PCOS families – are your male patients affected?

We now suspect that many of the drivers behind PCOS are heritable components – a genetic vulnerability passed from parents, possibly one but often both. This growing understanding has identified a phenomenon referred to as ‘PCOS families’ i.e. a family in which at least one female has confirmed PCOS.

Being a primary biological relative of someone with PCOS, it would seem, suggests a shared risk, even if you are a son, or brother or father. 

So beyond the very high rates of undiagnosed PCOS in sisters of someone already diagnosed, there is much talk now about a male PCOS phenotype equivalent. (more…)

End of Year CD Clearance

As we head rapidly towards the change over of our calendars we would like to offer you a special on the very best educational recordings from 2014 – buy 2 CDs before Jan 31st and receive one complimentary Premium Audio Recording of your choice  OR purchase 4 CDs and receive a 3 month Premium Audio subscription for free

It’s been a busy year during which Rachel has delivered 7 very successful new seminars in the area of mental health and  beyond, most notably fortifying her role as a leader in the field of diagnostics and pathology interpretation.  This has included collaborations with ACNEM, Biomedica, Health Masters Live, MINDD and Nutrition Care, however, each recording is classic Rachel – full of fresh perspectives on diagnosis & treatment, colourful analogies  & humour.  In case you missed some of these this year or want a copy for keeps – here’s a quick summary of the 2014 recordings included in this end of year offer: (more…)

Recognising A Tendency to Iron Overload Earlier

We’ve just had another mentoring case in which a 40 something female with deficiencies of almost all other minerals but ‘pretty normal ferritin levels’  presented with a range of endocrine problems and arthralgia.  Sounds as if iron’s not the problem right?  Except that in this case her iron studies also tell us that her transferrin saturation % on last check was 48%.  The diagnostic criteria for hereditary haemachromatosis  (HH) necessitates elevated ferritin – to indicate that the iron stores are reaching saturation, however, while this becomes evident at relatively young ages in men (20s-40s), who have no specific excretory pathway for iron, is this still appropriate in menstruating female, whose monthly periods may mask the HH tendency with regard to ferritin?  I’m guessing you know what my answer is already! 😉

Some would argue that HH, in spite of being an inherited disorder, is only clinically meaningful once the ferritin is elevated ( earlier and more potent elevations are seen in people possessing the C282Y genotype) but again this is very much up for debate in the current scientific literature, with a lot of research concluding that the transferrin saturation (also referred to as the transferrin ratio) being an important prognostic indicator for various chronic diseases including CVD.

When we go back to basics and remember the higher the transferrin percentage the more iron is being delivered to tissues around the body (whether they like/want it or not! so we refer to this as being ‘iron dumping’) and the higher the serum iron, the more unbound iron is in the system – a key source of oxidative stress..it becomes patently clear that these two parameters are important early warning signs of a tendency to iron overload, increased risk of heavy metal toxicity and already active mineral imbalance.  So in future keep your eyes open for women with fasting transferrin saturation values that consistently sit above 35% and men, > 40% and if you do see a series of suspicious values – consider the genotype test through mainstream labs.

Mental Health – The Real Story

“Two great speakers – inspirational in the first half and bang on in the second – I now know how much I don’t know”

Just out now in time for Christmas…no seriously though… this year I had the good fortune to team up with Biomedica and in particular Rachel McDonald and we delivered a 3 hour seminar called Mental Health in Holistic Practice.  The intention behind this collaboration was to shift the education focus for practitioners from a prescription based approach, to one really about the clinical reality of managing mental health clients.  Probably most of you will agree that the ‘treatment’ counts for only a portion of the positive outcomes in your patients and this is particularly true in clients challenged with mental health issues. After more than 20 years in practice working in this area, I’m keen to share what I’ve learned so other practitioners can get there much much faster! (more…)

Low T3 Syndrome & The Hibernation Effect

Apologies for having a one-track mind currently but yes I’m still banging on about the thyroid this week.  You see, this year in my own clinic I connected up some dots I hadn’t connected before via a series of young female patients.  Each of these women presented with some hypothyroid features, most notably, low basal body temperatures, fatigue and weight gain and while their thyroid hormones (TSH, T4 and T3) were all technically ‘within range’, their T3 levels were very low (low 3s) and the TSH seemed to sit low as well (<1.5).  Normally of course, when T3 levels drop we expect TSH secretion from the pituitary to rise in response, as a means to correcting this dip, however, this part of regulation appeared ‘blunted’ or even ‘broken’ in these women.

So why would their pituitary be sleeping on the job, allowing them effectively to experience long term suboptimal thyroid function? (more…)

T3 resistance?

Just been speaking on the thyroid at ACNEM last week and am finding that practitioners across the board are getting more and more curly thyroid cases.  One scenario that we increasingly see is something that might be described as ‘T3 resistance’, when your patient’s T3 value looks healthy but they continue to manifest the signs and symptoms of hypothyroidism.  There are several differentials to consider of course (more…)

What have you learned in 2014?

I’ve learned a lot (!) and as always that learning has principally driven by my clients – their pathology, the diagnostic investigations we’ve employed to better understand the drivers behind their conditions, their response to various treatment approaches & of course a million other subtle thing we’re learning along the way.  The other teachers are the many practitioners I interact with on a daily basis as part of our individual or group mentoring sessions – whether it’s some curly question or problem they bring that throws me into the scientific literature searching for answers or a fabulous bit of wisdom they bring to the table themselves, it’s a great reciprocal learning environment.  You know, the most common thing I hear from naturopaths is the frustration they feel at the limitations of their under-graduate education and how it is only since graduating that they’re ‘learning all this stuff” but in reality, as with most health professions, the bulk of the learning has to happen on the ground.

I’ve been in practice for about 20yrs (ouch!) and I don’t think my rate of learning has slowed at all.  It’s great if we can view this as the eternal fountain of inspiration that keeps us motivated and engaged in our profession…no not every minute of every day…let’s be realistic now…but overall it’s a strength not a weakness 🙂

Over the next month I’m being let loose on the major capital cities thanks to Nutrition Care to for a series of evenings of case study discussions – bringing together quick teaching points from all the things my clients have taught me this calendar year.  Whether it’s from a diagnostic or  treatment & management perspective I’ve got some juicy morsels to share!  I hope you can come along and  we can learn from each other yet again as a nice way to reflect on the year and our ever –growing profession…. If you’re interested in attending contact your local Nutrition Care representative for more information or call them on (03) 9769 0811

  • Brisbane – 12th November
  • Melbourne – 20th November
  • Sydney – 26th November
  • Adelaide – 27th November

 

Knowing your (Se) Numbers in Thyroid Patients

I’ve been re-reading lots of studies for a talk I’m delivering at ACNEM in Melbourne, investigating the relationship between selenium and a myriad of thyroid pathologies: from hypo- to hyperthyroidism and from subclinical thyroiditis to cancer.  The sheer number of trials is overwhelming & increasing, in fact I think there’s more every time I go back and look (!) and the bulk of the findings keep telling us yes! yes! yes!…selenium plays a pivotal protective & corrective role unmatched by any other nutrient. Whether it’s buffering the oxidative stress that comes with high TPO antibodies or lowering antibody titres, preventing or minimising the orbitopathy associated with Grave’s or simply maintaining a better level of T3 in euthyroid individuals, there are numerous potential positive effects from selenium supplementation …in the right patient… and therefore this is the bit we need to be clear about: while the majority of both epidemiological and interventional studies all concur that low selenium levels equate with a greater risk of thyroid issues in all our patients & poorer outcomes in patients with already established thyroid disease, the big question is how low are we talking?? (more…)

Roaccutane, depression & nutrition – the links

We’re all aware of the reported link between Isotretinoin (aka Roaccutane, Accure, Oratane), originally listed by the FDA in 1982 for the treatment of severe treatment refractory cystic acne, and depression & suicidality in some individuals.  Any suggestion of causality however remains hotly debated by the manufacturer of course & there is a recent small RCT not only refuting a relationship but claiming that via effectively resolving acne, patients’ depressive features decrease on this drug (Marron, Tomas-Aragones, Boira.  Anxiety, depression, quality of life and patient satisfaction in acne patients treated with oral isotretinoin. Acta Derm Venereol. 2013 Nov;93(6):701-6.). However most of us have read the media reports regarding tragic case studies, are aware of the warnings listed on the package insert and have met patients whose mental health problems appear to have been precipitated by use of the drug.  (more…)

When I grow up

When I grow up I’d like to be a few different things, forget any ballerina or astronaut aspirations, my list includes a clinical psychologist, an integrative psychiatrist and last but by no means least, an endocrinologist.  I’m fascinated by hormones, their regulation & incredible interconnectedness and the longer I’m in practice and the more patients I see with hormonal issues, the deeper I dive into the endocrinology texts (Endocrinology by Greenspan & Baxter is an absolute favourite of mine and you can now purchase this as a download to your computer which is super handy).  I think (more…)

Concentrating on concentration – getting urinary iodine right!

urine

Recently in our group & individual mentoring sessions we’ve been looking at lots of patients’ urinary iodine results.   Many of you will know that I’m a bit of a fan of doing spot urinary iodine testing to gain some understanding about patients’ iodine, in spite of several well-documented limitations of the test.  The first thing to remember is that urinary iodine has a diurnal rhythm, parallel to the rhythm seen with the thyroid hormones, so urinary values will fluctuate throughout the day.  We can get around this by always asking patients to collect the sample at the same time – preferably a fasting early morning urination, which represents the lowest iodine concentration in a day.  That way we know we’re always comparing apples with apples.  The second limitation and frequent cause for misinterpretation of results is not allowing for the concentration/dilution factor of the urine sample.  (more…)

You’ve got mail!

I’ve received so much lovely feedback (fan mail!) recently I just had to share some with you (note I look much more excited than Meg does when I get mine!). It’s so exciting to be a part of our burgeoning naturopathic & integrative network.  From Alyssa Tait a Brisbane based naturopath, clinical nutritionist & physiotherapist: “I am so appreciative of your mentoring and your professional development (e.g. recent Health Masters Live webinars). You make me really enthusiastic about being in this field, and you actually help me feel like I sort of know what I’m doing…most of the time!!” (more…)

Let’s talk about sex…

In spite of several advantages of salivary hormone assessment, one important piece of information you miss out on when you do this rather than blood assays, is the SHBG result. Sex hormone binding globulin is a protein produced in the liver that, as the name suggests, binds our sex hormones rendering them inactive and therefore buffering us against their full potency.  They bind the sex hormones to different degrees – the androgens most potently and oestradiol to a lesser extent but curiously it’s higher oestrogen  that represents the major hormonal driver of increased SHBG production (including synthetic oestrogens). (more…)

Get the 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… seriously!

Recently I had the pleasure of presenting a webinar for Biomedica completely and utterly focussed on N-acetyl cysteine – its key actions, pharmacokinetics, applications and contraindications.  In the process of researching for the webinar I learnt so much and to my surprise found even I was under-utilising my favourite supplement! How familiar are you with its application in cystic fibrosis,  fertility, biofilm eradication etc. etc ?  Not to mention, it’s incredible versatility in mental health.  Recently, buoyed by some new research suggesting the efficacy in severe glutamate excess of much higher doses than previously studied for depression and bipolar, I have stepped up my doses in patients with some forms of addiction, OCD, refractory insomnia to 4g/d with great results!  I could talk all day about NAC but perhaps for a starter if you missed the webinar you might want to listen to the recording?  We have the Clinical Knack of NAC now available as a CD with audio and notes for purchase on the website:

https://rachelarthur.com.au/product-category/audio/

This in-depth 1 hour webinar offers practitioners new to NAC, the practical knowledge and tools they need to start using it effectively and for the practitioner already dispensing it, to really broaden their understanding of indications , correct many misunderstandings and get the latest research on the why, when and how to use it.  From reproductive to respiratory health, from heavy metal burdens to biofilms and athletes to addicts, this webinar covers the latest information about NAC’s real therapeutic potential.  Having been a favourite nutraceutical/prescription of Rachel’s for some time, she punctuates the presentation with many of her own cases.  

A Guide to Globulins

Globulins…ever thought much about them?  Me neither really unless they were clearly below range which made me consider immune impairment but recently Dr. Michael Hayter, who I am co-presenting the Diagnostics Master Class (Health Masters Live) with, inspired me to take a closer look!  Globulins are typically reported in your patients’ E/LFTs or standard chemistry and they refer to a big group of molecules including CRP, transferrin, lipoproteins and yes all the immunoglobulins/antibodies. (more…)

Getting to know Billy Rubin!

I often say that if my surname was Rubin I wouldn’t be able to resist calling my son Billy. I am sure the joke would be lost on 90% of people & certainly on my poor child who might never forgive me but never on me – I get a giggle every time 🙂  Recently, I’ve been reading a lot of scientific literature on bilirubin, previously regarded as simply the end waste product of haem, it’s now attracting huge interest as a biomarker of oxidative stress.  There’s still lots of ongoing debate & contradictory research findings but here’s the general consensus so far…bilirubin is an antioxidant (particularly protective against peroxyl radicals & lipid oxidation although the latter is still being hotly debated).  Not surprisingly then, several studies have shown that smokers for example, consistently have lower total bilirubin blood values, indicative of their greater oxidative stress & yes, smoking cessation leads to partial correction of this (O’Malley et al. 2014 Smoking Cessation Is Followed by Increases in Serum Bilirubin, an Endogenous Antioxidant Associated With Lower Risk of Lung Cancer and Cardiovascular Disease)  A recent study also found a positive correlation between higher flavonoid rich fruit & vegetable intake and total bilirubin (Laprinzi & Mahoney 2014 Association Between Flavonoid-Rich Fruit and Vegetable Consumption and Total Serum Bilirubin).

On top of this, there is a wave of epidemiological research to currently surf, suggesting inverse relationships between total bilirubin levels and several diseases: hypertension & CVD, T2DM, metabolic syndrome, MS, renal disease, IBD, lung cancer and the list goes on.  The sort of cut-off point being talked about is a result < 10 µmol/L being associated with the highest risk.  What remains unclear is whether lower bilirubin levels are actually risk-promoting or whether they are just a signal of the individual’s oxidative stress.

Total bilirubin (aka Indirect or Unconjugated bilirubin) values are typically included in most pathology company’s basic general chemistry or E/LFT panels which means most of your patients already have had this test performed in the previous 12 months.  So next time you’re looking at patient results check out their bilirubin values and if they have bilirubin levels consistently <10µmol/Lconsider how you might better support your patient manage their oxidative burden to reduce risk of future disease and if you’re hitting the mark the bilirubin level should rise 🙂

Want to know more about Bilirubin and Pathology interpretation in general – Rachel is collaborating with Dr. Michael Hayter to present an online Master Class in Diagnostics starting this week.  For more information check out Health Masters Live https://www.healthmasterslive.com/product/clinical-diagnostics-masterclass/?mc_cid=cfd82dd367&mc_eid=014c831228

Something on my MINDD

I briefly mentioned in a previous post Dr. Robyn Cosford’s inspiring opening speech at this year’s MINDD conference.   A key point she made was the growing gap between what’s regarded as normal and what is actually healthy. 

Having worked in general practice for decades, Robyn provided us with one illustration after another – Type 2 diabetes, previously called adult-onset diabetes, now not infrequently diagnosed in primary school aged children; delayed speech and learning difficulties in male toddlers which many increasingly regard as ‘normal’; precocious puberty in girls; escalating rates of depression and anxiety in children and adolescents…Robyn asked us as practitioners to be vigilant about helping patients to distinguish between what has become perceived as ‘normal’ and what is actually healthy.

In my MINDD presentation this year I talked about the mental health challenges faced by young men and I expressed a similar concern: that when we witness extensive aberrant behaviour in young men we are prone to rationalise it.  Are we mistakenly attributing these signs of dis-ease in males as simply being an initiation into Australian culture?  When you hear of young men exhibiting binge drinking behaviour, does it set off the same alarms as it would if your patient was female and if not….why not? 

As part of a broader discussion of the issues, I presented two cases of young men with mental health problems – both from very different sides of the tracks, one gifted and the other a struggler but one of the features they shared included the way their use of alcohol & other substances had passively been condoned by society instead of being seen as a call for help.  We can help these young men but only once we’ve acknowledged there’s a problem. So now I’m extending Robyn’s plea and ask you to be vigilant in making the distinction between ‘normal’ and healthy… when mothers relay stories of their son’s ‘antics’, when brothers, cousins & uncles temporarily ‘go off the rails’,  when young men reluctantly present for a quick fix…

If you missed the presentation and are interested in the full recording check out  https://rachelarthur.com.au/product/new-young-white-men-mental-health-challengers-face-mindd-conference1hr-total-50/

 

Picking up Parasites?

Many of you would now be aware of the shift from culture (stool MCS) to gene-based stool testing (stool PCR) which has now become available under Medicare subsidy. While this has been an exciting development that promised greater accuracy for the detection of parasites in our patients, there remains limitations.  One of the biggest is the fact that the PCR test is based on just one stool sample compared to the 3 day samples used  in the culture test.

While this is rationalised, both by the pathology companies and some doctors, by higher test sensitivity and specificity, it flies in the face of our understanding about the irregular shedding of parasites i.e. the presence of the parasite in an infected individual’s stool can vary  from nothing to severe, just day to day, therefore diagnosis must be based on several days of stool collection to account for this.

A practitioner I mentor, faced with several patients with negative PCR results but a clinical picture and other pathology results (raised eosinophils, impaired iron levels etc.) that strongly suggested the presence of  parasites has been debating this with her shared care providers trying to encourage them to still refer patients for the stool PCR but performed over several samples.

She came across this article as a nice piece of supportive evidence Irregular shedding of Blastocystis hominis (Venilla et al 1999): ncbi.nlm.nih.gov/pubmed/9934969

While there are numerous other studies confirming the irregular shedding of most parasites this is a handy paper perhaps to use to strengthen the case for PCR stool tests performed over 3 days rather than 1.  Let’s face it – it’s a big enough ask to get our patients to collect stool – we should really ensure we have optimised their chances of getting an accurate result!

Dear Doctor …

As most of you know, I’m a big fan of establishing good communication with the other practitioners (GPs, psychologists, osteopaths, specialists etc.) also caring for my patients and what began as occasional letters that I found exasperatingly difficult & time consuming to write has become second nature.  That’s not to say every letter I write now hits the spot & evokes the desired response but I think I’ve got a pretty good run rate.  So I put together some tips that I thought might help you either get started or get SMARRRTer at it! :)

  • S – Service
  • M – Medical language & conventions
  • A – Accuracy
  • R – Reasonable
  • R – Rationale
  • R – Respectful
  • T – Time-conscious

Service

  • A summary of the most important medical aspects of the case is a great time saver for other health professionals & assists them in making better informed clinical decisions
  • Summarise key points of reference
    • e.g. Betty Smith (BMI 36kg/m2, Waist 92cm)
    • e.g. Depression (diagnosed 2010, Zoloft 100mg/d)
  • Pick out the salient features of the case
    • What are the absolute must-knows in the case?

Medical language & conventions

  • Only use medically accepted terms & diagnoses
    • e.g. avoid naturopathic speak such as dysbiosis, adrenal fatigue etc.
  • Quantify EVERYTHING relevant
    • e.g. weight loss/gain (7kg in 3mo), DASS scores, stool Bristol type & frequency
  • Include all units of measurement
    • e.g. 4.6 mmol/L, 129/84 mmHg
  • Summarise medical hx in table form for easy reference

Accuracy

  • Clarify which details you have first-hand Vs second hand – be careful not to be part of Chinese whispers
    • e.g. patient reports being diagnosed with lactose intolerance
  • When including patients’ own words – use quotation marks
    • e.g. patient reports feeling “dizzy & vague with brain fog most days”
  • Clarify if some things have been self-prescribed – otherwise the assumption will be that you gave/recommended it to them

Reasonable

  • Don’t use a scatter gun approach when suggesting investigations
  • Try not to ask for subsidised testing that the GP is simply unable to do under subsidy
    • e.g. Full thyroid function test can’t be subsidised without a prior diagnosis of thyroid disease or TSH outside of reference range…WEIRD BUT TRUE

Rationale

  • Present a brief, clear justification for any requests
    • e.g. Iron studies (vegetarian diet)
  • Include appropriate references when the justification is likely to be beyond expected knowledge
    • e.g. as a deficiency of this vitamin has Vitamin D – both 25 (OH)D & 1,25(OH)2 D, been implicated in a large number of autoimmune conditions assessment of both forms is recommended (Smieth et al.  Vitamin D in Autoimmunity. Am J Clin Nutr. 2013)

Respectful

  • Ask for their assistance/insight/review/guidance
    • Don’t forget – you want & need it!
    • Keep in mind also how the relationship your patient shares with this practitioner may be positively or negatively impacted by the respect & tone of your letter

Time-conscious

  • How far in advance should the GP receive your letter in order to give him/her adequate time to read & digest the content?
    • e.g. too close to consult – GP might understandably feel ambushed/rushed/unprepared
  • How much time does a GP or other professional have to spend with each patient?
  • In summary the less words the better –  look for ways to reduce your word count, cut to the chase and ideally get most letters down to 1 page

Happy writing :)

Gluten-Intolerance-Intolerance

In the Byron shire we have a fabulous local comedian called Mandy Nolan who makes a lot of fun of the health and food fads that regularly sweep this area and one of her favourite catch-cries is “I’m gluten intolerant-intolerant, if I meet another person who tells me they’re gluten intolerant I’m going to scream!” Although I take genuine gluten reactions very seriously I do get where she’s coming from and it stems primarily from pervasive misunderstandings & misuse of terms in the community.  The problems with this are multiple: firstly those people who are walking around with an exaggerated sense of their problem will unnecessarily limit their diet (and perhaps the diets of their loved ones) at significant financial, nutritional & even psychological cost and then we have people who have the most extreme gluten reactions not receiving the serious attention that they absolutely need in all sorts of settings like restaurants, childcare centres and schools…because seemingly everyone has some sort of ‘gluten issue’ & therefore it has become dangerously ‘normalised’.

So let’s just recap the possibilities and try to clear the confusion.  When people walk through our door and tell us they ‘can’t eat bread’ or ‘pasta makes them bloat’ or ‘I don’t think wheat agrees with me’, that’s where our work just begins in terms of needing to clarify what the nature of their reaction is. Putting them immediately on a gluten free diet is a mistake because it doesn’t tell us which one of the below issues is at play and therefore fails to give us clear guidance about what is an appropriate course of treatment & dietary intervention.

  • Coeliac disease – while there are a multitude of testing options for CD the first place to start is the genotype.  If you don’t have the gene it is extremely unlikely that you have CD.  If you have the gene then there’s about a 1/3 chance you might & specific tailored antibody testing or jejunal investigations are necessary.
  • A genuine wheat allergy (not CD) is rare but is more common in infants & toddlers.  It can be diagnosed by blood antibody tests (IgE RAST) or skin prick testing (SPT) for wheat
  • Non-coeliac disease gluten sensitivity – may not involve the immune system at all, however, raised anti-gliadin antibodies are frequently seen in these patients
  • FODMAPS – is not an allergy but a type of intolerance due to impaired digestion of the fructans found in wheat.  We must rule this out as a possible explanation for someone’s reaction  and I would start with a good checklist of other FODMAP foods to check tolerance e.g. soy, dairy, increased fruit intake and check for other conditions that can lead to this via disruption or destruction of the small intestinal brush border
  • Carbohydrate digestion issues other than (or in addition to) FODMAPs  i.e. underfunctioning of the pancreas
  • Red herring!  And don’t forget this old pearl… it could of course be a total red herring.  Perhaps the reaction is due to another component in bread (yeasts, preservatives etc.), or the other foods they always eat with the pasta (tomato etc.) or their general poor diet quality and speed of eating, lack of relaxation around meals etc. etc.

My one exception would be in children diagnosed on the spectrum for autism.  I think going gluten free where possible is appropriate from the get-go in ASD.  For everyone else, a correct diagnosis is the essential first step to effective & proportionate treatment so keep your wits about you my fabulous fellow diet detectives! :)

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