Well, obviously(!)…this has been a year heavy on pathology interpretation for me and the huge number of practitioners who’ve just spent the last 6 months taking that learning journey with me. I celebrate and congratulate them all for their commitment to their own professional development and also their investment, in what is arguably, the most potent yet overlooked set of skills of any health professional… the ability to read bloods. Basic bloods. Mainstream labs. No…but to really read them. Backed by all the scientific understanding about what these parameters actually are, how they perform and what they (dis)prove e.g. subclinical inflammation and ramped up oxidative stress – not an informed guess but mappable…right there but where no one else can apparently see it! But I digress!
Actually what I wanted to discuss was the whole erroneous notion of ‘normal’.
No, I am not speaking from the heart about my personal quirks, sense of humour or dress sense but rather the incorrect assumption that a reference range defines ‘normal’ and that our answer for each patient and each result is, a Yes or a No!
In this brilliant article by Whyte & Kelly published in the BMJ they spell out this falsehood succinctly. They note that the term ‘normal range’ has slipped into medical language from the misunderstanding that all lab results follow a Gaussian (aka bell shaped curve & later referred to as ‘normal distribution’) pattern but many simply don’t. So for some parameters a result near the ‘middle of the reference interval’ constitutes aspirational whereas for others it spells danger. Add to this, that these reference intervals are mathematically determined to reflect the expected values of 95% of your patient population (mean +/- 2 SD either side) so…that means the chance of a YES…”Your patient’s results are ABNORMAL!”… is just 5%. And hey…who said all the values within the reference range are all equally “normal” or better yet, healthy?! Not these authors, nor I, nor the praccies who’ve just done our course. So while, in many regards, these goalposts are too wide, they are also too narrow – typically only representing a subset of adults age-wise and Caucasians, yes they are both ageist and racist (yep, I said it!). And if our practitioners have learnt anything it’s about keeping an ol’ eagle eye on the sneaky intra-individual shift! Only spotted, of course, if you know your patient’s normal (not theirs compared to anyone else…just theirs) and then spot a shift. [I can hear they’re shushing 🤫me…they’ve got it already, alright!!]
So this is music 🎻to my ears, from Whyte & Kelly:
“The intraindividual variation in laboratory values is usually much smaller than the interindividual variability (ie, the variation in the population). Variation in the concentration of an analyte, if significantly outside of a patient’s usual values (but still within the reference interval), could be a sign of early or latent disease”
So if you want to tap into the power of pathology…start with Whyte & Kelly, maybe even dip your pinky in the pool by checking out Accurate Pathology Results Interpretation Starts Here – an easy little 1.5hr kickstarter…or jump right in the deep end with the rest of us pathology reading polo players and sign up for the MasterCourse 1: Comprehensive Diagnostics for some DIY summer fun 🌊
ps I know
your type and know that is EXACTLY the kind of weird nerdy thing you have planned for your break…you should see my summer fun list!!! 😅
MasterCourse 1: Comprehensive Diagnostics is a self-paced online program due for release in December.
The course has pver 18 hours of video presentations plus 2 free bonus sessions 1) Accurate Pathology Interpretation Starts Here and 2) Patient Pathology Manager and access to resources and tools within, for your own use.
This is a pre-requisite for MasterCourse II that will be delivered live in 2021.
This skillset has been found by many to be biggest ‘game-changer’ in Integrative Health
You can view the full course outline here.
I 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
I didn’t catch that Zonulin wave that hit Australian integrative health practitioners a few years back. I think it might have been after Dr. Frassano himself, made an appearance at one of our big conferences. Like the true bloody sceptic I am, I stayed dry on the shore. In fact, I chucked my board in my panel van and drove straight for the library to do some research. Yep…boy do I know how to have fun in the sun 😎 But I am really glad I did.
While I am forever grateful to researchers like Frassano and so many others, who pioneer new perspectives, if not paradigms, in health, I also know that research is a long, long, long road and sometimes we get a little over-excited trying to ‘catch that wave’ too early.
This was especially the case with Zonulin testing.
When I finally left the library about a year later in 2017, I flagged my concerns. As always, my stand was
subtle: Mind the Gap with Zonulin Testing. This was my Update in Under 30 offering, encouraging us all to think about this test more critically and make a balanced review of the evidence both for and against it, as a marker of increased intestinal permeability, especially in comparison with the Lactulose Mannitol Test, considered the gold standard of IP assessment.
I also flagged that not every individual has the capacity to make Zonulin no matter how ‘gappy their guts is’…and this was something most struggled to comprehend or accept. But guess what? This fact has now gone mainstream along with even more concerns regarding the inaccuracy of commercial Zonulin testing.
“Three genetic polymorphisms in human haptoglobin expression, Hp1-1, Hp2-1, and Hp2-2, are determined by the HP1 and HP2 alleles harboured by chromosome 16q22. As zonulin is the precursor to haptoglobin-2, individuals who bear the heterozygous Hp2-1 or homozygous Hp2-2 polymorphism are zonulin-producers whereas those with the homozygous Hp1-1 polymorphism are unable to produce zonulin.” But wait, Ajamian et al 2019 has so much more in store for any remaining believers. “In conclusion, the current commercial zonulin ELISA assays investigated in this study detect different proteins, neither of which was zonulin.” Yes, that’s what they found. Two different big commercial kit assays – one from China, one from Germany…neither actually measured zonulin. I am passionate about CAM and passionate about testing…but cautious & concerned about the CAM-Sham that does get peddled to us at times, under the guise of ‘cutting edge functional testing’. Another name for that..unfounded, not yet validated, waste of money and source of possible misdirection for the practitioner. It’s tough talkin’ Tuesday…just sayin’ 🙄
Need some more help to Mind the Gap with Zonulin Testing?
Following the important discovery of the role of intestinal Zonulin in the pathophysiology of coeliac disease our fascination with measuring zonulin in non-coeliac patients suspected of ‘leaky gut’, has moved faster than the facts. It’s time to critically reassess what value, if any, there is in testing serum Zonulin – which patients and when? Let’s talk about its false positives (flagging a IP problem when there isn’t one) and negatives (failing to flag a problem when there is one) and how it compares with the gold standard for detecting increased intestinal permeability, in our patients.
No doubt you’ve heard me refer to the thyroid Abs by their nicknames, TRAb is one I mention often, or Thyroid Receptor Antibody, as its mum calls it, when it’s in trouble. And it’s always in trouble! But TRAb is actually the collective name for several flavours of trouble. What these auto-antibodies share in common is the ability to bind the TSH receptors throughout the body. They differ however, in terms of whether, once engaged, they stimulate this receptor (mimicking the action of the real-deal TSH) or they block it, so that the real-deal can’t in fact dock and do its job. The contrasting consequence is clear: stimulating ones drive up thyroid hormone production, while the blocking variety contribute to low thyroid hormone levels – and what was meaningful was each patients (im)balance of the two to produce a net effect. Because yes…a proportion of patients make both.
In Australia, and many other countries, we previously measured TRAb as a sum total and then specified what fraction was each ‘flavour’ but then the ‘flavours went out of favour’!
So for a long time now, TRAb has been measured, undifferentiated, and the assumption is, they’re stimulating…because this is in fact a) more common and b) the most common reason this test would be referred for…a set of TFTs that look suspiciously on the high-side aka Grave’s disease.
But a new era has dawned, with many mainstream laboratories now opting for the more specific assay: Thyroid Stimulating Immunoglobulins (TSI)* over the old TRAb. Fancy schmanzy, I know. Considered more accurate in the detection of autoimmune hyperthyroidism and in this regard, we’re told we’ve made a diagnostic step forward and nothing has been lost. Except the much less common type of antibodies that bind the TSH receptor only to fill it full of gum so it won’t work. That apparently, due to its low incidence and reduced clinical impact is no longer something worth testing. So consider the TSI results for your patients, the new version of your old (drab) TRAb, with similar cut-offs etc. And remember detectable levels of this may be seen in toxic nodules, and acute toxic Hashimoto’s, as well as prodromal and active Grave’s disease.
AND DON’T FORGET
(and yes, I am screaming because it is so easy to forget!!)
Biotin!! Patients on biotin at the time of the test (even as little as 1mg as part of a formula) can produce False Positives for the TSI!!! And give you and your patient the ‘fright of your life’ with a pseudo hyperthyroid set of labs to match!
Need to read more on this because you’re left thinking WTF about the TSI?!@#%^ Check out Mayo Medical Labs (always a good go-to for info on pathology) or this recent review paper 🙂
*Note TSI does not stand for Turbo fuel stratified injection in this scenario!!
Want to learn all the thyroid antibody alphabet??!! Start Here!
Learn the ropes of Thyroid Dysfunction Assessment & Identification, including all the related thyro-nutrition! 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 as easy 1-2-3!…almost!
Recently a mentee reported that when attending an in-person training event (remember those, everyone?!) she approached a sponsor’s stand, promoting practitioner training in the nutritional management of mental health, based on the pioneering work of American scientist, Carl Pfeiffer. But when she and her nat buddy started asking questions, those manning the stand asked whether they were doctors and then, upon finding out they were naturopaths, encouraged them ‘to move along – this information isn’t for you then’. Or something to that effect…Ouch!
While I know a little about the decision behind offering this training only to doctors and specialists at this time, and I do understand that organisation’s reasoning, I also want to reassure you, this doesn’t mean that Pfeiffer’s important work, and the efforts of those that have followed him, is out of bounds to others.
No one can copyright cortisol or TM TSH, right? Equally, Histamine is his own man. Carl Pfeiffer and others brought histamine, the neurotransmitter to centre stage and many of us working in mental health remain eternally grateful for this. But CNS histamine has come a long way since then…and is currently a very hot topic in modern molecular psychiatry where they are always looking for new drug targets, given shooting at the previous ones, risked taking ‘an eye out’! The recognition of histamine as a key player in mood, cognitive and behaviour has been long overdue but is absolutely here now! Just give this search term a whirl in PubMed: histamine AND psychiatry, and you’ll be hit with quite the crush of citations!
An abundance of important info at your fingertips…no secret handshake required.
It was, in part, this story that inspired me to record an Update in Under 30 on Histamine Imbalance in Mental Health. Just the proverbial straw on the proverbial camel really, after years of examining, experimenting and experiencing the incredible results some patients can achieve when this imbalance is identified and redressed. So I’ve done my darndest to pull together those years of hands-on helping histamine imbalanced patients with the latest literature in under 30 minutes!! Surprise! I failed! There is a lot to convey but you’ll also be surprised by what I don’t say…there’s no infinitely long list of personality peculiarities that fit with too much or too little. Nor is there a didactic discourse about absolute treatment dos and don’ts. I’m communicating the common ground between the original evidence, clinical empiricism and contemporary neuroscience. So this month, consider the ‘under 30’ bit, merely a ‘Serving suggestion’…which would necessitate you playing it 1.5 X speed…go on, I dare you!!😅
About 15 years ago I was introduced to Histamine as a neurotransmitter. Not the allergy mediator or the ‘basophil baddy’ but rather this prolific and potent neurochemical we all produce in our brains which, in the right amount, regulates almost every biological rhythm, helps with memory and mood & much more. Being able to recognise excesses or deficiencies of CNS histamine in mental health presentations and, ever since then, fine-tuning my ability to support patients with these, has changed my practise forever and has been the key to some of my patients’ greatest recovery stories. Forever grateful to the pioneers of this model, 70 years on, the model is ready for a mini-makeover, to bring it in line with the current scientific understanding of histamine, methylation, genes and much more. This recording, together with a hugely helpful clinical resource, will give you the confidence to recognise and remedy this important imbalance in mental health. If you want to download this recording click here.
We’re midway through mentoring 2020 and we’ve temporarily shifted gear out of case presentations and into dedicated time for answering praccies toughest questions…and oh man, I love these opportunities! This year in our Mental Health Primer Group, there are clinicians whose questioning…nEVeR sTOps. [insert: excited squeal] and that means I have an excuse to dig deeper, go further, read more research and ensure I can provide answers confident of their comprehensiveness and that they reflect all the contemporary information to date. So amongst stiff competition – here’s my favourite from the gIAnT piLE on my desk right now…
“We often hear that the bulk of our body’s serotonin is in our platelets – so do platelets (counts, activity etc) have a role in mental health?”
Well, I’m so glad you asked! Yes, 99% of your body’s serotonin is found inside your platelets. Where did this come from? From the plasma. How did it get there? Using the identical transporter mechanisms that your neurons do. Sounds like all the pieces fit right…oooooh so low platelets might drive low serotonin and poor mood and and and…
You may get excited when you get a box of jigsaw pieces but you must first complete the puzzle and ensure everything is in its rightful place.
Platelets are linked to depression but not as a cause but as a consequence. Because their transporter systems & receptors for serotonin are virtually identical to those in the CNS, they suffer from the same serotonin deficit…in spite of a relative abundance in the plasma they’re floating in. So really platelets are of interest in mental health as a more accessible way of studying and understanding neurochemical regulation in the brains of those affected. Did she just say neurochemicalS…as in, plural. I sure did. Because healthy platelets contain a whole plethora of substances, even a relatively large quantity BDNF, the concentration of which also becomes severely compromised in the platelets of depressed individuals. So it seems like its tough-talkin’ Tuesday and just to bust a few more
moves myths while we’re here…
Your platelets get their 5HT from the plasma
Your neurons make it themselves
Platelet numbers are not indicative of your 5HT producing capacity…anywhere
Therefore treatment objectives that speak to platelet numbers or platelet activity are clearly non-sensical
A bit like measuring serotonin derivatives in your urine…and imagining that reflects the <1% from your CNS….hey?
Yes. That’s what I said. Want to learn more? Please do. A great review paper by Marlene Williams, from the World Journal of Psychiatry, for starters, anyone? 🙂
If this last point is news to you…sounds like you really Need to Start Here! Accurate Pathology Interpretation
Don’t be fooled by the false promises of functional tests. Make sure all the pieces of the puzzle fit to actually make something sensible, accurate, reproducible and meaningful. Mainstream pathology results actually offer a goldmine of information and insight about your patients However to realise their full value and make the most accurate interpretations we need to first learn more about ‘lab language’, upskill in finding our way around reports which are packed with a surprising amount of hidden extras, demystify reference ranges and then develop a logical critical process we can apply to every result of any patient to get the real take-home. Packaged with numerous specifically developed resources to aid in your application of these skills this is a foundational offering that changes practices.
Given 1 in 8 Australians right now are taking an antidepressant, chances are you’re seeing a lot of clients on these, especially the SSRIs. Erica McIntyre (fellow naturopath) and colleagues, found that in fact, mental health diagnoses affect about 43% of individuals who choose to seek help from a naturopath or herbalist, so clearly this is across all of our waiting rooms. Accordingly, by this stage in your clinical career you’ve probably seen more than 1 patient taking the identical SSRI – e.g. Citalopram (aka Lexapro or Cipramil) Have you also by now, therefore come to ‘expect the unexpected’, when it comes to patients on the same prescription, in terms of ‘weight effects’? The majority not reporting this to be a major concern or issue but the occasional client, experiencing such significant weight gain, they may even have seen this as a reason to discontinue the medication. So what’s up with that then? Don’t we all wish we knew for certain! But getting our heads around the potential mechanisms is important for our patients, in terms of making more informed choices, as well as offering us insight perhaps into their neurobiological nuances.
Some of you will know, this used to be my place of business.
I have a background in the pharmaceutical industry, specifically psychiatric meds, more specifically SSRIs and even I find every time I duck-dive back into the literature I come up with more ‘fish’ – critical new information about mechanisms, secondary and unexpected actions, unforeseen benefits, barriers and yes, some sad or bad new detail. Consequently, I always field lots of questions about SSRIs in our mentoring sessions & one that often comes up is why some patients gain weight on SSRIs. What’s most curious to many, is how the weight effects of antidepressants can be hard to predict. There is not a consistent pattern across any specific antidepressant class, nor just 1 or 2 medications within a class, that will do it, while the others never will. This is in contrast to the many determinations and drivers for who will or won’t get discontinuation syndrome. So what mechanisms might be behind such an individualistic weight response and is there any way to predict or prevent this?
Here we find ourselves again with the question that keeps all IM practitioners awake at night:
A worthy question indeed. According to comprehensive reviews of this issue: there are still multiple candidates – one is the incidental histamine blocking that some SSRIs exhibit (could this flag someone low in histamine to start with??), while others still hold some suspicion over an old foe, elevated prolactin, that we can see in a minority of patients on these meds…easy to measure and confirm or refute, right? But always ask your patients first, How has your diet changed over this same period? How has your activity changed? You may of course find, you need look no further. People can give you the answer on a platter with things like, “I just relaxed a lot more: about what I ate and my weight”…Bingo! As always, the patient in front of you is their own little ultimate black-box…🧐
Leaving Anti-Depressants Behind
Never our call to make, but with 1 in 8 Australians at any time taking antidepressants, playing a supportive role for patients wishing to discontinue their antidepressant medication is common. So what do we know, about how to really do this well, what to expect and how to perhaps mitigate some of the bumps that might lie ahead. What in our artillery should we go in armed with either during the discontinuation or, better still, beforehand? This Update in Under 30 outline the key principles of patient prescriptions in this context and may assist patients, in their desire to truly leave the antidepressants behind.
If you are an Update in Under 30 Subscriber, this is a previously release episode and you will need to search for it to find this in your library of UU30’s that are in your online account.
Not an Update in Under 30 Subscriber? To access this episode and the entire library of Update in Under 30 audio’s and resources become a subscriber here.
Trends in mineral supplements are like music genres, you can pick which ‘decade’ they were formulated very quickly. But instead of going by clothes, hairstyles or even the style of accompanying music video, it’s all about the form – the ‘thing’ the mineral is bound to, that gives the game away. While mineral carbonates , sulphates and oxides seem to many of us contemporary clinicians, pre even MTV, amino acid chelates take me back to a time when I was wearing shoulder pads in everything, even my pyjamas. It was called power-dressing and needed to be adhered to 24/7, you see. Then along came fancy forms like orotates, aspartates, hydroxyapatites as we moved confidently into the 90s…well, as confidently as you can, when the Y2K bug may ‘end life as we know it’ come NYE. The dawn of the new millennium saw us embracing picolinates and bis-glycinates in a big way and for the last little while, citrates have really been having their time in the sun. But you know what…here’s a few things you MUST know…
- These are trends, not truths
- Every mineral has its Mrs Rights and Mrs Wrongs, in terms of chelates and ligands, and these are not the same from one mineral to the next e.g. Zn sulphate is a decent form of available Zn, Mg sulphate, an over-priced laxative
- In almost every case, there is simply NO strong consistent body of evidence that one form of a mineral is superior in terms of bioavailability, regardless of what companies tell you..go on I dare you…check their references and then do your own quick literature search away from the cherry picker
- Nor is there one mineral form that is above adverse effects in everyone
Brutal. Welcome back to ‘tough talkin’ Tuesday’ 😉 But we have to state these facts because we need effective supplements for our patients and not understanding the different forms that are better (but not ‘best’) compared with those that are inferior (this we do have some evidence of) threatens the integrity and efficacy of an otherwise well thought out prescription. So here’s where you might want to move into a room away from everyone and lock the door…because you’re likely to scream. One of, if not the most commonly used single nutrient supplement almost across the world, is calcium. After almost 30 years of studying supplemental forms side by side, can we conclude which form is best? No. How about ‘better’….hmmmmm yes…maybe…citrates look good going by some markers but not all and vice versa for other commonly seen forms. I can say this, because I have followed the research over the decades, reading the primary papers, like this excellent one by Bristow et al from 2015 that should burst quite a few people’s ‘best!’ bubbles. Have you screamed yet?
I scream. Often.
Because I am frustrated by the lack of research that we need, to be more certain of our preferred forms and then even more frustrated by companies’ claims that the evidence is already in, and guess what, theirs wins!
But it comes back to the same call to action for us – know your nutrients and specifically, where possible, get familiar with the Mrs Right and Wrong for each mineral! Know that the supplemental forms that work for zinc will not necessarily be a good match with iron, that any company that formulates their minerals in the vain of ‘one form for all’, be that glycinates, citrates, picolinates…well they’ve probably got a good fit for some of those minerals and a shocker for others. And as always truly check efficacy with follow up bloods, if you had baseline deficiencies evident in lab tests. I know, that’s not everyone’s model of practice right, or ideal but not always ‘real’, so alternatively, if you are prescribing based on clinical signs of mineral deficiencies that should respond quickly to repletion e.g. white spots on nails in the case of Zn deficiency, then ensure that they do!! If they don’t and your patient is compliant then consider switching form! When I see good practitioners’ prescriptions let down by poor choices of nutrient forms, well, that’s when I need to go into that separate room once more….can you hear me? Ooh that reminds me of something else dated by Mike and the Mechanics: Silent running “Can you hear me?!”😂
Let’s make sense of the over-arching nutrition principles, that will profoundly change your understanding and application of this modality Truly understanding the ‘big’ concepts, so often overlooked, or incorrectly taught, ensures you get the critical ‘small’ detail in your nutritional prescriptions right. In this 4 hour recording, together with key clinical tools, we talk about the tough stuff: dose-response curves, active versus passive stores and excretory pathways and ooh lah lah…the myth of taking ‘activated vitamins’. And yes we even mention Mrs Right/Wrong forms for minerals. Even those who feel satisfied with their original training – will find a lot in this critical review that is new, insightful and truly practise-changing!
Click here to gain immediate access to Mastering Micronutrients – 4 hours & clinical tools that will seriously change the way you work in Nutrition
Gotta love all the clever inquisitive minds among our integrative health practitioner community. I think each of us, as children may have been that one kid who just never stopped asking questions. What a great quality to have because it prompts us to think outside the box, then outside the triangle, then the hexagon and beyond! Simultaneously, busy minds that never stop questioning and never quiet down can also feel like a curse! None of us have the time to go find the answer independently to every single question that our patient, prescription & pathology encounters raise for us. We need to use the force. Our colleagues, our workmates, our informal and formal practitioner networks, our mentors, our associations, our educators etc. A lot of practitioners recently got some questions answered with the Update in Under 30: Separating the B12 from the B*S#!...and then guess what…they had some more B12 related questions 😂😂
Q: What might a normal or even high serum B12 together with low Active B12 combination flag in a patient?
A: Exclude COCP use, & gross liver pathology, refer for B12 antibodies if possible & review the case for other evidence of functional B12 deficiency, as TCII values are more specific and sensitive than serum
Q: What evidence do we have to use a higher cut-off value than the labs give us for Serum B12 (< 400 pmol/L), as a decision limit for follow-up investigation for B12 deficiency
A: Just the findings of some of the biggest studies on B12 assessment – correlating serum values and markers of functional deficiency such as Harrington et al 2017, Spence et al 2016, which flag that there is already metabolic impairment typically when serum values drop below 400, well before the classic features such as macrocytic anaemia
You’re welcome 🙂 It’s nice to be surrounded by like-minded curious kids (disguised in big people’s bodies!) I love playing my part in adding to the collective knowledge in different ways and for those of you who are our Update in Under 30 subscribers, and of course anyone that purchased this as a single download, well we’ve gone that extra step and put together a nice little pdf: A B 12 Assessment Decision Tree for you and added that in as a bonus to your Separating the B12 from the B*S#! episode. So go take a look now and hopefully that answers just a couple more questions and we can all have at least 1 good night’s sleep… before you come back with more 😉 🧐 😂
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.
And now a new one to boot!!
You can purchase Separating the B12 from the B*S#! here
If you are an Update in Under 30 Subscriber, you will find the new resource 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 conscientious early career practitioner digging deep into GS research and upskilling, recently sent me a message to ask if I knew that the correct pronunciation of the condition was ‘Zheelbairs’…as in..imagine you’re French and say the word through a pencil moustache and barely opened lips! My answer? ‘Yes (or should that be Oui Oui!), but I gave up pronouncing it correctly when I realised no one in my very Aussie audience could make the connection between my fickle French impersonation and the word G-I-L-B-E-R-T-S on the screen”… 😂😂😂
Ok I know many of you imagine I read nothing else but Gilbert’s Syndrome guff and that not a day would pass without those sweet words passing my lips! But you know what? That’s not completely true 😂 But my series of mentoring sessions yesterday did end on another happy note, with both the final case presented being a Gilbert’s one (overt oestrogen excess, likely bile stasis etc) and then stumbling across this paper that I hadn’t seen before a longitudinal study of 100 Egyptians with GS, tracking their bloods and health experiences. I know you also imagine that I have a direct line with God in terms of receiving Gilbert’s research the second it gets published…again not completely true 😂 and somehow I had missed this one!
It’s not the greatest research in terms of sample size and methodology but hey beggars can’t be choosers and when you’re a condition with whom the word BENIGN is so commonly associated…you’re always begging for something: attention, validation, research crumbs!
So the practitioner presenting this case, actually asked a great question…”do I put these patients on everything you’ve talked about as having potential efficacy in GS and set and forget?” The answer of course is no. But it is good to clarify. The bulk of the heavy therapeutic lifting is always the education of these patients – what choices they need to make and perhaps make differently to get the best out of their body. The non-negotiable for me, is the direct glucuronidation support which for me typically would be cruciferae based and then if needed glucomannan (I now use this as much as possible instead of Calcium D glucurate…missed the reason why?…check this out). The next treatment tier is dictated by how the GS principally presents for the patient in front of me: GIT – choose any additional treatments to work on this aspect of the disorder (motility agents, bile thinners, fat digestion support) or Psych: mitigating and managing the longer half life of both dopamine and oestrogen and the potential imbalances that ensue. Throwing the entire dispensary at these patients (like any other) is often unpopular…especially when we know this is not something ‘solvable’ so in fact we need to aim for sustainable instead.
But following this approach has brought so many of my patients long-lasting benefits and a far better experience of their health that they are super grateful for. Now that’s a happy note to end on 🙂
A Guide to Gilberts Package
It all started way back when with ‘Gilberts Girls’…then came ‘Gilberts Guts’ because that is such a common source of unexplained hard to define gut dysfunction in patients…then latest instalment was news from the research frontier in Gilbert’s Syndrome, which is nothing short of thrilling, rewriting our thoughts on what medications and supplements (!!) are the most problematic, significantly improved dietary management of these clients, how to track their progress more accurately and why completely normalising their bilirubin is not the goal…hey did someone say…longer telomeres?! 😉 Included are kickass desktop clinical reference that comes with this months UU30 that aids a better understanding and clear treatment directives in your GS patients. All of these are combined for the newcomers in this Guide to Gilbert’s Package
A Guide to Gilbert’s package is 3 Update in Under 30 episodes combined into one
– Gilbert’s Girls; Gilbert’s Guts and Gilbert’s – New Goals & Good News.
If you are already an UU30 Subscriber you will already have access to these episodes in your ‘active content of your online’ account. Or you can purchase this complete package here
Copper deficiency happens in kids, so does copper toxicity and both are serious concerns, but do we know when to accurately call either? First, we have to know ‘normal’. If we know what normal Serum Copper values look like in children, then we can easily spot those falling below or above this, right? That’s the first hurdle we tend to knock over and break a toe on! Being a mineral whose levels vary widely in soil from country to country, globally, the differences in reference ranges are breathtaking & absurd. Add to that, that copper is a key mineral in kids, driving huge demand for it during key periods of development, so the range for pre-schoolers isn’t the same as the primary or high schoolers – not that your lab is flagging that. Unhelpful? Yes. Dangerous, even? Potentially.
To diagnose ‘Copper Excess’ in a child is a big call to make.
One, because most practitioners are unaware just how much Copper a child really needs at each age & two, high copper is often a messenger for something else going on and then three, the primary objective based on this diagnosis becomes to lower their Copper but we could be either shooting the messenger or missing the mark all together…right?
Copper excess does happen but not nearly as often as practitioners believe it does. And in kids, the fall-out from such misdiagnosis is bigger. And missing a Copper deficiency? (because we’re not as well-trained to recognise it and because Copper has been sadly demonised) Likely to have myriad negative impacts at this vulnerable age…almost none of which generate symptoms or a distinct clinical picture e.g. secondary iron deficiency, low neutrophils without necessarily compromised immunity. But what about the holy grail get-out of jail adjective: ‘relative’. You know, ‘this is at least a Copper excess relative to their Zinc?’
Well, to form this opinion you’re likely calculating the Zn:Cu ratio and applying an ideal adult value of 1:1 but show me the primary evidence that supports this for kids…anywhere? The Zn & Cu relationship shifts as we move through life-stages and in fact Copper is supposed to dominate through a lot of our childhood so…ummmmm…no.
HTMA Copper side-steps all of this?..double no.
I used to make the same mistake re Zn:Cu, I may have even taught you this?!🤦♀️ But as so often happens, a week spent in all the original scientific data and I’ve emerged a changed practitioner! Having been part of perpetuating this problematic premise in the past, I am determined to get the correct message out there to as many practitioners as possible. So help me spread the word on Copper in Kids – by telling others that this mineral is so critical to kids compared with adults, they will often have higher levels than ‘us’ and that until you’ve applied the right age-appropriate reference range and ruled out confounders you can’t possibly make a call on Copper. I mean, we kind of knew this all along, with healthy pregnancy Copper values being exponentially higher being a giant clue. Turns out kids’ ‘Copper Age’ extends way beyond the womb.
Copper, as a kingpin in angiogenesis, brain & bone building & iron regulation is a critical mineral during paediatric development. So much so, the kind of blood levels we see in a primary schooler might cause alarm if we saw them in an adult. So too their Zn:Cu. But higher blood Copper and more Copper than Zinc are not just healthy but perhaps necessary during certain paediatric periods. This recording redefines normal, low and high with a great clinical desktop tool to help you better interpret these labs, as well as reviewing the top causes and consequences of both types of Copper imbalance in kids.
The latest Update in Under 30 has landed. You can purchase January’s episode, Copper in Kids here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
-Your RAN Online Account has a NEW LOOK!!-
Next time your log in, you will experience a more user friendly way to search, view, listen and download your resources. Find out what’s new here.
Our knowledge is subject to constant change, and it is oh so necessary to stay up to date in our field for a bazillion reasons, give or take a few 😉 So sometimes we can feel like we need eight arms (for the visual amongst us) to manage and keep up with it all. However, if we ‘use the force’ together we are stronger, learn faster and can stop with the whole ‘recreating the wheel thingo’ that so many practitioners find themselves doing out there in solo practice. Like, like…well, how confident do you feel about putting pen to paper? How good are you at your inter-professional communicating?
*Cue* the release of a brand spanking new version of our
“Dear Doctor – Upskilling in Referral Writing & Inter-Professional Communications”
Referrals and inter-professional communication are just lightly touched on in the current undergraduate degrees (if at all!). But it’s actually such an important way to grow your own professional reputation while simultaneously the credibility of our whole profession. One might even argue, a pillar that stabilises the castle of shared patient-centred care & the future of true integrative health. I hear from my “New Graduates” as well as seasoned mentees about the unease that starts to creep in at the thought of writing the dreaded referral letter. I’ve been writing referral letters for 20+ years and it’s given me a lot of time to think! And refine. And refine again! To make inter-professional care a positive experience for everyone, we need to correct some misperceptions and ensure that our patients are everyone’s priority. And to fulfil our duty of care, communicating with the other practitioners on your patient’s healthcare team is fundamental. Sometimes, as you’ll learn, it’s about modelling the best kind of shared care to boot and being the bigger person 😉
Better still, positive experiences of inter-professional communication will bring collaborators out of the woodwork. Medicos and other allied health professionals you may never have been aware of otherwise, with a desire and openness to shared care tend to rise to the surface.
To get you even more excited about referral letters (you didn’t think that was going to be possible, right?!) and unlearn that Pavlovian procrastination you may have developed, Rachel has completely redesigned an older presentation to ensure it’s truly reflective of the contemporary healthcare landscape (oh yes, RACGP position statement included!). Expect to roll up your sleeves and get seriously practical advice with loads of examples about how to medico-speak naturopathic concepts, explain your role in the patient’s care, provide rationale for consideration of investigations and present ‘red flags’ with punch but minus the sensationalism. And above all else, reveal yourself as the asset you really are to the rest of the healthcare team.
“Thank you so much for a wonderful presentation yesterday, Rachel. It gave me a new perspective on how it must feel as a GP to receive incessant demands from Naturopaths/Nutritionists to order pathology for their clients. I am in awe of your integrity, desire for patient empowerment, humility and respect for other professionals in the mainstream health arena. I felt that every single naturopath and nutritionist out in the big wide world ought to have listened to your insightful words of wisdom when it comes to shared care of our clients. We are blessed to have you as our teacher.” – Michelle Blum (Mentee 2019)
If you’re interested in integrative care, want to learn the language of letter writing and follow Rachel’s SMART objectives to craft your comms and communicate clearly then you should take a listen to “Dear Doctor – Upskilling in Referral Writing & Inter-Professional Communications”
If my dispensary was on an island and could only stock 3 items, S-adenosyl-methionine would make the cut. That’s how important this nutraceutical is to my practice and has proved itself to be to so many of my patients. Regularly, I cross paths with practitioners who declare similar favouritism and then there are many others who remain apprehensive and uninitiated in its use. Often this results from 7 myths and misunderstandings, such as…
No.1 Giving someone SAMe will impair their own synthesis of it
No.2 If it’s not ‘right’ for your patient it could go horribly wrong – the risks are big!
No. 3 SAMe will increase homocysteine in your patients & shouldn’t be used if the homocysteine is high, or high-normal, to begin with
Wrong. Wrong &, you guessed it, wrong. But many of us don’t believe anything till we see it with our own eyes. Like a mentee of mine who is a seasoned SAMe savant but, like us all, continues learning more all the time through her own prescribing experience. Case in point:
“Remember when we discussed my patient with stubborn high homocysteine, who has not responded to high dose methyl factors? You suggested a trial of SAMe because other things pointed to her being an under-methylator. You were right (standard!)- it came down from 9 to 5 with 2 months of 400mg/day SAMe. She’s also been able to stop other supplements she was using for her mood and overall is much more stable emotionally, so turned out to be the perfect solution. Thanks as always :)”
So exciting to bring SAMe, together with other important CAM options in mental health management, to the attention of an increasing number of psychiatrists and other health professionals of late. It easily makes my top 3, and the other 2 supplements in my island dispensary?…well if we’re still talking mental health, Zinc and N-acetyl-cysteine, due to their versatility, potency and accessibility regardless of income. But I think you could have guessed those & likely have shared confidence, right?
This 3hr recording & resource is overflowing with case studies and the latest research relating not only to psychiatric presentations but also as a key nutraceutical to consider in liver pathology, Gilbert’s syndrome and some pain presentations. Together with this ‘literature lowdown’ we clear up a lot of misunderstandings practitioners tend to have about its prescription – busting the 7 SAMe myths along the way and giving you the confidence to know when SAMe is likely to be the solution and exactly how to prescribe and what to expect.
I’d love to continue this conversation with you…
so join me and be part of my ongoing dialogue on this and my other blogs by following my Facebook page.
Ok here’s some tough Tuesday talk..not all tests are valid. Tougher still…not all of the mainstream nor the functional pathology ones. I am talking across the board here. Each and every pathology parameter requires good knowledge about its strengths. limitations and, one of my absolute favourite nemeses, confounders. “How on earth am I supposed to learn all that and everything else I have to know too?!!” I hear you scream at your screen. Btw keep yourself nice if you’re in public while you’re reading this 😉
But rather than imagining you need to have this level of knowledge for all tests, I would suggest you set yourself a hit list of the ones you rely on most, either in terms of frequency or in terms of the degree to which they direct your decisions about patient care…can I mention (ahem) Iron studies here perhaps for us all…but maybe you have a specialist area so you use a particular investigation routinely or at least frequently…
CDSAs? Breath tests for SIBO? Oxalates?
May I please then politely suggest that you get to know these inside and out? Not based purely on the information and assistance that the test provider provides you..but you scrutinise them independently. Top to bottom. Because that’s your business, right? And your diagnoses and treatment decisions are pivoting on these results. Jason Hawrelak gave us all some great examples, including his informal experiment of sending the same stool sample to multiple labs. Don’t know about this and his findings?? If you’re in the business of ordering stool tests, you need to. I am doing this all the time with numerous pathology markers because diagnostics is my passion (alright, obsession)…and recently I put Oxalate Assessment to the test and oh boy!
Here’s something for free:
If you are measuring urinary oxalates to diagnose oxalate overload in your patients and you, 1) are using a lab that does not preserve the urine as you collect it, using acidified containers or providing additional preservatives for take home testing kits….you are wasting your patients money and you are likely getting a lot of false positives, i.e. the result infers the patient has a problem when they don’t!!
And 2) if you are simply following the labs reference ranges for what ‘healthy’ urinary oxalates look like – you’re wasting your patients money again and likely getting false negatives – a failure to show a problem that is actually there! If you’re hunting oxalates…please ensure you have a current effective hunter’s licence…by getting up to speed fast regarding accurate investigation of this. Oh yes…it’s tough-talkin’-Tuesday and I’ve come out firing…watch out this may become a regular feature 🤷♀️
Update in Under 30: Oxalate Overload – Assessment and Management
Oxalates are present in many healthy foods and in all healthy people, but when ‘normal’ levels are exceeded they can spell trouble in a whole raft of different ways due to their extensive distribution across the body. Some tissues, however, have more problems than others, especially the urinary system and soft tissue and joints but now there are also questions about oxalates’ relationship with thyroid and breast issues. We review the latest evidence about the health consequences, blow the lid on accurate assessment for oxalate excess and talk management in this jam-packed update.
Horses not Zebras. You’ve no doubt heard me repeat that quote which is famous in medical schools, something to the effect of, “When you hear a heard of animals outside your door, think horses not zebras”…unless of course you are practising in Africa might I suggest 😉 This of course reminds us all in short to think of the most likely explanations not the most exotic first. Likewise with our case taking. The number of times I ask practitioners for the ‘boring basics’ and am met with an embarrassed silence. Think:
Body Mass Index
There I said it…and yet these are like dirty words in integrative health. Why? Because we’re starting to ignore the ‘boring basics’ in favour of getting ‘fancy first up’, as I like to call it. Look I love a good bit of bioelectrical impedence assessment as much as the next clinician and I am not about to use this crude measure as replacement for that but I absolutely need to have these key landmark pieces of information to understand a very long list of things such as contribution to future health risks, current burdens from literally the weight on those joints leading to knee pain, to the weight/mass not pulling on their bones and therefore contributing to lower BMD their whole life. Even their likelihood of a leaky gut today, right, Brad Leech, our colleague and impressive IP researcher? BMI drives also the appropriateness and their capacity for any exercise interventions I might recommend, not to mention the frequently mentioned, accurate interpretation of their labs.
For many many labs that we routinely see for our clients…the reference range should actually be a sliding scale that moves with BMI…what do we really ‘expect’ and what is actually ‘healthy’ is different at different weights.
Like TFTs – this may be a big newsflash for most but I never want to see a patient with a BMI > 30 have a TSH anywhere < 2, unless they’re on replacement.
Say wha? You heard me. I promise I’ll tell you more about that soon.
But again…let’s not get fancy first up especially not in any of our paediatric patients and in spite of what their words or ‘tude may be telling you, that includes all the way up to 18 in our books! Brace yourself, I’m going to speak that dirty word again…BMI..boring basics before all else. We need to review their height, weight and BMI against paediatric growth charts. These oldies are goldies and can reveal so much about growth trajectories, puberty milestones when any other discussion is off the table, type 2 nutritional imbalances (protein, zinc, potassium, magnesium, sulfur) and flag all other sorts of concerns or reassurance…and you haven’t had to steal a drop of blood or any much hard earned money off mum and dad to work a lot out. Anyway, that’s my ‘boring basic beef’ for now…there’s a lot to be said for ensuring such ‘dirty words’ come before everything else.
Need help with wrestling all the most important patient information into a clear management plan?
As integrative health practitioners, we pride ourselves on taking in the ‘whole health story’ as a means to accurately identifying all the contributors & connections to each patient’s presenting unwellness. In the process, we gather a wealth of information from each client – pathology, medical history, screening tests, diet diaries etc. that borders on information overload and often creates so much ‘noise’, we struggle to ‘hear’ what’s most important. The management of complex patient information and the application of a truly integrative approach, requires due diligence and the right tools. Mindmapping and Timelines are two key tools to help you go from vast quantities of information to a true integrated understanding of what is going on in the case and the more time we spend learning and applying these tools, the more they will write the prescription for you. Not just for today but for the next 6-12mo for that patient.
No you’re right, it’s not long enough to be a Hemsworth’s mobile number but actually it’s more sought after 😉 If you’re up to date with reading & recognising all the different patterns of Iron Studies & the stories they tell, which is a daily business for most of us, then you will know by heart the striking pattern we call, ‘Pseudo Iron Deficiency’. You know the one where your patient’s serum iron & transferrin saturation are mischievously trying to trick you into thinking you need to give this patient iron…when in fact this is absolutely not what they need!
This is of course the result of the redistribution of iron during inflammation – iron is actively removed from the blood and sequestered in the liver instead. It’s designed to protect us from bacterial bogeymen, which is how our stone-age bodies interpret all inflammation of course.
Doesn’t sound familiar? Ok you need to start here or even embrace a full overhaul of all things iron here.
But for those of you nodding so hard you’re at risk of doing yourself an injury, this number is for you. We’ve often talked about the redistributional increase in patients’ ferritin levels in non-specific terms: it goes up..but by how much? Of course we would like to know because no one is fooling us with this transiently inflated value…but can we make an estimation as to what this person’s ferritin will drop to once this inflammation is resolved? Yes.
Write it down. Consider a tattoo, perhaps?
This glorious magic number comes from Thurnham et al paper in 2010 who did the number crunching on over 30 studies involving almost 9,000 individuals to determine the mathematical relationship between inflammatory states & markers and the reciprocal increases in ferritin. Their work is exceptional in that it also differentiates between incubation (pre-symptoms), early and late coalescence periods (if you want to differentiate your patients in this way and get even more specific then you need to read the paper), however, overall when we see a patient who has a CRP ≥5 mg /dL , we can multiply their ferritin by 0.67 and get a lot closer to the truth of their iron stores. Oh and another important detail they revealed, this magnitude of ferritin increase is more likely seen in women or those with baseline (non-inflamed) values < 100 ug/L..so generally more applicable to women than men. Thanks Thurnham and colleagues and the lovely Cheryl, my previous intern who brought this paper to my attention…you just took the guessing out of this extremely common clinical scenario 🙂
We’re not deaf…we heard that stampede of Iron-Inundated Practitioners! The Iron Package is for you!
Our recordings and clinical resources for improving your skill-set in all things iron including, your accuracy of diagnosing deficiencies, pseudo-deficiencies & excesses, plus radically rethinking the best treatment approaches for each scenario…have been some of our most popular. Because nailing iron (pardon the pun) is harder than we were all lead to believe and at least 1 ‘iron maiden’ or ‘iron man’ walks into our practice every day, right? So we’ve brought together 5 extremely popular UU30’s on Iron into one bundle for the price of 4! So if you’re more than ready to graduate from ‘iron school’, now’s your best chance!
Those ‘still-believers’ look away now. One of the great myths, misconceptions and misunderstandings in nutritional medicine is that supplementation with specific nutrients will produce change specifically in one system, or pathway, which just happens to be the one that the practitioner has determined would benefit most/is targeting. Let me explain myself a bit better. When we give patients any nutrient, in the cases where it’s not simply to correct a global deficiency & therefore improve levels all round, it’s typically on the basis of a specific desirable therapeutic benefit, e.g. some magnesium to help their GABA production…, additional B3 would improve their mitochondria. Beautiful on paper…but like sending a letter to Santa in reality (I did warn you!)
Truth Bomb No.1: There are nutrient distribution pecking orders that have nothing to do with who you ‘addressed’ it to
This dictates that when something is given orally, for most nutrients, the gut itself has first dibs. So the cells of your digestive tract meet their needs before any other part of your body gets a look in. Sometimes the digestive system’s needs can be quite substantial and leave little for any other part of the body…not mentioning any names (ahem) Glutamine!
Truth Bomb No.2: En route to the ‘target’, these nutrients get delivered and distributed to many other tissues – with possibly not so desirable or intended effects!
You may determine that a patient needs iron because their ferritin hasn’t got a pulse…so you keep giving them daily high dose oral iron to ‘fix’ this…not realising you’re making their GIT dysbiosis and gut inflammation worse in the process. Or you feel their mysterious ‘methylation cycle’, happening predominantly in the liver and kidneys, could do with a folate delivery…perhaps ignoring the very worrying fact that their colon may have already had a ‘gut full’. Literally. Hence the concerns and caution against supplementing with folate in patients with established colorectal cancer. So is bypassing the gut via IM or IV nutrients the answer…well yes and no…but mostly no. Read on…
Truth Bomb No.3: Those pathways that use the nutrient you’re supplementing, that are most active in the patient’s body currently – which is determined by many factors (genes, physiology, feedback circuits, pathophysiology) and rarely simply by the availability of nutrients – will take take the next lion’s share of that nutrient
Wanting to nutritionally support someone’s thyroid, you know tyrosine is the backbone of the thyroid hormones, so you include this in the hypothyroid prescription. Will it help? Who knows? Being a non-essential amino acid the body exhibits very complex regulation of its distribution and use – with thyroid precursor availability being only one job on a very long list! And if this was in a patient who is regularly smoking cannabis, due to upregulation of the tyrosine hydroxylase enzyme – there is likely to be more of the supplement headed for even more dopamine production and very little or none reaching in fact your intended target. And don’t get me (re)started on Glutamine – supplements of which in an anxious and glutamate dominated patient will make…G.L.U.T.A.M.A.T.E…right…not GABA! 🙁
Sorry, I know, it hurts right? But these are essential teachings, that tend to have been over-looked or under-played I find, in nutrition education, regardless of training: nutritionists, naturopaths, IM doctors, dual qualification practitioners remedial therapists. Nutritional medicine is a wonderful and potent modality when it’s done well…but we need to revisit some core truths and principles that many of us have missed out on, to ensure we’re not writing letters to Santa.
Want to revisit your core nutritional knowledge which will cover this and much much more?
Let’s start with Micronutrients. Let’s talk make sense of the over-arching nutrition principles, that will profoundly change your understanding and application of this modality Truly understanding the ‘big’ concepts, so often overlooked, or incorrectly taught, ensures you get the critical ‘small’ detail in your nutritional prescriptions right. In this 4 hour recording, together with key clinical tools, we talk about the tough stuff: dose-response curves, active versus passive stores and excretory pathways and ooh lah lah…the myth of taking ‘activated vitamins’. Even those who felt well trained – will find a lot in this critical review that is new, insightful and truly practise-changing!
As health professionals who take the time & have the incredible attention to detail to capture the ‘whole health story’ of each patient, we can end up with vast amounts of information for every client: detailed medical histories, broad systems-reviews, condition specific validated screening surveys, in-house physical assessment data, not to mention a pile of past pathology results…and that’s before we start our own investigative path! Does it sometimes feel like TMI? I see many really knowledgeable practitioners become overwhelmed right there They know they needed to know it all but now they’re struggling to hear the critical storyline above the ‘noise’, see the wood for the trees or [insert another metaphor that works better for you] 😉 What tends to happen next, though we might not realise it at the time, is we abandon systems-based thinking, because it is so challenging, and start treating superficially or symptomatically: ok well for now, I’ll just give them something for their hayfever and something else for these loose stools and then a good sleep mix for that insomnia and maybe with a bit of time I can work out the real underpinning cause and start addressing that. Just like we never wanted or intended to do!
Conventional medicine is intellectually complex but it is a lot simpler in many regards than holistic medicine.
Disease = medication. Another disease = another medication.
Versus the dogged determination of the systems-based practitioner – constantly asking ourselves: Why this person? Why now? What’s underneath it all? How do these elements connect?
Two key objectives for integrative health practitioners are 1) getting to the root cause and 2) least medicine is best medicine…these are inextricably linked, but with such voluminous information & a lot of ‘noise’ that can be very distracting, how do we stay on track with the work-up of each patient, to remain true to these principles and genuinely integrated? What tools and resources were you trained in to make clarity out of chaos? To sift the wheat from the chaff or [insert another metaphor that works better for you] 😉 And do these actually work for you in your real clinic with your (very) real patients? This is, after all, no longer about creating formulation diagrams or schematics because that’s the what worked for your clinical supervisor. This is about whether your systems for case analysis meet 3 critical criterion:
- they save you time – too many practitioners’ attempts at case analysis consist of writing out the entire case again….just more neatly…with dot points…and maybe 5 less words
- they reveal the connectedness of the seemingly separate elements & force your knowledge forward by asking you, ‘but how?’
- they write the patient prescription for you – not just the initial one, but typically, those for the next 12mo of this patient’s care
I do a lot of mentoring and it’s wonderful to help so many practitioners by sharing my integrated work up of their patient cases…but I employ just 2 secret weapons that are actually not so secret: timelines and MindMaps. Without them, I would be lost too. I’ve been thinking for a long time about how best to share these 2 not-secret-at -all-weapons…and finally my lovely shiny new grad mentees inspired me to come up with this….and boy didn’t it get us all thinking, talking, thinking some more….and most importantly…converting client chaos to clarity – here’s what others had to say:
“I really love the cases and listening and seeing how you interpret complicated presentations and methodically break them down in a way that digs down to the core/genesis of the issues. It helps me to provide more laser focus to my own complicated cases with your guidance.. Love the mind maps!”
“I loved this session and think its very relevant. I have used these tools before, but never mastered them or used them regularly. I have mostly used mind maps for study, so I love this application and with practice, think I will get used to using them for every case.”
“Most difficult is challenging existing patterns of thinking around mindmaps and training my brain to approach it more effectively (plus getting faster). This will come with practice. Most satisfying is seeing how useful they can be when done well at the start in terms of time saving in the overall case (across years) and getting to the core (s) of the case. Great session!”
As integrative health practitioners, we pride ourselves on taking in the ‘whole health story’ as a means to accurately identifying all the contributors & connections to each patient’s presenting unwellness. In the process, we gather a wealth of information from each client – pathology, medical history, screening tests, diet diaries etc. that borders on information overload and often creates so much ‘noise’, we struggle to ‘hear’ what’s most important. The management of complex patient information and the application of a truly integrated approach, requires due diligence and the right tools. This recording and associated resources will teach you to effectively perform a case work-up that does justice to the holistic framework and model & at the end of the first part, there is a practice run for you to create a MindMap and Timeline. Then part 2 takes you step by step through the same example, showing you how to build a really effective MindMap and then how to read it to show you the path of management! PDF sample case notes, MindMap and a Timeline template are included.
When I was studying my under-graduate I imagined my clinic was going to be full of them: well patients wanting to maintain or even improve upon their wellness. Turns out…not so much…all the really really sick people have taken their spots and the former has been listed as an endangered species. But I do catch glimpses of them, as I am sure we all do, in their natural habitat, with over-flowing baskets at the organic grocery store or farmer’s market, routinely up the front of the pilates class and also sometimes in our clinics. So now that naturopathy, by consumer demand, not practitioner intent, has transitioned so much into the ‘unwellness space’, do we know anymore what to do with the well ones??
I heard some great talks at the NHAA conference recently. One, in particular, was by my stellar colleague, Liza Oates, who observed that contemporary naturopaths tend to respond to these clients in 1 of 2 ways:
a) Unaccustomed to a patient who eats, exercises, sleeps and balances their work & non-work worlds better than themselves…PANIC…
b) Dig deep back through the dusty archives of their personal & family medical history until they FIND A PROBLEM THEY CAN TREAT!!! such as, ‘Once I was constipated for a couple of days’ or, ‘Once I took a course of antibiotics’.
I know…we’re hilarious…we have to laugh at ourselves 😉 Liza offered up some great ideas about how to approach our consults with these patients. Many of her tips, however, could be applied to the rest of our patients as well to gather some really valuable insights. And it’s always great to hear from someone who has been seeing patients over decades…there’s so much to be gained from those who’ve gone before us (or alongside us…in my case!) and can speak to these firsthand lessons. Here are just a few of her pearls
The ‘not stressed’ patient
We encounter a lot of people who can misreport their stress levels, not because they are trying to lead us astray but that’s that slippery slope of self-reporting & the possibility that someone has normalised their ‘load’. Liza says she likes to step away from that potential trigger word, ‘stress’ and instead ask, ” What are your tell-tale signs when the demands exceed your capacity?”
This is not so that we can fulfil option b) mentioned at the beginning…digging desperately to find some unwellness to treat – but rather as an aid for both practitioner and patient alike to understand better that individual’s response to their psychosocial environment.
Ask them to design their own health retreat
If they reply, “I would start every day with a little meditation and yoga, a chai and then a healthy hot meal”, then these can be translated into little goals we can set to bring some of their ‘best self ‘ into their every day. It also helps to better understand their values, individualised self-soothing and self-care & great prescriptions to begin with, given they’re telling you they are already at contemplation in terms of their readiness for behavioural change. They’re not going to require too much convincing – they’re already converts they just need permission and support to implement.
And if you’re sitting there reading this and thinking, ‘Hey! These are exactly the patients I want my clinic full of”…then to hear more of Liza & Greg Connolly’s commentary and insights about how the wellness space has been hijacked by others and how naturopathy needs to move centre-stage in this increasingly popular trend, take a listen to this interview they recorded at the conference.
Want to Improve Your Patients’ Compliance?
This UU30 recording from our back catalogue on the behavioural change model and how it impacts patients’ response to our advice is a key element in developing a professional approach that actually works. Unless practitioners are aware of the way that patients approach changing their dietary behaviour or exercise regimes, they the mystery of non-compliance will never be solved!
Oh no, it’s her again 🙁 I mean the chick in the photostock image not the other ‘her’, me. I know. It’s the end of another mammoth year, you’re tired, worn out, used-up all your brain-power quota (a little projection?) and I can hear you begging for mercy when I start a sentence with…”So you think you know….” followed by, “blah blah blah Iron,” but hear me out.
Correctly identifying & managing iron issues is a bread & butter part of our business, right?
With Iron deficiency affecting an estimated 1 in 5 women and Iron excess almost another 1 in 5 – patients with one form of iron imbalance or another tend to be over-represented in waiting rooms.
Anyone can spot overt iron deficiency anaemia or full-blown haemochromatosis but many health professionals find the ‘in-betweens’ confusing and fail to recognise some key patterns we see over and over again, that spell out clearly your patient’s current relationship-status with this essential mineral. This often results in giving iron when it wasn’t needed and missing it when it was. If you’re imagining someone else, i.e. the person who ordered the Iron Studies for your patient, will step in and accurately interpret the more curly results can I just say D-O-N’-T...they’re often as perplexed or even more so than you. After starting this conversation a year ago with So you think you know how to Treat Iron Deficiency, & its baby sister, So you think know the best Iron Supplements, our (imaginary) switchboard went crazy. While practitioners got the message loud and clear about how to improve the likelihood of treatment success in iron deficient patients, hot on the heels of this came email, after fax, after carrier pigeon, with examples of patients’ Iron Studies, the ‘somewhere in between ones’, accompanied by the equivalent of a dog head tilt…aka ‘I don’t get it’.
And this is to be expected.
What were you taught about reading Iron Studies? Was it made out to be all about ferritin? And TSH is a solid stand-alone marker of thyroid health, right? 😉
Were you introduced to the other essential parameters included in Iron Studies, explained how they contribute to your diagnosis and reveal important details about the patient’s ability to regulate this mineral or not? About when to dose and when to hold your fire?
Nah…I didn’t think so. But it’s up to us, people, to hone our skills in Iron Study interpretation…because individualised nutrition is our ‘thang’ and more than any other nutritional assessment, this collection of markers, actually allows us to go beyond the ‘one size fits all’ model…everyone must have X of this and Z of that in their blood tests…and see each patient’s actual individualised need and relationship with this mineral. In the latest Update in Under 30, I introduce you to 3 key players in iron assessment and the insights each offers become so clear, you’ll be able to read any combination or permutation of iron results that walk through your door. To boot, I’ve included a wizz-bang cheat-sheet of those iron patterns that are frequently seen and rarely recognised, including one totally novel one that I’ve never talked about before…to make your job even easier and put you well and truly ahead of the pack in understanding iron nutrition. It’s Christmas…and as the mantra goes…we can always fit just a little more in at Christmas time, right? 😉
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.
Hear all about it by listening by my latest Update in Under 30: So You Think You Know How To Read Iron Studies? 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.