Any steps towards inclusivity in societal & cultural terms are cause for celebration but in medicine, that can come in the form of a ‘diagnosis of inclusion’, the opposite, of course, of a ‘diagnosis of exclusion’ and potentially as slippery and loose as it sounds. That’s the somewhat precarious position we find ourselves presently in with perimenopause and menopause. With greater recognition of just how long health effects can kick in before there are any cycle changes [2-12 years for those of you playing along at home] and the widening lens now taking in the diversity of such health effects, women’s health has had a win. But, I would argue, this is not without a double edge. After all, aren’t we, as a result, more at risk, as women, of having everything attributed to “just ‘the change’, love”, and, in turn, going to be offered sex hormones more often as the solution?
Recently I asked practitioners to tell me where the ‘therapeutic reference range’ many of us were taught for nutrients comes from & no one has been able to answer that.🙄 If you’ve heard me refer to my original naturopathic education before you’ll know I generally hold it in high regard. And I’m forever mindful that there are always things that can be made better. What’s been playing on my mind lately is the recognition that I originally learned nutrition from one (exceptional) individual, and then went on to become the lecturer years later at that same and other institutions. Additionally, I am aware of some of my past students also going on to become the next generation of nutrition lecturers at those same places – and often in fact inheriting their lecturer’s notes, slides, overheads [showing my age!!] with the job. Can anyone else see a problem here? What’s brought this into sharp focus lately are many of the questions I’m endeavouring to answer as part of our much-anticipated Nutrient Prescriber’s Program. How much? How often? When? Which form when? & For how long? Which are the key questions we have to answer with every single nutritional prescription.
To not only source the most rigorous scientific answers to these core critical questions but to also develop a framework that we can all use to answer them for ourselves at the point of any future prescription creation, I have had to go to great lengths.
But as I research & write, I also keep asking myself, ‘How would ‘old-me’ have answered this?’ How did I up until now either consciously or unconsciously answer these sufficiently to make such decisions?
So it’s an ongoing little (& sometimes BIG🧠) internal debate that is raging as I write. And when I ask current praccies these questions they reflect back similar ‘old-me answers’, the vast majority of which were handed to us by our lecturers with plenty of top-up ideas from industry. These answers include things like:
How much? Somewhere within the therapeutic dose range? How often? Depends on lots of things but generally aiming for daily of course!
When? Minerals before food, fat soluble vitamins with or after, magnesium at night etc
Which form when? Now it gets tricky – because there are all these new forms that we weren’t even taught – but maybe ‘active’ – active is always better, right? Or is that natural? The most bioavailable?
& For how long?Ummmmm how long is a piece of string?! Until the signs and symptoms resolve?
Now all of these as general statements are partly correct. And with respect to the level of understanding we need to have when crafting a nutritional prescription for a specific patient, with a specific presentation and for a specific purpose (correction of deficiency Vs supranutritional Vs therapeutic antagonism etc)…well they are plain wrong in the majority of instances. Don’t freak-out in freefall!🪂 The prescribing of nutrients is a wonderful and typically, a wonderfully safe, modality that offers us the potential for extraordinary patient outcomes. When used well. We could all benefit, I believe, from just sharpening our tools so we bring out the very best in our medicines & in ourselves, as prescribers & clinicians. I am neck-deep in writing the 10 modules that can start us all on that journey. Want to join me?
And to be clear, about the educational echo chamber,
In the past I was part of the problem and ever since I have tried to be part of the solution.
With over a decade of mentoring practitioners, Rachel has recognised a need for an educational program that provides practitioners with more structure, more science, and therefore more certainty in navigating each individual prescription. This monthly meet-up is delivered in 5 live sessions and runs from February to June (10 modules). All sessions, encompassing both theoretical and applied learning will run for approximately 2 hrs each.
Let’s play a word association game of minerals & their major roles
I say, ‘Potassium’. Maybe you say, ‘Sodium Potassium Pump’ I say, ‘Magnesium’. You say, ‘Muscles?’ I say, ‘Calcium’. You say, “Bones’….
But I say, Second Messenger. And arguably the most pervasive & potent one, at that. Remind you about second messengers? Well, sure. They are the ones who get sh*t done. Not like a boss (i.e. hormone or neurotransmitter) who shout directives from above but never step foot inside the dirty guts of the engine room itself. It’s the second messengers who run these messages from the outside of the cell to the inside and the engine room, to ensure that the directive is actually actioned! Amazing huh! And free calcium in the blood is, as I said, really a superhero even among the second messengers – with its regular responsibilities including: Insulin, TSH, Adrenaline, Oxytocin, Serotonin receptor activation etc etc
Does, it have a dark side? Well, sure. Don’t most superheroes?
If the available Calcium in blood and the extracellular environment is too high then basically bad sh*t gets done. Including vasoconstriction, clotting, deposition of calcium in the wrong place like arteries and joints and etc etc. That’s why the amount of Calcium in our blood is the MOST tightly regulated of all electrolytes and, in turn, has the NARROWEST of reference ranges. But will a Serum Calcium level always tell you when there is a problem with Calcium regulation? No. You’d need to have measured the major regulator itself, Parathyroid Hormone (PTH). Wait, am I seriously trying to tell you, that Serum Calcium alone can look completely normal in spite of really damaging Calcium dysregulation underway – leading to accelerated BMD loss, increased cardiovascular and renal risks etc.? I most certainly am.
So do you know which of your patients’ really need PTH assessment and why 1 dominant group amongst those, is any woman leading up to and following menopause?
No? Well you better pull up a pew and have a listen and a watch then! Yes this latest Update in Under 30 episode even comes with a little video tutorial!🤓🤯
Parathyroid hormone is a career criminal. In addition to buoying dropping blood calcium levels via legitimate means, it illegitimately achieves this by stealing it from our bones. But you wouldn’t know it – because like all career criminals this occurs completely under the radar. Elevated PTH, however, constitutes the most modifiable risk factor for bone mineral density loss & fracture risk and offers the biggest BMD gains secondary to its normalisation. In addition to this, even within range but ‘high-normal’ PTH correlates with a range of other cardiovascular and urinary presentations & if combined with elevated serum calcium can become a multi-systemic presentation (GIT, Mental health etc) frequently mistaken for other aetiologies. So how can we be alert to this ‘bone thief’? Which of our patients will benefit the most from PTH measurement and monitoring? This recording, resource & video tutorial on how to use a Ca PTH Nomogram answers all!
You can purchase Unmasking Hyperparathyroidism – Menopause & Morehere. If you are an Update in Under 30 Subscriber, you will find it waiting for you in youronline account. You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audios and resources here.
Current New Graduate Mentee: Kelly Allan giving her elevator introduction in a recent New Grad mentoring session
The fabulous Nina, one of our behind-the-scenes-dream-team & early career nat, said, ‘During our training and early in our career it’s like we don’t “see” the Generalists. We’re only aware of the ‘rockstars’ in our profession and they are all specialists in IVF, vaginal microbiomes or gut ones. So we end up thinking, to be any good you’re going to have to specialise’ ‘Yes,’ I said, ‘but imagine if we only ever had the option of seeing a specialist?’
You’ve been experiencing a bit of gut stuff – and rather than being able to bounce this off a generalist you have to go ‘straight to the top of gastroenterology’ – wait in line for your time, pay the big bucks etc to get their thoughts. But really it was only ‘a bit of gut stuff’ and perhaps all this was over-kill?(more…)
Practitioners have been bringing their most challenging cases to me for mentoring & supervision for over a decade, that’s hundreds, in fact, probably thousands, of cases, tempting me to say, therefore I’ve seen ‘everything’.Except of course I haven’t. And each new case helps reinforce that and the utter uniqueness of everyone’s experience of health & disease.
From each & every case, no matter how unusual, remarkable, uncommon, exotic some or all of their experience and story, once we’ve asked the key clarifying questions that often prove to be ‘diamond diagnostics’, constructed a comprehensive timeline, suddenly bringing to the forefront: their disease chronology, causation & contributors, analysed their pathology for insights far beyond what a patient or their diagnoses can ever speak to, and then completed the work-up by incorporating all of this information into the step by step construction of a MindMap…
🤓We all leave each session with truckloads of new info & skills to apply to our own patients🤓(more…)
Especially given I am now a relic, my original training not quite pre-industrial revolution but pre-specialisation obsession. So that once I started seeing paying patients I just saw, and have seen…everyone. And because our patients always drive our desire for new knowledge and skills, I have therefore taken particular interests in & accordingly read the extra research pertaining to a whole variety of different systems, conditions and presentations etc. that I have then been able to share with others as part of my contribution to education. (more…)
After running a deeply rewarding Group Mentoring program for over a decade it is indeed time for change. I’ve witnessed first-hand the exceptional growth of thousands of practitioners, and in turn they have guaranteed and forged my own. It’s provided me, & my small team of naturopaths working behind the scenes, with an extraordinary opportunity to further develop, refine & sharpen many of the clinical tools I had originally created just for my own practice, to ensure they are user-friendly and outcome-oriented for everyone who choses to adopt them. Over this period, I’ve even seen some of my mentees become mentors themselves (!) carving out their own paths, creating their own clinical toolkits etc. I am eternally grateful for having occupied this space and role for so long.
But my contribution to ongoing practitioner development is not done – just done differently – moving forward.
Inspired by, & truth be told a little envious of, the content, culture and collegiate experiences my university attending big kids are having – we’ve decided to adopt some of the same elements including semesters! So our 2024 is now divided in half, with Sem 1 starting in Feb and finished by June. This means we can offer intensives, accelerated learning formats which will especially appeal to and benefit our intake of newly graduated nats/nuts/herbies into our New Grads program. This is the result of more frequent touch points and does not come at the cost of the comprhenesive content or outcomes. Likewise, all those returning (via a stampede!!) to our much anticipated Nutrition Prescriber’s Program
This is a Case Series delivered live via monthly meet-ups whereby a real case work-up, covering all key aspects of diagnostics, prescriptives, the therapeutic relationship, behavioural change & patient management etc is detailed and discussed. The cases have been hand-picked for their ability to offer maximal learning for us all – both in general terms of case work-up skills and tools, as well as an opportunity to upskill in the primary affected systems and the associated presentations – be that endocrine, skin, metabolic etc . We are so excited to announce this one’s arrival!
So if you want to head back to uni with us for Sem 1 at RAN Uni 😂 get in contact admin@rachelarthur.com.au
Ever feel like the universe has been preparing you just for this moment? Me neither really…but in this one weird way – yes!
So hear me out.
Thyroid disease as a result of a viral infection was first described in 1902 by Dr Fritz De Quervain and of course he and his ego called it De Quervain’s subacute thyroiditis. For some historical context, this predates the recognised role of iodine deficiency in thyroid disease! Skip ahead almost a century to deep in the 1990s and mini-me was sitting in a uni lecture room [front row & wearing fluro of course🤣] and over hundreds of hours (no scrap that zillions*^# of hours) of lecture content I was exposed to, the description of De Quervain’s Subacute Thyroiditis stood out and stayed stuck to me. I’ve brought it out for a twirl from time to time in the interim with some of my patients & in particular in correspondence with their docs.Skip ahead to the 2020s when we had this thing called. ‘a global pandemic’, and now everyone wants to talk viruses and their broader health implications & as a result, good ol’ Fritz, me and our buddy, De Quervain’s subacute thyroiditis, are all having a moment.
But just to recap – this is (clearly) not new.
What is new is the way this ‘virus of the moment’ has brought this Thyroid V Virus battle to the forefront. We are living an important chapter in history where all the textbook entries on De Quervain’s Subacute Thyroiditis are madly being rewritten to reflect the veracity of this viral attack on the gland and the wide-scale & varied damage that ensues over the months and years that follow. And so many of our patients are the walking embodiment of it – whether that be in the form of low or high thyroid hormones, nefarious changes to gland anatomy only evidenced on US. So what do we need to know? in short, that pathogens as goitrogens have never been more of an issue than right now for ourselves and our patients. And that compared with just our usual desire for comprehensive investigation of the HPT, taking a complete look ‘under the hood’, not only by way of a full TFT and Ab titres but also, wherever there is an additional suspicion – by way of a thyroid US – has become non-negotiable. But regardless of what you find there, once you look, do you know what to do next?
Biopsies and autopsies of diseased thyroid glands alike reveal the prevalence of many common viruses within, setting the scene perfectly for the Thyroid V Virus battle. So, what happens when a virus takes a specific liking to this gland? While there are several different possibilities, one brought to the forefront in recent years is viral thyroiditis wherein stage 1 is ‘spill’, stage 2 constitutes a gland that is now ’empty’ and while stage 3 is reported to be ‘recovery’, this is increasingly scarce – replaced with chronic or recurrent thyroiditis, relapses of previously remitted GD and a doubling of new AITD diagnoses – not to mention the wide variety of unfavourable anatomical changes being found on ultrasound. Comes with a great desktop reference with prescription examples.
You can purchase ThyVIRoidhere. If you are an Update in Under 30 Subscriber, you will find it waiting for you in youronline account. You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audios and resources here.
I shared this recently on socials but for those of us that don’t hang around that ‘hood I am sharing again here because it is just too important. While we’re busy updating our knowledge regarding reproductive health for women (soooo many huge headlines of late!)…ahhhhh…this might be something we all want to read!🤓
This thought-provoking reviewchallenges the long held assumption that oestrogen is at the root of much breast cancer causation. Instead it creates the case for PROGESTERONE as the actual source of oncogenesisand relegates oestrogen to merely (but monstrously) fanning the flames.
Now before anyone panics (?too late ) you need to read the article in its entirety – esp this not being about demonstrable differences in measurable P4 levels – and keep in mind that this hypothesis, though well argued and supported by evidence also from trans-gender individuals, is not currently a consensus. BUT what I think it does really well is SHAKE THE TREE🌴🥥 and prompt us to challenge our own biases and blind-spots. For far too long in IM Oestrogen has been made out to be the baddy. I too am guilty of having done that. And Progesterone everyone’s saviour! Of course there are a lot of PMDD sufferers who have good grounds to punch us for even suggesting this.
But of late – many of my peers have helped remediate oestrogen’s reputation and put us back on a more balanced path – I am thinking of @Sandra Villella especially here.
Who straight away responded to my post regarding this on socials, “I just got back from the Australasian menopause Congress in Queenstown, and the different types of exogenous progestogens are certainly implicated in breast cancer.” And then generously shared some of the hot off the press slides and stats from the Australasian Menopause Society.
In a nutshell she says, “Breast cancer increases with age and with increased time of use and those increases are greater when Progesterone is included in the MHT prescription”
And whoah…maybe we all need to rethink all the pro-progesterone prescribing…dare I say?!
Btw – the article implies that having anovulatory cycles might actually be protective too!!
Not my normal space and speciality area but I keep finding these gems in women’s hormonal & repro health and I feel a duty of care to share!
Update and Under 30 Podcast episodes are streamed monthly audios and resources to keep you up to date with the latest ‘must-knows’ in integrative medicine, covering a wide variety of topics from diagnostics to diet, all through the lens of an integrative health model. Every month each new episode will provide you with a quick scientific review with ‘clinic-ready’ practice tips, in under 30 minutes. In addition, the subscription gives you access to the ENTIRE back catalogue of UU30 audios that have been released…that’s over 120 episodes! You can become an Update in Under 30 Subscriber to access the entire library of Update in Under 30 audios and resources here.
The debasing of BMI as a stand-alone assessment of weight is long overdue given its significant limitations and lack of meaningfulness with respect to overall health. This coincides with a bigger societal and cultural shift towards inclusivity which involves redressing bias against people with diverse body sizes and compositions.
And how do we, as integrative health professionals, continue to uphold our principles of prevention and treating the cause when excess adiposity may be a very real contributor? While ensuring we ‘see’ and treat each individual in front of us, not our assumptions about adiposity, not our body size bias nor blind spots?
One part of the answer: read and be led by their lab results – because pathology is nothing if not personalised.(more…)
The builder responsible for my reno arrived one day with a frown. When I asked him what was wrong – he said he’d just had his second high PSA result and now the doctor wants him to see a specialist. It was apparent that he felt this was a real cause for concern. Talk about raising a red flag to a bull 🚩🐂 Yes, of course you know what followed. I insisted on reviewing the results myself only to find the reference range provided on his report was not specific to his age – and if we adjusted up for this (as the science supports) his result is just 0.5 ng/mL above the expected value!
Now, remember he is a builder so, ‘0.5’ in his mind might well be on par with 5mm which apparently is a big deal…or so he keeps telling me every time I try asking for some weird unconventional thing for my roof, windows, walls, whatever!! So I still had to provide a little bit more detail for him to get perspective and to understand the true meaning (and lack of scary meaning) of his results.
This however is just a micro-illustration of a big problem in pathology – we all risk a lack of perspective but if we can get it back, aids us to see that seemingly ‘normal’ results are sometimes a concern, and so-called ‘concerning’ ones, non-significant. The incredible patient insights that can be gained from being able to measure & monitor actual quantities of things in our patients; nutrients to novel disease markers, precursors to end-products, all comes down to understanding how their values compare with…with what? With someone of a different sex and age? With ‘all adults 18-108!’? With any other pre-menopausal woman regardless of reproductive or cycle stage? With ‘the average’ adult given that this current definition is overweight & unwell? Who are we comparing ourselves and our patients to?
When I undertook my undergraduate training many moons ago – there was no education in blood test interpretation. But as soon as I got out into practice I found my patients had all these bits of paper filled with magic numbers that I felt certain might offer me insights and a deeper understanding of their whole health – and how to best help them.
I desperately wanted to decipher this foreign language and made it my mission to do so. I was lucky enough to meet and be paired with a kindred spirit, Dr Tini Gruner, who happened to be my supervisor when I returned to undertake my honours thesis. Together we pooled our knowledge, sought out & shared with each other yet more and found that, together with comprehensive case taking, it provided excellent scaffolding to our work-up of patient cases. Better than that, it created this baseline for patients, identified clear treatment objectives and we could measure the success of our interventions based on how their results did (or didn’t) respond to our interventions. It was (and still is) a totally thrilling way to practice.
We talk about there being both an art & science to medicine generally and certainly an integrative approach. Without the benefit of pathology interpretation, I felt too at sea at times, without quite enough of the science to check the accuracy of the ‘art’ and my speculation.
Being able to understand what each individual result represents and reflects, to know how to form meaningful comparisons – with external reference ranges that speak to healthy individuals of the same sex & life stage, derived from rigorous research – and also form a comparison with the patient themselves, to pick up on the most subtle and significant early alerts to an emerging pathophysiological or healing process – is the skill, I believe, we all need in health to complete the toolkit. That’s why I made it my mission to learn the language of labs, from a conventional & integrative interpretative perspective, and then to share this learning with everyone wanting and willing to take this baton from me (& Tini) and run with it 🏃♀️🏃
MasterCourse I: Comprehensive Diagnostics. Click here to read more and here to purchase it.
*Please note that this is the place to start for everyone wanting to add preventive diagnostics to their tool kit. It is also the pre-requisite for MasterCourse II, so make sure you have completed this before continuing with MasterCourse II: Thyroid and Adrenal Diagnostics.
MasterCourse II: Thyroid & Adrenal Diagnostics. Clickhereto read more and here to purchase it and sign up for the Free Watch Party commencing tomorrow, 3rd August 2023 with is included with each purchase of the MasterCourse II.
Heck yeah. It’s going to take a lot more than 1 push-back post to turn this ship around! Likewise, I was only getting started with my recent Update in Under 30 episode, ‘What’s Hiding Behind Histamine’ 🤓😂 & part 2 has just been released where we unpack the case of a 41yo female with chronic diarrhoea, multiple food reactions, very high stress and very high oestrogen. Sounds like she’s a walking Histamine Headline – except she isn’t.
Right now we really do need to keep this conversation going such that a healthy discourse can help us deconstruct the histamine dogma.
I know I’m showing my age here, but anyone remember when Candida was having a ‘moment in the 90s? Ok, so that ‘moment’ stretched to over a decade of a ‘Candida-contagion’. No one could eat melons or mushrooms, eat ferments or feel joy. It was a bleak time that did our profession some reputational damage. Not only because seeing an ‘alternative practitioner’ became synonymous with being put on an unbearable, unattainable restrictive diet and positioned practitioners as peddlers of punishment but also because it took some time for science, in the form of accessible (& always improving) assessment methods, to come along and save us from the folly of the 1-diagnosis-for-all mentality.
Let me ask you, how many times do you actually see Candida overgrowth on reports from stool testing performed using best practice modern methods?
In my experience – never – not as a stand-alone issue. Occasionally, as part of the overgrowth of a suite of opportunistic organisms where the real-take home is the need to ‘remove the opportunity’ via the promotion of more good guys. So not only was the diagnosis incorrect, the proposed treatment for it was a complete misdirection as well.
Can’t help thinking in the current climate of Histamine Hysteria that history is repeating itself.
How will we all individually, and as a profession, respond this time?
In this follow-up episode we observe how the 3 key elements often hiding behind a histamine intolerance diagnosis: Misunderstandings, Missed Messages & the potential for Mistaken Identity, have played out in the case of a 41yo female who presents with chronic diarrhoea, a long list of problem foods including now a suspicion of ‘histamine foods’. Rachel offers up new ways to approach the patient work-up that cut through the ‘noise’ and enable us to better identify what is hiding behind histamine in similar cases of marked gut dysfunction.
You can purchase What’s Hiding Behind Histamine? – Part 2here. If you are an Update in Under 30 Subscriber, you will find it waiting for you in youronline account. You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audios and resources here.
You’re invited to attend acnem’s 2023 Annual Conference ‘Long COVID, Navigating the Complexity, A Clinician’s Roadmap’.
Saturday 29th & Sunday 30th July 2023, Melbourne. Both face-to-face and online.
To get 25% off acnem Annual Conference USE CODE: acnem25
Never done a MasterCourse in Diagnostics with me? Is that because you’re scared of…
a) investing that much time Aren’t we all – but we can hold each others’ hands & hold each other accountable each Thursday for just 7 weeks🤝 b) investing that much money We hear over & over again from our alumni that this was the best investment they made in their practice & it paid them back in spades! 💰💰 c) your own future fully fluent – all seeing all knowing (almost!) – diagnostic diva/divo self?! Don’t be: Dare to be remarkable. This will set you up & apart.🤓 d) of Rachel Well that’s a point – hard to argue! But feel the fear and then be pleasantly surprised by the fun! 🤸♂️🤸♀️ e) all of the above you best keep reading then…
Is now the time to face your fears, save a substantial amount of $$ and get on board with this train(ing) destined for your new empowered practice model, before it leaves the station?? Yep.
The MasterCourse I: Comprehensive Diagnostics has been called the single greatest change-maker to people’s clinical practice and likened to a total brain reboot. Not only with respect to the interpretation of patients’ results but to your complete understanding of integrative physiology. Liver function tests become markers of mitochondrial function, muscle mass and much more. Patterns in routine labs make patent the otherwise ‘invisible’: central and peripheral sleep-disordered breathing, the earliest signs of bone demineralisation etc And now it has a new sibling MasterCourse II: Thyroid & Adrenal Diagnostics. (more…)
Have you had a book that is so compelling & transporting you can’t put it down?
In the last year or so I’ve rewritten my own little book of sorts, on thyroid physiology and results interpretation and during that process I came across a paper that referred to ‘the thyroid biography of each individual’. I was so struck by this concept, how it brings into life my new appreciation of how a patient’s thyroid function speaks to the totality of their exposures – from their diet to their dopamine, from their exercise regime to their environmental pollutants, from their sex hormones to their stressors.
Being immersed in the research was deeply rewarding but the obsession proper began when I started applying everything new I’d learned to patient labs. Reading the ‘thyroid biography’ of every individual is the book I just can’t put down.
Not just because it enables us to see that our clinics are full of responsive thyroids more so than rogue and that the ultimate tailored ‘treatment’ is spelt out, right there, in the nuances of each patient’s TFT & other pathology patterns but also because these results themselves are a portal into the patient’s bigger story. During a recent interview on this topic, where I had the good fortune to be interviewed by someone who really understands health, we got deep into a discussion about how differing macrophage dominance (M1 or M2) in our adipose tissue disturbs thyroid function differently. The interviewer then asked – well how do you know if your patient is M1 or M2 dominant – is it just based on different measures like waist-circumference etc? and I said something to the effect of, ‘Well these can be indicators but actually more and more in someone with excess adiposity I look to their TFTs to tell me the answer to that!’
And that was actually a Tada! moment right there!
I realised the truth and gravity of what I’d just said – increasingly I’m looking to patients’ thyroid function to tell me the rest of their story – to reveal not only their totality of exposures but to shine a light into some darker corners that are otherwise hard to see or measure or know…like macrophage dominance patterns in fat tissue, or HPA setpoint recalibrations following trauma, or subinflammation that remains under the inflammatory marker radar.
We’re understandably critical of the over-stretch a name like ‘Thyroid Function Tests’ conjures up – how can 1 panel of 3 (ideally!) markers deliver on such a promise?! But I am here to tell you it can and in fact, it can deliver on far more than that once we learn to read TFTs as Thyroid First-Responder Tests, instead. And of course, we generally don’t see TFTs in isolation – so we can couple these with patient results for routine labs that add to our understanding, support our suppositions or challenge them based on their FBE, their renal or metabolic markers etc. This is integrative endocrinology within the broader framework of integrative medicine after all. This necessitates de-compartmentalisation while being able to disentangle one source of HPT directive or disruption from another. This is real-world results interpretation that optimises our insights and understanding & patient outcomes.
The back cover of my copy of this well-thumbed thyroid biography so far reads:
⇒Rather than rogue thyroids our clinics are full of responsive ones – responding to the totality of each individual’s exposures. ⇒If you don’t read patient TFTs through the lens of the HPT as a first responder – you’ll misinterpret what’s happening within their HPT. ⇒If you don’t read these results through this lens you will miss out on a much bigger understanding of their whole health story.
Of late, I’ve been woken at night to find I have been page-turning through a patient’s thyroid biography and a lightbulb moment of discovery is coming into land! I wish for everyone else the same…not the sleep disruption bit of course but those glorious Aha! moments. Oh and don’t get me started on HPA Assessments – that’s another page-turner!
MasterCourse II: Thyroid & Adrenal Diagnostics is NOW available. Clickhereto read more and here to purchase it and sign up for the Free Watch Party commencing 3rd August 2023 with is included with each purchase of the MasterCourse II.
I can barely bring myself to write the word given how overused it has been of late 🤐🙄😯😕🙃 But I gotta say something! If we have found ourselves currently in a place where every second (or indeed single!) patient has a ‘histamine issue’ then I am afraid that it is we, that have an issue. (more…)
The case of a slim 41YOF under very high stress due to marriage separation & the care of 2 young kids was presented in mentoring this month. Her a.m. Cortisol was 710 nmol/L – Rachel asked the group to identify 3 results in her routine labs that are consistent with & likely to be caused by this hypercortisolism…
Mentee & MasterCourse I & II Alumnus: In this case… – High-normal sodium – High neutrophil:lymphocyte ratio (on a few occasions) – Mildly elevated CRP
Rachel: The 3 markers you mention can indeed be consistent with and purely caused by high Cortisol: HN Na, HN Neutrophils and LN Lymphocytes producing an elevated Neutrophil Lymphocyte Ratio (NLR) and some low-level CRP elevation
I am just back from the NHAA Symposium – all informationed-up and raring to share!! LOL
I learned some great stuff about Black Pepper and that made me think about a case from mentoring last month🤓
One of the presentations was from Jason Hawrelak during which we ‘went back to school’ (as in old-school Materia Medica-based teaching – unsurprisingly I love this stuff!) and we (?re)-learned all about the herb Black Pepper and its active constituent piperine. It was brilliant and really challenged a LOT of uninformed thoughts I had about how to use this herbal medicine. It is now officially my herb of the month😆 But seriously, prior to this, I would have thought of this as being a great adjuvant and circ stim but primarily a gut irritant. Wrong. While it is contraindicated (CI) in ulcers or very active gastritis here are some GIT actions that might just surprise you as much as they did me(please remember, the below only applies to liquid (ethanol) herbal extracts at the ratio of 1:2):
Major carminative & antispasmodic for the GIT
It SLOWS transit time (TT) and hence its major indication, across different herbal medicine traditions, as anti-diarrhoeal
Coupled with very powerful stimulation of both digestive enzymes and absorption
Capable of increasing secretion of both saliva and HCl
I was most wowed by its documented positive effect on improved nutrient absorption via the saliva, HCl promotion, the slowed TT and increased villi length (true!!), increased bile flow, increased pancreatic (up to 90%) and intestinal lipase and amylase etc etc so massive increases in Ca uptake most notably along with phytonutrients (think curcumin as just one illustration of this) and, though much smaller, still improved uptake of Fe/Zn etc etc
In fact when Jason then created a profile of who he would think of Black Pepper for the one that really jumped out to me and related to this mentoring case was: the person who is eating good food but is surprisingly low in nutrient levels – esp if confirmed low pancreatic elastase. There is also evidence to support it as an effective strategy in both early and ongoing coeliac disease as well – which we still have as a differential in this patient
It is a UGT & SULT inhibitor & esp of p-glycoprotein efflux transporters however, so we need to use extreme caution in patients taking pharmaceuticals because there are loads of potential drug interactions,however, this is not an issue for this patient
Drop doses of a 1:2 liquid herbal extract of course – not pleasant to taste but not as bad as berberine (in my personal opinion!!)
Anyway – clearly I am a convert & keen to start trialling this in a variety of cases and want to spread the Black Pepper word right now!! Let me know your thoughts 🙂
Iron issues are an everyday encounter for those of us working in nutrition. As a result, we need to constantly attend to our skill set regarding iron assessment and refine our knowledge regarding best management.
This 5 episode compilation builds upon the foundations established in Iron package I and is unashamedly women-centric with 2 episodes on the complex area of iron balance in pregnancy, however, men and children do get a little look-in in other episodes!
You can purchase UU30 Iron Package II here. If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account. You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audios and resources here.
What level of Serum Ferritin represents ’empty’? As in complete depletion of iron stores?
Is it any value below the minimum of the reference range? e.g. < 30 mcg/L Or does the bottom of the reference range allow for a buffer and ’empty’ is substantially lower than this? Could patients actually be ’empty’ but still have Serum Ferritin values within the normal range? Could the same Serum Ferritin value occur in one patient on ’empty’ but with adequate stores in another?
Practitioner: I haven’t yet done the MasterCourse II in Thyroid & Adrenal Diagnostics but I want to better understand the HPA of that patient we discussed with significant sleep disorders. Waking blood? Saliva? Urine? Which one?
Rachel: Well, you’ve heard me say I am sure, that depends on the specific question you are trying to answer by way of this test result. For example, see this slide from MasterCourse II
which considers the best tests to answer qualitative questions about HPA behaviour and function (of course sometimes we just have quantitative ones like maximum or minimum output but I know you want to look beyond this)
Lastly, if I am running a <9am blood cortisol (which remains a good marker in most cases) then I always would add in DHEAs in the same sample which adds a WHOLE other layer of understanding: our capacity to weather the stress storm, to buffer the HPA activation or not! And if we’re collecting blood <9am why not include ACTH and then you can determine if there is a contribution from (mis)management…just saying…🤓
I have! And just recently a stark contrast between the results from 2 different methods of cortisol capture in the same patient illustrated just how likely this is. How do we ‘capture’ something so ‘dynamic’ and interpret anything of substance from a ‘static’ assessment technique? But rather than throw up our hands and throw out the whole attempt to measure cortisol, we can improve the rigor, reliability and real-world meaningfulness of our patients’ results by refining our timing of tests, choosing the medium wisely & manipulating test conditions to answer specific questions about their HPA function. Great desktop reference included!
You can purchase Cortisol– Have You Been Caught Out?here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.
Just as optimal integration of lab results into our patient work-ups makes ‘the invisible visible’ we thought we might make visible some of the everyday Q & A that we engage in with wonderful practitioners who are fast becoming Diagnostic Divas & Divos.
Praccie email arrives with subject header ‘Graves Help’ (or is that ‘Graves…HELP!’🤔)
Practitioner: I have a Grave’s patient who required Propylthiouracil (PTU) for a few months from late 2022 until Jan 2023 which obviously took her thyroid in the opposite direction (see labs). Following a miscarriage last year, she has conceived and is around 6/40 and her current TSH result has come in at 3.3mIU/L, her TPO Abs > 1000 and she also has low-level Tg Abs (TRAbs not measured this time) and this is what she just said to me:
“I just had my specialist session this morning – and she has put me on thyroxine (50mcg) as my thyroid is quite low. I also asked her about the prenatal vitamin and she said it was safe for me to be on iodine at this time, as the Graves isn’t present and baby needs it for the development of its own thyroid.”
Oh gawd! Preg? Iodine? Graves? Antibodies? Antenatal or postnatal aggravation?!
Is there an UU30 I can listen to to help me understand this?… sorry for the panicked email…
You can purchase 
The debasing of BMI as a stand-alone assessment of weight is long overdue given its significant limitations and lack of meaningfulness with respect to overall health. This coincides with a bigger societal and cultural shift towards inclusivity which involves redressing bias against people with diverse body sizes and compositions. 
MasterCourse I: Comprehensive Diagnostics. 
You can purchase 
