This is not about body shaming nor body positivity. I understand the crudeness of the body mass index, as a measure of (un)healthy weight – let alone (un)healthy muscle mass, so I don’t use this as a stand-alone assessment of weight, nor rigidly adhere to the categories it allocates individuals. With only minor recognised racial adjustments for BMI, I also recognise our concept of ‘healthy weight’ is incredibly whitewashed with minimal regard and consideration for clear ethnic and racial differences in physique. Patient’s lab results tell the real story. It’s in their results that we can discover someone is thin-on-the-outside-fat-on-the-inside (TOFI) or FOTI. These are patients whose BMI, WC,WHR, Body fat% etc identify them as obese – yet there is not a whisper of what I call ‘Adiposity Patterns’: no subclinical inflammation, no reduced glucose tolerance or actual IR, no raised transaminases that we expect to correlate with girth and the corresponding fatty infiltration of their liver. In this, as in so many other aspects of clinical practice, we are reminded to see each individual, individually.
AND if we adhered to this always, listening unfiltered to the whole health story and letting the labs speak, we would not miss those patients in whom unhealthy weight really is the most important underpinning, & all impacting, issue. And we are not doing our job, when we don’t.
I mean – we all know the detrimental effects of excessive adiposity – that’s like Pathology Unit 1 topic 1, right? I know we know it. Yet there are so many reasons why we might down-play, step-around, or even ignore its enormous contribution in our patient work-up and certainly the discussion that follows with our patients. That too is a no-brainer. Who wants to say to someone whose come seeking your help, as an explanation for their complex health concerns, ‘There’s no zebras here just a horse – one really over-weight horse!’ Knowing too that unhealthy weight results from the most complex constellation of factors (biopsychosocial) unique to each individual and that change in this health determinant, is arguably the slowest and hardest to sustain. But how are we serving our patients if we don’t?.
A practitioner presented this case of a 48yo F seeking help with the work-up: Self-reported inability to lose weight after 1st pregnancy = ‘obesity’ ongoing – now BMI 33.1 –> 25yo Reflux & Hiatus hernia Tx Omeprazole initiated – ongoing –> 26yo Depression Tx Venlafaxine initiated – ongoing –> 30s Back and other musculoskeletal injuries Tx Surgery & Opiates – ongoing –> 40s Hypertension & elevated resting HR –> Last 12mo – changes in Mx cycles suggestive of perimenopause & substantial weight gain
This patient didn’t ‘have’ any lab results but I think I can make an educated guess about how they would look and in particular whether they show the characteristic ‘adiposity patterns’ I mentioned before. What was my first thought about the most impactful element of the case? Obesity. What was my second thought? Where is all the weight (diet & intervention) history that would help us to understand how she is where she is, right now? We didn’t have any. The practitioner informed me that the patient was ‘not very interested in talking about her weight’ – in fact, according to her, it didn’t seem like losing weight was one of her goals. Now this could be several things: the fear of judgement, even her own self-loathing, the paralysing awareness of the enormity of such a goal, the dashed hopes of the past, or it could just be that her weight, as the key negative determinant of the majority of her health concerns & quality of life, has just never been brought to her attention, nor the connections explained to her in simple accessible language. So over to us, right?
There were other health determinants at play in this patient but the centrality of the adiposity was undeniable & the practitioner said this was the greatest take-home. She’d been ready to don some jungle gear and go hunting some zebras – but there was a horse right here in front of her and that could not and should not, ever be ignored.
What else became apparent was the lack of knowledge & skills regarding how to take a comprehensive weight history & why this is crucial. Not only for this type of unhealthy weight, the underweight require exquisite attention, as do those with a more labile weight than expected as an adult. This brilliant article by Kushner et al from 2020 is a total gift in that regard and a must-read for every clinician. We feel uncomfortable asking about certain things when a) a patient feels uncomfortable which is usually because b) we are uncomfortable and this ultimately comes from not being clear about WHY this information is so important and HOW this will ultimately enable us to better help THEM.
This is the very latest, comprehensive review of the key aspects of thyroid assessment that will revolutionise your understanding of thyroid markers. Gain a clear understanding of how to provide the best, most individualised, thyroid management by learning to read the real story in each patientâs pathology patterns. Boost your knowledge and confidence looking at TFTs, rT3, thyroid antibodies & related nutrient patterns, as well as AITD, environmental EDCs, HPA driven HPT issues, thyroid nodules, the impact of dietary macro- & micro-nutrient imbalances and much more!
This 4 part series provides over 10 hours of the very latest research & findings, punctuated with real case studies, that will both contemporise and deepen your understanding of all things thyroid, with a bonus recording on Adrenal Assessment.
And for weeks now I’ve really been banging đ„đ„ The 1st drum was me making us all salivate & suffer through my month-long Mediterranean feast The 2nd, my ongoing incurable fixation on the ‘Power of the Ps’ – Protein & Potassium, not just individually, in terms of meeting optimal requirements for each, but relationally, as in, the (im)balance between them & the clear goals that have come from research for best health outcomes.
Maybe now you can hear the individual drumbeats merging to form some sort of chorus rather than a cacophony?! I canđ¶ And largely that’s because I decided to put the Ps & Ps principles (Total Protein:Potassium < 1; Animal Protein:Potassium <0.6 etc) into practice, entering my own meals into software to see how often I kicked each goal and how often I missed (& [ouch] kicked myself). Personally, I think thirty years in the game can lead to some laziness around looking in depth at our own dietary habits. As in, I know the ‘rules’ right, back to front, so I’ve told the ref to have the rest of the season off! My meals are both mantra and memory foam. There’s a lot of eat and repeat. Like my heavy lunchtime reliance on my ‘protein power pack’: 2 XL soft boiled eggs on 1 piece of avocado paleo toast and a bunch of asparagus. My (in)famous buckwheat breakfasts loaded with nuts, yoghurt & fruit. My bulk-cooked plant protein heavy, animal protein light, stews, sauces and soups. Even, what I considered my laziest but luscious organic farmers market meal, pan fried lamb rump steak, steamed fresh new season potatoes & a bunch of asparagus. So which of these would you have put your money on for the most Ps& Ps goals kicked? đ€đ€Ż
The Lazy Luscious Steak & Veg Meal Wins with… Total Protein : Potassium of 0.56! Animal Protein : Potassium of 0.41 Btw that’s because of the Potassium-punch of Potatoes [>2200mg!] and the finale of Figs & dark chocolate [329mg]! Animal Protein : Vegetable Protein of 2 : 1 (ok so you can’t win everything!)
Now obviously I am just looking at each meal individually, but the Protein & Potassium goals are really daily ones, however, I, like most people, don’t lay out the totality of my ideal food intake for the day and then think, now how do I make this all edible?!  I think in meals not metadata! So this little exercise was already incredibly rich in insights, checking my assumptions and snapping me out of some misguided mental calculations into the real world, placing a ref back on the pitch! I’m not ditching any of these favourites – just more mindful of what meal goes with others across the day, for better balance. Now all this analysis is time-consuming of course and while various software will do the macro and micro crunch, as far as I know, you still need to do all the Protein and Potassium calculations by hand, Ah yup. So, 1) I’m stopping now & 2) I’m thinking about creating a little spreadsheet that auto-calculates a lot of these targets once you’ve obtained that basic elemental data to input, for easier use in the future – would you use it?? [insert answer here đââïž]
And then you can show me your kick arse protein/potassium combo! Because clearly even us ‘experts’ apparently need data to double-check our assumptions!
Now where’s the other đ„ in all this, that Mediterranean one, I hear you ask? It’s in the figs! My lamb dinner actually just missed reaching the targets for protein and potassium balance…until my fig finale! And remember, what the Greeks say, ‘A few figs a day keep the chronic-mild-metabolic-acidosis at bay!’ đ Just jokes…
To prevent or minimise our slow but steady march towards sarcopenia, the need for dietary protein adequacy to fuel muscle maintenance is a no-brainer â but how does ageing affect this? We get less bang for our buck. We have to eat more, to get the same âamountâ but do you know why this is? Add to this, that also as we age, we experience a greater acid burden from a lower acid dietary load. And given that a higher acid load (PRAL), has been shown to have a negative effect on muscle and bone markers in the past, clearly to ensure optimal health of our bones and muscles as we age, we have a riddle, or two, we need to solve. How do we use Protein and Potassium intakes to benchmark our patientâs diet quality and musculoskeletal risks and can we modify their consumption of either, to drive therapeutic gains in terms of both BMD and muscle?
You can purchase The Protein & Potassium Riddle of Ageing – Muscles and Bones 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 audioâs and resources here.
Ok look away now if you’ve already heard too much from me about Greece. I understand. For the rest of you, still prepared to tough-out the travel tales, we’ve been discussing my recent thrill at eating something very similar to the Mediterranean diet – often touted as the panacea of dietary principles by nutrition researchers worldwide. And then, I also confessed to some [ahem] deviations from this, and from what I would normally think would constitute a healthy diet for me. Lastly, I put out the question, “So how is it that with all these dietary demons I felt great?”
Just like me, some of your busy brains got busier! “It’s the holiday-factor aka lower cortisol!” “It’s all the incidental exercise you did at the same time!” “It’s the climate – you were basking in sunshine!” “It’s the different bread!!!”
Just like me, you were alert to the unmistakable fact that this was not a single variable intervention! All of the above, & more, had changed along with my food intake. I was on Ikaria for most of my month – which is a Blue Zone due to the locals remarkable longevity – above and beyond that of other Greeks and those living in the Mediterranean generally. While there, this conversation about the contributions to Ikarians’ health came up, again and again: ‘It’s our attitude – we just don’t stress about things” says the man who doesn’t open his little Taverna till 9 or 10pm each night because his ‘real job’ is looking after his goats & vegetables. So the locals, who all know where the key is, let themselves in and await his appearance. He cooks for his friends as a way to keep company and community not to make a living. “It’s our physical labour”, says another who splits her time between Ikaria and Sydney, “the 70 and 80 year olds aren’t sitting at home waiting for a visit, they are out in the fields, tending to their garden, mending their house etc” “It’s our unique thermal pools around the island at the edge of the ocean”, say many, “they’re rich in Radium & Thorium”
Hang on, back up there, I’m soaking twice a day every day, in what?!
Yes it is a well-researched phenomenon that the levels of radioactive elements in the oceanic geothermal springs of Ikaria exceed the amounts safe to consume. Luckily, I wasn’t ingesting it, outside of the occasional wave that caught my face off-guard. But this is not the end of the issue. Actually, the hot springs featured in my video above, where I stayed and bathed for a week, is referred to by locals as ‘immortal water’ and considered potable. While, I didn’t meet any such locals who made mention of drinking the stuff, several warned us against spending too long in the pools, but with the hottest temp recorded in Ikaria springs, also the hottest recorded anywhere in Greece, at 58.3 C, that may have just been because we were cooking our insides! While the science says dermal uptake of Radium is unlikely and volatilisation leading to inhaled vapour is also unlikely – I am still undecided about what role the unusual radioactivity of the place – also seen in the soil- plays in the health of the Ikarians – either good (longevity-wise) and bad (anecdotal reports of very high rates of thyroid issues – but this could be a very well-cooked red herring!). Listen I am the first with my hand up for hot springs, anywhere!! Case in point above. But this has left me with an open tab in my brain about the real health implications of the unique make-up of each.
So what is the Mediterranean diet’s most powerful mechanism-of-action (MoA)? Well if you’re doing it properly, you’re somewhere in the Mediterranean 💕😂
Notice a bit of a theme? Me too. Ok, so 50 is a landmark year, for lots of great reasons & they are all staring me right in my (increasingly wrinkled) face. But just at the edges of my now newly bespectacled visual field, I catch a glimpse of that stealth threat and thief: senescence! Consequently, for purely personal gain 😂, a couple of months ago I took a microscopic look at what happens to our ECM as we age, and [ahem] all you glib young folk, that starts at 18 😱😱😱 so wipe that smile off your incredibly elasticised and collagenised faces!!
Now my lens has zoomed out, to take a more macro view of what happens to our musculoskeletal system as we get older and the very latest research about what role these 2 key indicator nutrients (of dietary quality, of PRAL, of many key health outcomes) play.
For most of us, the need for dietary protein adequacy to fuel and fund muscle maintenance or growth is a no-brainer â but how does ageing affect this? We get less bang for our buck. We have to eat more, to get the same âamountâ but do you know why this is? Add to this, that also as we age, we experience a greater acid burden from a lower acidogenic dietary load. And this has been shown to have a negative effect on muscle and bone markers and well â we have a riddle (or…spoiler alert… 4) on our hands! This has been a hotly debated and controversial area of nutritional research â particularly with respect to the acid-ash hypothesis and especially with regard to how this influences bone dynamics, the risk and trajectory of, osteoporosis etc
But at last we have a very meticulousmeta-analysis & systematic reviewthat has clarified much â and certainly given both âsidesâ (the ânay-sayersâ, as in, acid base balance plays no part whatsoever in anything & the âPRAL preachersâ, as in the end is nigh if the acid is high) some re-direction.
And then thereâs the ever-growing recognition of the potent and pervasive impact of sarcopenia (yes Iâm talking to ALL of us!) Together with a new heightened appreciation of how powerful a player nutrition is, especially Protein and Potassium, in setting the scene for healthy homeostasis and preventing decline. So take a read of these key articles yourself or join me in the latest Update in Under 30 Episode to get the low-down on how we can master the musculoskeletal ageing slowdown!
To prevent or minimise our slow but steady march towards sarcopenia, the need for dietary protein adequacy to fuel muscle maintenance is a no-brainer â but how does ageing affect this? We get less bang for our buck. We have to eat more, to get the same âamountâ but do you know why this is? Add to this, that also as we age, we experience a greater acid burden from a lower acid dietary load. And given that a higher acid load (PRAL), has been shown to have a negative effect on muscle and bone markers in the past, clearly to ensure optimal health of our bones and muscles as we age, we have a riddle, or two, we need to solve. How do we use Protein and Potassium intakes to benchmark our patient’s diet quality and musculoskeletal risks and can we modify their consumption of either, to drive therapeutic gains in terms of both BMD and muscle?
You can purchase The Protein & Potassium Riddle of Ageing – Muscles and Bones 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 audioâs and resources here.
But just like so many well-meaning researchers who purport to employ ‘THE’ Mediterranean diet while their dietary intervention is actually just a rough approximation, I can’t claim that what I ate over my month in Greece was an identical replica of what the locals were munching on circa 1960.
The majority of meals absolutely ticked every tenet of what we’ve come to associate with this style of eating: 💪Dominated by Vegetables e.g. 9 serves a day
💪A few foraged Fruits e.g. 2 serves
💪Olive oil over everything!! e.g. up to 8 serves
💪Loaded with Legumes AND Grains e.g. up to 13 serves!!
But of course the ‘cereal’ serves in my month-long feast were primarily presented in the form of *BREAD*. Yep gluten-full, yeast-abundant typically white, bread! And rather than ‘our daily bread’ try…thrice daily bread 🤯 None of us being bread-eaters back home we tried to initially politely decline the *BASKET OF BREAD* that automatically arrived on every table. every time! This, in turn, was received by the waitstaff with either SHOCK or LAUGHTER😂 and often even a genuinely astounded, âWhy not?!â Ring any bells for anyone else? And to be honest, this was a question, we ended up asking ourselves. Because, while none of us would cope with that kind of bread burden in Australia – digestive and or energy-wise – we were right as rain wiping up all the oil and left over sauce off our plate with big pieces of the fluffy lovely stuff!
Add to this some other things I would never dream of back home: 🤯Adding sugar to my coffee – hey if you’ve tasted Greek coffee you’ll know this is non-negotiable!
🤯I’m a ‘grilled gal’ over fried but in Greece I became a fan of fried aubergine, zucchini you name it!
🤯Eating almost without pause – grazing*lazing*grazing –Â and not even extended overnight fasting which is my norm
🤯Executing a ‘seek and destroy’ policy on pastries like this…
So how is it that with all these dietary demons I felt great? Full of energy, no GIT issues, and while my clothes don’t fit like they did before my trip, it’s in the opposite direction of what you might suspect! But of course, the adoption of the Mediterranean diet AND these transgressions were not the only things that changed over my month…and just like speculation on other elements of lifestyle, which may convey the health benefits to the Mediterranean people, we might need to examine these as well…more to come…(again, if you can bear it!!!)
Somehow it didnât dawn on me immediately, that I was in fact living this nutrition nerdâs dreamâŠI WAS ACTUALLY EATING THE MEDITERRANEAN DIET! 🤯 😍 Like, the real-deal, legit, bona fide, honest-to-goodness, original, dinkum 1960s Greek diet.
That realisation occurred to me, I think, on the very remote island of Ikaria, not far from Turkey. After walking several kms from our already remote village to the next, we entered the tiniest of shops (and there was only 1), and slowly surveyed every single thing on offer to that community. Which prompted me to turn to my daughter and insist she immediately take a photo of the disproportionately large shelf-space dedicated to legumes! Ah yesâŠcanât travel with themâŠ(nats/nuts/herbies you know who you are!)
Now of course, and Iâve acknowledged this before, in some regards Iâm a bit slow. Because this fact was there from the outset for the taking â along with all the figs (fresh, dried & every stage between), pomegranates, grapes, blackberries, almonds, walnuts, prickly & wild pears, freely available, growing along most roadsides, footpaths, farmers tracks & parks, that we enjoyed collecting on any & every walk. With the bounty deposited straight into my open mouth, all my and my bagâs pockets and even my keep-cup, which proved a great way to protect delicate delicacies. With more time I even scaled-up, employing egg-cartons for mass-movement of figs, when making our teary but timely departure from the Dodecanese & return to Athens.
In this way, while consuming them in abundance every day, we were able to consistently cross âfruit and nutsâ off the list. Shopping done!
And perhaps it might have occurred to me after the 5th, 6th or 17th taverna meal, comprised essentially of all my favourite vegetables, absolutely swimming in olive oil, with a small bit of lamb, goat, fish, or seafood, tucked in there somewhere for good measure. Or given the meatâs exquisite flavoursâŠâself-seasonedâ as my partner called itâŠtasting of the wild herbs & greens the animals themselves had eaten, all served with a side of beans â either fava, giant beans or lentils and oh myâŠwe must discuss the bread… but next time.
Iâm just getting started with tales from my feast field research tripâŠthereâs so much more to tell (if you can bear it!!)
Gone are the days, thankfully, when we could all easily identify any individual taking an antipsychotic 1) because they were the marginalised ‘mad’ and 2) stigma and shame were rife. With the seismic shift that has occurred both in psychiatry & society we now know so many of the people we live or work with just might be taking ‘something’ & under any number of diagnostic labels. And increasingly the ‘anti-psychotics’ are not reserved for the psychotic nor the ‘mood stabilisers’ for the manic. Which can complicate things – especially when it comes to their thyroid.
You see it’s a mistake to think that only Lithium spells trouble for thyroid function
The latest piece of evidence from a study of over 25K BPAD patients in the US tells us this common misunderstanding makes us prone to not recognise all the other patients in whom their psych meds are disrupting and in fact driving thyroid (dys)function. Though Lithium carbonate remains the most noxious goitrogen due to its multiple disruptive mechanisms – the rest of a large group of Psych meds (yes even antidepressants!) are impacting to the point of effecting the thyroid function test results you are likely to see in patients taking these. And this is something we need to be alert to – these medications are essential, non-negotiable in most scenarios, but a secondary hypothyroidism is not their intended goal and can make matters worse.
Cue our growing understand of psychoneuroendocrinology, of course. Your HPT is influenced by your mood & vice versa
I told you I’ve rekindled my love and passion for thyroid pathology and this is one of the many elements I got to include in our latest updated training * Advanced Thyroid Assessment* and the upcoming MasterCourse. But I just had to hit record on this one aspect immediately – because if we don’t recognise the cause we are likely to be throwing all the wrong things at the thyroid – to no avail. This kind of subclinical or overt hypothyroidism is not due to nutrition per se, or due to some other kind of HPT re-setting influence like inflammation…it’s the meds & that necessitates different solutions & a much bigger conversation…so join me…
Many of us recognise the bidirectionality between thyroid function and psychiatry wherein ‘stress’ and mental illness can produce a predictable pattern and shift in TFTs and vice versa but regarding the question of psych meds as potential goitrogens, many of us are mistaken in thinking this issue begins and ends with the use of Lithium carbonate. As it turns out, an increasing number of these pharmaceuticals are recognised to disrupt thyroid health & activity via a variety of mechanisms both centrally and peripherally & as a result many patients may get stuck in a vicious loop of worsening thyroid function and mental wellbeing. – until someone calls it – someone like us.
How much? How often? When is the best time & timing? do you know about friends, foes and frenemies? Which form, when? e.g. building blocks or bioactives? And for how long? aka are we there yet…?
These are the kind of questions that one would imagine nutritional prescribers can always answer – but can you? Yet this is the goal, right? So that with each and every unique individual who needs supplements – we have a clear, consistent go-to framework to guide & direct these prescriptions. One that makes scientific sense, offers optimal outcomes and removes the uncertainty.Â
From my interactions with thousands of practitioners, however, I know many of these key questions plague practitioners & they feel, at times, as if they’re flying without a net, or without a strong systematic approach, or at the very least without all the answers to these questions.
I’ve had so much good fortune & so many others to thank for providing me with this foundation. Fay Paxton – my nutrition lecturer in my under-grad who indoctrinated me with a systematic approach. Dr. Tini Gruner – my principal supervisor at SCU, who shared & further fuelled my passion for biochemistry and reading labs to extract insights into each individual. And thanks also to all the pharmacists I’ve delivered education to over the years, who, as a result of their grounding in the principles of pharmacokinetics, always ask the best questions – questions that if I don’t know the answer I know I need to know the answer! So I made it my mission to find out!
While we dip into these aspects of nutritional prescribing in our regular mentoring groups on an ‘as needs’ basis, I’ve decided the time has come to create a year-long program dedicated to sharing this information and building this skill-set in practitioners.
This monthly meet-up is delivered live (max 1.5hr) and runs from Feb to November with the following currently proposed format *subject to change dependent upon the needs of the group
March  What happens to what gets left behind?  e.g. enhanced enterocyte micronutrient concentrations & their effects plus unabsorbed nutrients & their interactions with the colonic environment
April What happens to what’s absorbed e.g. distribution, hierarchy of needs, activation and deactivation
May  The pharmacokinetics of prescribing
June Where do our ideas on dosing come from? e.g. Physiological Vs Pharmacological dosing & actions. The basis & believability of maximal intake boundaries?
July  Bioefficacy V Bioequivalence. Beyond building block nutrients: Is ‘Bio’ (-active, -peptides, -materials) always better?  e.g. GABA Vs Glycine, NAC Vs GSH, PLP Vs Pyridoxine, Niacin Vs Niacinamide riboside ——————————————————————Aug month off—————————————————————————
Sept  How often & for how long? Are we there yet? And how would we know? Plus Fast Vs Slow Nutritional therapeutics
Oct Strategies for Supplement Success e.g. friends, foes and frenemies in nutrition underpinning principles with examples; compliance changers for clients
Nov Live attendance & opportunity to participate in a case-based mentoring session
This monthly ‘live’ meet up will be delivered as part of 2023 Group Mentoring as The Nutritional Prescribing Program Group Mentoring applications open 17 October 2022.
To join the waiting list and be notified when applications are open, email the team at [email protected]
Find out more about what groups are available for Group Mentoring in 2023 here.
Have you been told somewhere by someone that the âperfectâ TSH is 1.5 mIU/L?  This is a wonderful, terrible & wonderfully terrible example of âmagical numbers medicineâ.  As a push-back against the published reference ranges weâre given, that are so wide you could drive a truck through them, there has been an over-correction by some, leading to the myth of âmagic numbersâ.  We can narrow the reference range substantially for many parameters with good rationale, make no mistake about that but once we start setting âaspirational goalsâ that are explicitly rigidâŠwell weâve done 2 things 1) forgotten about the patient to whom this result belongs and 2) disregarded viewing each result as part of a âpatternâ, that we must piece together and make sense of.
Back to TSH then⊠if my obese patient had a value of 1.5 mIU/L this in fact would be woefully inadequate – so too a child at any weight.
And we expect a higher value as well in our elderly clients too and this level there may be, in fact, increased mortality.
But the same result would be excessively & worringly high in my patient whoâs undergone thyroidectomy.Â
Realising the full value of any test result in terms of what it reveals about the person sitting in front of you, requires these more thinking and more thoughtfulness. Unfortunately, a list of ‘magic numbers’ will often lead you astray.  And building your scientific knowledge about labs will not only help you avoid the pitfalls of pathology but will strengthen your pathophysiology prowess in surprising ways, saving your patients a packet in terms of additional extraneous testing and help you truly personalise your prescriptionsâŠbecause the âinvisible (biochemical individuality, oxidative stress, genetic probabilities, subclinical states, imbalanced or burdened processes etc) just became visibleâ.  I started requesting lab results early in my career and years later was lucky enough to be taken under the wing of Dr. Tini Gruner. I found some of our shared notes, from 10 years ago, scribbled all over patient results recently and I was struck by just how lucky I was to have her encouragement to really pursue my interest and how she was a guiding force about learning to recognise pathology patterns over single parameters. A decade on I can concede, much of my clinical and educative success has come off the back of this foundational skill-set and I know, this is true for so many Iâve taught too. Â
âThe guidance Iâve received over the years from Rachel in relation to pathology interpretation has been one of the most valuable (and fascinating) investments Iâve made as a clinician. Her teachings have filled gaps in my knowledge base I never knew needed filling and have significantly enhanced my understanding of the inner workings of the body! Rachel has an incredible ability to make the numbers that patientâs so often present us with, both understandable and clinically meaningful. The knowledge Iâve gained by investing in this skillset has paid off in dividends and Iâm certain will continue to do so into the future.â
Stacey Curcio â Cultivating Wellness
I hope youâll join me for the most exciting up-skilling opportunity in learning labs yet. OhâŠand all this talk about thyroid testing..this next MasterCourse series is focused on revolutionising your understanding of thyroid, adrenal, HPT & HPA markers based on the very latest research & findings & marry these together with everything you learned in MasterCourse I (ELFTs, FBE, Lipids & Glucose) to understand the âwhole storyâ.
âŠan absolute treasure trove of free integrative health information about your patient!
DEEP DIVE INTO REAL CASE STUDIES TO DEMONSTRATE EACH PATHOLOGY PATTERN IN ACTION. ]\
There are limited places. To sign up for Rachel’s LIVE Series – MasterCourse II: Thyroid & Adrenal Diagnostics and for more information click here.
One of my dear friends told her husband several years ago that she had noticed he was now making, ‘old man noises’ upon standing up from couches & chairs. She told him that must simply stop. She pointed out that he was only 50 and that she neither could nor would listen to that for another 40 years!
He stopped!
But aging and old (wo)man noises are coming for all of us, right? And by the time we’re making those noises or excusing ourselves from certain activities due to sore, dodgy or NQR [insert joint or body part], we’ve spent several decades unknowingly right on course to get here! We don’t generally pay any attention to our ECM (extracellular matrix) which suffers in silence, slowly but surely losing its structural & functional integrity from the age of 18 on, until we reach the tipping point: joint degeneration, repetitive soft tissue injuries etc, and a problem that will never be silent again! Cue your choice of anti-inflammatories it seems – til death do us part!
The Ageing Matrix is a thing.
And no I haven’t seen the movie – I don’t need to – I’m living it.
When I was pregnant I thought I wanted to specialise in pre-conception & pregnancy care. Then my babies arrived and I took a fancy to paediatrics. Sound familiar to anyone? Now, unsurprisingly, I have a real thirst for knowledge expressly aimed at bettering this whole ageing-thing! So in preparation for this Update in Under 30 episode, I’ve relished the opportunity to put the Ponds Institute & all similar cosmetic companies on notice! Scrutinising their claims that every woman on the planet would do better with more Collagen, more Elastin, more Hyaluronic Acid, just more of every key ECM component really. Ok, but in accordance with my bias and my business, my lit review pertained to oral supplements, not outrageously priced magical middle-life-crisis rubs and the therapeutic action I had in mind was the integrity of our ECM, and the roughly 2kg of collagen, we rely on, for functions a lot less frivolous than stopping sag. I have to say, I started out as non-believer but the research was quite the awakening…still there’s a lot to unpack here in order to repack our ECM and prevent against the erosion of its integrity and everything we build, and rely on, upon it – to live well!
Osteoarthritis (OA), like osteoporosis, is a diagnosis made after decades of disease. Underpinning it all, is our aging Extracellular Matrix (ECM) with its characteristic compositional change that leaves us vulnerable, from the ripe old age of 18! The ECM, like all other tissues, is made from basic building block nutrients but presented in their most fanciest of forms with triple helix structures, aggregates and other large molecular weight components, that each possess remarkable physico-chemical properties & convey extraordinary functionality to structures like joints. But is prevention against, and effective intervention for, OA as easy as consuming more of these ECM biomaterials?
You can purchase Supplementing Collagen & ECM Biomaterials – Whatâs the story? 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 audioâs and resources here.
13 years ago I was first asked to contribute to ACNEM’s thyroid training 8 years ago I put together a little Masterclass on Diagnostics & 6 years ago co-created another one on Thyroid 2 years ago I dived deep into new literature to update my ideas & my teaching for ACNEM again & reinspired by all I had discovered 1 year ago I promised a new MasterCourse, for all those eagerly awaiting the next instalment: Thyroid & Adrenals Now it is about to land!
Across this time I have fallen in and out of love with this topic. ‘In’, in the early heady days of learning some great tricks and tools, ratios and relationships between thyroid parameters (T4:T3, rT3:T3 etc) to aid interpretation but then ‘out’, when I discovered in my own patients and many others, that while this solved some thyroid patient puzzles, it left the curlier ones with questions remaining. I became unsatisfied with the simplistic stereotyping of the thyroid hormones (T3 important & always good, T4 not, rT3 never) and frustrated by the misapplication of ratios & lazy labelling of the thyroid as the ‘problem’. All of these things I intrinsically knew didn’t make good scientific sense and actually revealed a lack of depth in mine & our understanding. So I re-immersed myself in the very latest research and, wouldn’t you know it, in the time between there’s been a mini-revolution taking place in relation to our understanding of the HPT axis and the other endocrine circuits that manage it! Thank goodness for science!!
As a result, not a slide, possibly barely a dot-point remains from what I wrote back in 2009 and not a great deal more from 2015 even.
Thatâs how far the research has revolutionised my ideas & understanding.
Some of the assay techniques & technologies are new, thereâs a river of research & a mountain of meta-analyses published in the time between & I have had the privilege of innumerable more clinical encounters in this space, to really nut out how all this translates into the real world. And most importantly I can confidently say that this training and teaching reflects the truly integrative nature of psychoneuroimmunoendocrinology…did I just make up a word?! Basically, if you think that the hypothalamus and/or pituitary is the boss of the thyroid – we need to talk! Thereâs a lot I need to catch you up on.
So like our first MasterCourse in Comprehensive Diagnostics earned us a reputation for, we are going to leave no stone unturned – no difficult question – unanswered, like…
Can you list the critical roles in health of T4 that are independent of its precursor potential?
How about rT3 – what are the important health implications for us if we don’t have enough?
When shouldn’t the T4:T3 in the plasma be approximately 3:1?
When and why would a drop in TPO & Tg antibodies signal progression not remission of AITD?
In the absence of imaging, can you still be confident that thyroid nodules are the most likely differential in your patient?
What is the one test result that differentiates between Euthyroid Sick Syndrome and Central Hypothyroidism?
Exactly how low in Selenium, Iron or Zinc do you need to have a measurable impact on thyroid hormones and function?
Who escapes from the Wolff-Chaikoff effect and how long after iodine dosing can we be certain?
So stay tuned… and watch this space! We thank you for your patience and know it will be worth the waitâŠ
âAbsolutely loved this course, Iâve listened to each of the recordings at least 3 times now taking furious notes and am still picking up new gems. Love that itâs helping me build up my knowledge and confidence in such a fundamental area of practice. The case studies are super valuable as they bring the labs to life, Iâd be keen for more of these! Really appreciate all the extra PDFs / audios that have been added also. Eagerly awaiting MasterCourse IIâ â Naturopath | Australia
âWhy wasnât this content covered in medical school? As a psychiatrist, I have greatly benefited from attending this course which comprehensively covers the ins and outs of interpretation of pathology labs and how this applies to clinical cases â many of which have both physical and mental health considerations. I believe all doctors from general practitioners to specialists will gain from attending! â â Psychiatrist | Australia
âThank you so much for this course, it has been brilliant. It has âfuelled my practiceâ and many people have benefited already â from such insights. Itâs quite thrilling!!! Iâll definitely be signing up for the second course later next yearâ â Naturopath, Medical Herbalist | New Zealand
I’ve spent the best part of about 4 months recording my *NEW* Advanced Thyroid Assessment training. I told my team this would be easy and quick, given it was to be based on a great little 2-part, 2hr updated presentation I delivered just last year for ACNEM!! Sixteen weeks (like seriously…most of it) numerous rewrites and retakes later, our final product is 4 parts that goes for over 12hrs in total & has a bonus Adrenal recording! And yeah my team are impressed but unimpressed too if you know what I mean?!🙄🤪
Every time another, ‘Oh wow!’, or ‘No way!’, escaped my lips, it was a source of personal celebration, as another deeper layer of learning revealed itself.
But to the wonderful, somewhat weary and definitely wary Sally, who does all my powerpoints, it was met with, ‘Oh boy!’, because it meant many multiple new slides to build full of visual metaphors, animation acrobatics, if not an entire new Part!*#@^
Her sage advice along the infinite research road I’ve been travelling was : ‘Stop. You’re going to have to stop.’Â
So I did but now I am this meme. Everything I see currently through the lens of thyroid health, I talk in tongues TFTs and my brain is one giant neural network of integrative endocrinological circuits! I have fallen in love with this topic, this neuroendocrine axis and its ‘first responder’ role all over again! Hence our little thyroid character below – all ‘antennaed’ up – is one of the many tools we’ve developed for this training, to teach us that ‘bad thyroids’ per se are extremely rare – but bad scenarios are common (too much or too little of any macronutrient, key micronutrients, a change in the internal or external environment etc etc) and this little fellow and his board of directors (no – not the hypothalamus or pituitary!) – well it’s their job to ‘read the room’, right?!
In the absence of this key understanding we risk: A lot of lazy labelling in thyroid health – ‘You have a bad thyroid – that’s why you…[can’t lose weight, feel tired, have SIBO etc]’ Misdirected treatment & especially a tendency to overload the butterfly with ‘thyroid’ nutrients – which can do more harm than good
I’ve said many times, ‘perfect number pathology is a myth’ but it runs rife in practitioners’ beliefs about TFT results with complete disregard of the person those labs belong too! Did you know, for example, that your TFTs should all be higher if your BMI is? That your T4:T3 ratio should never be 3:1 if you are on replacement, have hot nodules, are pregnant or are acutely unwell etc etc etc? How about how low your Selenium or Iron levels need to be before this factor will influence the actual levels of thyroid hormones measurable – & what the impact of these deficiencies are well before then that is far more sinister and serious? Yep…you see here I am, pouring just some of the tiny take-homes of Advanced Thyroid Assessment ALL over you!Â
Watch this space my new Thyroid training is just around the corner!
An increasing number of our patients have thyroid concerns but unbeknown to many of us the most likely explanation of all is thyroid nodules, whose incidence is on the rise globally. The development of nodules has always been primarily viewed as a nutritional disease. Traditionally attributed to chronic iodine deficiency but recently novel nutritional causes have emerged. Benign nodules come in 2 flavours: hot and cold and while patients can present with a mixture, it is the presence or absence of a hot nodule that radically changes what complementary medicines you can and canât use and what an effective treatment plan looks like. The pointers, as is often the case, are there for us in the patientâs presentation and pathology, so knowing the difference is no longer a guessing game. This UU30 comes with a great visual clinical resource and includes key papers on the nutritional management of nodules.
Any pathology test is only of value if the result produced is ‘real’, or, representative of that individual, right? So the timing of the test is a major pivot point then: do I tell my patient to present for the test, or collect the sample themselves, on their ‘best’, their ‘worst’ or their ‘average’ day? đ€·ââïžÂ Well, that all depends on the question you are trying to answer.
Whenever we reach or refer for a test, we have a question in mind we’re seeking an answer to. But the question always comes in two parts, at least.
Part 1: How much progesterone is she making? Part 2: …When she’s ovulated & her corpus luteum should be most productive?
A third might refine the question you’re answering further by adding another contextual clarification
Part 3,4,5: …When she’s eating her regular diet, not exercising excessively or under extreme stress
Without these other parts – the answer to the first one: How much progesterone is she making (full stop), is hard to correctly interpret, right? By refining and expanding on the full extent of our question, we can be clear about which elements of this patient’s life the result likely reflects. We might say that for her, this time-point, or set of collection conditions, is a ‘real reflection’ of her generally and therefore, representative. But what if she does occasionally undertake a 5 day fast, or train for & compete in marathons? If we were to specifically test during these times, we answer a different question, right? Likewise every time we instruct a patient to present for their blood tests (routine or fancy schmancy): Fasted, Rested, Hydrated and off their supplements – is this sound advice or a misdirection? Well it depends on the individual in front of you and the real question you want answered about them đ€
Ahhhhh I love rules: both the making of them and the subsequent breaking of them đŠđŽââ ïž
The collection conditions for any pathology test – can refine or ruin the question you were hoping to have answered about your patient but is it always appropriate to ask everyone to ensure their preparation for the test was ‘ideal’? What if their real life is far from ‘ideal’ and contrasts dramatically with these ‘conditions’ e.g. they forget to drink water but never alcohol! Or do they run 20km every weekday and 40 on weekends? And why would we tell some patients to stop their supplements prior to a blood-test and not others? If our goal is to ensure any pathology test answers the question we need answered we need to know how to respond to these and other scenarios. This new update is all about keeping results ‘real’ & representative.
You can purchase Fasted, Rested, Hydrated & Unsupplemented? Exceptions to the Rule 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 audioâs and resources here.
No, I can’t leave it alone. I’ve been gabbing on about Gilbert’s Syndrome for about 15 years now and it’s not going to stop anytime soon! This is not because I think it’s the most common condition we encounter but, rather because it is not uncommon. It is also not because this diagnosis explains everything for the individual who has, not just the genotype but the phenotype, with only 1/3 of the phase II glucuronidation capacity the rest of us have, but it does explain much of what they’ve sought an understanding for and some assistance with, often to no avail. And all the evidence tells us that Gilbert’s Syndrome continues to suffer from ‘poor visibility’ in general practice – meaning that more often than not it goes unrecognised and undiagnosed. But we can do better…
New research has helped us hone our diagnostic detective skills, refining (actually, redefining) our reference ranges – dramatically lowering our threshold for suspicion of this condition.
While other studies have torn down old notions of: ‘just a tendency to jaundice’, detailing clearly the real health narrative Gilbert’s Guys ‘n’ Gals will present with, including an increased number of self-diagnosed ‘food reactions’, fatigue, greater mental distress, menstrual issues, poor tolerance of certain meds & alcohol etc
But just as SIBO, Mast-cell-activation, Ehlers Danlos Syndrome or [insert…other on-trend-‘explain-all’-in-spite-of-no-1-definitive-result-diagnosis], the Gilbert Syndrome ‘call’, can be completely on the money for some clients, and a complete misdirection for others.  These are big calls to make in our clients: ‘Here’s your why and here’s a 12 week, 12 month, lifelong management plan to address this!’ So we need to be absolutely thorough in our consideration of all things that mimic or overlap with certain aspects & features, so we don’t misdiagnose and, simultaneously, miss the real underpinning cause! When it comes to looking at labs and asking, Well, Is It Gilbert’s? – this means being across all the other explanations for high-normal or high bilirubin and following a methodical process excluding all others, to answer in the affirmative & with confidence.
I get Google ‘Gilbert’ alerts daily so IÂ have no life and am reading the latest research all the time, refining my own processes and certainly the way I teach others about this.Â
Cue my latest Update in Under 30 episode, which is really 15 years in the making. That’s 15 years of reading research, seeing patients, educating and answering the questions of thousands of other practitioners, in order to be able to see where we are getting it right and wrong, to produce a clear 5 step process you can follow to ensure your Gilbert Syndrome call is on the money, not a misdirection and therefore going to be a game-changer in their life – not a time and money waster.
Well, Is It Gilbert’s Syndrome? Many of us are now alert to this common but still under-recognised polymorphism that has pervasive effects on health. But if you were to base your diagnosis of Gilbert Syndrome on your patient having above reference range bilirubin levels, you will both miss some who have this condition, and misdiagnose others who don’t. Because of this, we need to be competent & confident in our process of identifying the real reason for greater than expected bilirubin levels, which include liver and biliary disease, abundant precursors, dyserythropoiesis esp B12 deficiency and several other genetic hyperbilirubinemias. This recording and the amazingly helpful desktop reference we’ve created to go with it, provide a clear process to follow, with concrete cut-offs for parameter values. Together these ensure you won’t miss a Gilbert’s Syndrome diagnosis but you won’t misdiagnose someone with it, either.
You can purchase Well, Is It Gilbert’s Syndrome? 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 audioâs and resources here.
We all (inaudibly🤞) sigh when patients utter this & adopt the brace position for whatever mis- or dis-information may follow.
So how would you feel, if instead, these were the words of the health professional you’re seeing?
We could debate forever the pros and cons of FB and its forums – & indeed it offers both – but one thing we must never lose sight of is what it has in common with the ‘wild west’: unregulated, unvetted, and with plenty of cowboys – often sadly, masquerading as experts, or just ‘very “generous” very very active group members’, with hidden agendas. I don’t generally engage with the naturopathic forums but occasionally I catch sight of things that I can’t look away from, and I can’t not speak up. Recently, someone (with a not-so-hidden-at-least-to-me-agenda) was raving about the dangers of N-acetylcysteine as a supplement & the way it was spoken about made it seem like it would be *poison* at any dose. Wha? As you may have learned from me it is definitely potent and in turn, demands our respect as a powerful therapeutic agent – directing our decisions about timing and reminding us, yet again, that least dose is best dose. But what this individual was purporting were adverse effects I’d never heard of in relation to this nutraceutical. So I simply asked, ‘Can you please share your reference(s)?’
Prior to me inserting myself into the comments – there had been enormous engagement specifically with this individual’s claims- which mostly went like this: ‘Oh wow! I didn’t know this!!’ ‘Thank you – that’s so interesting!’ “Oh that explains why Tom doesn’t like it, and Dick won’t take it and Harry says it’s horrible!” 🤦♀️
FB forums – seeking out the support & opinions of our peers can be truly wonderful but it can totally derail our knowledge too if we don’t keep checking the quality of that information. A simple: Can you share your references, or, where did you learn this? Should be part of the respectful and expected scientific discourse in our profession. I’ve asked that before when I’ve found myself yet again in a forum thread and had a truly fabulous response – with the practitioner generously sharing a number of high quality published articles that would have taken me ages to find myself! 💪Not the case in this recent episode. The 3 distinct claims, which all centred on NAC being bad for high histamine individuals, were ‘substantiated’ by just 1 primary reference & that was a Poster Presentation: “Human placental tissue was minced and subjected to a fractionated ammonium sulphate precipitation (35% / 65%). A fraction high in DAO activity was purified using hydrophobic interaction chromatography (HIC), and incubated with the drugs in prescribed concentration” . The full research has never actually been published in its entirety and the brevity of detail on a poster means you know barely any of the important details regarding the methodology. I also looked for any other research that emulated these methods or findings or even cited this paper – nada. And if you lead with your best – this was appalling low level evidence that is really unlikely to be relevant. But hey – here’s the 1 provided reference – make your own mind up! (see how easy that is?!)
I asked for clarification and for papers to support the other 2 claims. Silence.
But actually before silence a bit of ‘How dare you ask!’
That’s when I got a different insight into this forum & arguably a culture that doesn’t foster curiosity & questioning, if that risks challenging the ‘poster’s’ position. And when several incredibly intelligent, kick-arse clinicians quietly contacted me on the side to say, ‘THANK YOU!~ This person posts comments like this all the time & it’s so misleading & someone needed to say something, but it probably had to be you.’ Well that really made me 😥 because it didn’t, you know – any one of us can ask, “Can you share the reference(s) for that?” and clearly we need to more often 🤓
Why are we afraid to question information or ask for references and why are people afraid of the question? This should not be a competition or hierarchy of who can ask or not ask questions. And if the forum that you’re a member of makes it seem that way – then ask yourself, if its doing you more harm than good.
Aren’t we on the same team here? We all have a professional duty of care to our patients to ensure that in looking for quick answers we don’t get incorrect ones that misinform us, our patients and our treatment decisions.
Have you ever noticed that our products don’t work if our patients don’t take them?!đÂ
The reasons for non-compliance, dis- or non-engagement, poor patient buy-in & follow through are many:
*My dog ate the instructions * My inbox swallowed the instructions *As soon as I left your clinic, your instructions left my brain
Reasons also include far more credible things such as non-patient centred prescribing.  This is what most of us do when we’re full of good intentions but short on time at the end of a consult, so we just throw a bunch of products and a script with them out the door. Arguably many of us make this mistake also because our training perpetuated this relic of conventional medicine and paid insufficient attention to the therapeutic relationship. In contrast, patient centred prescribing recognises the patient as best-placed to find personalised solutions to their very individual challenges, including, decision making around dosing regimes. So while we continue to ensure & oversee that therapeutic doses are used and that best conditions for taking certain things are adhered to – your patient remains the expert in the room about how to actually achieve this – both in terms of when & where in their very real lives – with a little help from us – and what ‘works for them’, in terms of taste, texture & temperature.Â
That’s right, I said temperature…are you telling patients to take everything at room temperature??
You need to think again – this is something we can safely manipulate with many powdered & liquid remedies (some exceptions of course!) to match patient preferences & radically increase palatability, pleasure and ultimately patient compliance.
Are you like me? I have supplements scattered all over my house – in places that correlate with an action or moment in the day when I am most likely to take them. This is another important element of Patient Centred prescribing, so I work with my patients to identify these easy solutions too. After the gym? In the gym bag. After breakfast as you leave for work? In the key bowl. At work? On the desk beside the computer screen. Keeping taurine in the drinks cupboard in front of the alcohol is another nifty reminder and trick for those looking to ‘pre-load’ and cut down! Tips and tricks like these save our over-loaded memory. They remove or minimise barriers. They make compliance less effortful. And as a result, you know what? They might just get the results we would have expected!
Compliance Changers – Strategies for Success
At the end of an information & insight heavy appointment, formulating a list of products and doses for our patients to take can feel like a bit of a ‘tada moment’, like a magician pulling a rabbit out of the hat. “Here is the solution – now off you go!” Research tells us, however, that treatment-plans that are a co-creation between you and your patient – evolving from a discussion that not only allows them a voice, but a major role in the decision making – are far more likely to succeed. While we are the authority on our medicines, our patients are the authority on what makes them tick & what’s likely to succeed, in terms of taste, texture, temperature & timing! This is called Patient Centred Prescribing and together with some other tips tricks and hacks I share with you in this episode, can really increase patient buy-in, compliance and therefore bring your treatment plan to fruition and fulfilment!
You can purchase Compliance Changers – Strategies for Success 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 audioâs and resources here.
A recent foreboding article featured in NewsGP Pathology requests under the microscope warned, ‘More than 5000 GPs are about to receive a letter from the Department of Health about their pathology requests.’ This is a ritual cleanse performed by Department of Health (DoH) all in the name of fiscal prudence. They’re trying to weed out the ‘over-ordering outlier GPs’, who requested too many – wait for it – Iron Studies, B12, TFTs & Vitamin D tests between June 2019 and July 2021. That’s right, during a pandemic – when people were inside, locked down, had reduced food security and telehealth, as good as it is, removed clinical examination as an option!! Oh my…where do you start with this?đ€
No. 1: 5.,000 GPs out of a workforce of 31,000, constitutes 15% so clearly NOT in any way correct to call them outliers!
No. 2: These so-called ‘nudge’ letters have arrived & sadly the recipients are not the ‘rogue doctors’, they’d perhaps hoped to catch but actually GPs who see more pregnant women, more refugees, more aged care residents.
And mostly female GPs – I might addÂ
Or said most eloquently, in this online piece, by Dr. Carrington: “Who are the pathology nudge letters really targeting? Judging from the response on social media, these letters seem to have been received largely by GPs who treat our most vulnerable and marginalised patients.” And don’t get me started on how much $$$ identifying and correcting said-deficiencies SAVES the health system in terms prevention.đ€đ€đ€Â Has anyone actually done the maths (aka cost benefit analysis)?! In short, no. I am angry for my GP colleagues. This is sadly yet another example of the punitive system that they have to operate under and under which, as GOOD GPs pushing back against 5 minute medicine, they effectively have a target on their back. And I am dismayed for our shared patients and the general public, for whom basic nutritional assessments (2 of which are well-established as the most common micronutrient deficiencies we encounter in general practice), it seems, are being deemed a poor use of tax-payer funds, this DoH fear-mongering campaign is value for our money?!
Back to Dr. Carrington: “Nudge letters are not harmless. They inflict enormous anxiety and dread amongst GPs and inject a real sense of fear into clinical decision making. Many GPs are already feeling burnt out and are contemplating how to transition out of the profession. Trainee numbers are at a frighteningly low rate.
Targeting GPs in this way is inappropriate and discriminatory against those who practice high rates of womenâs health, mental health and aged care.”
The biggest way we can help is accessing old results!! True. Many patients have a lot of lab results across multiple medical practices. Step one – see what they can retrieve and provide you with, such that you can pull it all together. This way: a) you know what has been assessed and when and avoid any doubling up & b) you extract maximal value from these by creating a cumulative & comparative dataset for your patient – being best placed then to ‘see their normal’ and be alert at the earliest possible time to any intra-individual shift – likely reflective of an emerging process that then c) WE CAN TAKE ACTION TO PREVENT FURTHER PATHOLOGYđȘ And if you are going to write letter to a GP, now more than ever this requires a clear understanding of the kinds of issues they face & a respectful & rational approach to communicating the merits of any follow-up investigations you might wish them to consider.
âThank you so much for a wonderful presentation yesterday, Rachel. It gave me a new perspective on how it must feel as a GP to receive incessant demands from Naturopaths/Nutritionists to order pathology for their clients. I am in awe of your integrity, desire for patient empowerment, humility and respect for other professionals in the mainstream health arena. I felt that every single naturopath and nutritionist out in the big wide world ought to have listened to your insightful words of wisdom when it comes to shared care of our clients. We are blessed to have you as our teacher.â â Michelle Blum (Mentee 2019)Â
Over years of delivering independent education in integrative health I have spoken to some diverse audiences. This has included health professionals from very different backgrounds: from hospital-based psychiatrists & mental health nurses, to whom I presented on site in hospitals both in Australia & NZ, to a national sparkle-arkle speaking tour, in front of large groups of aesthetic practitioners. They’re the doctors & nurses for whom botox and fillers are their tools of trade, and yes I got to see actual demonstrations of their work performed live!!!đ¶ More recently, I’ve had several opportunities to deliver evidence-based independent education on nutrition to pharmacists en masse – which I always enjoy because they ask some of the best questions!
Underpinning each decision to accept an invitation from a 3rd party, be that a company an organisation or an institution, to speak, is: 1.The realisation of an opportunity for nutritional medicine to reach more people, a wider audience, & ultimately expand the circle of influence amongst health professionals, who interact with & advise the public at all different levels 2. An agreement and/or contract that ensures my independence, the correct use of my materials, image, brand and IP & removes any expectation to promote their products/services etc
And my ‘door’ is open to any invitation which meets these 2 criteria. So you might have seen my name, previously associated with some brands or organisations, in the last few years disappear off their speaker announcements, or no longer connected, and in turn you might see my name pop up in new places! Like….Metagenics Congress on Autoimmune Disease!! After many invitations from this company, that I wasn’t able to previously accept, I am pleased to be speaking at this face to face event on the Gold Coast in August. What a novelty, hey? Face to face?! My talk is about the 4 Mistakes not to Make in Hashimoto’s and as always, I’ve completed a full mini-literature review in order to speak to the very latest on diagnostics and nutritional management, in this condition. Yes, to quote a Costanza, “We’re back baby, we’re back!” And to see my full current smorgasbord of speaking commitments & all the people I am ‘spreading the (nutritional) word’ to – just click here.
This previous training will take your understanding of the interplay between food, nutrition, environment and the thyroid several steps further. With more supportive research and a greater focus on the mechanisms behind the relationships between these macro- & micro nutrient & environmental factors, this presentation is for the true thyroid die-hard.
How much has THE worldđ changed in the last 2 years?! Have the changes within the field of Integrative Health been equally seismic? I’m sure there are many different aspects to speak to & we all have our own thoughts to share on this. I shared my thoughts on this topic in 2021 with AIMA conference attendees and now I’m pleased to share them with you as well. Of course, your position in the integrative health landscape influences your perspective. I’ve relished the ongoing opportunity to mentor and supervise clinicians of various persuasions (nats, nuts, GPs, pharmacists, psychologists etc) and at various levels of experience – from new grads to some seriously seasoned & stand-out successful practitioners, as well as being a member of several medical & health communities such as ACNEM, AIMA, NHAA , not to mention my inner circle being dominated by health professionals, to boot!
As you might have noted too – oodles of this research has come from Down Under âĄđȘ And btw – we have some serious gratitude owing to our publishing peers here in Australia, who are making huge contributions to making ‘us’ and our work visible in academia: (Amie Steel, Hope Foley, Erica McIntyre, Mathew Leach to name just a few!) So while our visibility is improving in academia – are we also being more ‘seen’ by the population as a whole – you know- the ones that make up our client base, stimulate our brains, engage our empathy and sustain our clinics staying open? The data, both published and from practitioner ‘word on the street’, tell us in unison
When the challenges we as humans face, grow in number and variety, the skills and our contributions Integrative Health professionals offer, in terms of advocacy, time-taking, a person- centred approach & individualisation of treatment is in demand more than ever. And on that note I want to leave you with one of my favourite quotes about person-centred care from Psychiatric Interviewing by Shea – but it is true no matter was the presenting complaint, nor where you are in the process of helping that patient:
âIn person centred interviewing, the patient is not viewed as the problem but as a unique individual filled with solutions to the many problems that life invariably brings to all of usâ Shea 2017 page 9
Oh and P.S. The AIMA FACE-TO-FACE Conference is BACK in November this year!! And given the last time I did this, we were just on the eve of the pandemic and I raced home to just miss curfew…it feels like a perfect place to gently, gingerly come out the other side(??)!!đ
As integrative health practitioners, regardless of the tools of our trade, we empower people and advocate for those that donât feel powerful with respect to their health and well-being. We are compassionate and empathic, âalternative thinkersâ and notoriously dogged diagnostic detectives. This talk aims to remind us about our true super-powers. These distinguish us from other health professionals and service providers and are in greater demand than ever before, during this time of significant planetary and population change and challenge.
Last week, yet another patient with refractory diarrhoea, up to 10 stools a day, Bristol type 5-7, for 3 decades following a diagnosis of Crohn’s at 16 years old. A range of specialists have thrown everything at ‘it’ – single & combination immunosuppressants, TNF alpha blockers, buckets of sulfasalazine and bathtubs of antibiotics – she’s been gluten and dairy free for years, trialled strict diets that are FODMAPs free, low histamine etc etc etc. She’s even had 50cm of her terminal ileum removed & the diarrhoea continues unabated – perhaps even worse than before…& therein lies a major clue.
 1/2 patients with Crohn’s exhibit bile acid malabsorption –> diarrhoea but with terminal ileum resection this jumps to > 90%
This is Type I BAD (Bile Acid Diarrhoea) & is the easiest to spot, being the result of anatomical change. You remove the section of the small intestines responsible for 95% of the reabsorption of bile acids…a LOT of bile acids are going to be present in the colon where they act as potent osmotic laxatives, right? But there are 3 other types which are a little trickier to identify – including one that affects up to 50% of IBS-D patients.Â
Being a child of the 80sâĄđč (ok a teen of the 80s but who’s counting?!) and a personal fan of fat, I NEVER thought I would EVER be recommending a ‘low fat’ diet to ANYONEđ€
But hey, that’s another ‘absolute’ that needs challenging, right? I mean this is the primary, almost only, dietary change these patients need to make and as a stand-alone intervention, is highly effective for many. We’ve had several patient successes in the last year – a total game-changer for patients in similar situations where all kinds of ‘restriction’ had brought zero joy and reward for all their ‘good (dietary) behaviour’. While sequestrants (like cholestyramine) are recommended in BAD, and are certainly worth a trial at least, patients have very mixed results – for some, in combination with the low fat diet it’s a winner – for others these meds cause GIT upset all on their own and actually undo the good of the fat restriction. Being able to identify the true reason for their loose stools and stop them going down endless rabbit holes of ..is it? is it? is a great way to re-empower people who’ve been bossed and bullied by their bowel for far too long đ€đȘđ§»
This is not a trick question. Up to 50% of all patients diagnosed with IBS-D actually have bile acid diarrhoea (BAD) underpinning their digestive complaints as well as some patients with non-resolving diarrhoea post-cholecystectomy and gastro. Knowing which ones do and how to manage this, which requires distinctly different approaches from our general management of IBS, is the key. As always, good lessons come from those we learn in the clinic and this story starts with a patient and how we came to recognise the BAD in her belly.
