There’s enormous potency in nutritional medicine for mental health but it ain’t in the form of a ‘dash of precursor here and a sprinkle of co-factor there’, like some may have you believe. Many nutritional prescriptions can look good on paper but that’s the extent of it, take the suggested use of glutamine for GABA production, for example. Sure it can be said to be a precursor (so is glucose!) – so will higher intake of this equate to higher production of this neurotransmitter? Ah, no. The reasons relate to distribution and hierarchy of use for this amino acid, as well as determinants of glutamatergic neuron activity.
Why would we limit our prescriptions to precursors, anyway, when we have 2 amino acids at our disposal, whose oral supplementation is known to translate to higher CNS levels and their actions and efficacy as major inhibitors of neuronal firing (akin to GABA), involves no modification nor maybes?!
Hello, Taurine & Glycine, where have you been all this time?
While, many of us may have been using taurine in combination formulas for mood, chances are you’re not entirely clear why sometimes those work and sometimes they don’t. The answer may be in the regulation of CNS taurine transfer & balance- sometimes the people who need it most, have the least capacity for its uptake across the BBB. This is well-established in neurobiology, but news to many nutritional and integrative health professionals, who have been using it in patients where Glycine, in fact, makes more sense. So while taurine has myriad impressive strings to its bow in relation to mood-modulation and powerful protection of brain structure & function, Glycine, has an extensive network of receptors throughout the brain and spinal chord, enabling it to exert inhibitory effects, second only to GABA itself. And, most importantly, BBB transfer of this amino is not subject to the same impediments that we see with taurine. These are two of my most frequent and favourite mood-modulators, affordable and accessible when used as single ingredients, for patients, with anxiety, addiction & sleep disorders etc but understanding how they work (and when they won’t) is essential in choosing which one to use, when.
For example, do you know the Tmax for either of these oral supplements? How long it takes, to create a spike in patients’ plasma, better still their CSF, and therefore speed of onset of action? What about their elimination half-lives to guide your understanding their duration of action and therefore the timing of follow-up doses?
When we’re trying to realise the full potency of our medicines – these are important details to know that convert our ‘prescription potential’ into something powerful. Just like die-hard herbalists will tell you, its an art and a science and this is true in nutritional medicine as well. Don’t skimp on the science!🤓
Both taurine & glycine have a claim-to-fame as amino acids that effectively calm an over-revving brain, via their net inhibitory actions within the CNS. They achieve this via different means and while in some circumstances, one, either or both will is the result of differences in the regulation of their BBB transfer, pharmacokinetics, as well as add-on benefits or detractors, unique to each. Learn how to use both of these powerful and affordable mood-modulators, to their fullest, and be more able to know ‘which one when’, by listening to this latest narrative review.
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Don’t know this thrash anthem for all nutritional medicine practitioners written by Supernova about 20 years ago? Do yourself a favour and check it out!! It makes me laugh to the point of tears every time. What also got me giggling recently was a coffee catch-up with a fellow nat (relax, it was decaf people!) Both being active women approaching the half century we found common ground discussing our ‘war wounds’. She, an ankle injury, me, lax ligaments in my knee thanks to touch football minus any pre-season prep whatsoever. I was waxing lyrical about the wonders of swimming, which I’ve taken up to heal said gammy knee, at which point she asked, “What are you taking for it?”
My mouth dropped open & nothing came out…because the answer was *!NOTHING!*😂 At which point, she mentions a couple of supplements I have *!ON MY SHELF!* that really helped her ankle 😂😂
I text her 3 days later with, “Man, our medicines really work!!” You see, like the song says, I do ‘take my vitamins’ and ‘they’re good for you! Good for you!’ – just this physician health yourself thing can be a blinking full time occupation sometimes! Anyway, it got me thinking about how we choose the products we do. So turmeric caps are part of my new regime and they seem to be working a treat. I stock one brand only. Now how did I come to that decision amongst an ocean of options?! Well in this instance, I had asked a colleague who works OTC and dispenses a variety of turmeric products en masse – better still she sees those people come back either for more…or not. I’ve found asking my well-placed peers about these kind of products invaluable!! But there are so many different ways each and everyone of us may have made product choices – ethical concerns, personal experience, research, a teacher, mentor or rep’s influence. Anyone who has done the UTAS post-grad, of course, has exhaustively analysed the options, complete with comprehensive spreadsheets of all comparative products…god love these guys!! But for the rest of us mere mortals, how do we make such choices?
Let’s just talk turmeric for now, I’d love to know…
My gorgeous sister first brought this ditty to my attention & we’ve had a wonderful trip down memory lane today (with our elderly mother as our hostage as we both belt out the lyrics in laughter down the speaker phone)…she’d be cross if she didn’t get the credit here, rightly so 🤣
I’m gonna take my vitamins! (Vitamins! Vitamins!) You better take your vitamins! (They’re good for you! They’re good for you!)
You better take your vitamins, Two by two! Two by two!
I’ve seen two 20-year-old young men in my practice this last month who’ve already made a lasting impression on me. The first, is buff, full of cheek and humour while deeply engaged with his health, earnest in his desire to understand his 7 years of daily upper gastric pain, for which he has read much, changed his diet & given up what most 20 year olds would consider their rite of passage and right (late nights and alcohol). The second is pale, gaunt, neuro-atypical, full of tics and avoiding eye contact at the beginning of each consult, only to look me solidly in the eyes as he reveals incredible insight about ‘being different’ & his desire to be able to engage with something/anything so that he can live a more normal life, by the end. What do they have in common?
They’re 20 & trying to make their way in the world. Undertaking all these newly autonomous actions, previously taken care of by parents, including fronting up to a health professional with concerns, seeking understanding and support.
The first, in spite of 7 years of gastric pain and irritation (I can see mum took him to a GP with similar concerns at 13 years & again at 15!!), self-reported extreme worsening with gluten exposure and a family history of similar GIT issues, was not offered a single investigation by the GP they visited but was given a month long trial of a PPI. I caught him 3 days in. Was he feeling less pain? Yes? What does this mean? He has gastritis at best, something more sinister at worst? Does it reveal the cause? Not one iota. But tests for H.pylori, coeliac disease and a few other basic labs, might. Does it offer a long-term solution? Nope – even the GP said , ‘Now this will probably help but you won’t be able to stay on this too long!” While up to 80% reductions in gastric acid, will definitely lessen gastric irritation and pain for most, will a month ‘fix’ anything? Unlikely. Especially when the well-documented withdrawal rebound effect kicks in, once he stops! After a month of actual stomach repair work, he’s feeling dramatically better and yes, we’re still pushing for those test results.
The second 20yo, was seeking a mental health care plan from a GP he’d never seen before. He walked out after 15minutes instead with an SSRI.
With a diagnosis of Asperger’s at 12, ADD at 13 and a series of high level neurocognitive assessments and stimulant trials – how could anyone make an informed decision about appropriate medication for this neurobiologically complex individual in 15mins, while simultaneously ignoring his request for hands-on psychological support? I was a bit stunned. He was too. How long, and how much effort and courage, will it take for him to make another appointment, get himself back to a medical clinic and ask again? He struggles to remember to eat. I’m glad he came. I can’t offer all of the services and support he needs, far from it, but I can listen long enough to ‘see him’, acknowledge that his personal priorities and values are valid and in turn, direct mine in terms of how best to support him. I can also try to encourage him not to give up on getting the support from others he desires and desperately needs. This is not gender specific of course – I’ve heard similar stories from young women. I remember being 20 – perhaps all health professionals need to take a moment to remember what that was like too? 🤔🤗
That’s not a word you hear often spoken by people practising nutritional medicine. Which is odd. I mean outside of the whole, ‘I’m not good with sulphites so I just have to add these magic drops into my glass of red so I can knock back my share,” often overheard at our conferences… it’s like this essential macromineral, pivotal to human health for things like barrier function, antioxidant defence and our basic ability to create the white cells for immune defence (for that matter), detoxification, musculoskeletal tissue integrity etc has just not received its due attention from us. Not entirely surprising given 1) there’s no RDI and 2) there’s no lab test to assess an individual’s status and how about 3) because we were never taught about it!
But the biggest ‘call to action’ here is that, in spite of items 1, 2 & 3, we’re ‘prescribing’ Sulphur Strategies all the time!
Take one of my favourite examples;GAGs. Glycosaminoglycans like Glucosamine sulphate (not the crappy, found to be not as effective, other forms that we now see more commonly) hit the headlines back in the noughties as an effective arthritis remedy. This is one of the 100s of our body’s ‘end products’ of its endogenous Sulphur Stream. We naturally make this in adequate amounts to ensure the integrity of our joints (and many other tissues of course!) when we have enough Sulphur in the ‘top pool’ (organic Sulphur) to trickle down to the 2nd pool (Inorganic Sulphur), therefore creating a constant essential supply of something known as ‘the universal Sulphur donor’ – ‘PAPs’, to its friends 😉 Like a waterfall, it helps to have a good flow from the top to increase the likelihood we’ll have anything to ‘show’ at the bottom.
So when we give a patient Glucosamine Sulphate it may well help. Or not. But did we ‘treat the cause’ of their Sulphur problem? Should we have treated higher up, increasing the size of either the organic or inorganic pool to have improved and widened the benefits for their health? Or, as is equally common, actually identified why someone might need more Sulphur than most – due to increased demand and losses?
Herein lies my reason for liking this particular Sulphur story somuch. The common medication that places the highest ‘demand’ on Sulphur (due to its need for detoxification) is paracetamol. There’s no debate regarding this – just absolute scientific consensus. NSAIDs and steroids also negatively affect the Sulphur status of individuals, as does Vitamin D deficiency and chronic mild metabolic acidosis. Now how commonly are these phenomena co-occurring in our patients afflicted with arthritis? And traditionally of course, what was the remedy for arthritis? Sulphur springs.
Unseen Sulphur – Time To Take A Look If you don’t have a clear picture of the gross daily requirements, determinants of altered individual needs, sources, regulation & associated deficiency picture of Sulphur, you’re not alone. Turns out this essential macromineral remains ‘unseen’ by most, even though you’re probably writing prescriptions every day that have Sulphur as their key component. From the simple: Taurine, N-acetyl cysteine, Protein powders, to the sublime: Brassica extracts & concentrates, N-acetyl Glucosamine, Alpha Lipoic acid etc. In order to use these Sulphur strategies successfully and safely, however, we need to fill in the missing detail on its metabolism, the difference between the ‘organic’ and ‘inorganic pools’, how regulation regularly goes wrong even in those seemingly consuming enough and how to balance the risks of this reactive medicine with its substantial therapeutic value. This recording comes with a great clinical tool to help you, at last, see the Sulphur strategy most indicated for your patient.
You can purchase Unseen Sulphur – Time to Take a Lookhere.
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 say: Biotin, Broccoli Sprouts & Bone Broth You say….?
If you said: ‘Sulphur’, go directly to the top of the class, passing ‘Go’ & collecting $200 on your way!🤓 If you nervously said…”I don’t know, they all start with ‘B’ ?”, you are not alone. In fact, most integrative health professionals aren’t aware of the Sulphur Strategies they’re using, probably, everyday. But it’s time we all were.
How about this list? Glycosaminoglycans (GAGs for joint, gut etc tissue integrity), Cerebroside Sulphate (Myelin), Metallothionein, Glutathione, Hydrogen Sulphide (H2S), Co-Enzyme A, Lipoic acid, SAMe, are just some things Sulphur is essential for.
I could go on…and on and on. You see Sulphur, in spite of being an essential macromineral (adult dietary requirements > 1g per day) and critical to health, remains largely unseen. Often we don’t know when we’re writing patient prescriptions that actually we’re using a particular vehicle for Sulphur and therefore we’re also not able to discern which, of the very long list of options (dietary and supplements), makes the most sense in this patient at this time. We’re not to blame, not many ‘possess the power’ to see it, it seems. Por old essential, irreplaceable Sulphur doesn’t even have an RDI. But the time has come to take a good look. We need to know how patients are able to meet their needs, who needs more and how, very commonly, someone who is seemingly ‘consuming enough’ may still exhibit a functional Sulphur deficiency with poor musculoskeletal tissue integrity, low white cell replication capacity or higher oxidative stress load etc and in those who do have a shortfall, how to treat successfully & safely. Who needs a top down approach (more protein, methionine, cysteine, bone broth) and in whom would that be a risky path and using ‘downstream’ Sulphur products instead would be a better balance of pros and cons?
Because all Sulphur needs to be handled with care.
That’s right. Like other highly chemically reactive minerals, with reactivity comes risk – a great potency that requires careful consideration of both form and dose, so that we can harness this power for good not…well evil’s a bit strong…but how about, for not-good. I’m a bit of fan of Sulphur and using Sulphur strategies in my patients. I think it has interesting echoes with our past: the ‘healing’ waters of a Sulphur Spring and of course even further back the old ‘brimstone and treacle’ medicine of eons ago. This paper by Nimni in 2007: Are we getting enough sulfur in our diet? got me thinking about Sulphur again in a contemporary context, over a decade ago, I’ve done a lot more thinking, researching and prescribing since then but it seems that Sulphur still remains ‘unseen’ by most. But with the rise and rise and rise of popular Sulphur-based supplements (alpha lipoic acid, GSH, N-acetyl glucosamine, Brassica & Allium extracts and concentrates, N-acetyl-cysteine etc) I think it’s time to talk.
If you don’t have a clear picture of the gross daily requirements, determinants of altered individual needs, sources, regulation & associated deficiency picture of Sulphur, you’re not alone. Turns out this essential macromineral remains ‘unseen’ by most, even though you’re probably writing prescriptions everyday that have Sulphur as their key component. From the simple: Taurine, N-acetyl cysteine, Protein powders, to the sublime: Brassica extracts & concentrates, N-acetyl Glucosamine, Alpha Lipoic acid etc. In order to use these Sulphur strategies successfully and safely, however, we need to fill in the missing detail on its metabolism, the difference between the ‘organic’ and ‘inorganic pools’, how regulation regularly goes wrong, even in those seemingly consuming enough, and how to balance the risks of this reactive medicine with its substantial therapeutic value. This recording comes with a great clinical tool to help you at last see the Sulphur strategy most indicated for your patient.
The latest Update in Under 30 has landed!!!
You can purchase Unseen Sulphur – Time to Take a Lookhere.
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.
The first time I saw a set of lab results was when a patient brought them in to her appointment. True. In spite of the comprehensive training I’d received in nutrition and biochemistry and pathophysiology my undergraduate did not include one single lesson on lab interpretation & now here I was faced with some badly formatted inkjet printed document full of numbers I was supposed to make sense of. Was the patient right to expect me to be lab literate?
We profess to be proficient in identifying and correcting nutritional deficiencies, as much as, cardiovascular risk, chronic inflammation, methylation imbalance etc etc so surely these ‘numbers’ are essential to informing our baseline understanding of & decision making regarding the management of our patients, as well as tools for monitoring their progress & safety.
Let alone the knowledge we need to work collaboratively with other health care professionals and show ourselves to be the asset that we are.
And herein lies the golden opportunity, I believe. Most of us do possess excellent foundational knowledge in nutritional biochemistry etc, much more so than other health professionals, who are ordering and seeing these results routinely, they will often tell you this themselves. And while more recent naturopathic, nutritional & herbal medicine graduates have had some basic orientation and education in pathology, are we really making the most of this powerful marriage of knowledge areas? What would we see, if we made it our business to view the same labs?So much more.
We can see warning signs well before the diagnosis, we can see the process behind the emerging or established pathology rather than simply a disease label, and accordingly, the individualisation of our patients’ presentations and their prescriptions.
But first we need to learn our labs.
That very first patient who turned up with results in her hot little hand started me on this path to lab literacy. Later, I was lucky enough to find a kindred spirit & mentor during my time at SCU, with Dr. Tini Gruner and then Dr. Michael Hayter, whom I co-presented my first diagnostics course with many years ago, and every day my patients and my mentees’ deepen my understanding. This path to lab literacy goes on forever I suspect, but with every new corner I turn, I am reminded of and rewarded by all that it has gifted me and my patients.
I’d like to share that gift with you through stories filled with new favourite characters, like ‘Mr More More More Monocyte’ above, engaging animations, loads of real cases, heaps of humour and plenty of practice in pattern-recognition, that make remembering, what can be very detailed content, doable.
In other words: The MasterCourse in Comprehensive Diagnostics I is finally here as a self-paced learning program you can undertake yourself. We know you’ll get as much out of it as those who attended live:
“I thought my pathology skills were pretty up there until I did Rachel’s Diagnostic MasterCourse! Nothing like being knocked off my perch by a literal avalanche of new information, especially when it comes from the most commonly tests that we all use so often. The course has beena fantastic learning opportunity for me, and has since helped me pick out many intricacies in cases that have previously been missed.”
– Rohan Smith | Clinical Nutritionist
MasterCourse 1: Comprehensive Diagnostics is a self-paced online program Gives you access to 24+ hours of streamed video presentations, 2 x Bonus Update in Under 30 episodes (The Calcium Conspiracy & Using Urea to Creatinine Values for Protein Adequacy) PLUS resources, a template and pdfs of all presentations. This package includes $200 worth of bonus material and remains forever in your online account. You will also receive access to any future updates of resources and our template. More information can be found here.
This is a pre-requisite for MasterCourse II that will be delivered live in 2021.
Key texts tell us, 2nd trimester Serum Ferritin may be between: 2……………………………………………………………………………………….and……………………………………………………………………………………….230 mcg/L But a 2nd trimester Ferritin even > 40 mcg/L is remarkable – and not in a good way🙄 So, ummmm what should it be and why?
Given all the attention iron gets from me alone, you would think we would be a lot clearer and a little ‘clueier’ regarding the answers to core questions like this. But we’re not. Correction, they’re not. Who is this ‘they’ of which I speak, um well, just the dudes in the top level office who write the practice guidelines for GPs, Obs, Midwives etc. Big call I know, but answer these to get my drift:
What is the average Serum Ferritin in healthy women with healthy pregnancies in the 2nd trimester? After all the routine Iron treatment given across numerous countries, in line with the WHO recommendations, is there any evidence that values higher than this have irrefutable benefits for mother or baby? Is there evidence to the contrary, that it can be harmful?
And while we’re busy asking questions that shake the flimsy foundations of the practice guidelines regarding monitoring and managing iron levels in mid-pregnancy – how about we get up to speed with the evidence that shows 1st trimester Serum Ferritin is in fact the most meaningful as an iron marker both in the short and long-run for any woman’s pregnancy. I know, right…this is all sounding very different from the, inappropriately named, ‘normal’, which is to test women at wk28, in the midst of peak haemodilution, and therefore physiological anaemia, and to then send that patient home often with a new diagnosis of iron deficiency and a sense of urgency to ‘fix this fast for you and baby’. In some instances this is appropriate and important, especially women who weren’t comprehensively cared for & whose iron status wasn’t monitored & well-managed in the first trimester. But for so many women, who are just riding the Ferritin-Fun-Bus…they are right on track with looking their very worst!
Couldn’t resist finishing this year of Update and Under 30s with a serious BANG! 🧨🧨🧨
In this continuation of our discussion about better iron balance for mum and baby we now map what is happening in each trimester with regard to requirements and regulation, and accordingly, what ‘healthy looks like’ in terms of both serum ferritin and transferrin, at every time point. This also gives us a clear practice protocol around when and how exactly to treat iron deficiency in pregnant women. Additionally, we review the risks of both under and over-treatment.
The latest Update in Under 30 has landed!!!
You can purchase Pregnancy Iron Balance Part 2 here.
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 love a little temporal lobe tap. Especially the kind patients provide. This week mine came from a mentee’s patient who, while presenting with concerns about possible perimenopause, was found to have radical shifts in her thyroid hormones, largely thanks to a dramatic increase in TPO Abs (>1000). The patient’s other presenting complaint was ongoing gastritis (confirmed via scope) and reflux…and that’s when I started to deep-dive into the archaeological archives of my brain…with the…’didn’t I have somewhere in here, in some dark dusty deep recess…a connection between the two?!’
Aha! With the help of a torch [read Google Scholar] the temporal tap bore fruit. 1 in 4 patients with AITD (Hashimoto’s or Graves, you choose!) test positive to Parietal Cell Antibodies
I’ve created (clearly, not-so)SmartArt graphics on powerpoint slides on this exact topic, waxed lyrical about it in my thyroid training packages…but in fact needed a temporal tap to be reminded! And in turn thought, well gosh if this has slipped from my mind, it might just have slipped from yours too! ‘Thyrogastric autoimmunity’ as it’s called, refers to a patient group that exhibit antibodies to both and remember, the antibodies precede the condition in both disorders, so you can have a patient with established AITD, who has zero gastric symptoms but tests positive for the antibody…an important heads-up, as it speaks to significant risk of the subsequent development of gastritis in the following years. This excellent prospective study of AITD patients by Tozzoli and colleagues mapped exactly that! Jump forward just another day or so and…
I’m preparing for our final FiNAl FINAL Q & A on Haematology for our MasterCourse in Comprehensive Diagnostics and I’m wrestling with all the conflicting ‘facts’ about the anaemia that may present alongside hypothyroidism – it has been documented and described as being macrocytic, normocytic and even microcytic… how can it possibly be so diverse I wonder and then 💡 I’m guessing the presence or absence of these parietal cell Abs likely has something to do with it!!
Anyway, it’s getting towards the end of a VeRy loooooooooooooooooooooooooooooong year…thought we could all do with a temporal tap 😉
A few things really took up a disproportionate amount of our time & attention in 2020: Zoom, Mask Fashion & Gin based hand sanitiser.On a personal note I need to confess another: Iron. So while my one true (mineral) love remains zinc, iron answer hunting has infiltrated a lot of my days and some nights! There’s no hiding it…3 out of my 12 UU30 episodes this year have iron in the title 🙄 a sure sign its been on my and my mentees’ minds and sitting across the desk from a lot of health professionals in human form. And this affair I’ve been having, like most, started innocently… it started with a just a ‘quickie’, you know a quick question from a well meaning practitioner: “So, what’s expected in terms of ferritin levels across pregnancy?”
There are 2 answers to this. The first reflects the practice guidelines for GPs and obstetricians in most western countries: > 30 mcg/L regardless of trimester And then there’s another that is [ahem] evidence based, accounts for the essentiality of physiological anaemia in pregnancy &, naturally, trimester specific
There’s a big Fe-ar factor at play when it comes to answering the question, ‘Does this woman have enough iron for her and bub?’ Public health and practice guidelines appear to assume we are ‘guilty’ until proven innocent, patients are worried and health professionals are plagued with their own doubts about whether they’re ‘reading this right?!’ I’m sure we’ve all been in the situation where we feel our pregnant patient is doing well iron wise early in pregnancy, only for them to have that routine antenatal 28wk GP/Ob visit and discover a total panic has descended upon the patient and the rest of the health care team, with calls for ‘IV Iron STAT!’ But 28wks is the height of haemodilution right? You know, that time when ferritin, Hb and Hct should look at their lowest, right? There certainly is a limit to how low we want any pregnant woman to go – for her and her baby’s health but that limit is not the one routinely used and the truly evidenced based one is going to shock you. So what? What’s the issues if we are a little Fe-ar based about Fe, resulting in hypervigilance (calling a deficiency when there isn’t actually one) and giving them a ‘boost’ of more iron, surely this is good news ultimately for baby’s iron levels and for lactation and for…sorry what? No?
There’s a U shaped Curve for Iron supplementation & serum Ferritin levels in pregnant women?!!
It starts with a simple enough question: What should women’s ferritin levels be in pregnancy? But the answer will surprise many. There are in fact two. The first reflects the practice guidelines for GPs and obstetricians in most western countries regardless of trimester and then there’s another that is arguably more evidence based, accounts for the essentiality of physiological anaemia in pregnancy & is also, sensibly, trimester specific. To challenge the ‘noise’ and have the confidence that ‘normal’ is ‘enough’, we need to better understand the mother’s protective physiological adaptation of iron regulation and the intricate systems the foetus has to ensure its needs are met. This of course is not without limit, so we need to also be clear about the maternal serum ferritin threshold for negative impact on the foetus and newborn. Getting the balance or iron right in pregnancy for both mother and baby, is perhaps easier than we have been led to believe.
Well, obviously(!)…this has been a year heavy on pathology interpretation for me and the huge number of practitioners who’ve just spent the last 6 months taking that learning journey with me. I celebrate and congratulate them all for their commitment to their own professional development and also their investment, in what is arguably, the most potent yet overlooked set of skills of any health professional… the ability to read bloods. Basic bloods. Mainstream labs. No…but to really read them. Backed by all the scientific understanding about what these parameters actually are, how they perform and what they (dis)prove e.g. subclinical inflammation and ramped up oxidative stress – not an informed guess but mappable…right there but where no one else can apparently see it! But I digress!
Actually what I wanted to discuss was the whole erroneous notion of ‘normal’.
No, I am not speaking from the heart about my personal quirks, sense of humour or dress sense but rather the incorrect assumption that a reference range defines ‘normal’ and that our answer for each patient and each result is, a Yes or a No!
In this brilliant article by Whyte & Kelly published in the BMJ they spell out this falsehood succinctly. They note that the term ‘normal range’ has slipped into medical language from the misunderstanding that all lab results follow a Gaussian (aka bell shaped curve & later referred to as ‘normal distribution’) pattern but many simply don’t. So for some parameters a result near the ‘middle of the reference interval’ constitutes aspirational whereas for others it spells danger. Add to this, that these reference intervals are mathematically determined to reflect the expected values of 95% of your patient population (mean +/- 2 SD either side) so…that means the chance of a YES…”Your patient’s results are ABNORMAL!”… is just 5%. And hey…who said all the values within the reference range are all equally “normal” or better yet, healthy?! Not these authors, nor I, nor the praccies who’ve just done our course. So while, in many regards, these goalposts are too wide, they are also too narrow – typically only representing a subset of adults age-wise and Caucasians, yes they are both ageist and racist (yep, I said it!). And if our practitioners have learnt anything it’s about keeping an ol’ eagle eye on the sneaky intra-individual shift! Only spotted, of course, if you know your patient’s normal (not theirs compared to anyone else…just theirs) and then spot a shift. [I can hear they’re shushing 🤫me…they’ve got it already, alright!!]
So this is music 🎻to my ears, from Whyte & Kelly: “The intraindividual variation in laboratory values is usually much smaller than the interindividual variability (ie, the variation in the population). Variation in the concentration of an analyte, if significantly outside of a patient’s usual values (but still within the reference interval), could be a sign of early or latent disease”
So if you want to tap into the power of pathology…start with Whyte & Kelly, maybe even dip your pinky in the pool by checking out Accurate Pathology Results Interpretation Starts Here – an easy little 1.5hr kickstarter…or jump right in the deep end with the rest of us pathology reading polo players and sign up for the MasterCourse 1: Comprehensive Diagnostics for some DIY summer fun 🌊
ps I know your type and know that is EXACTLY the kind of weird nerdy thing you have planned for your break…you should see my summer fun list!!! 😅
MasterCourse 1: Comprehensive Diagnostics is a self-paced online program due for release in December. The course has pver 18 hours of video presentations plus 2 free bonus sessions 1) Accurate Pathology Interpretation Starts Here and 2) Patient Pathology Manager and access to resources and tools within, for your own use. This is a pre-requisite for MasterCourse II that will be delivered live in 2021.
This skillset has been found by many to be biggest ‘game-changer’ in Integrative Health You can view the full course outline here.
I talk so much about iron, I feel like I’m cheating on my life partner (Zinc)…but these two are arguably the main mineral deficiencies we encounter most consistently in our patients and, don’t tell Zn, but quite frankly, in terms of who’s more well recognised out there, Iron throws some serious shade! But the truth is they’re a ‘twofor’, as a result of their similar distribution in food, with both demonstrating significantly better bioavailability (read: virtually double) from flesh foods etc, ‘Watch out, she’s on the attack again!’ I can hear the V’s (vegetarians and vegans) say and yes I think you see this one coming…but I think it’s possible to be pro moderate meat, without being, antiV.
Ethical and environmental aspects aside (just momentarily) it is hard to argue against the nutritional benefits from moderate meat for most patients.
I tried, trust me. Put my own body on the line (and my babies) to be a vegetarian for over a decade. But as the wheels fell off for me, I noticed them falling off for so many others…and these were people who were educated, with a capital ‘E’ and putting serious ‘E for effort’ into substitution etc Not everyone of course – but a LOT of women and occasionally some men. There was no denying their ‘iron hunger’ (high serum transferrin), their movement towards microcytosis (however slight that ‘smallifying’ may be…we don’t wait for anaemia, right?), their poor zinc status and more importantly, the clinical chaos of impaired immunity, some cognitive or mood issues that presented, as a result. I went back to the mineral manual, back to all the science that helps us to understand these minerals especially in a modern dietary context.
Ah yes…meat has become marginalised in our diets compared to those of our yesteryear selves (ABS data) while our consumption of potential mineral inhibitors…you know, all the good, but bad, but good foods, like legumes and grains and green tea and and and…has risen…especially among the kind of clients who come to see us, right?
Which ultimately leads to a lower iron ‘income’ with the same outgoings, again especially for menstruating, pregnant & breastfeeding women.
The books don’t balance. (So then…IV Fe to the Rescue???)
Bite me…it’s just science. There have been some wonderfully thorough studies on this very issue and thoughtful discussions. This study in particular, by Reeves et al, of Australian women in their 20s followed for 6 years to 2009, argues that just a 1mg/d increase in heme iron from flesh foods could reduce susceptibility to the subsequent development of iron deficiency amongst omnivores. So while the median daily intake of fresh red meat in these women was just 39g/d, their analysis found that an additional 70g of lamb or 60g of beef…or about 140g of chicken and 250g of fish if you prefer white over red, appeared to be the positive tipping point for women and their ability to stay iron-replete. Well below ‘dietary guidelines’, nowhere near the scary cancer correlations (which of course may be more about fat or nitrates or ??). Moderate meat intake, right? Just saying. And don’t worry, I know. The only thing worse than an evangelical ex-smoker is a rambunctious reformed vegetarian 😂
Need A Manual on Minerals?
Minerals represent a critical tool in naturopathic nutrition and there has been an explosion of research in this area over the last 10 years. In order to optimise patient care, practitioners need to keep up with the constant stream of information, updating their previous beliefs and understanding in the process. This seminal 7hr seminar (!!)…yes…seriously..it’s THE MANUAL..is designed to facilitate and accelerate this process of review and re-evaluation via a fresh look at the key minerals iodine, selenium, iron, copper, zinc, calcium and magnesium.
When I deliver foundational nutrition training to GPs I talk tough. It’s a tough field, right? Compared with the relative certainty of pharmaceuticals, their established pharmacokinetics, their sophisticated delivery systems to ensure high bioavailability…trying to fix micronutrient deficiencies in patients can feel a lot like you’re trying to perform minor miracles. Take iron for something different, its homeostasis pivots on its tight regulation at the gut wall – and this is a wall that is very tight!! At best you get about 10% of a supplement taken up, at worst you get none and the harder you push & the higher you go with your dose…the lower the fractional uptake. Tough stuff, right?!
It’s about at this point in my talk I read their collective minds and say, “I know, you’re thinking, oral supplementation is for suckers – what about we bypass that road block and use IV?!” [Ok, I definitely use nicer words than this]
And then I put up a list of pros and cons about IV micronutrient repletion: ‘100% bioavailable’ & ‘Bypasses the body’s regulatory systems’, go on both! You see, time & time again we discover, when we think we’re outsmarting the body, it still manages to outsmart us. There are some exceptions to this – some nutrients (Vitamin C) and some contexts (late pregnancy iron deficiency) but the broader promise of ‘rapid replenishment’ for everyone, in your lunch break, via an IV infusion..is not realistic, responsible nor without risk. Don’t get me wrong, I am an advocate of appropriate IV Fe use and have encouraged a small fraction of my patients to take this path. However, given the dramatic rise in prescriptions for this since 2013, I think it’s time to stop and seriously review each element: In reality what does it achieve and in whom is it a responsible recommendation; Was a risk benefit analysis performed for & communicated to each individual & was the remaining risk mitigated?
Think anaphylaxis is the major concern? It might be the most lethal but there are more serious concerns due to higher incidence with newer preparations.
So, how well do you know your different IV iron forms, and their predilection for potential problems? And have your answers ready to all the questions raised above? In order for all involved to make an informed choice (both practitioners and patients), we must.
You’re welcome 😉 and hey welcome back to tough talkin’ Tuesday…
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?
Shhhhhhhh(eesh)! I am confessing my sins. As part of our mentoring discussions we try to keep one another honest & in-check with, what seems to be, integrative health professionals’ innate flair for over-delivering. Name someone right now from another health modality that spends as much time on researching & working up your patients as you do. Name another kind of health professional who makes themselves as accessible as you do to their patients. See, I know your type. And feeling like a donkey (in many regards) but especially as in the context of this evocative picture, is not something that happens just once in your career, which you learn from, adjust your load, and never repeat. I should know, I’ve had a bit of a donkey year, myself 🙄
Our old mate, Albert (Einstein), said, “Wisdom is not a product of schooling but of the lifelong attempt to acquire it.”
I think, for health professionals (at-times) over-endowed with care mixed with an infinite curiosity (for answers), we can find ourselves with quite the ‘heady mix’, an excessively heavy load and on a slippery slope of over-delivering. This manifests in different forms at different stages of our career. I’ve talked about some ‘so-common-I-wish-I-had-a-dollar-for-every’… ways practitioners over-deliver in the clinic before. But for those of us that are seasoned practitioners, we master the basics…no sharing of personal mobile phones or even email addresses, clear communication with clients about appropriate times and means of contact, we even commit to taking some time out for ourselves and our own wellbeing (Wowee watch us go!! Physician Heal Thyself!) but often we just find new ways to over-deliver. They sneak in and up on us. It takes us a while to realise we’re back in a familiar place of dangling donkey feet in the air, over-burdened by our load.
But perhaps we should think of this as Process (a lifetime one of becoming wise, like the other guy said) rather than a pathological problem.
And as we near the end of another year, a very taxing year for many of us, take this opportunity to pause, process the strengths and limitations of our practice model over the last 12months and adjust the load so we can proceed towards an ever more sustainable practice.
Because people need practitioners like us; full of care and curiosity, not overloaded donkeys who can’t go anywhere or carry their own load, let alone anyone else’s.
Got some tips you can share about healthy boundary setting for health professionals? We’d love to hear them 🙂
I feel a bit Trumpy…because whenever someone says ‘N-acetyl cysteine’, I want to reply, “Big fan, I’m a big fan”. And yes that’s an uncomfortable awareness. But unlike he who shall not be mentioned, I can qualify my statement and provide supportive evidence, both of the research and real-world varieties. So, of course, can so many of you as well. I know of fertility specialists who place it in PCOS patients’ preconception prescriptions and respiratory specialists who regard it highly in COPD, CF and a range of other conditions. And I am a signed up supporter of its adjunctive use in many psychiatric conditions. Then there’s the biofilm-breaking buffs…
This is where non-believers might be tempted to call ‘Snake-oil!’
How can one very simple tricked-up amino acid possibly contribute to the health of so many systems? Oh, just via the chameleon qualities of its chemistry of course! As a rate limiting ingredient and precursor of GSH, as well as a potent mucolytic agent and and and…we get it. We surrender! But I want us all to back up here just a few steps. As a mucolytic agent…renowned for biofilm busting…hmmm. I prescribe a lot of NAC for a lot of people for a lot of days-weeks-months….because all the research in mental health points to it being a long-term intervention. I’ve heard Professor Michael Berk say, that patients still on it at 2 years had even more improvements than they had experienced at the 6 month mark and of course mental health, for most, is a chronic illness, so no one is surprised.
But we can’t contain its chameleon chemical qualities. Given orally, it will be having effects within the gut of these individuals on the way through…and not all biofilms should be busted, right?!
So what to do? Well thankfully, NAC is not something that patients rely on for short term acute effects, that would then make missing doses problematic – like pharmaceutical psychiatric medications, and some CAM options as well potentially, like SAMe and SJW. So a regular sNAC break is likely to be free from negative impact for those with mental health issues and in fact, beneficial long term. With all this in mind, we’re now using a dosing model of taking weekends off from this supplement – which works for most. Do we have any concrete research to say this makes sense and doesn’t compromise efficacy yet? Well no, and don’t hold your breath, because research can be very reductionistic (you heard it here first LOL) and there is a lack of consideration of the effects on an individual as a whole. The psych researchers are not measuring the impact of all interventions on the microbome of patients (yet!) and the gut researchers not always monitoring the mind. But we clinicians can pioneer the path, fuelled by two old buddies of mine: first do no harm & least medicine, best medicine, right?
Oh and has anyone managed to open a tub of NAC and not accidentally snort some?…I don’t have anything else to add or a solution, I am genuinely asking if this is humanly possible 😂
“There are few complementary medicines that come onto the market with such a bang, opening up genuinely new therapeutic options for the effective management of such a broad range of health complaints. N-acetyl cysteine stands out for this reason and has changed the way I practice” Rachel Arthur
Want to learn more about its diverse applications? Check this out
If you’re like me, Creatine as a therapeutic option for psychiatric & neurological disorders, has been stalking you for years. Lurking in the shadows, only showing its face occasionally to say, ‘Hey, I’m not all about body building and sports you know, you should check me out some time!’ But, haunted by the ghosts of yesteryear & all the wanna-be-muscle-men I served working in retail in my 20s, and scared off by the very mention of ‘sports’, I have kept running briskly walking, beyond Creatine’s clutches. Until now.
The evidence of the essentiality of Creatine for healthy brain function is undeniable and together with a wealth of pre-clinical data which likens the impact of oral Creatine to both fluoxetine, in terms of its ability to stimulate and support healthy neurogenesis, and ketamine, in relation to its fast acting glutamate inhibition, we need to at last all finally face our friendly stalker!
Thrilling as this amassed evidence is, to date the number of actual RCTs using Creatine in mental health patients, including treatment resistant depression, bipolar affective disorder, schizophrenia etc. is still too few and their sample sizes suffer from ‘smallness’ to boot, making it clear that we a long way away from a clinical consensus. Regardless, Creatine seems too important a therapeutic option to ignore while we await new larger studies and a trial of this supplement in many of our patients could be all the n=1 proof we need for its benefit to many. The skill we need to develop now is being able to identify those patients most likely affected by CNS creatine depletion. But if we follow the trail of crumbs… they clearly lead us to those at risk, due either to impaired production (amino acid and micronutrient shortfalls, most commonly) or those experiencing increased requirements (vegetarians, vegans, the elderly, high histamine??)…we are likely to recognise our patients likely to benefit the most.
While our CAM dispensary already offers us some great nutraceutical & herbal options for helping our depressed patients, I am always on the look out for more. Especially when these represent more upstream approaches…providing true building blocks for brain health, rather than just XXX the signals
Creatine and its colleagues (carnitine, choline and many micronutrients) fit this bill. Building blocks are beautiful things. Are a more ‘grassroots approach’ and accordingly, generally less expensive to boot. I’m doing more and more augmenting of my most reliable CAM antidepressants, with creatine and select aminos these days and being rewarded with great results. If you want to learn how to use Creatine supplements as part of a multi-pronged approach for your patients’ brains rather than their brawn…then there’s no better place to hear about it than here and, I guess, at last, there’s no time like now. 🙂
Creatine – The Brain Builder Part 2
Creatine for brain building over brawn, begs the question, ‘What is the ultimate supplement regime when trying to maximise uptake into our mind not our muscles?’ So much important groundwork has been done in the field of sports science to determine basic bioavailability and pharmacokinetics of this nutraceutical, we can certainly borrow much from this – but what do we do differently? This second instalment on ‘Creatine the Brain Builder’, does the complete number crunch for dosages and regimes, expected onset of action, necessary duration of use, cautions and contraindications and much much more!
When we recap the contemporary science of shared pathophysiology in mental health, we have: oxidative stress, impaired neurogenesis, monoamine deficits, glutamate excess, hypometabolism & mitochondrial dysfunction. When we ask researchers which of these supplemental Creatine might be able to assist with, we get hits at each and every point. Turns out, Creatine’s capacity for enhancing performance is not limited to athletes but can be capitalised on for anyone vulnerable to a CNS shortfall. Ignored for far too long, this economic and impactful brain nutrient is coming to the fore for psychiatric and neurological disorders.
The latest Update in Under 30 has landed!!!
You can purchase Creatine – The Brain Builder Part 1 and Part 2 here.
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.
No, mastication. I’ve touched on this before but I believe we need regular reminders. Or maybe that’s just me? I am a fan of chewing. I don’t profess to be good at it (I am a wolfer of food tbh) but I see the enormous therapeutic benefits it has to offer. Seriously. Think I’m taking the mickey? Here are some tasty brain bytes for you!
Ancient Mayans – Chicle Ancient Greeks – Mastic Gum Native Americans -Sugar pine and Spruce sap Then there’s of course the Coca Leaves (South Americans) Betel Nut (Asians) etc
But putting aside those that come with a buzzy bonus🙄 …the tradition of chewing non-digestible substances between meals according to anthropologists and archaeological evidence dates back to the neolithic period. Nowadays, of course, we barely break from constant feasting…but perhaps when we do, we should maintain the mastication? There’s a lot to be said in favour of this. From brain benefits to dental deterrents against plaque but of course the main gain for many – is the potential for better digestion. For GORD it’s the oldest trick in the book, right? The increased saliva generated by the process neutralises any untoward excess acidity in both the oesphagus and also the pharynx. So naturally, not one to forget in Barrett’s oesophagus either and of course my beloved Silent reflux. While also producing greater amounts of salivary amylase to assist with CHO digestion and lingual lipase to kick off the first fat digesting process within the stomach. But could it help beyond this? Well, though the jury is out on this increasing the rate of actual gastric emptying (though still worth a crack in Gilbert’s Guts), it’s well regarded as being able to stimulate small and large bowel motility more generally. Some SIBO soothing in certain scenarios, perhaps? So much so, it has been recommended post almost all types of surgery (GIT, gyne, renal etc) to ‘get things going again’.
And while this doesn’t have the highest quality evidence to support efficacy…encouraging people to trial chewing a natural gum – no pretend sugars, no plastics & no PK for my patients (Sorry dad! ), is a recommendation that is accessible to just about everyone, easy to try and gives people a quick yes/no.
Yes I come from a long line of chewers. My dad chewed gum between meals and during them, he popped that piece behind his ear to ‘save for later’. I swore there and then, as an offended on-looker that I would never be so disgusting. Well… I’ve finally turned into him and I think he might have been onto something 😉 [except the behind the ear bit…ewwwwwwwwwwww]
Chronic dry coughs, rhinitis, postnasal drip, the sensation of ‘a lump in their throat’ or even asthma? Have you ruled out silent reflux aka laryngopharyngeal reflux? This UU30 helps you to better recognise the myriad presentations of this condition, understand the latest about why it occurs and is on the increase & finally outlines my top & somewhat unusual interventions for management of these presentations that have proved highly successful in my own clients. Up-skill on this sinister ‘silent’ one, here!~
We’ve been talking all about the dangers of excess fuel in our blood recently. You know, just like nature…too much fuel underfoot creates a fire hazard. So too in the bloods of our patients. The key fuels I am referring to, of course, are lipids (triglycerides & cholesterol) and glucose. Our tissues need ready access to both but Balanced Blood Supply & Mastery of Management is key.
In terms of excesses, lipids play the long-game…wreaking havoc over a long period primarily via their vulnerability to form peroxides, which in turn create a chain of oxidative stress and depletes our antioxidant artillery.
In contrast, even outside of insulin dependent diabetes, for the rest of our patients, glucose plays a fast and furious game, being a highly reactive substance capable of causing both glycation and oxidation. We describe even high-normal levels of glucose as something akin to the ‘Bull in the China Shop’, disrupting the function of the endothelial linings and damaging a variety of plasma proteins (not just haemoglobin) that float within them. But do we have a way to routinely measure the level of damage occurring in our non-diabetic but somewhat glucose intolerant patients? Sure! Just check the C-CCTV footage!
The extra C stands for ‘Carb’ and yes we can potentially check the Carb-Closed-Circuit-TV ‘tape’ in every patient.
It’s called HbA1c and measuring this provides us with an opportunity to review their personal ‘tape’ of the last 2-3 months for evidence of excesses.
Helpful, hey. But we actually have so many great tools through regular routine labs at our disposal to understand the glucose disposal or dys-disposal(!) at play in our patients! You’ve just got to know where to look (urate, triglycerides, insulin, HOMA-IR etc) and what each piece of information is telling you. We’ve had SO MUCH FUN with this particular topic in the MasterCourse this month…or is that just me 🙄 No, I know it was, because our live session chatbox was full of ‘blown brain emojis’!! 🤯🤯🤯 I can’t wait to share this course content far and wide at the end of year with those of you that missed out on attending live.
In the meantime if you want to learn more about glycation which is the new inflammation, out there in research-land, you know…the source of all evil including ageing itself(!!) then check this out…
Glycation is a normal physiological process that, just like inflammation and oxidative stress, can get out of hand, contributing to disease processes. Currently there is an explosion of correlational research suggesting relationships between higher levels of Advanced Glycation End-products (AGE) in individuals who have fertility problems, psychiatric conditions, osteoporosis, premature skin ageing, cancer…you name it! New research implicates diet heavily in the determination of individual’s levels of AGE but there is devil in the detail – there are ‘4 Ps’ of dietary AGE contribution that we need to be mindful of when we are giving dietary advice and trying to move patients towards wellness. This Update in Under 30 recording: Are You Feeling Your ‘AGE’ will open the lid on the ‘new black’ in chronic health & ageing.
My how the time just flies when you’re chasing answers from private pathology companies! As Brisbane based naturopath, Sandi Cooper, can attest to having recently been down the seemingly eternal email trail with a pathology company trying to ascertain if their urinary iodine result accounts for the concentration of the urine sample (via the iodine:creatinine) or doesn’t….because of course it can make the world 🌎 of difference. Like clarifying that someone who appears to have very little iodine in their urine, actually has a lot or vice versa! I wrote about this back when I was a mere ‘babe blogger’, more than 5 years ago. After recently reading this historical document, Sandi has been practising due diligence and checking with her providers whether they have already corrected for creatinine..or whether she needs to herself and she shared that multi-departmental epic email endurance event thread with me. The short answer? They used to and now they don’t. Why? Oh…formatting issues or something 🙄
But just in case you do want the ‘short answer’ regarding your particular pathology provider…without emailing enigmas…the answer is, in fact, in front of you & it’s Super Short!
mcg/g Vsmcg/L
If your patient’s urinary iodine result (random or 24hr) is reported using the units on the left, sometimes actually written mcg/grCR, then BiNGo! The pathology provider has done the creatinine correction for you. If they only report the urinary iodine results using the units on the right…it’s time for some maths to avoid misinterpretation. No one panic, the formula is easy: Iodine (mcg) ÷ Creatinine (mmol) X 8.85 = Corrected Iodine. So don’t lose time sending endless emails like poor Sandy or placing countless calls, like poor Nina on my team…who has to pursue pathology providers on an almost daily basis for answers to our zillions of sensible questions!! Just check the units! You’re welcome everyone 😉 oh thank you Sandi for chasing this again and sorry about needing to chase this again! 😳
And if all of this is nEWs to yOU, you might want to review what you thought you knew, about Comprehensive Thyroid Assessment too!
We can never rest when it comes to learning more about the individual nuances of our patients thyroid pictures! In this 90min recording, Rachel covers the key thyroid parameters both functional & autoimmune (TSH, T4, T3, rT3, TPO, TgAbs, TRAB). As well as the most accurate methods of assessing relevant thyroid nutrients: iodine & selenium & a genuinely game-changing insight on interpretation of these . Finally she pulls all the individual parameters together to illustrate common patterns of thyroid imbalance – making it almost as easy 1-2-3! Well, hey..it’s the thyroid…a fickle fellow.
Here’s a newsflash for absolutely no one, we’re all practising healthcare in racially diverse communities, right? Take Australia for example. At last count, at least 1 in 4 were not born here and of those who were, 3% are indigenous and many many more come from migrant families. This spells DiVeRSIty. Yet our pathology reference intervals are a whitewash, frequently derived from in-house samples that stratify by gender and age but not race, or adopted external data from predominantly Caucasian countries. Think it doesn’t matter? It does. I learnt this as (almost) always…on the ground.
I have had the privilege of mentoring health professionals in South East Asia for several years but in hindsight, I can see I was under-cooked for the role: Almost every patient these professionals discussed with me, had a vitamin D result that made me feel faint at their ‘rickets-like readings’.
“But all our patients have blood levels like this, that’s normal here”, they reassured me.
And of course, they were right.
I hit the books science databases to find out more and sure enough, new evidence has emerged of racial differences in relation to vitamin D binding and therefore definitions of ‘adequacy’ in terms of blood levels of 25(OH)D, and this has been particularly well documented amongst SE Asians Gopal-Kothandapani et al., 2019 But who of us knows this outside of that region? When we see patients of this background, are we alert to the strong genetic differences that drive different Vitamin D metabolism and therefore redefine healthy, or are we incorrectly comparing them to Caucasian Cohorts?! I have to confess in the past I’ve done the latter 🤦♀️ So what else are we over or under-diagnosing or just plain misunderstanding, in our patients who are not Caucasian? Chances are quite a lot. But the more I’ve dug into the topic, looking at racial differences in pathology markers, the more complex it gets, with plenty of conflation for example with increased rates of certain diseases. So it’s not an easy answer, granted, but that shouldn’t stop us from trying to achieve better clarity, for us and our patients.
We all pat ourselves on the back because we’re across the understanding that a healthy weight is defined differently depending on your racial background, we’ve nailed (hopefully!) the whole ‘healthy BMI < 23 in Asian populations and the smaller WC cutoffs’…but really…there’s so much more that needs to be done.
Want to be on the front foot with critical pathology interpretation? Join the club!
There is such a groundswell of naturopaths, nutritionists, physical therapists etc working in integrative health that are ‘lab literate’. It appears to be a combination of both a choice and consumer expectation. With patients thinking, surely, we can make sense of those numbers on the page that remain a mystery to the patient…and tbh to some doctors!? We should. We’re currently halfway through our 6 month long MasterCourse in Comprehensive Diagnostics which is custom-built for this context. It has been incredibly well attended and well-received to date and we’re excited about the amazing content that Rachel has had to redevelop along the way. If you missed out on the actual live classroom experience…your chance is coming soon. Promise. Your DIY Diagnostics version will be released at the end of this year. Let us know if you’re keen by sending an email to [email protected], and we’ll put you on the ‘first to know’ list.
I think I’m finally able to put my ‘late-90s-Creatine-frontline-trauma’ behind me. Back then, like many good nats in training, I was working the trenches of the health food stores and was faced on a daily basis with two types of men with two types of Creatine questions. The first type was scrawny and would ask, ‘will taking this help me build muscle?’, the second, built like the proverbial brick *&#@ house, asking, ‘will it help me build more muscle?’ Cue, eye roll. Come on… any of you current or ex apothecaries, pharmacy or retail assistants…you know exactly what I’m talking about!!! So deep was this trauma that I put Creatine as a supplement, into the ‘strictly sports folder’ in my brain (the bit in the deep dark back with other rarely accessed items) and never gave it much thought when I left retail and moved exclusively into private practice. Even back when I was a sub-editor for the Braun and Cohen 4th edition, it was apparently still too soon.
A great colleague of mine, Emily Bradley, had written the chapter on Creatine and, in doing so, presented compelling case to reconsider this supplement as offering great therapeutic potential well outside of the sports-field. That one was accidental 😂
I actually remember reading that chapter, especially the sections on Creatine supplementation for neurological & psychiatric conditions and thinking….WOW…who knew?! ??!! Well, clearly Emily for one 🙄 and also every author and researcher whose work she had read…so that made quite a lot of people actually! But another [ahem 😳] several years had to pass before the research into Creatine and the argument that this has been a grossly over-looked CAM option in mental health, beat down my door and finally got my full attention. Better late than never. And boy, do we all have some catching up to do!
Let’s start with 5 fun facts: 1. Creatine is critical for energy – like cellular currency it ‘tops’ back up our funds, after increased spending, everywhere, including the brain 2. The Brain consumes >20% of our resting energy expenditure & is fifth on the organ list in terms of highest concentration of this molecule 3. Creatine CNS depletion is a thing – and it happens in a wide variety of scenarios – from the seemingly benign (like chronic sleep deprivation) to the more sinister (neurodegeneration) 4. This then leads to higher Glutamate, Oxidative Stress & a spell of other sorts of ‘brain badness’ 5. Oral supplementation can cross the BBB and ‘refuel’ the brain and correct the Creatine deficit
Out of the thousand or so pages of research on this topic, I’ve just indulged in, there are several great reviews to pick from…it’s a tough call to make but perhaps this older one by Patricia Allen remains my favourite. This marks the beginning of a new era…I’m putting the trauma behind me & moving on & hope you’ll come along too!
When we recap the contemporary science of shared pathophysiology in mental health, we have: oxidative stress, impaired neurogenesis, monoamine deficits, glutamate excess, hypometabolism & mitochondrial dysfunction. When we ask researchers which of these supplemental Creatine might be able to assist with, we get hits at each and every point. Turns out, Creatine’s capacity for enhancing performance is not limited to athletes but can be capitalised on for anyone vulnerable to a CNS shortfall. Ignored for far too long, this economic and impactful brain nutrient is coming to the fore for psychiatric and neurological disorders.
The latest Update in Under 30 has landed!!!
You can purchase Creatine – The Brain Builder Part 1here.
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.
