of excellent resources from videos demonstrating in-house tests you can perform to aid diagnosis, as well as our own Ready Reference which assists correctly categorising the different paraesthesia patterns and the nutrient issues behind them
You can purchase The Patient with Paraesthesia Part 1here and Part 2here.
BUY PART 1 & PART 2 TOGETHER AND RECEIVE 10% DISCOUNT BY USING CODE BUNDLE12
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.
I’m ready to zip my lips 🤐 and ride off into the sunset of silly season. But first I wanted to tell you about the BIG PLANS we have ON THE BOIL! Noticed a bit of a thyroid theme of late? Last month I presented training in thyroid assessment for the 4th time for ACNEM but not a slide, possibly barely a dot-point remained from the original one I wrote back in 2009. That’s how much my ideas & understanding have changed.
Some of the assay techniques & technologies are new, there’s a river of research & a mountain of meta-analyses published in the time between & I have had the privilege of yet more clinical encounters in this space, to really nut out how all this translates into the real world.
There’s a lot I need to catch you up on. And as I start creating our new MasterCourse II in Comprehensive Diagnostics…which will include 🥁…you guessed it…the humongously hardworking HPT, I’m just about bursting at the seams! And will those four little friends of every good practitioner, that sit superficially atop the ‘butterfly’, make it into our MCII?? I hope so because a) they should be our besties – being the director of Ca Mg D & P regulation and b) research tells us that where we find, ‘thyroid’ dx we should have another good hard look for ‘parathyroid’ dx and vide versa and c) over the last few years it has become increasingly apparent to me that this is one incredibly common source of ‘medical mysteries’ in our patients – remember the ‘Bones, Stones, Abdominal Groans & Psychic Moans’ catch-cry? Yep, that’s the patient who typically finds their way to us, with pervasive but hard to pinpoint gut issues (often misdiagnosed as SIBO, FGD, IBS -D or C), some significant stress perhaps even depression and insomnia and, if someone bothered to look, premature bone demineralisation. What other pathology panels and parameters will we be able to squeeze into our MasterCourse II?
Our current plans are to deliver the MCII live from May but just a reminder, because this next instalment assumes you have the exquisite foundational knowledge we laid down in the MCI – this is a pre-requisite for attending the MCII. So if you’ve been putting off your pathology apprenticeship now you have a hard deadline to work to!
And finally the last, last words. On topic because they came from someone who specialises in thyroid, did the original thyroid training with me, way back when, and last month was my fellow presenter & panellist on all things thyroid for ACNEM:
I’m sure I’m the 1 billionth person to reflect this back to you but I’ll do it anyway because I think we all need reminders sometimes – you have a truly special gift in critical thinking, discernment, and most importantly passing on complex knowledge in a very digestible way without making anyone feel silly for asking questions or not getting something the first (or fifth time…no, just me?). The endless analogies are a teaching tool you’ve well and truly nailed and boy am I grateful because it speaks to my way of learning very well.
So, a big thank you! Endless gratitude for your brain, passion and generosity with your time/knowledge/resources. Natalie Douglas
Here’s to another great year of learning, teaching, sharing & mentoring in 2022 – 1 billion and counting I hope 🌟🌈😂
We love hearing from our fellow fearless friends on the frontline – working with lab results & pathology providers – everyday. We recently received an SOS! from the Francesca Naish over yet another iodine assessment issue that you may need to also be alert to:
“Ever since you first drew our attention to the need to correct urinary iodine results, I have used your formula for all my patients’ results. Thank you for this. As most GPs don’t seem to be aware of the need to do this, I find it essential to warn my patients to wait for my interpretation before acting on their doctor’s advice! For a while now, Laverty have started giving the corrected result, which complies with the calculation you recommended. However, very recently Douglass Hanly Moir have started to give a corrected result on their result sheets, but it does not tally with the calculation I have been using (the one you recommended) and generally gives a lower figure.”
Well, as always, cluey people ask cluey questions…and this did take some back & forth with DHM to solve. Increasingly, all the major pathology companies are coming around to the essentiality of urinary iodine correction, something I’ve been banging the drum 🥁 about now for….yikes…7 years..no wonder I’m going grey! This is a mathematical formula applied to any raw score for urinary iodine to account for the dilution/concentration of the given sample, because, as we all know, hydration status varies widely between individuals and even within an individual at different times – and this is something that can wildly lead you astray in your thoughts about their iodine status, if not accounted for. Some companies are now employing the formula we use: Iodine (mcg) ÷ Creatinine (mmol) X 8.85 = Corrected Iodine in mcg/gCr which is wonderful to see. But DHM have taken a different path, strangely enough, using this formula BUT rather than using the patient’s own reported urinary creatinine they instead use a ‘median creatinine’
Which…I am going to say it… MAKES NO SENSE!^%@* aka we WILL correct this iodine for hydration status – but we’ll correct it for someone else’s no yours! – Ms/Mr average…ok? Ahhhh no. Just look at the difference this makes in a patient with very dilute urine, in example number 2 above!!
So Francesca & all of you on the frontline, can be assured, if you’re using the formula above – it is correct – keep up the great work and know that it is often better to do something yourself than blindly trust a 3rd party when it comes to pathology…unless that 3rd party is our RAN Patient Pathology Manager template which calculates this perfectly of course!
Increasingly our patients are coming armed with lab results and this cumulative data helps us to clearly see their ‘norms’ (as opposed to textbook ones) and therefore be alert to any changes. However, results from different labs at different times, and even the same lab, are unlikely to be presented side by side for easy comparison. They certainly don’t come with all the important information about what was happening for that patient at each time point – important details pertaining to the blood collection itself (fasting, inflamed etc) which can profoundly alter results or the broader context: menstruating, breastfeeding, losing weight, on meds and supplements.
The Patient Pathology Manager retains all the results for you, including the critical contextual elements, helping you to keep more accurate records to make the most correct interpretation. It also assists you to monitor changes related to various interventions.
Previously, the RAN Patient Pathology Manager has only ever been available to clinicians who participate in Group Mentoring but due to frequent requests for access, we thought it was time to share this great tool for those wanting a foot up with some better systems in their practice.
This provides you with a template that can be used an infinite number of times plus a short training tutorial.
There are some things we say so often to patients we could record them and just press <PLAY> Like this daily dogma: ‘When you’re under stress, your demand for Magnesium rises and then in turn that can make you more susceptible to further stress, so we’re going to give you some to support you’. But is this actually the whole story? You guessed it, no. (I know I am fairly predictable like that 😅)
Recently, a personal new record – a patient reported ongoing daily use of a very high dose Magnesium ‘practitioner only’ product 8 years after it was prescribed by her then naturopath – and guess what, the patient still hadn’t reached nirvana* not the band! – a transcendent state in which there is neither suffering, desire, nor sense of self
Jest as I may – I think this raises some serious questions. The pervasiveness of our prescriptions when patients are not given an end-date coupled with ongoing access. How (not) effective this intervention was if someone perceives ongoing undiminished dependency on it. And specifically with Magnesium – whether our prescriptions (form, dose, adjuvants, advice) are the problem? If stress is synonymous with a shortfall of this mineral then Magnesium is not a solution to stress itself but the amplified stress response and the stress still requires its own redress, right? But do our patients hear this as well when we press <PLAY>?
Likewise – the BIG doses per serve being recommended might make sense for the minority (seeking potential NMDA antagonism) but are a real mismatch with the majority, who are just stuck in the stress loop and weathering a perfect storm of Magnesium under-supply and increased demand.
I love my minerals as much as, ok more than, the next practitioner but I’m always keen to refine my repletion approaches and oh yes, by the way, there is good data, a meta-analysis in fact, examining how long it takes to achieve repletion using oral Magnesium – and guess what, it’s not 8 years! The latest Update in Under 30 goes into all this and much MuCh MUCH more…you’re welcome 😂
Practitioners working with nutrition appreciate that Magnesium is vulnerable to depletion by the stress response and that in turn, can make people more prone to stress & keep patients stuck in a so-called ‘stress loop’. But do we understand the intricacies of this and how we, as practitioners, can get stuck in another kind of loop – one of endless Magnesium prescribing without reaching repletion? We discuss ways to improve your Magnesium prescriptions – in particular, ‘doping Vs drip-feeding’ and other things to assess & address if the long road to repletion risks becoming an endless one!
You can purchase Magnesium – Stuck in the Stress Loophere.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.
An ideal T4 is 15
An ‘anti-aging’ DHEAs must be >7
A ferritin of 100 is optimal for women…
I’ve heard it all, probably you have too, and far too often & too recently from practitioners who should have rationalised & researched their way beyond these functional falsehoods, by now. I bought into these ‘optimal wellness truths’ hook line & sinker early in my career and proceeded to even propagate a few but with (not much) more experience in clinic, I had to seriously question this pursuit of ‘perfection’ & ‘perfect pathology’…in favour of reality & scientific evidence! They didn’t add up. Not with my patients – even the healthiest ones, in fact some of the really unwell ones occasionally had these kind of high-normal results and they were part of the problem!. ‘But that’s because no one is truly healthy outside of those seeing a functional medicine practitioner & supercharged on supplements & hormone replacements!!’ came the counter-argument. Ahhh, really?
How then do we reconcile this with the following: Individual genetics & biochemistry
Our biological resilience Healthy & appropriate senescence Large datasets of mixed race populations from other comparable first world countries…where these figures denote the statistical outliers?
I mean, if the 50th centile value for ferritin for actual living, breathing, bleeding, women in the US, Canada, Australia etc etc is 30-40 ng/mL and the 95th centile is 126 ng/mL and the WHO says that in fact, anyone menstruating with a ferritin > 150 ng/mL should attract suspicion for iron overload….but functional medicine men (mostly…sorry but it has to be said!) say 100 IS OPTIMAL FOR EVERY WOMAN #@^*…please tell me in which women, consuming what kind of diet, where in the world, & based on what improved or better health outcomes?
And while you’re there can someone please support this bold claim with a scrap of high quality evidence?? [Rant over🎤💧]
The falsehoods of functional medicine include the blanket belief, ‘more is better’ (ahhhhh not when it comes to many things, including iron where women’s lower levels have been found to be an evolutionary advantage…guys). But you know what, we’re better than that! We see each individual, recognising all the factors at play that make for their uniqueness, help to define what ‘healthy’ looks like for each person and don’t fall for one-size-fits-all claims without any evidence nor common sense even, to support them. What do you think?
Let’s make sense of the over-arching nutrition principles, that will profoundly change your understanding and application of this modality Truly understanding the ‘big’ concepts, so often overlooked, or incorrectly taught, ensures you get the critical ‘small’ detail in your nutritional prescriptions right. In this 4 hour recording, together with key clinical tools, we talk about the tough stuff: dose-response curves, active versus passive stores and excretory pathways and ooh lah lah…the myth of taking ‘activated vitamins’. Even those who feel satisfied with their original training – will find a lot in this critical review that is new, insightful and truly practise-changing!
It’s quite the meme of the moment and while I completely get the sentiment behind its original meaning, my take is a little different:
Results in Practice 2021!
How were yours?
Here were some of ours from the cases presented in group mentoring:
💪 We correctly identified hyperparathyroidism in several presentations of GIT, mood & musculoskeletal concerns (remember bones, stones, groans & moans?) with good response to targeted doses of D & Ca
🎯 We correctly identified BAD in a patient with ‘refractory IBS-D’ for decades – who responded well to lowering her fat intake & other support
🧐 We determined HFE mutations were present & a pathophysiological player all over the place – with presentations from psych to fatigue
🤯 We stumbled across several cases of concurrent Gilbert Syndrome & PCOS – ‘mixed messages’ in both labs & presentations – which research now suggests may be related! & should change the way we treat these PCOS patients e.g. not with CHO restriction!
But the best result of all – arguably was the growth we got to witness in all our mentees – from those in our New Graduate Program:
“I truly appreciate your compassionate way of lifting everyone up whilst stretching our brain gently to build up on knowledge, and confidence. You have such beautiful skills in navigating us – how you treat us all helped to restore my trust in this industry/naturopaths and myself 😅 so huge thank you 🙏❤️🔥” Reiko Fujike-Stirling | New Graduate Group Mentoring 2021
…to those dedicated practitioners working to build their competency & confidence in mental health:
“There’s so much to learn and stay on top of in terms of new information, I realise it is important for developing integrity and how I practice. Having a mentor, like Rachel, who I can rely on who is super on top of what’s going on in research in Mental Health. Someone I can rely on for very accurate and practical information that keeps me on my toes and challenges me and is practical for my clients. Doing mentoring and learning how to refine my understanding of case taking, mental health screening / testing, treatments and just really deepening my understanding has ignited a passion in me as a practitioner. Rachel presents everything so brilliantly and practically. Thanks so much Rachel, the content and everything is just brilliant.” Steven Judge, Naturopath, Nutrition & Herbalist | Mental Health Group Mentoring 2021
We’re sharing some of our ‘Conversations with our Community’ via our social platforms at the moment – it’s such a joy to listen to each individual practitioner’s journey…and we might end on just such a note here courtesy of Amanda Astrop – another ‘survivor and thriver’ from our 2021 New Graduate Program:
Want to join me next year so we can make RIP 2022 mean something far more positive?? Email us at [email protected], before the 22nd November, to tell us your needs, wants and desires (educational only of course 😅) & we’ll find the right group for you 🙂
New Graduate – great opportunity for New Grads to build confidence as they leap from student to practitioner, or for practitioners wanting to refresh their core clinical skills such as MindMaps, Pathology, Case Taking etc
General – our regular case presentation groups, with one practitioner presenting a case each month, or just listen in.
Mental Health Primer– topic based to build on your knowledge in the role of naturopathic medicine in Mental Health – from screening tools to key management issues, specialist diagnostics and beyond.
Mental Health Applied – this group will help you fortify and buildupon what you already know and increase your confidence when working with clients who present with myriad mental health issues & shared care arrangements. This is a case presentation group, with one practitioner presenting a case each month, or just listen in.
And it will. It knocked again on a practitioner’s door last week. She in turn knocked on mine. It turned out to be a very familiar story:
Firstly:Patient presents distressed – recently a nurse applied the term ‘Chronic Kidney Disease’ to HER (note no one has ever mentioned this diagnosis) Secondly:She is in stage 3 of 5 Then: This practitioner is left to have ‘the conversation’ but wants to know where to start, ‘What do I say?’ Next up:And what else can I do for her – are we really able to make a difference?
Familiar to you too? So,1st & 2nd: Yes, this is not uncommon we would have to say and even with age-appropriate reference range adjustment, her GFR consistently in the 50s, flags premature decline. Then: What DO you say? Well this clearly is a delicate area, not only because of the level of patient distress and concern but because, at this stage the practitioner knows nothing more than what the patient tells her and her ELFTs over the last 2 years. This is not enough information, right? Chronic Kidney Disease is a heterogeneous condition, with many different causes, manifestations, comorbid conditions, and factors affecting prognosis (Levey et al., 2009) So while most individuals certainly progress from stage I to II and II to III the rate at which they do this differs dramatically.
Two years of data is not long enough for us to appreciate the trajectory of her CKD & means we are unable to provide the patient with any kind of perspective:
‘With no further decline in GFR or progression in stages over 5 years, you’re doing well, so keep doing what you’re doing!’ Vs ‘Ok, I can see what looks like a little period of accelerated decline – let’s review what’s been happening and how we can turn this around”
“Please sir can I have some more?’ Yes, back to her primary carers to request more information to fill in the gaps, and ideally more labs to calculate & observe the trajectory for yourself. Next Up: What do we have to offer the patient with CKD stage III? Soooooooooooooooooooooooooooooooooo much!! When is adequate hydration helpful? Always, except Stage V! (and these patients are not coming to see us) What are our treatment objectives & our evidence backed medicines to meet these? Hcy lowering (note often referred to as ‘folate refractory’ in renal dx), vitamin D adequacy, lowering the acid load, supporting the microbiome & in turn the Renal-GIT axis…hang on, got to go…someone’s knocking 😅 but hopefully we all can see, when they present to us, they are indeed knocking on the right door ✊
Nutritional or naturopathic support for the kidneys tends to have been over-looked in our training and yet research suggests there is much in our tool kit that can make an enormous difference to this system, in particular, slowing the progression of chronic kidney disease in patients. Rachel talks about what these key evidence based interventions are and also gives you the tools to identify the early pathology markers of renal impairment – the earlier the recognition, the earlier we can make a start on the remedy.
It seems almost farcical to question the merits of hydration for our renal health but is this actually the truism we have been lead to believe? Where does the recommendation of ‘8 glasses a day’ come from and what is the level of evidence to support it and in whom? Or should we in fact be setting our sights on output ie. 24 hr urinary volume, over input. Do all kidneys love water – or does this relationship change with the progressive impairment seen in CKD which affects up to 30% of our middle-aged population? When does hydration become harassment?
Most practitioners graduated with not much more than a few ‘kidney’ herbs and an under-appreciation of the contribution renal health makes to wellbeing. It’s not just about waste and water. In reality, the kidneys are pivotal in just about every major element: blood, bones, pH balance, methylation, control of oxidative stress, the GIT microbiome and more! And we are seeing the impact of this in our patients in all sorts of subtle and not so subtle presentations. This new instalment in diagnostics, brings the renal system into the spotlight so we can confidently identify and better manage its critical contribution. In addition to this, just like with other routine labs such as LFTs, we unpack how these so-called ‘renal markers’ can flag a plethora of other insights into your patients, from reflecting (un)healthy muscle mass, to calculating individual dietary protein adequacy, from key ‘danger and distress’ signals in response to disturbed metabolism, oxidative stress to certain types of GIT dysbiosis! We call this Explained, Expanded and Exploded because these routine labs can deliver XXX sized insights into your patients.
And not in a good way, right. While we’ve known about the potential for peripheral neuropathy with excess B6 supplementation since the 1980s, currently there’s a seismic shift in our sense of safety even with previously regarded ‘safe’ levels. You may have heard individual whispers, or the chorus of voices coming together, both here and overseas, belonging to members of the public who report suffering sensory nerve impairment with as little as 2mg/d! Is this a mess of mis-diagnosis, false attribution & nocebo? Perhaps for some, but certainly not for all.
How could this be the case given the many RCTs employing hundreds of mgs per day over months, with no such events recorded? How could this be given, your (?), certainly my, high dose prescriptions, with only 1 case of quickly reversed, peripheral neuropathy in over 20 years, on my books? The pieces of this complex paradoxical pyridoxine puzzle are coming to light.
Is it the form?, the dose? the duration? individual differences in B6 metabolism & toxicity threshold? amplification of risk secondary to levels of other nutrients, or the use of certain medications? Yes. And we need to understand each element to better tailor every B6 prescription to the individual & mitigate risk. I have spent the best part of this month reading almost every paper on this from the 1970s to last month and I am now alarmed but more importantly, alert, to what prescription practice changes we can all make to lessen the risk, and control the power of B6. It’s been the most compelling deep-dive. Because in spite of a clear TGA warning issued last year that likely prompted the quiet removal of high dose products from market, it would seem none of the companies have the courage to have this difficult conversation with us 🙁 I invite you to ‘feel the fear & do it anyway’ & listen in to our latest Update in Under 30.
Haven’t we always known that nutritional medicine is a potent prescription? Now thanks to more sophisticated research we have a much greater understanding of this and of both the intended and unintended effects of micronutrient supplements that have the potential to achieve supra-physiological levels. B6 metabolism is arguably the most complex of the Bs – involving 6 different forms, at least 2 of which are active – and exhibiting some of the most complicated regulatory control designed to both harness the power & limit the accompanying risks. Excess B6 supplementation, however, has long been known to present as peripheral neuropathy in some individuals and case reports of this are growing, at lower and lower doses. New information has come to light to help us understand the why, the how and better still how to mitigate risk to our patients.
You can purchase Dynamics and Dangers of B6 – Controlling the Powerhere.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.
I’m intrigued by the silence. Hair loss in women is frighteningly common, following pregnancy, menopause & with extreme stress (wait is that a tautology? 🙄) In fact it can strike at any age and for a multitude of reasons. When it happened to me a few years back I also initially responded with silence, terrified that if I said it out loud it would make it real, but when my daughter suddenly asked, ‘Mum are you losing your hair?’ with her trademark attention to detail & exquisite empathy, she gave me the words & a good kick into gear, simultaneously. Now I am fascinated by women’s silence around this generally, how little we share our stories & forewarn others, & as practitioners, the lack of adequate training we’ve had identifying the different types (hint: it involves donning gloves or if restricted to online consulting, knowing how to organise correctly positioned pics) & from there finding the right solutions.
While Female Pattern Hair Loss (FPHL) is the dominant type in women – it only applies to the following pattern:
But alopecia due to stress, thyroid disorders, autoimmunity, contact dermatitis etc will affect different regions of the scalp and with a different onset & progression.
And remember, by the time YOU, the practitioner, can spot a patient is losing hair when they simply walk into the room, they have ALREADY LOST 50%😢 This is why I think we need to push back against the silence. The research is unflinching about the serious psychological impact this has on women – especially in cultures which place so much emphasis on looks generally, and hair, specifically as a commodity of very high value in women. The diagram above comes from a 2019 update on the phenomenon of FHPL and it’s a good articulation of the knowns and unknowns (pssst spoiler alert…it ain’t about androgens!) but let’s never forget the other causes and cures. So let’s make sure as the trusted practitioners women present to so often, we are sensitive enough to have this tricky conversation & skilled enough to help 💪
Stop Pulling Your Hair Out – The FPHL Answers You Need
Female Pattern Hair Loss (FPHL) is everywhere, perhaps you just haven’t been looking. As the leading cause of alopecia in women globally and with 1 in 5 women affected at any age, we’ve all got clients who have FPHL to different degrees. We need to be better able to recognise the early features of this condition which profoundly impairs quality of life and induces depression in its sufferers and that begins with validating patients’ concerns when they report “thinning” or “increased losses”. But what do we do from there? This recording talks you through the assessment, diagnosis and management of FPHL based on a combination of the most recent research and Rachel’s clinical experiences. Once you’ve ‘seen’ FPHL.., you won’t ever ‘unsee’ it and your patients will thank you.
I confess I was a chemistry nerd ‘way back when’, but my skill for stoichiometric calculations had sadly slipped by the time my kids needed help with high-school science & now my son, who’s about to graduate from chemical engineering, is my ‘chem-friend’ 🙄🧐 I suspect he feels FB messenger wasn’t intended for such use – or at least there should be some veneer of, ‘Hi darling how are you?’ before…’Need to talk through these pharmacokinetic datasets’ However, the one equation that was like turning a light on in my brain & therefore never forgotten was the Fenton reaction – basically metals’ MO for messing with our biology, especially iron. Turns out – it’s the most essential and helpful in understanding health & disease:
Endometriosis IBD Neurogenerative disorders: MS, PD, Alzheimer’s Higher than healthy GGT Impaired COMT or catechol excess for other reasons Cardiovascular disease & Diabetes Vitiligo Both the Big Cs Heavy metal burden Iron dysregulation (Obesity, HFE mutations, Thalassaemia) & Excess (IV or oral over-treatment etc)
(almost) All roads lead to radicals & reactive species…if you follow the Fenton pathway & iron leads us down this path more often than any other metal. Certainly sometimes for good: like protecting us against pathogens and destroying dodgy cells, but when it gets out of hand, a key pathophysiological process in a long list of disease. So understanding how to recognise patients prone to dysregulation of this mineral, avoiding iron over-treatment at all costs (I am seeing incorrect and excessive use of IV iron in many patients make it stop!) and identifying means to contain and control its movement, are important. Oh and in case the Fenton has faded in memory, it goes a little something like this:
While rates of iron deficiency and related anaemia continue to grow, the increase in prescriptions of IV Fe have expanded exponentially in western countries. What is behind this change in practice regarding how we treat iron deficiency and does it match with responsible prescribing? Do the benefits always outweigh the risks? And while we’re on the topic, who is most likely to benefit and what are all the risks? In light of a current class action in the US, relating to a lesser talked about adverse event associated with IV Fe and recent complaints here in Australia against GPs, allegedly due to inadequate information to enable informed patient consent…it’s time to answer these questions and more. When is IV Fe a means of rescue and when is it a risky repletion strategy with no evidence of advantage? Click here for this episode.
Ok, so maybe I don’t quite look like this after 100 episodes & almost a decade of our Update in Under 30 series but sometimes, in the depths of researching & developing each episode I can feel like this! The idea for this subscription series came out of a desire to share little monthly snippets from my patients and was called, ‘From my desk to yours’, but over time as its following grew, I came to realise how large and valuable a resource – a library of sorts – this was to practitioners. In particular, those hungry for answers, rich in critical thinking but time poor. And so, it evolved to become ‘Update in Under 30’. The topics are remain typically ‘home-births’, from my patients or those shared with me through mentoring but I realised recently, each episode goes through 3 stages of development, something like:
1. Answer a key Clinical Question that’s out there in our professional community generally 2. Answer the often more complex questions clinicians, with significant first-hand experience, have directly asked me about this same aspect of practice 3. Then, last & most challenging, is endeavouring to answer all the questions that I have now after reading the first 50 or so articles to answer the first two questions!!
And let me tell you – that last one can take weeks!!🧐😵🧐 often stalling or stopping all together, the recording or release of an otherwise near-complete episode 🙄 Ask my team – I drive us all batty. But that’s because I recognise the great responsibility I have so wonderfully been awarded and I take that to heart. And I have these questions of yours, of ours, in the driver’s seat when I research (and research again), write and rewrite, record and re-record these [messing with the myth, hey…did you think was my passive income?!^#@}
Take this month’s topic – to celebrate our 100th episode it seemed fitting to pick a BIG one!:To NAC or Not to NAC (that is the question!):
1.In integrative medicine opinions on NAC are divided – among all the fans it has its dissenters – why? 2.If such concerns about NAC are well-founded (and they are) how do we mitigate these? 3.What risks are real & relevant to the kind of plasma values we are likely to see? How precise can we get with our prescription through changes to form, dose, dosing regime etc to ‘accentuate the positives, eliminate the negatives & not mess with Mr In-between,’ as my bestie, Bing Crosby says?
Relax – I refrained from singing this line in our latest update!! But what I do let loose on is a whole lotta juicy answers to our collective questions about a much loved nutraceutical! Happy 100th UU30 🥳
That is indeed the question for most of us working in integrative medicine. While there is hardly a nutraceutical with more therapeutic flexibility and potency – with potency comes risk and responsibility – hence NAC’s dissenters. Many of the concerns regarding the use of NAC are well-founded and come down to its dynamic chemistry in both the gut and blood together with its specific pharmacokinetics. With improved understanding of both, however, to direct dose, dosing regime & duration for more precise NAC prescribing – we can accentuate its positives, eliminate its negatives and not mess with Mr In-Between, so to speak!
And for our 100th session this is of course a SUPER SIZE ME SERVE coming in at about the 40minute mark 🙄🥳
You may have noticed I don’t often have recipe raves, swap serving suggestions or generally dialogue about diet. That’s because about a decade into my career as a naturopath I hit food fatigue – my enthusiasm for explaining basic food swaps and increasing kitchen competency with clients, back to back, day in day out, took a bit of a nosedive. Admittedly, the significant time I spent on oil and gas sites educating workers about the same things ad nauseum, in the early part of my career, may have hastened the arrival of food fatigue for me a little earlier than others. There’s nothing like feeling the need to ask the few male miners who bothered to turn up to your talk, ‘Does your index finger work?’ to convince them of their capacity to make smoothies – to wear a gal down 🙄 But today I heard another practitioner comment on a patient’s breakfast choice with a simple but eloquently said: ‘Nah, it tastes too good, that can’t be right!’
This took me way back. I taught my kids (when they still were!) that the breakfast bench test was easy: any cereal you would be happy to eat straight out of the box or bag was a ‘no’.
I also used this with my patients. Somewhere along the way – let’s say in the seriously over-committed second decade of my career and, as it happens, my mum role, I lost my way, and after rearing my kids on such truisms and a wide selection of hand-cooked ‘wholegrains’ for breakfast – millet, buckwheat, barley – I morphed into a ‘muethie mum’ (muesli or smoothie). To be honest – the transition was seamless and insidious – buried under a seemingly never-ending list of tasks I had to get through – it’s only in hindsight I can see the shift. But I’m here to announce, the buckwheat breakfast is back baby & it’s back for good!
Not puffed not milled to make pancakes, not processed in any way. Just boiled. (gotta love the purple in the water that screams polyphenols!!)
A pseudo-grain, of course, that’s high in protein, lower in phytates. Served with lots of fresh nuts, fruit, a couple of prunes for even more polyphenol punch and some yoghurt. Costs about 30cents a serve for the buckwheat – so my big boy tells me- and it definitely passes the breakfast bench-test. I don’t have any desire to eat the thing on its own, ‘out of the box’, but boy oh boy with this combo…it’s worth writing about, in case you too have had a bit of food fatigue and are ready to start your recovery 😉
But sadly, still not cloned! While it may sound like Big-Brother was responsible, it was the efforts of my tremendous team responding to feedback from fans – who said things like:
I just LOVED EVERY SINGLE MINUTE of the MasterCourse in Diagnostics but would love to be able find a little gem I know I’m digging for, or re-listen to a very particular section without having to RELISTEN TO EVERY SINGLE MINUTE? Someone with a life, Somewhere not in lockdown
Ok I am paraphrasing, but you get the gist. So we thought, reasonable request really. With over 24hrs of core training modules plus all the bonus sessions that you get to have & to hold for the rest of your RAN’s life, even we might be out of lockdown by then and have other things to do!! And while I personally couldn’t stomach my 99th listen…I made St Sally do it 😂 This now means you can find the time-stamp from the video on the top right hand corner of your pdf copy of the notes and go, ‘Hey, that amazing animation of what’s behind increased Neutrophil counts – here I come’ & go directly there (39minutes & 21 seconds) without listening to a single extraneous, ‘you know’, ‘right?’ & ‘ummmmmmmmmmmmmmmmmm’
So, while I am already working up a serious head sweat (too much information?) working on the development of MCII which will kick off early next year…oh boy…did I just say that?!*%#@ and already getting outrageously excited about our next adventure together – we thought we’d go back and increase the value of the investment many of you have already made…and maybe entice a few others with our trail of breadcrumbs that takes you to the best treasure trove of all in our toolkit! I think this was Western Herbalist, Penny Henderson’s experience 🤩
“I’ve been in practice as a herbalist for many years and have to say that your master course has been one of the most exciting, inspiring courses I’ve done for a very long time! What a ripper! Your understanding and love of biochemistry and pathology brought it out of the too hard basket and into the sunshine for me. I can’t thank you enough. I have piles of patients blood tests on my desk as we speak which I have to say is rather daunting. Hopefully with much practise I won’t feel quite so laboriously slow!
Anyway thanks so much Rachel -you’re an inspiration to so very many practitioners!”
You know when you learn about a ‘new’ dis-ease driver and then you actually have to stop yourself from diagnosing every patient with it? I’ve done this dance with Gilbert’s Syndrome for over a decade, so too maybe have some of you? And while there have been many, many occasions when I’ve been certain it’s Gilbert’s (clear robust & reproducible patterns of high bilirubin without other explanation) there are other times when I’ve been left wondering, and with questions. Like – what about a fluctuating pattern – sometimes ‘within range’ sometimes above or at least high-normal – with no other explanation? What about the patient whose symptom-story is a perfect fit – prone to nausea, early satiety, gut issues, food reactions and anxiety all worse for increased oestrogen…but the total serum bilirubin is 14 micromoles/L? I mean, 14, right? that’s well below the top of that range, but remarkably higher than the majority of women of the same age, eating the same diet. And you ask yourself…could it…be??
It could.
The latest UU30 offering on Gilbert’s Syndrome constitutes a complete overhaul of everything we’ve previously been told about how to recognise and diagnose this polymorphism & it’s going to answer a lot of those ‘could it be’ questions we’ve all had! Known also as familial non-haemolytic jaundice and episodic hyperbilirubinaemia under stress – is everyone with Gilbert’s prone to jaundice? Uh, no. Total bilirubin levels typically have to get to 45 micromoles/L to evoke this effect – many of our GS patients won’t ever get there, some will with increased illness or other stress and may yellow a tad (like a fading bruise), while other patients of mine routinely have a bilirubin at this level but won’t experience jaundice unless they impair their UGT further via doing what they know they shouldn’t: extreme exercise or excess alcohol. The latest deep dive into GS diagnostics
But as much as we don’t want to miss this diagnosis we don’t want to mis-diagnose patients with it either!
Can you spot the difference? Don’t forget total serum bilirubin levels are the net result of haem catabolism – so you need to account for rate of blood production, destruction and of course rule out any biliary dx before you can take a guess at Gilbert’s. Oh and watch out for expected high bilirubin values in the fasting fan(atic)s!
For those people living with Gilbert Syndrome at last the research world & the real one are uniting – with greater detailed documentation of how this very common polymorphism presents and the mark it may make in their health story. However, given only 1/5 with Gilbert’s syndrome actually know they have this condition, who are we missing? This latest instalment rewrites our diagnostic criteria and corrects our past misunderstandings based on the very latest science, while shedding further light on what it’s like to live in Gilbert St.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
Are we all just a bit prone to panic at the moment? I received a 9pm call from my 21year old son. Trying desperately to disguise my reflexive s’mothering, I ask in a voice feigning carefree, ‘Everything ok?’ to which he replies, ‘Well, [long pause] not really…”
⚡NOT REALLY??????!!!!!!!!!!!!!!⚡
My fingers are poised to dial 000, I just know I’m not going to sleep tonight now (or possibly ever again!!) I become aware of a lot of background noise around him (?is he at hospital), my heart is in my throat as I ask, “What’s goingon?!!”
“There’s no organic kale
…I mean there’s rainbow chard, but that has things in it that reduce the absorption of minerals, right, mum? But is it ok to buy just once?”
Ok everyone exhale. He’s not in ER just the produce aisle of his local late-night supermarket and his main concern is optimising his nutrition 🙄😂 Oh and not overly relying on food delivery services because, “well that’s just depressing and I know whatever I cook is so much better’. And while he might be the scientific one of the siblings his area is oxy-fuel combustion as opposed to oxalates so he thought he’d call a friend 😅 My children have demonstrated the most incredible resilience under some trying times in their young lives of late but good to know their #kidsofnaturopaths qualities are alive & well 🥰 Now I could have kept him on the line for longer to explain all the ins and outs of oxalates and how to keep the levels low…but nah…with my heartrate returned to normal I was suddenly very ready to sleep, he can just listen to the recording😂 …and so can you!
Oxalates are found in high concentrations in many of the ‘healthy food choices’ we promote and are even higher again, when these are organically farmed! Given the importance of individualising therapeutic diets are we able to quickly recognise those who need to lower their level of these naturally occurring plant products? Who shouldn’t be drinking green juices? And which of our patients might benefit from being educated about different food combinations and preparation to lower the oxalate load from these otherwise fabulous foods?
“After our group session I suggested the low fat trial but she was ‘no, no, no….I can’t take anything more out of my diet’. It was at the beginning of lockdown & she had other stressors as well. So I asked her to be mindful of her fat intake & if one meal was higher in fat then go low fat for the rest of the day. I saw her last week & she did this & guess what her diarrhoea has dramatically improved. She is not experiencing watery diarrhoea nor the sense of urgency nor leakage. Mostly 4, sometimes 5 on Bristol Stool. She’s now happy to trial low fat (<40g/d)”
This is the story of a 50-something female who has battled IBS-D for over 30 years. Along the way she has diligently sought the help of so many health professionals and tried numerous ‘tried and true’ IBS approaches, like FODMAPS minimisation, gluten minimisation, dairy minimisation & joy minimisation with hardly any minimisation of her symptoms!Why? Because her loose stools and urgency were BAD. A very particular form of bile acid dysregulation that is present in almost half of IBS-D patients and responds best to low fat intake, together with a few other tricks.
And with the corresponding slowed transit time, we now can more clearly see if there are additional actual food reactions at play – without all the background BAD confounding and now that her gut has time at last to actually correctly absorb things that she couldn’t before due to inadequate time in contact with digestive enzymes and absorptive surfaces.
Ahhhhh we love a great ending – especially one that reminds us the most powerful prescription is getting to the root cause such that we can empower patients 💪🧐 This patient and her practitioner inspired the recent Update in Under 30 on how we can all learn to recognise….
This is not a trick question. Up to 50% of all patients diagnosed with IBS-D actually have bile acid diarrhoea (BAD) underpinning their digestive complaints as well as some patients with unresolving diarrhoea post-cholecystectomy and gastro. Knowing which ones do and how to manage this, which requires distinctly different approaches from our general management of IBS, is the key. As always, good lessons come from those we learn in the clinic and this story starts with a patient and how we came to recognise the BAD in her belly. Get this as a single download here.
No, this is not a trick question & it’s certainly not a silly one. IBS, as many of us know, has a very loose diagnostic criteria: visceral hypersensitivity coupled with altered motility in the absence of organic disease. Hence it tends to ‘loosely’ fit a vast number of patients struggling with GIT issues. The differential diagnostic algorithm all health professionals are encouraged to use for patients presenting with GIT issues leads us to this IBS label, just as soon as we’ve excluded the red flags. But this ‘early opt out’ according to many experts, including Schiller et al in the American Journal of Gastroenterology, tends to propagate the illusion we’ve reached our diagnostic destination: practitioners stop thinking about the ‘why’ & stop looking for the real drivers & causes, which is the key to shifting the refractory patient into remission.
For those presenting with chronic diarrhoea, Bile Acid Diarrhoea (BAD) is in the diagnostic algorithm & there is strong evidence it’s at play in almost half of these patients! It’s just that BAD, is the next station along the line after IBS-D, which means most clinicians have sadly disembarked already 🙁
Bile acids, as key biological agents, in both the behaviour & health of the gut & metabolic dx, are getting a lot of attention right now. While Bile acid malabsorption (BAM) in disorders of the small intestine such as Crohn’s & undiagnosed or refractory Coeliac dx, as well as other miscellaneous GIT disorders that clearly disrupt the bile acid balancing act of the gut-liver axis, have been known for a long time, there’s a new kid on the gut block, previously only known as the idiot, I mean, idiopathic BAD. But us idiots have finally worked it out! This is not about malabsorption but about excess production of bile acids and this pathophysiology is drastically over-represented in IBS-D patients.
And knowing if your IBS-D patient has a ‘BAD-thing’ going on, every researcher wants you to know, is game-changing. Explaining the strong heritability of this particular IBS subtype and the reason so many patients are refractory to standard IBS approaches.
We need to use distinctly different dietary strategies when IBS is BAD. Once again patients are our greatest teachers & I’ve relished the excuse one practitioner and her patient gave me to deep dive into the enormous body of BAD research, that is ‘so hot right now’! The way I look at, ask questions about and assess patients with chronic diarrhoea, especially IBS-D, is forever changed 💪🙏
When is I.B.S. B.A.D?
This is not a trick question. Up to 50% of all patients diagnosed with IBS-D actually have bile acid diarrhoea (BAD) underpinning their digestive complaints as well as some patients with unresolving diarrhoea post-cholecystectomy and gastro. Knowing which ones do and how to manage this, which requires distinctly different approaches from our general management of IBS, is the key. As always, good lessons come from those we learn in the clinic and this story starts with a patient and how we came to recognise the BAD in her belly.
Burning, tingling, crawling, buzzing, humming, zapping, pins & needles, numbness:
