Good Great Better Brilliant…

I’m experiencing some serious POTTS exhaustion – how about you?  No, not POTS, POTTS: Preposterous Over The Top Selling of supplements, which seems to be at an all time high even amongst our practitioner brands.  I saw a product name recently that included the word, ‘supreme’!*^#  Is the choice of nutritional supplements now on par with selecting our pizza toppings?

When I previously delivered university lectures on population nutrition & the role of the food industry – we acknowledged that all the processing, packaging, and promoting the food industry invests in, creates a market and a source of competition that essentially doesn’t exist for their primary whole-food ingredients.

Take apples.  How can we increase the profit margin on a humble apple? Aside from organic V conventional farming, the price that any of us would pay is pretty narrow and fixed.  But send that apple to the factory to make juice (and chuck in some added vitamins to boot so you can feature this on the label!!), puree and package it in the most non-biodegradable way for kiddies, dice and stew the stuff and put it in little plastic tubs for the slightly older or throw in a long list of nasties with ‘essence of apple’ to make sauce for idk and suddenly you have the capacity for mark-up, an exponentially expanded profit margin & ‘something to say and something to sell’.  In supplement companies, it’s not as far from this as you might imagine. Because nutrition (**WHAT A SURPRISE**) is a lot like primary whole-food ingredients – how does vitamin C compete with vitamin C? Hey,  make it liposomal!! And the nanoparticles that we’re fearful of in our sunscreens and cosmetics..let’s use the same technology for our ingestives!! YES!!! Ummm any one recall, our fears re folic acid?  Just asking…

Then I see the promotion of bioflavonoid supplements that have been modified to exhibit **UNPRECEDENTED BIOAVAILABILITY** and I am like, ‘Um, why?’ Given these show very low uptake across the gut naturally and research now speaks to a primary MOA or pivot point in their efficacy being the result of their interaction with our microbiota & digestive environs…

I propose that ‘practitioner only supplements’ come under the same plain packaging restrictions placed on tobacco in Australia [I am joking but only just].  Remove the bright shiny distracting graphics and hyperbolic descriptors and only state the full ingredients and excipients list plus source where relevant. Let’s bring it back to simple(?) science, basic quality ingredients and affordable effective products for our patients.  Then let’s see if we can spot the difference 🧐

The Supplement Sleuth

Rachel loves nothing better than breaking through marketing babble and spin to get to the truth about supplements – their real strengths, niches, weaknesses, contraindications, therapeutic doses and best forms & therefore there is a dedicated section of her website with resources and recordings that do just this, here. These include reviews on B3, B12, Folate, Selenium, Zinc & Iron (of course!), Calcium D Glucurate, Co Q10, Quercetin, high dose Vitamin D and Fish oils for Mental health. These are a mix of Update in Under 30 recordings and longer presentations and her library is ever expanding!  So, if you have a supplement you think needs some serious sleuthing on – send us an email…we’re always sniffing around for more!!

How Much Can You…?

“How much can you misbehave & get away with it?” I listened with fresh ears, as a practitioner asked my son this question recently. I use similar ones with my own patients but hearing it from someone else, I could sit back and appreciate its true purpose and how well it achieves this. Most of us adjust our behaviours, when we can, to ‘manage’ things that cause us problems.

Sure I can eat food I haven’t made myself
………..but once a week is my max. or ‘X’ flares

My energy is pretty good
…… but 1 night of poor sleep & I’m back on ’empty’

No impaired alcohol tolerance
………I just never have more than 1

My [insert: gut, skin, energy, immunity, mood] is not a problem
………as long as I don’t miss a dose (of supplement/medication etc)

And sometimes this ‘adjustment’ (or avoidance) is unconscious. Hence the beauty of the question: How much can you get away with, coupled with our understanding of how much ‘room to move’ there should be in a patient who is truly well.  So the teenage to early 20s patient sitting in front of us, theoretically, should be in their prime of wide mischief margins, and we are alerted to individuals in this age group who are having to live like an older person, needing to exhibit vigilance around early bedtimes and allowing themselves almost no indiscretions.  In contrast, as we age, we understand too, the margin for mischief narrows. Our over-50s selves are unlikely to get away with half as much as did in years gone by but we shouldn’t require the stricter self-care hypervigilance of our senior selves.  

And for the patient who answers ‘no’ to everything on your GIT or stress/mood screening questions, for clarification, follow them up with, “and how much can you get away with and still have no issues?”

You may very quickly get a different understanding of what lies beneath and how much ‘management’ is required to maintain ‘balance’ or ‘no symptoms’ or ‘health’ 🧐

MasterCourse in Comprehensive Diagnostics – Let’s Do It Together! 
**Our Watch Party & 6wk training starts 8th July**

The primary objective of MasterCourse I is to realise the true value we can extract from the most commonly performed labs (ELFTs, FBE, WCC, Lipids & Glucose) which constitute the largest biochemical dataset we have on almost every patient. By learning how to comprehensively interpret these labs in an integrated medical framework, using the very latest science, we can extract the gold often buried in this goldmine.  Accordingly, we prove ourselves to be the greatest asset to our patients, to other health professionals we are sharing care of patients with and we cut the cost of additional expensive testing, that is less well understood and validated.

MasterCourse I will help you access that gold and has been intentionally designed to match each lesson with real learning– with the time spent in theory and in application.  Delivered across 24+ hrs of streaming video sessions with bonus pre-sessions, audios, resources and tools – this MasterCourse is likely to be a genuine game-changer for the way you practise and the potency of your patient prescriptions.

B12…12kms?

Is it just me or do you view everything with a trained eye?   My son always laughed when I wrote him a shopping list: I would list items under each shop and I always wrote down our local supermarket the Independent Grocers Association, like this: IgA…you all see what I was doing, right?!! It’s actually known to everyone else as IGA…well truth be told, I didn’t until he pointed it out 😂 Then there’s this relic I regularly pass, as I walk through bushy parkland near my home, ‘Hmmmmmm, B12 hey?’, I’d muse. I’d be embarrassed to tell you exactly how long it was before I realised OMG it’s not  a shrine to the vitamin but an old road sign telling you…Byron 12kms!!! 

I preferred my take on it to be honest, because invariably once past this, the remainder of my walk was full of scintillating B12 banter. Just internally, people, no one panic, I don’t walk the streets of this town spouting out crazy random nutritional tidbits…although, let’s face it, I would be in good company in, the Byron Bay region!

I have a deep respect for B12 – weird but true. As a result of my clinical experiences helping patients who had a previously ‘unseen need’ for this nutrient and the significant improvements that come with its replenishment. Plus the deep dive I did into the science of the different forms and their actions last year. In particular, I now have 2 families where the TCNII SNP is evident in mum and all her children.  No gene testing necessary, the pattern is self-evident once you know what to look for and the clear ‘call to action’ – more B12 please! And just this month, a fresh aspect has come to my attention in regard some brand spanking new research on B12 and IBD and the microbial (im)balance of this vitamin as a pivot point for the pathophysiology. Wowza!  Early days, but I think we’re headed next level on this nutrient again! And I can’t say, I’m surprised.  For while I don’t think the CHOICE of the supplemental form for B12 is complex at all (hence why we need to separate the B12 from the B*S#!) I recognise it is a complex character far beyond what regular dietetics has reduced it to. 

Separating the B12 from the B*S#!

B12 is a routinely under-rated and recognised micronutrient, which is in fact in high demand by many of our patients. As nutritional research pushes back against defining adequacy as simply the prevention of the deficiency-associated disease (macrocyctic anaemia, irreversible neurological damage) we enter a new landscape of more individualised approaches where we’re better able to recognise and treat those at risk of falling below ‘optimal’.  But how do we accurately identify this and then choose the ‘best’ B12 (methyl- cyano- adenosyl- hyroxo-) supplement? Does it need to be this complex?  Time to sort the B12 from the B*S#!!  This recording comes with a bunch of great resources including a clever clinical tool.

 

Present But Not The Problem

Something’s just come up today again and I think we need to talk about it.  A positive result on a stool PCR microbiome test for H. pylori, understandably, might be heard as a clear call to action to go in guns blazing with an eradication approach.  But is it?  Trust me, I’ve had more than my fair share of battles with this bug & can understand being keen to have it be gone BUT first things first, let’s be clear about what the result speaks to.  

Does it say, “Here!  Look over here!  Here’s the source of your patient’s GIT distress,”  or even, “Here’s a pathogen that has taken up residence in their GIT and is a risk for future dx!”

No, not necessarily. It speaks to its presence.

And that may be only fleetingly, as it passes through.  I’ve seen it before and so have many other experienced practitioners: a positive stool PCR that is at odds with the results of gold standard H.pylori testing, the UBT, faecal antigens or blood serology, all freely available through the GP.  And the reality is, if you have a negative UBT, there’s no urease production, the trademark trouble-making of this bug. If you have negative blood serology, your immune system has never ‘met’ this bug or, in the minority of cases, you’ve tested in that brief early exposure window prior to antibody production (2wks) so you should retest within the month, to confirm or refute. And if you don’t have any faecal antigen…it ain’t in da’ house…so to speak 😅 If there’s something new here, then have a quick read of Medscape’s great work-up summary.  So, clearly we need to confirm before we open fire.

 We (me included) have been so single-minded about increasing the ‘sensitivity’ with our testing methods, we may have left ‘specificity’, in broader sense, behind & that creates a new problem.

This leads us and the patient down the garden path of false attribution and time and money wasted ‘treating’ a ghost gut issue. And no one wants to be put on a pylori protocol when they really didn’t need to.  Trust me 🙄 But if someone does come back confirmed, well then…

H.pylori – Eradicate or Rehabilitate?

For a bacteria identified just a few decades ago as being a cause of chronic gastritis, atrophic gastritis and gastric carcinoma, the escalation of number of antibiotics used to eradicate it (4 at last count + PPI) has been nothing short of breath-taking.  A management approach more consistent with both integrative medicine and with an improved understanding of the delicate microbiome focuses on changing the gastric environment to ‘remove the welcome mat’. What do we know about how to do this successfully? It turns out…quite a lot.

Well…Does He Need Iron?!

If I could be granted 1 wish regarding all health professionals, it would be that we were all competent in reading Iron Studies.  Think that’s overstating the issue? Or not a bodacious enough way to ‘spend’ my wish? I don’t. Especially when you consider the impact of GPs in this space. 

This 57Y male was asked to make a follow up appointment with his doctor, to discuss his ‘abnormal’ results which he was informed constitute Iron deficiency. 
Consequently he was was advised to start an iron supplement! #@!*

Your thoughts?  Revoke this doctors medical licence?  Insist on some very du jour ‘re-training’ at the very least?  I mean, if you think this Iron pattern flags a deficiency or shortfall, then you’re as good as reading a map upside down and back to front…and written in a foreign language!! The ‘Ls’ in his latest labs flag he has suppressed transferrin, indicative of negative feedback inhibition of GIT uptake of this mineral, secondary to healthy stores or inflammation. And it’s not just that more iron is not indicated but that more iron in fact presents a patient like this with increased and unnecessary risk: to their microbiome, intestinal wall health, even according to the larger longer studies a potential correlation with colorectal cancer risk, if taken long term. Let alone the whole cardiovascular conundrum.  Better still this same patient was told a few years back that he might have iron overload!  Again the ‘map’ could only have been being read, upside down, back to front to reach such a conclusion! 

So the one patient in just a few years by 2 different doctors has been diagnosed incorrectly with 2 different iron issues. Yep.

And sadly I have sooooo many more cases of missed and mis-diagnoses with regard to this mineral.  The latest RACGP Position Statement on the Use of Iron Studies, underscores that assessment of iron status and GPs competence in knowing when to do this and how to interpret, is an important part of core general practice. Given it “is the commonest nutritional deficiency state in Australia and is significantly under-diagnosed” This succinct document offers a quick crash course in Iron nutrition for doctors and it hits all the right marks with advice about not ordering ferritin as a stand-alone because “the interactive nature of the three components allows for more accurate interpretation” and this simple but sage advice:

Transferrin, iron transport protein, tends to increase in ID…
A better strategy (than being tricked by Serum Fe) is to report transferrin saturation.
A low transferrin saturation in the setting of an equivocal ferritin level is suggestive of iron deficiency.
An elevated transferrin saturation is the first manifestation of iron overload.

I mean seriously, do doctors read these RAGCP resources & recommendations, or is it just me? 🤓😂  

Need a rip-roaring review on how to really read iron studies?  Or know another health professional who does?!! Consider this Easter Educational Gift Instead of Eggs!!
So You Think You Know How To Read Iron Studies?
Overt Iron Deficiency Anaemia or Haemochromatosis aside…do you understand the critical insights markers like transferrin and its saturation reveal about your patients iron status?  Most practitioners don’t and as a result give iron when they shouldn’t and fail to sometimes when they should.  This audio complete with an amazing cheat sheet for interpreting your patients Iron Study results will sharpen your skills around iron assessment, enabling you to recognise the real story of your patients’ relationship with iron.

 

We Need To Talk About Kevin…aka B3

Just like Kevin, ‘Niacin’ is profoundly misunderstood and consequently runs the risk of doing us harm. Unlike ‘Kevin’, we can’t watch the movie to see how this (our arguably excessive use of the wrong forms of B3 in supplements and fortified foods) is all going to play out, so that we can be suitably alarmed and start making some different choices. The risks that follow from our B3 ignorance are twofold:

One comes essentially from our gross under-estimation of this B vitamin – we’re stuck in the Pellagra Paradigm, believing that prevention of the 4 D’s is confirmation of adequacy.

The second, is our lack of discernment when it comes to the different forms or precursors of B3 & our unfamiliarity with their very specific physiological roles – good and bad.

In this regard we’re all likely to say, ‘Well back up there 1 second, we do know that Niacin (aka nicotinic acid) is different from the other forms!’  Producing flushing, yes.  Used as a lipid lowering agent in pharmacological doses, yes. But can you tell me, which serious concerns and biochemical disruption is shared between both gram doses of niacin and everyday ‘routine’ mg doses of niacinamide? Yep, that one, the so-called ‘safe’ one. Better still, can we all list the various B3 forms in order from most to least potent, in regard to their capacity for NAD+ promotion in the human body? 

Because this is now the definition of B3 ‘adequacy’ or ‘optimisation’ according to modern scientific understanding & it is a long long way from the absence of  Diarrhoea, Dermatitis, Dementia and Death!

In fact, the boosting and optimisation of NAD+ pools in the human body is key to life – a long and healthy one according to the current research consensus – and its depletion is akin to ‘death’, or a faster one, anyway.  From increased metabolic disorders, mitochondrial dysfunction, impaired gene stability (cancer, infertility etc) and higher rates of neurodegenerative disorders, just to start, these take up the lion’s share of our chronic health burden and battle that currently dominates the dis-ease landscape. And more niacinamide might just make that worse. 

I didn’t mean to to alarm you. I am alarmed.  Want to deep dive into this yourself?  Start with this older but still brilliant review article by Bogan & Brenner.  Want me to hold your hand while we jump off the high platform diving board together into this vastly different and powerful new understanding of B3?  Let’s do it!

The Balance of B3

Most of us have been taught to ‘balance the Bs’ when supplementing, which discourages the use of single B vitamins in case this interferes with the regulation and roles of others. In reality, outside of a couple of dynamic duos like B12 and folate, there is little concrete information & evidence of this. In the case specifically of B3, however, we now know, the risk of an excess of the most common B3 forms found in supplements and fortified foods, results not only in disruption of other nutrients but imbalanced B3 biochemistry itself. Given B3, in its coenzyme form NAD+, is regarded as highly valued currency in the prevention of many diseases, as well as the key to our optimal health and longevity, it’s critical to understand the different forms and functions of the various B3 sources.

 

You can purchase The Balance of B3 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.

A Sprinkle Of Precursor & A Dash Of Co-Factor?

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.

The latest Update in Under 30 has landed!!!

You can purchase Take A Fresh Look: Taurine & Glycine in the CNS 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.

Someone Say Sulphur?

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 so much. 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 Look 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.

The Year For Iron & Gin

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?!!

Say it isn’t so!!  But I can’t.🤐

Pregnancy Iron Balance – Sorting the ‘Normal’ from the ‘Noise’

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. 

 

The latest Update in Under 30 has landed!!!

You can purchase Pregnancy Iron Balance 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.

The Pathology Path

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.

 

What’s A Little Flesh Between Friends?

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 iodineseleniumironcopperzinccalcium and magnesium.

At less than $10 per hour of recording, the real investment is your commitment to making the time for a mineral makeover.

 

 

IV Iron To The Rescue?

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?

 

 

The latest Update in Under 30 has landed!!!

You can purchase IV Iron to the Rescue? 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.

Boundary Breaches

Well that got tongues talking!  We’ve cried, and we’ve laughed, hearing from practitioners about their ‘over-delivering donkey experiences’ for 2020. We’ve heard many memorable & relatable tales of either failures to set the best boundaries or even, in instances when we do, patients’  incredible dexterity to scale these in single leaps, ala James Bond style.
Practitioner: “On the very same day we talked about this important and ignored topic, I’d received an email at 9am from a patient asking for advice and a 2nd opinion about the prospect of surgery (first mention of this and clearly outside my scope!!!!), which they wanted before they saw the surgeon in 2 hours!!”
Sometimes it’s not patients, but professional colleagues (& friends)! I personally took an urgent call on Sunday morning from one of my psych colleagues, only because she is a dear friend, only to discover she needed help regarding a friend with mental health escalation…ah…yup…nup. Her blurred boundaries breached mine and then I bugged another colleague out of hours for further assistance…bad boundary blurring behaviour all round!  We’ve been talking about the uncomfortable truth that a lack of healthy boundaries is a fast track to burn out for health professionals in group mentoring and the end of the year is always…opportune!
Mentee: “I felt challenged in a way where I was reviewing my own boundaries from an overall perspective over a period of time.  I’ve worked in retail for 15 years now (as a student nat initially and then as a qualified naturopath) and I still find myself questioning how far I will go in certain respects especially when it comes to mental health (or people who appear vulnerable).  When I was initially in practice I found my boundaries challenged to another degree, where I would accept every person who came through the door, whether I felt ready or not, or willing to take on the case, which essentially led me to burning out. 
Now as I get ready to start again in practice, I feel more prepared to set clear boundaries from the get go (give myself permission to do that) and check in with myself if I feel they are about to be crossed or not in alignment with me.  It feels like an important and healthy assessment tool to utilise as a health care practitioner.”
As a profession we need to pool some solutions. 
Instead of the reflexive, ‘Just pop me an email if you have any questions’, at the end of each consult which can constitute the equivalent of a blank cheque (!!), perhaps we can say, “If you need to clarify any advice I’ve given you today drop me an email and for any other questions that arise, we can decide whether we need to bring your next appt forward or schedule a between appointment phone consult”   Or if you’re a practitioner who sees the value (and there is much research to support this) in increased touch points with patients, for better compliance and improved outcomes, then structure your billing accordingly.  This from one of our cluey new grad mentees, ‘If you want to offer this add-on time as part of your service then you need to account for it e.g. shave 15 mins off the actual face to face time that they’ve been charged for, so as to have this ‘up your sleeve’ for this express purpose.  They breed ’em smart these days!  Love it!  
The end of the year is such an important time for reflection. What have you learned this year about your professional boundaries? Got some tips you’d like to share?  

Over-Delivering Donkey

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 🙂

 

The Clinical Knack of the NAC Break

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 😂

The Clinical Knack of NAC

“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

 

Can You Hear Creatine Coming?!!

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.

The Underrated Art of Ancient Mastication

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]

Is Silent Reflux Still Sneaking Under Your Radar?

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!~

 

 

In Need Of Some Fuel Reduction?

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.

 

 

 

 

A Simple…

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 Vs mcg/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.

 

White Australia Pathology?

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 admin@rachelarthur.com.au, and we’ll put you on the ‘first to know’ list.