So this is not news to most people who know me but I don’t like taking things out of people’s diet. As a result, in a room full of naturopaths & integrative medicos, I might be voted the least likely to use the phrase, “No Gluten or Dairy for you!” [said with the Soup Nazi’s accent from Seinfeld]. I must have slept through that class when we were taught to do this for absolutely every patient. But seriously, I try not to remove or exclude foods without a very strong rationale and evidence-base that relates directly to the person sitting in front of me, for several reasons: 1) those seeds are powerful ones to plant in your patient’s mind…how do they carry that with them as they move through life, navigating food and social settings etc etc…all well and good if this is a proven life-long pathological provocation for them but otherwise… 2) dietary exclusion is stressful for families & in kids especially, can create disordered eating and a range of other psychological impacts and 3) GFDF diets are not necessarily healthier in the basic nutrition stakes…if you haven’t read Sue Shephard’s work on the deterioration of diet quality in GF patients…you should. It can be much healthier of course…but often the real-world application of the principle doesn’t always match the lovely ‘serving suggestion image’ on all the GFDF highly processed, packaged foods!!
So listen up people, because now I’m talking about when I would seriously consider joining in on the GFDF chant.
The one patient group I’ve never quibbled over the benefits of GFDF, has been the autistic one. I was taught the merits of this approach early on by a few fabulous courageous integrative doctors and paediatricians who came back from the front-line of their clinics, reporting good effects. I then had the important firsthand experience of unprecedented verabilisation in a non-verbal ASD child’ after excluding these foods. But what I’ve been thinking a lot (and reading a lot!) about lately is the possibility that these ‘dietary exorphins’ may have negative mood effects in other subsets of mental health patients. My thought process is like slow TV! That aside, there’s a lot to be said for taking the time to really getting across an issue – even if that involves reading papers from as far back as the 1960s when the idea of a negative role for dietary exorphins in schizophrenics was first floated by Dohan & colleagues.
Let me say, when you go back to the beginning it’s undeniably a shaky start for the exorphin evidence base, but as you read the studies that emerge from decade to decade until the noughties…it reveals a nagging research topic that won’t go away and a fascinating process of discovery.
So is the devil really in the (regular commercial cow’s) milk? Well I think for some patients it may well be a contributor – most notably those with features consistent with the pattern of excess opiate effects including a higher dopamine picture, regardless of the mental health label they’ve been given, although, more commonly seen in ASD, psychotic presentations etc. But how do we work out which ones, because none of the evidence points to it affecting 100% of these groups…well that’s where we need to go back and truly understand the structure of these dietary exorphins and just how they potentially wreak havoc in some.
The latest UU30 takes your through the story of BCM-7 with a summary of research compile over half a century in Under 30 minutes!
There is a well-rehearsed chant in the integrative management for ASD individuals, “Gluten free- casein free diets” is based on the dietary exorphin theory which suggests these foods generate bioactive peptides that act unfavourably in the brain. Where did this theory emerge from and how strong or weak is the evidence upon which this therapeutic intervention stands? Even more interesting, is there support of this theory in a wider range of mental health presentations such as schizophrenia, post-partum psychosis and depression. Is there such a thing as milk madness for a subset of our patients?
So you’ve gone to all the effort. Be that writing referral letters suggesting some pathology investigations might be warranted or you’ve coached your patients endlessly to get copies of ones done elsewhere so that you may be privy to their findings. Worse still, you’ve directly requested the pathology, with your patient paying out of pocket for the tests. Then the results come in and they look…well wrong. You, as the conscientious clinician, typically do 3 things:
Step 1 Spend hours pouring over & over the labs and back over the case notes
Step 2 Worry about the new differential diagnoses that are now suddenly seemingly a possibility in your patient. It doesn’t look good.
Step 3 Doubt your own pathology reading ability, ‘Hey maybe I just don’t understand these bloods like I thought I did’
But (often)…it’s not you, it’s them.
And that’s what I often explain to practitioners who contact me (step 4). You see sometimes what they’re losing sleep over are what I call, Bad Bloods. Occasionally, the fault of the pathology company…but way way way more often the fault of the patient and the referring practitioner, who has not educated the patient correctly about what to do and not do prior to blood collection for certain tests. I am excited to see how many practitioners are competent with pathology reading these days and building their skills and confidence all the time, that’s why it is so so disheartening for the practitioners (and for me as a mother hen mentor) when they lose time (& sleep) getting to Step 3 when they should be able to spot ‘Bad Bloods’ fast. There are 7 classic give-away patterns.
Will are unlikely to know every quirk of every blood test our patients will ever have done, but knowing what constitutes the ideal time and conditions for the most commonly performed ones, can go a long way to minimising any future Bad Bloods between you and patient as well. This includes things like exercise, alcohol intake, duration fasting and even sexual intimacy…yup!
This month’s Update in Under 30 installment Beware of Bad Bloods teaches you the 7 patterns to watch for and provides you with a great resource stipulating the best collection conditions for the most common blood tests. Don’t let Bad Blood come between you and your patient, the right diagnosis & management or just some well-deserved sleep!
Good practitioners are being led to bad conclusions by some patients’ pathology results. Not because they can’t interpret them or the testing has no merit but because they just don’t know when to discard a set because they are ‘bad’. Occasionally, the fault of the pathology company but much more often the fault of the patient and the referring practitioner, who has not educated the patient correctly about what to do and not do prior to blood collection for certain tests. This recording clearly describes the 7 classic give-away patterns of ‘Bad Bloods’ which will enable you to spot them fast in the future. In addition to this. while we are unlikely to know the idiosyncrasies of very lab our patients will ever have done, knowing the ideal collection times and conditions for the most common ones assists you and your patients to avoid any in the future – handy clinic resource included.
Hear all about it by listening to my latest Update in Under 30: Beware of Bad Bloods.
For all Update in Under 30 Subscribers, it’s now available in your online account and if you are not a subscriber you can purchase this individually here.
As Britney so famously put it, ‘Oops, I did it again!’ I remember the actions on my to do list but not the intended recipients! D.O.H. I was talking with a practitioner the other day who lamented that she had never really learnt about stats nor how to assess the quality of research in her undergraduate and could I point her in the right direction towards a resource that simply explains this increasingly important basic skill-set…well I would if I could remember who you were!! Anyhoo, I followed through in my usually dogged way to the bottom of my actions list and with the help of a lovely past-intern, got directed to these free BMJ resources on how to read research…G.O.L.D.
Papers that go beyond numbers (qualitative research) Trisha Greenhalgh, Rod Taylor
Papers that summarise other papers (systematic reviews and meta-analyses) Trisha Greenhalgh
Papers that tell you what things cost (economic analyses) Trisha Greenhalgh
Papers that report diagnostic or screening tests Trisha Greenhalgh
Papers that report drug trials Trisha Greenhalgh
Statistics for the non-statistician. II: “Significant” relations and their pitfalls Trisha Greenhalgh
Statistics for the non-statistician Trisha Greenhalgh
Assessing the methodological quality of published papers Trisha Greenhalgh
Getting your bearings (deciding what the paper is about) Trisha Greenhalgh
Anyway…while I continue to ponder who this was actually intended for… it dawned on me how many people would just LOVE these & benefit from them immensely in the meantime. Couldn’t most of us do with a little more research literacy? So I thought I’d share. Don’t you love it when we work as a team. Now…who can help me find my keys?! 😉
It’s starting to feel a lot like…that Update in Under 30 time of the month!
Update in Under 30 are dynamic power-packed podcasts that will help you keep abreast of the latest must-knows in integrative medicine. Focused on one key issue at a time, Rachel details all the salient points so that you don’t have to trawl through all the primary evidence yourself. All topics are aimed at clinicians and cover a range of areas from patient assessment to management, from condition based issues to the latest nutritional research. Most importantly, each podcast represents unbiased education that can contribute to your CPE points, so if you haven’t subscribed yet…what are you waiting for??!! 🙂
Forever fascinated by the neurobiology of various mental health presentations, addiction included, two medical news items caught my attention this week. If you’ve ever heard me speak on addiction, in somewhat simplistic terms, it is very much about the reward centre of the brain and how strongly all recreational drugs hit on this. Think rats tapping levers with their feet to continually self-administer cocaine…to the exclusion of all else….kind of magnitude of reward hits. You may have also heard me quote or misquote (!) someone famous who once said something to the effect of….and I am totally paraphrasing poorly here: if we can’t seek pleasure legitimately, we will seek it illegitimately.
So this story from ABC news about a Newcastle addiction group support program showing some early signs of greater retention and engagement and therefore potential success with addicts…because they incorporate prizes…well that makes so much sense!
The article is important to read in its entirety as it creates the context – especially for many people suffering from addiction who tell tragic stories of lives where the only rewards/prizes and even gifts they’ve ever known, being drug-related – even from a young age. So to normalise reward to some extent, and give individuals an experience of constructive legitimate versions of this, is actually desperately needed and ground-breaking.
How can we incorporate some element of this in our interactions with these patients?
The second ABC news item touts ‘a new generation drug that restores balance to the brain’ but is actually just a teaser about…wait for it…cue stage right…a not so old favourite…N-acetyl cysteine! Although this is effectively a recruitment drive for methamphetamine addicted individuals into a new 12 week trial of NAC, run by the National Drug Research Institute, taking place in Melbourne, Geelong and Wollongong, it gives NAC a great wrap and rationale for being a good adjunct in addiction, of course. Just a reminder folks that naturopaths belong on that multi-modality health care team for people struggling with addiction, and we do have some potent therapies to contribute.
A couple of years back I was asked to deliver an educational session to a group of hospital based mental health specialists on the merits of NAC. My favourite question/comment at the end of my detailed presentation from a very experienced psychiatrist was, “Well if N-acetyl cysteine is so good for mental health…why haven’t I heard about it before now?!”
I hope they follow the ABC news 🙂
Want to Get Up Close to N-acetyl Cysteine in Mental Health? Previous ideas regarding the pathophysiology of mental illness have been profoundly challenged in recent times, particularly in light of the limited success of the pharmaceuticals that ‘should have worked better’ had our hypotheses been correct. Novel drivers such as oxidative stress, inflammation and mitochondrial dysfunction are on everyone’s lips and N-acetyl cysteine is in prime position in this new landscape, to be a novel and effective therapy for mental illness. This presentation brings you up to date with the current NAC research in a large number of mental health conditions & translates this into the clinical context.
This weekend I re-experienced an incredibly potent therapeutic intervention firsthand. We drove 40 minutes inland to vamp under the stars (that’s between camping and glamping and has nothing to do with vaping!) That was a good start. Breaking from the ‘norm’, looking at different scenery, digital detoxing, these are all important aspects of what helps us to distinguish time off from ‘time-on’… but the real therapy started when we lit a fire.
So we sat, just the 2 of us, in front of our little fire.
Talking for hours, being silent as well. Warm and cosy against the brisk night air, both totally mesmerized by the flames and glowing embers.
And surprisingly quickly – I could feel all its goodness – letting me down, filling me up, expanding me out. The antidote to our ridiculously busy lives.
And it made me think of all the times my patients need to sit in front of the fire. When the therapy, the remedy doesn’t come in a bottle or a powder but actually an act of reconnecting, of intentional slowing down, whatever you want to call that. I’ve prescribed some pretty funny and unusual things for my patients over 20 years and a lot of them, I guess, not dissimilar to this powerful charcoal remedy. Daily naps. A completely spontaneous trip away. Podcast Diets (aka health info abstinence periods). Long baths. Cups of tea with friends. Walks with a loved one after dinner. Candle-lit nights for one. (more…)
If you’ve not seen Kitty Flanagan’s skit on current coffee culture...it’s essential viewing. In true Kitty-fashion, she wants to simplify coffee ordering down to 2 basic lines – White or Black – says all our pretentious coffee orders; macchiato, skinny, decaf, half strength, latte etc can essentially be reduced down to a much faster 2 queue system. But she’s forgotten the line for taking your coffee rectally. Sorry – did I make you just spill your coffee? Knowing How across health trends Kitty is, she’ll add this 3rd queue soon, if the number of patients asking me about this or telling me they’re already doing it. Now, while enemas had a place in naturopathic history, my training never covered them and, consequently, I’ve never included them in my practice. But the more hype I heard around coffee enemas specifically, the more I thought we better find out as much as we can, so at least we can better inform ourselves and our patients. And of course the monkey on your back, called FOMO, jumps up and down, incessantly asking, “Are you (and your patients) missing out on an amazing therapy?”
The first patient who told me they were using coffee enemas daily was a celeb. A very anxious one. Who also told me she couldn’t possibly drink chai let alone coffee because of the caffeine. This had me a bit stumped…I knew she wasn’t inserting decaff up there and I thought…well given the colon is SUCH an absorptive surface surely this is why she reported feeling, ‘so energised, more clear headed’ etc. with every enema?
But I wanted to find out for sure (more…)
Quite the month for it, I hear. My inbox has run hot with practitioners deeply concerned about some serious finger pointing that’s been going on.
The fingers in these instances have belonged to medical practitioners and the direction they’re all pointing, is seemingly at any complementary medicine their shared patient is taking.
Here’s a couple of good examples: “Your high blood pressure is the result of the combined mineral formula you’re taking!” These were the words of a GP to a 50 something female patient when he discovered she was taking a calcium, magnesium, potassium containing formula. The patient was hypertensive at the initial appointment, at which time the naturopath encouraged her to actually seek review, assessment and prescription of an anti-hypertensive, however the patient declined. The nutritional prescription was recommended in response to high acidity (raised anion gap) and prematurely low GFR (impaired renal function). Patient’s HBP continued to be problematic so the next doctor she sees, points the finger and says, it must be this product!
Would anyone like to explain that to me? In fact, that was my advice back to this very concerned and understandably rattled practitioner…just to cordially request the GP to outline the mechanism by which this might occur. (more…)
Ever feel like you’re chasing your own tail trying to treat & find the source of GIT parasites in some patients?! Well guess what, you just might be!
We’re seeing more & more patients test positive for Dientamoeba fragilis and increasingly patients struggling to eradicate it and prevent relapse. And then there’s Blastocystis hominis affected patients… and then those lucky enough to have both.
Well, while we might have been grouping D.frag together with B.hominis, being the two most common GIT parasites in humans, looking for what they share in common, they are worlds apart (we think!) in terms of how they are transmitted to humans. (more…)
You know I’m not one to raise my voice and make scene.
Ok, I always raise my voice and make a scene, but only when I think something really warrants our attention and the issue of under-recognised, under-estimated and mismanaged chronic worms, demands our attention. I’ve been talking about this ever since the first patient stepped into my clinic, a young girl with severe mood issues who just happened to also have treatment-resistant chronic threadworm, and since then, as the volume of patients I see affected by this has grown, so too has the volume of my message. And there’s actually so much to say.
Chronic worm problems don’t always come with an itchy bottom calling card. In fact, many individuals don’t have any of the telltale signs you might be used to screening for. Recent research suggests adult men, in particular, are commonly asymptomatic when infected with them (Boga et al 2016)
So what alerts us as practitioners to the possibility of chronic worms – so many things…but here’s just some thought bubbles to get you started.
Are you treating patients with recurrent or treatment-resistant Dientamoeba fragilis?
Are you seeing women who have thrush-like symptoms, in spite of negative swabs and no benefit from antifungals?
Are you faced with families coming undone because of one child’s behaviour whether that’s aggression, defiance, emotional lability or just serious sleep problems? (more…)
I have a good friend…who happens to be a naturopath…who happens to also be a patient of mine. Have you got a few of these as well? A month ago, looking over her recent bloods which included fasting lipids that had been steadily climbing for the last couple of years, post-menopause, she said, ‘do you think I should take something for that?’ Ahhhhhh no. My reasoning went like this:
“You love saturated fat right? You eat butter and cheese and and and…and the type of elevated lipid pattern you have LOOKS like it is at least partially the result of this, your triglycerides are low, your HDLs are good it’s just this LDL component that is too high. You could add in another supplement…and take it…forever…or you could do a little n=1 experiment and just lower your butter, cheese & coconut oil intake for a month and repeat the test.”
The horror on her face! You see I didn’t know exactly how much she loved butter but it all became clear with the first text a few hours after I had thrown down the gauntlet…which included a sobbing emoji and the comment that her afternoon snack will never be the same…turns out it was a shortbread biscuit with butter on it!!! But as a practitioner who does pride herself on walking the talk…off she went determined to give it a good go for a month. But boy did it hurt! (more…)
I think we’re all going to scream when the next patient says, ‘I’ve got an MTHFR’, right?!
Congratulations, I want to say, because you would be in much more serious trouble if you didn’t have a copy…
‘Oh, sorry, you mean you have a mutation on at least one allele encoding for the MTHFR enzyme…Oh, I hate to tell you but contrary to popular (online) belief, you’re not special.’
Just because most of us have been on holidays doesn’t mean the thyroid knowledge wagon has stopped or even slowed! Always amazed at what we continue to discover about the complex working of this amazing gland and how its health impacts so much of the rest of the body and of course our babies’ bodies! So I thought I’d give you a quick recap of an important study published while you were at the beach/in the bush/in bed ;)…
- A Finnish prospective cohort study of over 3000 pregnancies by Heikkinnen et al has revealed that at 16yo, offspring from these pregnancies, had a 1.56 increased rate of unhealthy weight and a 2.5 greater likelihood of meeting criteria for metabolic syndrome, if their mothers were thyroperoxidase antibody (TPO) positive during their first trimester
- TPO antibodies affect up to 20% of pregnancies but in this study they defined ‘TPO positive’ as those women with levels ≥ 167.7 IU/mL (the 95th centile in this sample)
- What adds to the noteworthiness of this news is that:
- More than half (55%) of the TPO positive mothers were classified as euthyroid during their pregnancy, suggesting that the effect was not driven by maternal hormone concentrations
- The offspring of mothers with actual thyroid dysfunction did not show any statistically significantly greater risk of cardiometabolic issues
- The offspring of hyperthyroid mothers in fact demonstrated significantly better insulin sensitivity at 16yo than children of euthyroid mothers
- Thyroglobulin Abs over the 95th centile (≥ 47.7 IU/mL) did not correlate with any increase in cardiometabolic risks for their children
When we consider the substantial evidence of poorer maternal cardiometabolic outcomes for women who are hypothyroid during pregnancy – it would seem that the abnormal thyroid hormones are most impacting for mum but in fact the TPO Abs the most detrimental for bub! (more…)
No this is not a joke. The room they enter happens to be the clinic space of a practitioner I mentor. The older women are friends, both originally from the UK and they sit in on one another’s consultations sharing many of the same experiences: grief over loved ones lost, memories, laughter and both describe waking in the morning with a sense of dread, because they’re tired, feel they’ve lost their oomph, their motivation, their chutzpah…that’s mostly why they’ve come today.
But know what else these two have in common? (more…)
Have you been a bit vitamin D trigger happy? Does a patient’s low blood 25(OH)D test result have you reaching for a vitamin D supplement like the rest of us? Yes…you might need to listen up then. Sunshine doesn’t come in a bottle. That’s right, if your patient’s problem stems from inadequate sun exposure, have a guess what the best remedy is. I’m not meaning to sound flippant but I think in all my ‘complex highbrow nutritional understanding’, occasionally (ahem), I have lost sight of the simple truths. (more…)
I had the privilege of presenting at the Integria GIT Symposium last weekend. For those of you who attended, you’ve gone back to your clinic with a bunch of new ideas and inspiration I hope…oh and a new respect, terror and watchfulness for threadworm thanks to me! In my presentation I outlined the many presentations of this infestation, what to watch for and the risk of chronic recurrence due,in particular, to a reduced ability for some individuals to produce chondroitin sulfate which renders the GIT environment hostile to worms.
Chronic threadworm is a huge & grossly under-recognised issue in paediatrics, often presenting as behavioural & cognitive disorders (and these can be severe), bruxism, enuresis etc. of course, but another presentation typically missed is vulvovaginitis, vulval pain or UTI like sx in young girls. (more…)
Ever got to the end of a day or a week and felt like this? Or woken up to find your skin looking like this?! Just quietly, me too. When my son was about 3 he was sitting in the back of my car with my mum (she would have been in her early 70s) and he asked how people get wrinkles. We told him it was from having a fun life with lots of laughter, to which he replied out loud while still staring intently at my mother’s face, ‘Wow Grandma! You must have had the best life ever!’ I digress.
I personally am not a crusader of anti-ageing (seen my pics recently?!!) but my recent research into effectively reducing Advanced Glycation End-products (AGE) via the diet, to in turn potentially lower both my risk of tuckshop arms AND just about every other disease you can name (cardiometabolic, neurodegenerative, psychiatric, malignant, you name it), got me sitting up and paying attention! (more…)
Let’s play a little word association game:
I say ‘Fibroids’ – you say, ‘Oestrogen’.
I say ‘Cyclic Breast Pain’ and you say, ‘Ouch!’ [because it just slipped out] but then you say, ‘Prolactin’, right? Me too.
Prolactin driven breast pain’s most characteristic form is the premenstrual ‘oh my goodness get these off me!!’ kind, with patients experiencing anything from burning, aching, bruised feelings and acute hypersensitivity to touch, which builds in intensity for days leading up to their bleed. Of course cyclic mastalgia can progress to being full-time mastalgia in women whose breasts start to exhibit structural tissue change in the form of cysts, fibrosis and ultimately fibrocystic breast disease. If you’ve ever experienced even a day of mastalgia it is truly hard to conceive there are so many women (about 50% of premenopausal women!!) living with it daily.
Adding to our concerns about this so-called ‘benign breast disease’ (BBD) is that researchers are now certain it’s a significant risk factor for breast cancer, with women with any form of BBD experiencing at least a doubling of risk of a subsequent breast cancer diagnosis, while those women with proliferative BBD exhibiting a risk of 3.5X that of women without BBD. Castells et al 2015 (more…)
Setting: Local cafe
Scenario: Run into friends of friends who join us in the sunshine for a cuppa & we’re discussing the finer details of chai (western version V the real streets of Delhi stuff), tumeric lattes etc etc. as you do. I comment on how unpleasantly strong I found the cow’s milk in those downtown Delhi chais we had when we were there.
50 something man: Oh I LOVE that – I just LOVE cow’s milk. I drink loads of the stuff. I used to drink 2L a day but now it’s more like 1L a day.
50 something man: Absolutely. Then there’s the cheese as well – I would eat at least 1kg of that a week. But it’s good for my bones, right? I have that thing, you know, before osteoporosis…brittle bones. (more…)
I am frequently asked what scientific journals I subscribe to and often by the same practitioners over and over, because they can’t reconcile my answer: “None”. Yet I constantly have my head in the scientific literature, right? The two are not mutually exclusive, it’s just about knowing which free scientific and medical news-feeds are worth their weight in gold! If you really are digging into the itty-bitty detail of things these won’t answer all your questions on all your topics but they do a great job of 1) keeping you up to date with the big headlines in general medicine, or, with the use of alert systems and filters, just the areas of health you’re particularly interested in and 2) offering you a huge highly credible resource database that is easily searchable.
Point 1, Exhibit A 😉 :
Here’s just a few examples from the last month that popped into my inbox from Medscape that got my pulse racing:
Watch the gap! You know I love a good diagnostic test probably (way!) more than the next person but I am slow to come around when there’s suddenly a ‘new-kid-on-the-block’ that every functional testing company wants to offer you. This is how I felt about serum zonulin testing as marker of intestinal permeability too. In spite of Fasano’s important work, identifying this molecule and its role in the reversible opening of tight junctions in the small intestine – I didn’t embrace the test. Why not? Didn’t I love Fasano’s ability to add this piece to the jigsaw that had been missing til now? Well I did. Does that make it an accurate and reliable marker of intestinal permeability in every client with any kind of digestive issue…? Well heck no! That’s not how science works friends and I suspect we may have really jumped the gun a little on this one. (more…)