I’ve always been a bit of a fan of Vitamin A but this has grown again in the last year or so, having seen some great responses to short term high dose treatment during active infections or when trying to break a cycle of chronic reinfection. For me, and I think probably for others as well, I previously would get a bit twitchy around even briefly exceeding the UL (upper tolerable limit) for retinol as set by the NHMRC. This was because the potential toxicity of vitamin A, especially for certain vulnerable populations such as children, pregnant women and individuals with liver disease, had been burnt into my brain during my undergraduate training.
As a result, I think many of us have become over-concerned about risks associated with Vitamin A therapy and need to refresh our perspective about the difference between long term high intake above the UL, which does have established risks, and short term equally high doses with have enormous therapeutic potential and extremely low risks if we exclude the most vulnerable patient groups.
We don’t have to look too far for support of this idea, with numerous RCTs employing 5000IU per day ‘until discharge’ to young children inflicted with measles to successfully reduce morbidity and mortality or whopping one off doses of 200,000 IU to treat recurrent urinary tract infections in adults etc.
Of course the therapeutic potential of vitamin A is not limited to an immune one, but it does star in this role. The first identified feature of a vitamin A deficiency was an increased susceptibility to infections and compromised ability to resolve these, regardless of the microbial origin. How often do we see this picture? Frequently…and while our first reflex might be zinc (as of course my bias was for a long time), more often now I am looking for evidence of concurrent or even stand alone suboptimal vitamin A that may also explain this.
In terms of being forgotten, I think many of us need a quick reminder also about the limited distribution of retinol in our diets and that the common exclusion of dairy foods, reduces this further down to a very small handful of foods with any significant amount.
This means that a decent bunch of our patients are going to be at risk of suboptimal vitamin A. Why can’t carotenoids or foods rich in provitamin A always fill this gap?…well you might have to listen to the latest Update in Under 30 to find out! 😉
Vitamin A deficiency is more common than you think and understanding the reasons behind suboptimal intake & status help us to identify those of our patients most at risk. In terms of therapeutic potential, acute high dose retinol supplementation can produce dramatic resolution of infections or break the cycle of recurrent infections in immune compromised individuals. For many clinicians, however, retinol has either been forgotten or become feared due to its toxicity profile. This Update in Under 30 recording, sharpens our focus around not only recognising those who need it but also how to use retinol effectively without the risks.
I think most of us visualise the clearly malnourished young woman, when we think of eating disorders however, while anorexia nervosa is something to be on the watch for, our patients are presenting increasingly with more unusual, atypical patterns of disordered eating, that are easier to miss. Some of you for example, will be familiar with the term ‘orthorexia’ which is an emerging diagnosis characterised by an obsessional approach to only eating those foods deemed by the individual as healthy, ‘pure’, ‘good’. Gluten-, Dairy-, Soy-, Grain-, FODMAP-, Sugar free organic cookie anyone?
Are we likely to see people afflicted with this…absolutely! As practitioners who deal extensively in food and health related behaviours we are really sitting in the hot seat when it comes to eating disorders – likely to see more of these clients than many other practitioners and also walking a fine line when giving restrictive dietary advice to patients, so as not to trigger this sort of unhealthy thinking.(more…)
From the giddy holiday highs to the lows! As you know we kicked off these school holidays with a birthday celebration at Stradbroke Island…time travel forward just a short distance to the end of school holidays and you’ll find us we’ve now taken up residence in the paediatric ward of a local major hospital! Because mucking around with mates and a soccer ball is as worthy way as any apparently to break your tibia AND fibula! Yep! Teenage Boys!!!
Anyway. We’ve been through the heart fluttering dash to emergency, the bone chilling reduction in A&E, the prep for theatre, the truly jaw dropping…’I can’t believe this is how our Friday night turned out, now I’m sleeping on a chair fully clothed in a kids’ ward listening to my precious boy cry out in unmedicatable pain’ (yes apparently his break defied standard pain relief!).(more…)
The understanding that certain infections produce mental health presentations is not a new one. However, based in part on observations of some of the features of tick borne diseases (TBD) such as Lyme like illness, a reawakening of the role for infection in psychiatry is underway.
‘Microbial madness’ is not limited to TBD. There is a large body of evidence linking a long list of pathogens to possible mental ill health. Our role then is to be able to quickly recognise the clinical course and the blood markers that flag this as a possible driver then support the body in its attempts to resolve, not just the infection, but the unchecked inflammation secondary to this.
Ever had a patient where all the arrows point to a microbial burden but you can’t find or name the little blighter!? I have.
Question: What has 22 legs, 11 mouths, sounds like your tv, radio and CD player are all playing at their loudest deafening volume together and an appetite like a small army? Answer: the 11 teens I took to Stradbroke Island to celebrate my twins 16th birthday! Yes, this is what I do for fun and to unwind! 😉
Without shops within walking distance this mob was at the mercy of my food choices and the meals provided by me and the 5 other adults present. I played head of the catering team and spent a lot of that telling the other adults to never ask, just do, when it comes to feeding teens. (more…)
A patient walks into your client and reports that they think they might be reacting to gluten. Happens every week, if not every day, right? Awareness about potential negative health effects from gluten is exploding and often patients present self-diagnosing and self prescribing a gluten free(ish!) regime. What’s your role? To simply back them up with a, ‘Yeah gluten is bad’ response, congratulate them on removing it and encourage them to keep going or to support them in pursuing a proper line of investigation which involves both critical thinking and appropriate testing? You guessed it…the latter!
I know my opinion about keeping gluten in the diet until you understand the ‘why’ is not popular right now but let’s think about it using the following common scenario: 27yo Jo has recently taken gluten out of her diet because she experiences bloating and some flatulence when she eats wheat.(more…)
Robert Bransfield MD DLFAPA likes to start off his presentations with a full and frank disclosure about potential conflicts of interest. After all, he is a well known psychiatrist andAssociate Clinical Professor at Rutgers-RWJ Medical School, who is frequently also asked to lecture to doctors and psychiatrists on the causes & treatment of mental illness, so the need for transparency about commercial links & potential financial gain is essential. I’ve heard Robert’s disclosure and it goes like this:
“Patients pay me money in return for trying to help them.”
Cute, hey! No links to bigpharma that happen to have a new med for CNS infections, no patent pending, not even a book he wants to sell you! You see Robert, or Bob as he prefers to be called, lives and practices in an area of the US that has a very high rate of Lyme disease and came to be regarded as an international expert in tick borne diseases/ illnesses simply as a result of trying to understand and resolve his patients increasingly complex presentations. Based on his extensive clinical experience & research he is now regarded as the brain’s trust when it comes to the role of actual pathogens (spirochetes, viral, bacterial, fungal etc.) in the brain and their ability to cause every psychiatric diagnosis.
Sorry if I’ve been quiet for while but I promise have been very very busy!The Australian Naturopathic Summit is getting tantalisingly (& frighteningly!!) close, and I’m just back from a great Aus/NZ tour with Professor Vormann talking my heart out about Acid Base Balance. Now we’re in full flight organising the final details of our Access the Experts Webinar series in July and just this morning, I was chatting with William Ferguson, my most impacting personal mentor, who is presenting the first webinar on 7th July.
Actually while I was chatting with William I wanted to scream…’Oh my goodness! Everyone has to hear this!!’
If you’re reading this you already know how much I love a good set of blood test results, right? It’s always (tragically!) a bit of a high point of my day when they spit out of the fax machine or become available through some other more modern little IT miracle! 😉 But joy turns quickly to frustration when I look through the results and can take an educated guess that patient wasn’t fasting at the time of the test – there goes the validity of most nutrient levels (Zn, Fe, Se etc), the acid base markers etc. etc. What a waste of time and money! While we have a rough idea about the impact eating might have generally on some parameters e.g. increasing HCO3 levels & lowering plasma zinc etc., this is not quantifiable, we don’t know by how much exactly and therefore we are left guessing. 🙁
But food intake isn’t of course the only confounder that can mess with your patient’s blood test results and lead you to erroneous interpretations. There are several things that with good patient education and better record keeping, we can control for, which would otherwise jeopardise the accuracy of our patients’ pathology results.(more…)
“Access the Experts with Rachel Arthur” is a month long intensive webinar series focusing on the best of Mental Health Education. Every Thursday night for the month of July, Rachel will be interviewing a hand-picked guest speaker about a particular area of expertise in Mental Health.
Each speaker is a clinician with years of experience (from a psychologist, to a GP, to psychiatrists) who Rachel has worked with and/or been mentored by and she is thrilled that these interviews create an avenue to share their incredible & very practical knowledge with a wider audience.
Rachel’s role as the interviewer will be a feature of the webinar series – ensuring you get the best of each speaker; translating the complex into easy-to-understand concepts and clinically relevant content that you can start applying immediately. (more…)
The New Practitioner Drop In Class is a monthly drop in class that focuses on providing an easy to access drop in opportunity for integrative health practitioners to participate in some of the most accelerated form of post-graduate education and clinically relevant skill development.
The group mentoring class takes place via Skype on the last Tuesday of every month so that’s at 1:30pm (NSW time) on Tuesday 31st May. The session is also recorded, so you can listen at any time – a perfect option for those who are interested but unable to make the live session or for those who like to listen twice and get the most out of mentoring!
A sneak peek into tomorrow’s case: 26 year old female presenting with an unusual diagnosis of Erythema nodosum, a hypersensitivity reaction on the skin … but what can we all learn from this case? This case will be an interesting investigation through presenting health complaints, concomitant conditions and pathology test interpretation.(more…)
During a mentoring session this week a practitioner asked me, ‘How could paracetamol relieve anger?’. After the initial, ‘What the..??.’ reflex, I thought well the placebo response is really a wonderful thing, the potency of which should never be under-estimated. I mean this is just one of many ‘afflictions’ I have been told by patients can be rectified by a popping a Panadol! But just to ensure I wasn’t missing something I went digging into the scientific literature about the latest understanding of its mechanisms and actions and lo and behold (!!!) several RCTs have shown paracetamol can “blunt emotional pain” and reduce the negative effects of “social rejection” specifically!
Back to my…’What the…????!!!!’ reaction 🙂 While Michael Berk (ie NAC pioneer) did co-author a huge paper on the potential application of aspirin in a range of mental health conditions https://www.ncbi.nlm.nih.gov/pubmed/23506529 given what we now know about the inflamed brain model of psychiatric illness, this one is easier to grasp than perhaps paracetamol for the pain of emotional interactions & experiences.
I really enjoy mentoring practitioners in business – it’s a real privilege to be able to hear about each practitioners’ aspirations and challenges. A few weeks back I had the good fortune to speak with a fresh one! A practitioner who has only been in business for a short period of time. As always before our session, I looked over all aspects of her online presence from her website, to her practice newsletters, Facebook presence etc. Goodness how things have changed from when I graduated and you literally just hung out your shingle!! As much as the online world has created incredible opportunities for people working in integrative health and the public who use our services, I think it has also of course brought the ‘competition closer’.
Perhaps you’ve been keeping abreast of the bone broth debate? The practice of preparing broths made from slow boiled animal bones and made popular by the GAPS diet as well as many Paleo advocates, has come under scrutiny thanks to a small pilot study that evaluated the lead content of bone broths prepared from chicken. The likelihood of lead leaching out of the bones and into the broth after prolonged boiling is quite high of course, given that, just like us, animals are tricked into thinking it’s calcium, and accordingly store this heavy metal in their bones. This study by Monro et al and published in the journal Medical Hypothesis in 2013, suggests that regular bone broths could contribute significantly to the lead exposure of an individual given the lead content of the 4 samples they analysed:
(i) organic chicken-bone broth: 7.01 mcg/L
(ii) broth from organic chicken meat without bones: 2.3 mcg/L
(iii) broth made from skin and cartilage off the bone of organic chicken: 9.5 mcg/L
(iv) control (tap water): 0.89 mcg/L
Due to popular demand and increasing interest, I am so pleased to announce that I will be starting a secondRachel Arthur Mentorship Program (RAMP) from May until November 2016!
RAMP is a program that focuses on providing practitioners with the most accelerated form of post-graduate education and clinically relevant skill development. RAMP will be commencing in May, on the last Monday of every month at 10:30am until the final call in November (a total of 7 skype call mentoring sessions).
RAMP group mentoring is a great way to build a supportive networkamongst likeminded practitioners, whilst refining your skills in areas of pathology interpretation, differential diagnosis, shared care navigation, research skills, and nutritional & naturopathic interventions.
How many of your clients are on a combination OCP?
Do you know the full extent of the physiological impact in each? Are you able to identify to key pathology indicators regarding the magnitude of that impact?
Like you I see a lot of clients who are on the COCP – whether it’s for contraception, skin, dysmenorrhoea or ‘hormonal balancing’ (interesting concept!!). It’s typically the case that these clients are aware that, beyond contraception, it’s not really a ‘solution’ & ‘isn’t ideal’. They have, as all patients (un)consciously do, carried out a little risk benefit analysis though and here they are. I really feel reluctant to make more difficult, an often already difficult decision for women, and I always want to respect people’s autonomy and choices, so whenever possible I simply go about my job, supporting them naturopathically in light of the impact it is likely to have on their nutrition & physiology.
However, there are occasions when I look at their pathology results and put it together with their symptoms and realise that the ‘danger signs’ are flashing & the COCP is not playing nicely with their unique biochemistry.
Women’s responses to the COCP are not one-size fits all. Apart from the fact that there are multiple combination OCPs available with varying ingredients and actions, we know that each individual can respond to the same formula differently based on a range of factors we might not completely be aware of until they start taking it. For example, all oestrogen (whether it’s yours, synthetic or bio-identical) causes mobilisation of copper from the liver. So when we see blood Copper levels rise following OCP initiation, it’s not because these women are suddenly absorbing or being exposed to more, rather it’s as a result of the liver mobilising a large proportion of the copper that it previously stored, for use by the [imaginary] foetus. The question is – how much does each woman have in the wings, ready to go? And does this result in a blood copper rise that’s mild (S Cu levels < 20 mmol/L) or severe (S Cu levels >20 or even > 30 umol/L). What would be the consequence of being someone in the last group? Apart from the significant increase in oxidative stress and the jump in glycosylated haemoglobin (a particular issue for those with pre-existing IR or T2DM) how would this disproportionately high copper impact your mental health in relation to its role in neurotransmitter synthesis? What about the COCP’s additional effects on each individual woman’s SHBG levels (and therefore available TT), HPA axis, glucuronidation etc. etc.?
We’ve all come across women who’ve stopped the OCP because ‘it didn’t agree with them’ but what about the ones whose biochemistry is really battling with the COCP but they’re none the wiser? We can identify this quickly via reviewing standard blood tests & help the client to understand their individualised reasons to be look for other alternatives.
Research continues to clarify the physiological impact of the combination OCP & individualised responses – we live in a world where the COCP will continue to dominate as a contraceptive choice but surely a step towards an individualised approach & improved patient education & informed decision making, are steps in the right direction?
We’re all aware that in theory OCP use correlates with a range of elevated risks but in reality many females will make the decision that the pros, in terms of contraception or control of acne etc., outweigh the cons. What if we could provide more individualised advice by looking to their pathology results and identifying and quantifying specific danger signs for each individual? This approach enables us to better support patients who chose this form of contraception but accurately identify those that might want to consider safer or more suited options and equally reassure those for whom it remains a sensible choice.
I’ve been sick – real sick just for a couple of days…an acute exotic respiratory thing that the northern Rivers and specifically the period around Bluesfest (!) seems to specialise in. Anyway, apart from it being terrible timing (I ask my patients ‘when is it EVER good timing?’) it has been a quick gruesome but instructive reminder about what’s called ‘sickness related behaviour’. This is a cluster of behaviours that come as part of the package with being unwell. They’re usually short-lived as a result of acute infections like colds, flus, gastro. Trust me – you know them well 😉 they include: loss of appetite, social withdrawal, fatigue, amotivation, anhedonia or depression etc.
These behaviours are thought to be critical to our individual preservation and that of our community and at a physiological level are attributed primarily to the rise in pro-inflammatory cytokines (PICs) that are part of being ‘sick’. It makes sense right? If we’re sick we need to lie in bed, be still, rest up, stop working and most importantly, if it is contagious, stay away from everyone to prevent the spread! So really this sickness related behaviour is a very clever adaptation.(more…)
I was recently asked to speak at an ACNEM conference on ‘Clinical Pearls in Paediatric Practice’ and I talked about 3 key things that have proved to be absolute game-changers in my understanding and better management of children…and guess what one of my topics was…threadworm!!?? Yup. I am convinced some people who’ve heard me mention this before may start to think I have some sort of perverse interest in these little blighters because what could we possibly need to know about kids being infected with worms that we don’t already know? However the answer is….HEAPS!
I have spoken on this topic previously (basically when anyone will let me! ;)) and I can tell you that it’s this information specifically, what I’ve learnt about the myriad presentations, the individual susceptibility and fresh perspectives on treatment, that attracts the biggest ‘Wow!’, lightbulb moments and ‘oh my goodness you’ve just explained a riddle in half a dozen of my patients that I’ve been unable to solve’ kind of comments more than anything else. I just experienced this again at the ACNEM conference in NZ. It’s so wonderful to be able to spread the word! (no pun intended!)
Ok here’s a gripe I’m having currently. I have a number of patients who are taking anti-epileptic drugs (AEDs) and most of these are children who require them for seizure control. Naturally, working alongside such serious pathology and these critical medications requires a conservative and evidence based approach to ensure the safety of any added intervention. Fortunately, this is something I would like to think is one of my strengths. When these patients present seeking nutritional support, I typically refer them for investigations that can help to clarify what, if any, nutrients are imbalanced because of their long-term AED use or perhaps because of other independent reasons that may compromise they’re overall wellbeing. I feel that in such a vulnerable population I need to confirm nutritional deficiencies to check my assumptions, prove a need for supplementation and prevent against any excess or creation of further imbalance…and by doing so, I can adhere to my motto of least medicine, is best medicine.
The fact is AEDs are notoriously associated with a long list of potential negative nutrient interactions and the evidence to support this is extensive, this includes but is not limited to: folate, B12, B3, B6, zinc & vitamin D and the deficiencies potentially produced by the AEDs can be quite severe depending on a range of individual factors. For many of these nutrients, the research goes further and has shown that correction of the deficiency leads to better drug efficacy – therefore adjunctive nutritional monitoring and correction would seem like a real ‘win win’ situation.
(Stargrove,MB. et al. Herb, Nutrient & Drug Interactions – Clinical Implications & Therapeutic Strategies. 2008)(more…)
It’s taken a little while for me to collect my thoughts on this one. Initially there was a little flash of anger, frustration and a good deal of huffing and puffing when I heard about the RACGP guidelines recommending GPs say no to any requests from naturopaths for further investigation of their shared patients… but I’m over that now. In an interview on 702 ABC Sydney radio last week, Stephen Eddy, the vice president of ATMS, responded to these guidelines by suggesting that a blanket directive for GPs to ignore all requests from all naturopaths about all testing didn’t really sound sensible or appropriate. Here here! Surely, in the pursuit of evidence based medicine and discerning practice decisions, each case should be considered on an individual basis. I think Stephen Eddy gives GPs more credit for being able to make these judgements than their own association! (more…)
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