Integrative Psychiatry is an inspiring area to work in & its evidence base, acceptance and recognition of potency is rapidly growing & offering more patients, more.  Going beyond the ‘neurotransmitter imbalance model’ for each presenting diagnosis helps us to see the unique mix of biological & psychological drivers in each individual who presents seeking our help. However sometimes  I believe, we find ourselves falling into looking through the lens of just another short-list of alternate models: What kind of methylation imbalance does this person have?  What sort of Zn, Cu issues?  

While I am so grateful for having learned these tools and watched them be very successful in a portion of my mental health clients, they are simply not the answer for everyone.  We need to keep our thinking and practices dynamic and up to date, to reflect the incredible increase in research in new areas of integrative psychiatry, such that more of our patients can benefit and that we can continue to think beyond the box…even if that box itself was originally so progressive!

What do you know, for example, about abnormal purine metabolism in mania and using serum urate as a BPAD prognostic marker in depressed patients?  Think you can simply be guided by the reference range provided, think again. What could good old LFTs reveal about our patient’s mental health vulnerabilities and what have we potentially misunderstood about copper in this area, particularly in children?

I appreciate Zinc’s role in mental health as much as the next integrative practitioner. Okay, given my 20K word thesis manifesto, more.  But increasingly I am seeing mental health patients who need treatment with different tools.  This upcoming ACNEM Mental Health Module in Perth is on point: thinking outside of, outside the box!

While the above only speaks to what I’m presenting, I know Dr. Sanjeev Sharma will also be sharing his wealth of individualised management insights and he’s a big fan of addressing Chronic MIld Metabolic Acidosis as an early treatment objective. Maybe we all need to hear why? And I am so looking forward to getting a PTSD update from Christabelle and hear all about the research into therapeutic keto-diets in psychiatry from Cliff Harvey…haven’t read all those papers to know which conditions and when this approach shows merit?  No, most of us haven’t. That’s the point of outsourcing our up-skilling to colleagues who we know are across these more than us and to boot have the clinical experience to ‘make real the research’.  As I’ve said before, given the content of this upcoming ACNEM Mental Health program, I wish I wasn’t presenting really, so I could just kick back and take it all in, uninterrupted.  But alas, I have some important new information on reading basic bloods through a mental health lens to share!  I really hope to see you all there.  Let’s get out of the rut of 3-4 nutritional approaches to mental health and make the most of the explosion of research and shared clinical experience.

ACNEM Face-to-Face Training
Fremantle, 27-28 July 2019 at the Esplanade Hotel Fremantle by Rydges
https://www.acnem.org/events/training

Oh and while you’re here…did you know the research into both beta-casomorphins and IgG casein reactions in relation to certain mental health diagnoses has taken some giant steps forward in the last couple of years?  You should.  Milk Madness is back and it’s via two distinct mechanisms – identifying which might be at play in your patients & correct management is now clearer than before.  Want to get up to date in this area of mental health – check out our UU30 recordings: Milk Madness part 1 & part 2

 

 

 

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.

X 0.67

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!

 

 

 

 

In July I go west again (seriously any excuse…love the place!) and fly over to Perth for the ACNEM Foundations (formerly known as Primary Modules) training course that ACNEM have been rolling out this year around the country. If you haven’t seen it already I’m presenting my hot favourite talk on Micronutrients.  But wait….. there’s more… in the Mental Health module that runs concurrently with this, I’m presenting my newly developed: Mental Health in General Practice: The Hidden Clues in Pathology. Which delves into reading regular blood work through a ‘mental health lens’.  Fancy, expensive testing need not apply 😉

The highly-regarded psychiatrist, Dr. Sanjeev Sharma, is presenting on Addiction as well as a case study on schizophrenia, Dr. Christabelle Yeoh will speak to better PTSD management, our lovely naturopathic colleague, Susan Hunter will talk on the relationship between diet and paediatric mental health, Cliff Harvey on keto-appropriate diets in this context…and many more. 

To be honest, I’d like to not be presenting so I can just sit back & listen to this entire mental health program uninterrupted!! 

In terms of ACNEM Foundations, I am really pleased to be one of the presenter/practitioners to help ACNEM deliver their new offering, with a renewed focus on delivering independent, unbiased and high quality training. The modules being offered over the training period are the Foundations (formally Primary Modules) of Nutritional and Environmental Medicine (2 days), Metal Health (2 days) and Sports Medicine (1 day). Here’s a little bit more detail about the training…

PRIMARY MODULE

The Primary Modules in NEM, designed for GPs, registrars and other graduate healthcare professional, are ACNEM’s foundational training in post graduate Nutritional and Environmental Medicine. The modules will be delivered over 2 days face-to-face, plus equivalent of 2 days online (4 months online access) to view the lectures and to complete the required learning activities.

These modules provide an introduction and overview of NEM within primary care. Each major biological system is explored covering the key nutritional, environmental and biochemical factors affecting health and disease. Through case studies delegates will gain practical tools to aid integration into daily practice. The Primary Modules enable practitioners to begin practising NEM confidently and safely.

To enhance your education and reinforce what you have learned, completion of each module requires pre-disposing and reflective activities and an online quiz.

MENTAL HEALTH MODULE

This module will address a number of the most common functional mental health conditions that present to clinic.

Conditions to be covered include depression, anxiety and addiction. Our highly regarded presenters will bring their clinical experience and knowledge on the application of nutritional and environmental medicine in collaboration with conventional medical practice. Current scientific evidence for the effectiveness of treatment modalities will be presented including nutraceutical prescription, dietary manipulation, lifestyle modification and environmental factors, alongside the range of available testing and investigation options.

Our speakers will explore:
– The contributing NEM factors to common mental health conditions including depression and anxiety
– The investigative methods for assessing mental health from a NEM perspective
– The role of specific dietary and environmental approaches for the management of anxiety
– Evidence-based lifestyle interventions that can assist in the management of addictions
– Nutritional treatment and management of mild-to-moderate depression

When you get clinicians with extensive real-world experience talking about the things they know best, not just academically but also clinically…then you’re in for a very practical & clinically impacting learning opportunity.

ACNEM Face-to-Face Training
Fremantle, 27-28 July 2019 at the Esplanade Hotel Fremantle by Rydges
https://www.acnem.org/events/training

 

I’m calling this one early. The presentation with the most dramatic rise in incidence this year is women aged 20-50 with ‘atypical’ joint pain.  Probably good I don’t have a betting account, hey, but in all seriousness I am struck by the increasing familiarity of this story: previously well woman, develops significant joint pain picture, sees rheumatologist who says; ‘don’t know’, ‘not bad enough yet to call it’, or ‘could be fibro?!’ But if we listen closely to these patients, we will typically hear another symptom story running parallel: ‘my gut isn’t right’.  Often vague in nature with all the usual non-specific features: bloating, self-reported food reactions, changeable stools and has frequently had thrown at it the IBS label…but is it?  Or are we staring in the face of the key to these women’s musculoskeletal woes?

At it’s simplest, systemic inflammation (including joints) opens the tight junctions in the gut.  Consequently we know these women suffer from increased intestinal permeability – but could the relationship between their gut and their joints be more sinister than this, with GIT abnormalities not purely as a consequence but actually as a cause of their chronic, for may patients life-long, disease?

Ah yes, the elusive ‘environmental trigger’ ingredient in everyone’s (not so) favorite autoimmune recipe. Patients who have drawn the short straw genetically (family Hx of rheumatoid arthritis or the HLA B27 antigen) may never develop the joint diseases that this makes them susceptible to…if only their ‘environment’ hadn’t pulled the trigger. Now the possible ‘environmental offenders’ make up a long list of candidates, from smoking to vitamin D deficiency, infection and trauma but what are the chances and where is the evidence at, regarding very specific bacterial culprits?  And is it possible, that the identification of these in action in your patients doesn’t just have historical value, ‘ok…this was the wrong turn your gut took back there that lead you down this awful alley of ailments’, but rather equips us in the here and now to target our treatment and improve patient outcomes today? You know the answer is yes, right?

Whether we’re talking about Rheumatoid arthritis (both seropositive and negative) or Ankylosing Spondylitis or Reactive Arthritis…or…or…or… this woman’s gut may have a huge case to answer! But do your current lines of investigation, lead you to the pathogens and processes that the scientific community are all pointing at?

There are many reasons why these women are falling through the cracks in mainstream medicine in spite of the growing body of evidence (molecular, animal, human, in vitro, in vivo, dietary intervention studies) that at the very least, leaves us in no doubt about the reciprocity of inflammation & disruption in the two systems of many of these patients.   Want to read some great articles on this to bring you up to speed?  Start with Rashid et al 2013 and Lerner & Mathias 2015Want to hear my summary of these and about a dozen key others on this topic, gently mixed with some real world spotting tips from clinical experience?…then check out the latest Update in Under 30: Getting to the Guts of Women with Joint Pain.

There’s a significant increase in the number of women in their 20s to 50s presenting with ‘atypical’ joint pain, that seems hard for specialists to diagnose and therefore, hard for any of us to know how best to treat. If we listen closely to these patients, however, they are often telling us that their, ‘gut isn’t right’. It doesn’t tend to grab so much attention but maybe it should! We examine 3 ‘atypical’ arthropathies that can have GIT symptoms and arguably may represent a key driver of their joint pain. The different clinical pictures & targeted investigations for these big 3 together with some key papers are covered in this audio.
Hear all about it by listening to my latest Update in Under 30: 
Getting to the Guts of Women with Joint Pain
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.

 

I’ve been asked to speak at the Mental Health, Medicinal Cannabis & Other Nutritional Medicine Conference, on the 20th July in Melbourne, organised by the Global Health Initiative for all health professionals primarily wanting to learn more about this therapy, not just for pain but also psychiatric presentations. Now I reckon a lot of people might have thought this was right up my alley considering I live in the Byron Shire and in such close proximity to Nimbin, but I’ve some news for you, on the recreational side, I’m not a fan!  And I have seen firsthand the unfortunate fallout on people’s mental health.  But I am seriously keen to get up to date about this emerging area, from experts in this field. I’m like the moth to the mental health flame – anything that offers some hope – I’m keen to get close-up.

This one day conference explores the evidence base for using medicinal cannabis in treating a variety of mental health & neurological conditions such as PTSD, depression, Alzheimer’s and more, plus a review of the endocannabinoid system, the delivery methods, pharmacokinetics/dynamics & safety of various forms. All the while, not losing sight of its potential for harm via precipitation of psychosis in the vulnerable.

It sounds like a fascinating examination of the inherent complexity and contradictions of Cannabis. 

I’m hooked already!  Not on cannabis people – but rather, on this topic in terms of the likelihood of it teaching me much that is new and challenges my assumptions.  And what, I hear you ask, is my contribution? Relax, the sativa side of this story is being presented by an impressive list of experts such as Dr Sue Sisley MD, US medicinal cannabis expert,  Prof. Nick Lintzeris, Dr Genevieve Steiner PhD (NICM), Justin Sinclair and GPs with firsthand experience of prescribing for these presentations.  I am in my sweet spot, talking about the role for nutritional medicine in Mental Health management…and I’ve put together a super strength strain just for this conference.

I’m really looking forward to listening to these international speakers and learning myself so I can share this new information in my future blogs & resources with you… Like some other cannabis products, it’s good to pass it around 😉

If you’d like to know more about what is being offered at this conference visit www.globalhealthinitiative.life

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!

I’ve had a bit of ‘a bee in my bonnet’ this year. I heard that! Ok, arguably it extends a little further back…like my whole career! But if you’ve seen the topics I’ve been speaking on at conferences in recent months, you’ll know exactly the soapbox I’ve climbed up onto.  Inter-professional communication & collaboration. My particular focus (naturally 😉 ) has been current issues regarding the sharing of, and access to, pathology results for our shared-care patients. However, in the face of several distinct threats to the practise of both naturopathy and medicine in Australia of late, especially in the form of anti-collaborative rhetoric/push affecting both professions right now (read PHI reforms, promptly followed by proposed MBA review..if you haven’t read this regressive and repressive set of recommendations you seriously must), the question of how to improve collaboration in order to ultimately serve our patients better, has never been more urgent.

Last week, at the ICCMR conference, I outlined the current barriers for naturopaths to accessing patients’ pathology results (current and historical) and the heightened risks that this results in, either because of incomplete information or because of the subsequent direct pathology referring by naturopaths. Yes, bypassing the GP and another set of trained eyes on your patients labs comes with risks. I also spoke to the opportunities that await us if we can overcome this: in terms of improved patient outcomes, reduced risk, more economically responsible public health budget spending etc. etc. need I go on?!  In the Q & A following my presentation,  a doctor in the audience made two very important contributions, which deserve some additional air…she said:

“Shouldn’t the patient ultimately own their own pathology results?  Then it would be a case of them electing who has access to these: their GP, their naturopath, their osteopath. Rather than the other way around – after all, we are all supposed to be members of their health care team, right?”

She said it.  Not me. But I applaud her. She’s right of course. Right now, under the current proposed changes, we and integrative health care delivery and patients’ right to choose and self-direct their healthcare and public health budgetary burden…are all under threat of de-evolving. Right at the time when, with the current chronic disease burden and predicted public health budget blowouts,  it should be all hands to the pump!  Who has ever conducted a cost-benefit analysis of what integrative health care (successful patient sharing between naturopaths and GPs /specialists) saves the government?  No one is my guess and when I proposed I do exactly this for my PhD on a particular parameter some years back, I was not so subtly told, that in spite of a great application, given the primary funding of the research group was from government, and a clear conflict of interest with the head researcher who was also a government advisor, ” my proposal was not in line with the current directives”.  Yep.

Last week, a dear mentee of mine mentioned that a GP one of her patients sees responded to her respectful correspondence regarding their shared patient with absolute terror, citing possible de-registration if they are seen to be collaborating or interacting with her in any way…assuming the MBA changes go through.  This doctor then decided the lesser risk, was to cease communication with this other key member of the patient’s health care team, not refer the patient for any follow up investigations (including those representative of basic duty of care) and certainly not enable access to any pathology results for this patient from the past or in the future.  My mentee’s exemplary response to this doctor:

“My apologies for placing you in an uncomfortable position. I do understand the restrictions and guidelines GPs must work within for Medicare and AHPRA and understand that as you are the requesting practitioner you are liable for any pathology referred for.  I make this clear to all my patients and that my referrals are on a request base only and it is up to yourself or the requesting GP for the final decision. I only try and request pathology through a GP or other medical practitioner to try and minimise both risks (of only myself viewing these labs) and unnecessary costs to the patient.

…’X’  has currently been seeking medical and alternative treatment for over 2 years and yet has had no change, if not a worsening of his condition and when I saw them 2 weeks ago, it was my understanding that not even basic assessment of full blood count, liver function and other general health markers had been completed. I had advised X that not all pathology may be covered under Medicare, and to come back to me so I could send him privately for those tests not able to be completed under Medicare. My apologies this was not made clear to you at the time of his appointment.

I take pride in my evidence-based approach to nutritional health in my practice, and work frequently with other patients’ medical practitioners in supporting their health. Thank you for your time and I appreciate your thoughts on this matter”

If the patients’ best interests are no longer the primary goal, as decided by bureaucrats, both government and organisational, is it time to ask the actual health professionals to please stand up?! Is it tipi-talk time for practitioners from all disciplines?  Growl over.

Want to ensure you are writing professionally to other health care practitioners?  Then our recording and resource Dear Doctor, is for you!

In this 45min podcast Rachel succinctly covers the serious Do’s and Don’ts for your professional letter writing. Rachel gives step-by-step instructions and examples for key phrasing and clear medical justifications, what terms to use when in order to come across respectfully, and how to present urgent red flags without sensationalising. This podcast is will  help your professional letters improve collaboration for you and your patients need.

 

 

 

What makes integrative health professionals stand out is that we take the time and have the attention to detail to capture the ‘whole health story’ of each patient.  As a result, however, we  tend to 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!

So as you sit at your desk with a plethora of information in front of you, you’re probably thinking, ‘Great, so much valuable information – Oh dear…so much valuable information!’ and struggling to separate the critical narrative from the noise. 

Plagued by circular questions:  ‘Where do I start?’, ‘What needs to come first?’, ‘Which treatment objectives will pack the most punch for this patient right now?’, ‘What really requires further investigation and what can wait?’  … your thoughts jump around, from one shiny thing to the next…you can ‘see’ so many of the connections… but can you see them all, the whole interconnectedness, and therefore the prescription, laid out in front of you like a road map to follow?

Introducing the two essential tools (aka secret weapons)…

MindMapping & Timelines

… the actual practice of gathering vast amount of a patients case onto one piece of paper.
Yes, that’s what I said ONE PIECE of paper!

Sounds too good to be true?? Well, they don’t quite give you super powers but they will help you write the patient prescription for you and not just one prescription but typically, for the next 12 months.  These tools can turn good clinicians into great ones and, once you master them, save enormous amount of your time on your patient work-ups.  Relevant to all health professionals who use an integrated approach, the utilisation of these tools, will also reveal to you much about what you know, but didn’t immediately realise (e.g. the means by which gut dysbiosis contributes to impaired oestrogen detoxification), and just as importantly, highlight your knowledge gaps & therefore opportunities for further growth along the way (e.g. how do inflamed joints disrupt GIT tight junctions?).

As ‘whole picture people’ we bite off a lot!  It’s these systems, timelines and MindMapping, that Rachel has found help her, and so many other clinicians, truly ‘digest’ the case, optimising our understanding and management.

“I loved this session and think it’s 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.”

“AMAZING!!! Fantastic health links that I did not know and really consolidated my knowledge on how to produce a Mindmap and how to be better at it! Fabulous session. Thank you”

“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!”

MindMaps & Timelines – Effective Integrated Patient Work-Up

In the Part 1 Video, Rachel teaches you how to effectively perform a case work-up that does justice to the holistic framework and model. At the end of this presentation there is a practice run for you to create a MindMap and Timeline. PDF sample case notes, MindMap and timelines are included.

In the Part 2 Video, Rachel demonstrates in detail how to put a MindMap together from case notes. You’ll be able to see ‘in action’ how to apply all the information from Video 1 and have all your questions answered. PDF’s of both slideshows are included.

and watch this presentation now in your online account.

 

 

Do you know that saying, ‘mind your Ps and Qs?’  It basically means mind your manners and I heard that a lot as a kid 😉 But what we really need to hear now, as practitioners and promoters of healthy eating and wellness is really, Mind your P’s and P’s because a lot of biggest health consequences of any diet are determined by the balance or imbalance of two major players; protein and potassium. We’re always looking for simpler ways to enable patients and ourselves to  be able to both recognise the strengths and weaknesses of their diets and, better still, apply a simple method to making better choices moving forward.  Eyeballing the protein and potassium rich sources in any diet speaks volumes about other essential dietary characteristics and the likely impact of diet on health – and getting the relationship between these two right should be a goal for us all.

“World Health Organization (WHO) Dietary Targets for Sodium and Potassium are Unrealistic”, reads the recent headline from yet another study finding that humans would rather challenge the solid science of  human potassium requirements than acknowledge the urgent need to turn this ship of fools around!

This large study, conducted over 18 countries, involving over 100 thousand individuals, reported that 0.002% met these targets.  That’s 1 person in 50,000.  Now, the researchers’ response to this is that we should lower our dietary potassium expectations….such that the targets are more achievable and so that (frankly) we are less perpetually disappointed in ourselves and our terrible food choices. Wha???? Back up there. The WHO guidelines, just like any other nutrition authority, derived these minimum amounts from a thorough review of the science that speaks to our physiological requirements and the level of nutrients that have been shown to be associated with health. Australia’s own fairly conservative NHMRC suggests even higher amounts for good health!  Perhaps rather than revise the established dietary targets we should revise what we’re putting in our mouth!

So where does protein come into this?  Well one of the most important and central nutrient dynamics is the balance or imbalance of our intake of both.   And in this regard, yet again, we have a surprising lot in common with plants!  Whether you’re trying to understand optimal nutrition conditions for growth (nitrogen alone won’t get a plant there, nor protein alone in a human) or the intricacies and nuances of finely tuning our physiological processes such as cardiovascular function, renal health, blood glucose management etc. the answer lies in a happy marriage between these two.

In this area of nutrition, we should be listening most closely in fact to renal specialists/researchers.  These ‘undercover’ protein and potassium experts have been talking about this for a long time and in particular, in my humble opinion, Lynda Frassetto has lead that charge for decades.  If you haven’t read much on this issue and want somewhere to start at least, jump into her pivotal paper from 2001 which eloquently explains why the human design can not shoulder a potassium shortfall…well not without causing real health problems…like the ones we’re seeing in record numbers currently and why the protein potassium balance of any diet is a major health determinant. That’s why giving ourselves and our patients the knowledge and the tools (yes lovely shiny meaningful infographics included!!), to quickly determine their protein potassium balance, are so necessary and important.

Thanks to Frassetto and many other researchers’ work, looking at food through this protein potassium lens has sharpened my focus and I think it’s about time we all took a good look 🙂

Check out the latest UU30 to hear the latest information…

The health consequences of any diet are largely determined by the balance or imbalance of two major players & proxy markers; protein and potassium. When it comes to this area of nutrition, we should be listening more closely to renal specialists whose research shows why the human design cannot support a potassium shortfall and the health consequences of this. Whether you’re trying to understand optimal nutrition conditions for growth (nitrogen alone won’t get a plant there, nor protein alone in a human) or the intricacies and nuances of finely tuning our physiological processes such as cardiovascular function, renal health, blood glucose management etc. the answer lies in a truly happy marriage between our intake of these two.  These recording comes with a clinical resource tool to help you quickly identify the dietary protein:potassium balance for your clients.
Hear all about it by listening to my latest Update in Under 30: Mind Your P’s and P’s
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.

 

 

 

 

ACNEM’s annual conference is almost upon us and this will be a jammed packed weekend of fascinating talks and lots of great networking.

Evolving Landscapes of Nutrition in Medicine – ACNEM Conference 2019
in Melbourne 24-26 May

This year there is a range of international and local speakers presenting on:

  • Chrono Nutrition – the interplay between the biological clock, hormonal function, time-restricted eating and intermittent fasting
  • Gut-Immune Disruption – research update on the mycobiome and auto-immunity
  • Metabolic Insights – multi dimensional aspects of metabolism and implications for patient management
  • Personalised Nutrition – finding the solution for individualised management

 

So if you haven’t booked your seat yet, you are in luck! 
Our friends at ACNEM have provided a special offer to subscribers and followers of RAN for ONE WEEK ONLY, so if you haven’t registered already you can use the promo code RACONF from now until Wednesday 1 May to RECEIVE $200 OFF* your total registration fee.
*This offer is only available to people who have not already registered for the conference.

 

Immerse yourself in cutting edge information and mix with like-minded practitioners – inspire your healthcare practice. So…will I see you there?

If you have any questions about this deal or the ACNEM conference please call the ACNEM office directly on (03) 9583 1320 or email mail@acnem.org

For more information see: https://conference.acnem.org

 

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:

  1. 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
  2. they reveal the connectedness of the seemingly separate elements & force your knowledge forward by asking you, ‘but how?’
  3. 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!”

MindMaps & Timelines – Effective Integrated Patient Work-Up

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.

 

Ok I need to straight up apologise for the 80s pop culture (and I use that last term loosely) reference.  That was uncalled for…especially because this message might need to be heard most by those next gen naturopaths who weren’t even born when mullets had their first moment in the sun.  I’ve been preparing for a conference where I’m speaking about naturopaths and their current pathways for accessing pathology results in Australia but relax that’s not wanted to share with you. I was reading yet more papers on the Australian naturopathic workforce…trying to find out a little more, who indeed are we? In among several important studies on this topic now there is an oldie but goody by Matthew Leach, which was based on ABS census data back in 2006 in which he revealed some big potential pointers for those naturopaths still trying to find ‘their place’:

His analysis of the workforce data spoke to distribution, population provider ratios (how many potential patients to each practising naturopath), average hours worked per week, average income etc.

In short….the answer might be to stop competing for the same suburban clients and for many more of us to, ‘Go West’!

I mean, move to & start practising in a remote or regional area.   I’m fascinated by this whole topic.  Not least because some of the loveliest, happiest and busiest practitioners I know are in such places – hey Stacey Curcio? Amanda Mullemeister? Sophie and Belinda? Rae Powys? Rian Smith?  In 2006, only 22.8% of naturopaths reported working regionally or remotely but Matthew found these practitioners were busier & seeing more patients than their city slicker peers and he reasoned, this could simply be a result of ratios, fewer competing services and increased health care needs. If you add to this some thoughts from another one stepping further in these areas into the role of primary health care providers. Which is a response to the notorious gaps in rural health services. This reminds me of doctors I know who feel nostalgic about their past life as a ‘Country GP’. Which meant they were the one-stop-shop…Doc I need stitches.  Done. Oh no, I’m in labour!  Have no fear, I’m a good catch!  Grand-dad doesn’t seem himself.  I’ve known him for almost as long as you and sadly, I know you’re right. Anyway…stop the soft backing music to the latest RACGP feel good ad…but this could be you!  Well not exactly…different skillset but you know what I mean.

I’m lucky enough to be in regular contact with a lot of regional and remote practitioners (as per previous name drops!) and they absolutely seem to share some things in common with the old country doctor. They become a key resource for whole families which extends across generations.  They are embraced as a core, positive part of their community that, as its best self, always tries to take care of its own.  And they know the reality of living this life: how local business is, what local issues are affecting their patients, access to food, green spaces, resources and all the local services, making their advice, real, sustainable, personal.

From my experience these regional practitioners are the ones also who put effort into their professional support networks.  We saw a huge rural representation at the Australian Naturopathic Summit both years and I know a lot of my most active mentees are based remotely. Maybe us more metro naturopaths get lazy because we imagine being surrounded is the same as being connected, while our regional peers in reality are more engaged? Just a thought. Would love to hear more from some regional practitioners out there…wherever you are 🙂

I’m feeling a little ‘Go West’ myself!

I tell you which state has a lot of regional praccies – that’s WA!  And for all you in the sunny west, you might like to know I’m heading over your way twice over the next few months.  One is for the Rener Health Expo, which I have to say is a pretty remarkable & exciting program of presentations, that’s very much on message about communities looking after themselves! That’s on the 22nd May and the other is for the ACNEM’s mental health module in July, where the highly regarded psychiatrist Sanjeev Sharma, plus from the naturopathic contingency, Susan Hunter and myself will be presenting new content on improved assessment & management of a range of mental health conditions. For more information and contact details check out my live appearances page here.

 

How often were we told this in our training?  And how often have we found this to be true in practice?  And now suddenly, it seems, the medical researchers (at last!) are rapidly coming around to this core concept?? Our microbiome is suddenly the hottest property on the body block, and it seems every interested party is shouting, ‘Buy!Buy!Buy!’ As integrative health practitioners, of course, we had a major head-start, not just by appreciating the gut’s central positioning in the whole health story (iridology beliefs, maps & teasers aside!!) but also a heads-up about the damage the western diet, our medication exposures and lifestyle tend to wreak upon it. A favourite quote of Jason Hawrelak’s by Justin Sonnenburg, “The western diet starves your microbial self”, underscores the significance of just one element of this impact. And…are we all clear that the increasing number of patients reporting adverse food reactions, once again, overwhelmingly are a response to aberrant processes in the GIT?

Sounds silly it’s so obvious right, but it’s easy to get distracted & misattribute blame…for example, it’s the food that’s the problem. Well yes in a minority of situations interactions between someone’s genes, immune system and a particular food turns something otherwise healthy into something pathological, but for the majority, the food itself & in others is healthy, & could  be beneficial to this individual, if only we could resolve their GIT issues…like FODMAPs for example.

Not the problem, just the messenger.

So if the ‘problem food’ is just the messenger, what’s the actual message we need to understand?  Is it that this patient has medication, disease or otherwise induced hypochlorhydria, impairing ‘chopping up’ of potential antigens implicated in immune mediated food reactions? Or is that this person’s got fat maldigestion &/or malabsorption so that in addition to not tolerating fats, they may experience dietary oxalate intolerance to boot? Or are the food reactions the result of altered microflora changing what we can and can’t digest (via their critical contribution) & absorb?

So what message does the presence of IgG antibodies to consumed foods send us about the state of someone’s gut? It’s telling us 2 things: this individual exhibits abnormal intestinal permeability  & currently in the context of this leaky gut, these foods may constitute a barrier to resolving this & other symptoms as well.

We’ve recently released the mp4 (that’s audio plus the movie version of the slideshow so grab your popcorn…that’s if you don’t have a corn issue!)  of A Guide to Investigating Adverse Food Reactions – What’s IgG got to do with it? which details the science behind IgG, including debunking, the incorrect debunking of IgG food antibody testing!! But more than this, it overviews the whole maze of adverse food reactions, articulates a logical investigative path for practitioners through this maze, and helps us to really understand that finding the food(s) responsible for a patient’s symptoms is not the final destination..and can be in fact a distraction, if we don’t cut to the chase and find out the why…and funnily enough…my dear old iridology teachers and colleagues...it almost always comes back to the gut 😉

Confronted with the possibility of adverse food reactions in an increasing number of our patients can be an overwhelming prospect, in terms of accurately identifying and understanding the faulty mechanism underpinning these aberrant responses to healthy foods.  Elimination of culprits in most situations is only a short term reliever, not an appropriate long term solution, so to optimise results we need to know the real mechanism of action.  The majority of these, of course, stem from the gut, but being able to elucidate exactly which of the many things that can go wrong there, is going wrong and therefore what foods are problematic until we address this, is the key. This 2hr mp4 is all about the bigger picture and helping you find method in the madness that can be the AFR landscape. Along the way, we detail the science of where IgG reactions fit into this and it’s a fascinating story that just might be the missing puzzle in your leaky gut patients.
and watch this presentation now in your online account.

a. Some hip new (truly undanceable) track

b. Every herbalist’s jaw at my table at the NHAA conference gala dinner, when I got almost all my Latin binomials right during the trivia quiz?…and after some champagne, that’s a particular achievement 

c. My jaw, when I saw firsthand how much those herbalists could drink of ye-not-so-olde herbal extracts!!

d. The latest Update and Under 30 – Milk Madness Part 2

e. All of the above

If you answered, ‘e’…. you must have been one of those herbalists at my table, otherwise you have way too much insider information!  But yes you are correct on all accounts. So this latest UU30 is an extension of our discussion last month about the potential contribution from to mental health from dairy intake in a subset of patients.  This whole topic, the research for which dates all the way back to the 70s, was too big to fit into one – given the current evidence base that now depicts at least 2 different mechanisms that might be at play, and the different types of mental health problems, each has been linked with.  Last month was all about retracing the ‘dietary exorphin’ path, this month it’s about the propensity for some individuals to make antibodies to casein and the significant growing data that suggest this happens to a larger extent in patients with certain psychiatric diagnoses. More importantly, we talk about the ‘why’.

What compelled me to make time to look through all the literature on this was that there is some. No seriously.  When I initially learned of the GFCF dietary approach to ASD patients I was told that in spite of a lack of supportive research, the empirical clinical evidence was irrefutable, which I later saw with my own eyes.  In the couple of decades since, I only really heard about negative findings, short trials of the elimination diet specifically in ASD kids, that failed to produce significant change.  Funny how the bad stories rise to the top, right?  But when I spent the time doing a thorough literature review, I found these negative findings were far from the whole story.  In fact, I was really surprised by the high level of evidence employed by researchers of late, who have repeatedly found associations between either exorphin or antibody levels and patients with particular diagnoses, in addition to really progressing our understanding of why these measurable differences (urinary exorphins, plasma IgG and to a lesser extent IgA casein antibodies) are meaningful. Do we know everything? What do you think? The answer, of course, is always no.  But we know enough to consider this aspect in our comprehensive workup of mental health patients and all their biological drivers and we know dramatically more than anyone in mainstream medicine, or the dairy industry for that matter, is ever going to let on!

If you want to hear a synthesis of the casein antibody link with mental health then download the latest UU30 – Milk Madness – part 2.   If you can’t go that far, then “do yourself a favour” and read a couple of seriously important articles on this topic – and why not start at the deep end with this study by Severance in 2015.

Update in Under 30: Milk Madness – Is It A Thing? Part 2 

Could dairy intake in susceptible individuals be a risk promoter for mental health problems?  In addition to evidence of the exorphin derivatives from certain caseins interacting with our endogenous opiate system discussed in part 1, we now look at the evidence in support of other milk madness mechanisms.  Specifically, the IgG and,  to a much lesser extent, IgA antibodies about what this tells us about the patient sitting in front of us about their gut generally and about their mental health risks, specifically.  The literature in this area dates back to the 1970s but the findings of more recent and more rigorous research are compelling.

 

 

I arrived home from the Farmer’s Market this week ready to cook a little number I like to call ‘egg dinner’ (fancy I know 😉 ) and found my organic bunch of kale, covered in dirt. Ok, admittedly, there was a small reflexive, barely-audible-beyond-immediate-neighbours, ‘tsk’ that may have escaped my pursed lips…quickly followed by my own auto-correct that went something like this, “thank goodness we have a Farmer’s market with real farmers and they grow real food, that actually grew in real dirt and you know what else I love about it…it goes off real fast.” Seriously, that should be a selling point and proof of the kind of substances I want to put in my mouth…readily biodegradable! Not long after these thoughts popped into my head…this article popped into my inbox…

A new year, a newly issued list of the famous ‘Dirty Dozen’. And look who just made it in at number 12!!

Kale

Not my kale from the certified organic farmers at my local market, but regular Kale. The Kale that is in your green smoothie at a cafe & stuffed into every other recipe plausible on many menus. The kale that many patients will go and buy from the supermarket shelf, spurred on by sound advice from us and fabulous intentions.

A recent Medscape Review talks all about what the Environmental Working Group (EWG), a nonprofit organisation focused on human health and the environment, have found in their annual report about the agricultural contamination of fruits and vegetables in the USA. Even though the report is always good food for thought and a routine reminder that some of ‘best foods turn bad’ as a result of unhealthy modern agricultural practices, we should not assume complete translatability.  The Australian dirty dozen is not likely to be identical to the one from the US, given farming practices and laws around food safety vary significantly between countries. If you want to drill down more into this then make sure you read One Bite at A Time co-authored by one of very our Own Clean Fifteen 😉 Tabitha McIntosh.

Far from wanting to place any further barriers or discouragement in path of regular patients keen to increase their vegetable intake, which the report states are the (currently accused) growers concerns (hey, how about you spend more time focusing on cleaning up your farming practices guys!), It is just a gentle reminder that a bit of (certified organic) dirt is far preferable & the kind of dirt want to be eating.

PS You might also like to know that the clean list of fruit and veg for 2019 in the US includes: Avocados, sweet corn, pineapples, frozen sweet peas, onions, papayas, eggplants, asparagus, kiwis, cabbages, cauliflower, cantaloupes, broccoli, mushrooms and honeydew melons

Love getting back to grassroots with a bit of dirt therapy? 

Our famous Dynamic Balance recording is the foundational teaching resource in mineral nutrition.  Minerals represent a critical tool in naturopathic nutrition and there has been an explosion of research in this area over the last 10 years. In order to optimise patient care, practitioners need to keep up with the constant stream of information, updating their previous beliefs and understanding in the process. This seminar is designed to facilitate and accelerate this process of review and re-evaluation via a fresh look at the key minerals iodine, selenium, iron, copper, zinc, calcium and magnesium.

Q: If a patient says they can only tolerate 7 foods…how many did they start with?

A: Typically about 20

No, this answer doesn’t come from some complex mathematical formula…it comes from appreciating the low dietary diversity of those eating a Western diet.  When we boil down these diets to the number of foods from different biological origins (families) it can be a frighteningly small number.

You see, like most practitioners, I feel utter dread when I encounter the patient who prefaces their diet story with a statement similar to the one above. It speaks to the severity of their symptoms, their attribution of these with food, that by the way is essential for their sustenance and nutritional salvation, and implies an exhaustive pursuit they’ve undertaken probably over years to find ‘safe foods’.  And yes, as discussed in my recent talk A Guide to Investigating Adverse Food Reactions – What’s IgG got to do with it? – food reactions, as in more than one mechanism of food reaction, often do move in packs and that comes typically back to a poorly functioning gut…BUT…that latter assumption…’they’ve explored and exhausted all foods’ is the one we need to keep in check.

Have they tried daikon? Prickly pear or jambu? Okra?  Snake beans? Quail or duck eggs? Kangaroo? Crickets?  Etc Etc. Etc.

Are you catching my drift?  Because someone has DIY diagnosed a wheat, dairy, soy and, and, and, reaction (correctly or incorrectly) and perceive themselves to react also to most of the limited fruit and veg they can identify in Woolies…doesn’t mean they’ve remotely exhausted the global food supply! Where am I going with this?  When patients tell us they’re down to 7 foods they can tolerate – some sensible follow up actions on our behalf may include:

  1. Check the strength and validity of their level & strength of evidence for their DIY diagnosis
  2. Think about the linking ‘process’ (more than likely gut) that is the real potential issue (aka don’t eliminate the messenger and do nothing more!)
  3. Encourage and advise them to shop anywhere other than where they normally do – somewhere that sells fresh produce they don’t recognise at all…like Asian, Indian or Middle Eastern supermarkets and grocers

My tour of A Guide to Investigating Adverse Food Reactions – What’s IgG got to do with it? (and the weeks of lit review leading up to this) provided me with enormous food for thought…and this is just one! If you want to hear more about how to find method in the madness of food reactions…you should probably listen in to the whole shebang…goodness knows with the increasing number of patients who present with self-determined food reactions and an increasingly narrow menu of safe foods…practitioners and patients alike need all the help we can get!

Confronted with the possibility of adverse food reactions in an increasing number of our patients can be an overwhelming prospect, in terms of accurately identifying and understanding the faulty mechanism underpinning these aberrant responses to healthy foods.  Elimination of culprits in most situations is only a short term reliever, not an appropriate long term solution, so to optimise results we need to know the real mechanism of action.  The majority of these, of course stem from the gut, but being able to elucidate exactly which of the many things that can go wrong there, is going wrong and therefore what foods are problematic until we address this, is the key. This 2hr mp4 is all about the bigger picture and helping you find method in the madness that can be the AFR landscape. Along the way we detail the science of where IgG reactions fit into this and it’s a fascinating story that just might be the missing puzzle in your leaky gut patients.
Click here to purchase A Guide to Investigating Adverse Food Reactions – What’s IgG got to do with it?

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We’re not deaf…we heard that stampede of Iron-Inundated Practitioners!

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!

1. So You Think You Know How to Read Iron Studies? (≤30 min audio + Cheat Sheet)

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.

2. Pseudo Iron Deficiency (≤30 minute audio)

The most common mistake made in the interpretation of Iron Studies is this one: confusing inflammation driven iron ‘hiding’ with a genuine iron deficiency.  Worse still, following through and giving such a patient oral iron – when in fact it is at its most ‘toxic’ to them.
This audio together with some key patient pathology examples will prevent you ever falling for this one! Learn how to recognise a ‘Pseudo Iron Deficiency’ in a heartbeat!

3. Iron Overload… But not as you know it (≤30 minute audio)

We’re increasingly seeing high ferritin levels in our patients and getting more comfortable referring those patients for gene testing of the haemochromatosis mutations; but, do you know how to distinguish between high ferritin levels that are likely to be genetic and those that are not?  This can save you and your patient time and money and there are some strong road signs you need to know.  In addition to this, what could cause ferritin results in the hundreds if it’s not genetic nor inflammation?  This Update in Under 30 summary will help you streamline your investigations and add a whole new dimension to understanding iron overload…but not as you know it!

4. So You Think You Know How To Treat Iron Deficiency? (≤30 min audio)

And then you don’t.  The reality is we all struggle at times with correcting low ferritin or iron deficiency anaemia  – so what have we got wrong?  In spite of being the most common nutritional deficiency worldwide, the traditional treatment approaches to supplementation have been rudimentary, falling under the hit hard and heavy model e.g. 70mg TIDS, and are relatively unconvincing in terms of success. New research into iron homeostasis  has revealed why these prescriptions are all wrong and what even us low-dosers need to do to get it more right, more often!

5. So You Think You Know the Best Iron Supplement, Right?!  (≤30 min audio + Iron Supplement Guide)

Iron supplementation, regardless of brand, presents us with some major challenges: low efficacy, poor tolerability & high toxicity – in terms of oxidative stress, inflammation (local and systemic) and detrimental effects on patients’ microbiome.  What should we look for to minimise these issues & enhance our patients’ chance of success.  Which nutritional adjuvants are likely to turn a non-responder into a success story and how do we tailor the approach for each patient? It’s not what you’ve been taught nor is it what you think! This comes with a bonus clinical tool, a fabulous easy reference guide – to help you individualise your approach to iron deficiency and increase your likelihood of success.

You’ll never look at iron studies or your iron-challenged patients the same way.

Listen to these audios straight away in your online account.

In 1 of about 3 storage facilities for tinctures…yes they go through that much!

My career path has taken me a long way and in a very different direction from the one I started on.  During my uni days I wildcrafted herbs, enthusiastically made potions and, yes as the semi-famous story goes, even misidentified one wild-crafted species and accordingly almost poisoned my mother and me. Ahhh the good old days.  But seriously, I did initially aspire to become a great herbalist. Then I almost poisoned myself again with some over-enthusiastic dosing in fourth year – and perhaps like people who’ve ever made themselves truly hideously sick on a particular alcohol, have struggled consuming tinctures myself ever since.  I know…right…it was as much that the nutrition path chose me as it was that herbal medicine said, no thanks!

Last week, after speaking at an event, I went walkabout around Hobart & had the great fortune to visit both the Gould’s Apothecary & their herb farm, Bronzewing and I was potently reminded of why this core naturopathic modality is so incredibly appealing & powerful – for practitioners and patients alike – when it is executed with such a high level of integrity.

You’ve heard it all before, right? Perhaps even done the taste test comparison between a ‘regular’ ginger or echinacea or…whatever herbal prep and one born from Gould’s and had that ‘Aha!’ moment? Yes, me too, but seeing it with my own eyes from paddock to…product…was even more impacting. Herbs are not my strong suit in naturopathy & never will be, that’s why I have monthly mentoring specifically in herbal medicine with a colleague who lives and breathes herbs, however, I love that it is hers and others and via collaboration, we can give our patients it all. Especially, if we are discerning regarding herbal product quality.  Oops did I just say that out loud? [trouble maker!]

Drying calendula and some other green herb! LOL

 

 

 

Apparently, this 3 storey heritage apothecary is already firmly on the selfie-taking map among tourists (who happen to also be naturopaths) – but if you haven’t already done so, don’t miss it if you go to Hobart…that and Mona 😉

 

 

 

 

 

Harvesting Echinacea flowers, I know, how instagrammable right?!

 

The incredible Greg Whitten who runs the herb farm

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?
Hear all about it by listening to my latest Update in Under 30: Milk Madness – Is it a thing?
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.

 

Let’s talk turkey about our pharmaceutical Pet Hates, mine are Proton Pump Inhibitors (PPIs). They irk me more than any other drug class. It’s not entirely rational. Let’s face it, they have some stiff competition but for some reason, in my mind, they almost always win: helping so little & at such a high cost to patients. What fuels my fire of course is their over-prescription, followed closely by the complete disregard for the prescribing guidelines which state:

“When clinically indicated, PPIs should be used for the shortest duration necessary and chronic use is not recommended except for treatment of pathological hypersecretory conditions including Zollinger-Ellison syndrome and maintenance healing of erosive oesophagitis.”

Sorry…did I hear you correctly? Chronic use is not recommended – yet this is one of the drugs most commonly on ‘set and forget mode’ in general practice. To boot, their chronic use has been associated with a number of serious concerns, which I’ve touched on before, from osteoporosis to increased rates of GIT infections. not to mention just the little ol’ detail of malabsorption of multiple nutrients!  But this week, yet another health concern has popped up and into my inbox…and well..I found myself shouting at the medical newsfeed on my screen…[again] 🙁

“In their analysis, more than 42,500 adverse events reported to the US Food and Drug Administration by patients on PPI monotherapy were compared with more than 8300 reports from patients on histamine-2 receptor antagonists (H2RAs)….Patients on PPIs alone were 28 times more likely to report chronic kidney disease than those taking H2RAs, while the frequency of acute kidney injury reports was around four times higher…Reports of end-stage renal disease were 35-fold higher among PPI users, while reports of renal nephrolithiasis were three times higher”

To be clear, while these increased rates are TERRIBLE and unacceptable in the context of the ‘set and forget’ prescribing that seems it be rife in most countries, they still only effect a small % of patients e.g. approx 5%  of patients had adverse renal effects on PPIs Vs 1% on the older generation H2 blockers for reflux but  it’s yet another reason (like we needed more?!) to think twice before our patients are initiated on these meds, which are presented to patients as being benign.  Typically with drug development, the older drugs in  a class are superseded by newer ones that are ‘cleaner’, and therefore more effective with less adverse effects but this is one situation where if one of my patients really did need a med, I would say out with the new and in with the old!

One scenario where PPIs in combo with multiple antibiotics get routinely rolled out is of course H.pylori infections.  But does this make sense??

For a bacteria identified just a few decades ago as being a cause of chronic gastritis, atrophic gastritis and gastric carcinoma, the escalation of number of antibiotics used to eradicate it (4 at last count + PPI) has been nothing short of breathtaking.  A management approach more consistent with both integrative medicine and with an improved understanding of the delicate microbiome focuses on changing the gastric environment to ‘remove the welcome mat’. What do we know about how to do this successfully? It turns out…quite a lot.  You can find out here with our previous UU30: H.pylori- Eradicate or Rehabilitate?