Have you been told somewhere by someone that the ‘perfect’ TSH is 1.5 mIU/L? This is a wonderful, terrible & wonderfully terrible example of ‘magical numbers medicine’. As a push-back against the published reference ranges we’re 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 ‘magic numbers’. We can narrow the reference range substantially for many parameters with good rationale, make no mistake about that but once we start setting ‘aspirational goals’ that are explicitly rigid…well we’ve done 2 things 1) forgotten about the patient to whom this result belongs and 2) disregarded viewing each result as part of a ‘pattern’, 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.
Also too low for any patient, no matter their size, if their T4 is low and we’d like a higher value as well for risk minimisation in our elderly clients too.
But the same result would be excessively & worringly high in my patient who’s undergone thyroidectomy.
Being given a list of ‘magic numbers’ will never replace learning labs correctly. When we do this, we come to truly know that meaning can only be made of the markers when you can answer the following questions:
What is this (metabolite, analyte, binding agent, plasma protein etc)?
What do I know about its physiological and biochemical context – what is its role and regulation in the blood, what moves it and to what magnitude?
How have the reference ranges been determined for this lab – who am I comparing my patient to?
Therefore, what is the significance of a result that is: ‘normal’, ‘low normal’, ‘high normal’, below or above the range?
Does this value ‘fit’ with my patient?
What else could explain an unexpected result?
How strong is my level of evidence?
What do I need to do from here to confirm or refute this?
And a few more 😉
Realising the full value of any test result in terms of what it reveals about the person sitting in front of you, requires these skills. Unfortunately, in contrast 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 prescriptions…because the ‘invisible (biochemical individuality, oxidative stress, genetic probabilities, subclinical states, imbalanced or burdened processes etc) just became visible’. 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 confess, much of clinical and educative success has come off the back of this foundational skill-set and I know, this is true for so many I’ve taught too.
“The guidance I’ve received over the years from Rachel in relation to pathology interpretation has been one of the most valuable (and fascinating) investments I’ve 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 patient’s so often present us with, both understandable and clinically meaningful. The knowledge I’ve gained by investing in this skillset has paid off in dividends and I’m certain will continue to do so into the future.”
Stacey Curcio – Cultivating Wellness
I hope you’ll join me for the most exciting up-skilling opportunity in learning labs yet. Oh…and all this talk about thyroid testing..that’s just a serving suggestion 😉 this year my MasterCourse is focused on the most routine labs of all: ELFTs, FBE, WCC, Lipid and Glucose Panels…an absolute treasure trove of free integrative health information about your patient!
This skillset has been found by many to be biggest ‘game-changer’ in Integrative Medicine!
There are limited places. To sign up for the MasterCourse: Comprehensive Diagnostics click here. For more information about the program click here.
I wanted to pass on this image (from Twitter by Victor Tseng) that was shared with me by a medical colleague – it’s important. Many of us are thinking ahead now in terms of the ‘coming waves’ of COVID. I have certainly been very mindful of a future wave of mental health problems in patients of all descriptions, those predisposed and already vulnerable, as well as those for whom it may be unprecedented. As my wonderful wise colleague, Kate Worsfold pointed out, it’s important to be anxious to some extent right now because anxiety is a protective mechanism to ensure our survival. So during this time, the anxiety drives us to wash our hands more often and more thoroughly (at last, we’re mastering basic hygiene!) and socially distance ourselves and these are constructive, reactive behaviours, right? But of course for others, it may trigger or provoke destructive emotional and mental states and for some of these will be the result of new hardship (economic, relationship, occupational etc). We are perhaps seeing some of the early increase already, but according to the diagram above, it is the ‘4th wave’ and its true peak will be reached after all the others.
This image also speaks to the ‘3rd wave’ which will result from people putting their (very real) health needs on hold, right now…indefinitely.
No one wants to visit the doctor right now, (that’s not an insult to all my lovely doctor friends…you know exactly what I mean), patients are avoiding getting their blood tests, and aren’t maintaining continuity of care with all sorts of health professionals and therefore, interrupted care of chronic health conditions is certainly at hand.
We all know someone making these choices right now, I’m certain. Elderly family members, our own patients, even, perhaps, ourselves…all concerned about placing ‘unnecessary burden’ on the already burdened health care system. But in each scenario we need to do a quick risk-benefit analysis: what are the risks of letting chronic care lapse, or new possible acute presentations be triaged by Google instead of the ER? Yes one of my patients with a suspected fracture even, has held back and home-diagnosed! Versus what are the risks of presenting for assessment or for ongoing management and monitoring if you apply due diligence in terms of hygiene etc. And from what I understand, the medical clinics in most areas with low COVID case numbers have ample appointments available and have everything in place to protect patients and their workers. They know the risks more than anyone – both of COVID19 AND of everything beyond (COVID) being ignored and their doors are open! And of course so are those of the nats, the nuts, the herbalists etc – just now often virtual doors rather than those found among bricks and mortar.
We all need to encourage and be encouraged to not drop the baton of better health.
Because we can not be certain of when this will change and our health should not be left on hold.
One good thing to spread widely right now…pardon the pun 😉
Our NEW! MasterCourse in Comprehensive Diagnostics starts 28th May!
The primary objective of this first 6 month MasterCourse is to realise the true value we can extract from the most commonly performed labs (ELFTs, FBE, WCC, Lipids & Glucose) which constitute the largest biochemical data-set we have on almost every patient. By learning how to comprehensively interpret these labs in an integrated medical framework, using the very latest science, we can extract the gold often buried in this goldmine. Accordingly, we prove ourselves to be the greatest asset to our patients, to other health professionals we are sharing care of patients with and we cut the cost of additional expensive testing, that is less well understood and validated. Limited spots available – email us at [email protected]
I am feeling concerned about many of you because chances are, given you’re reading this, you’re running a small business in healthcare right now. Relax, I am not a ‘Doomsdayer’…I don’t think the current situation has to be the death knell for our clinics and businesses, nor even a near-death experience but I do think it requires:
Dedicated and directed thought
Dedicated responsive planning
Follow through actions NOW to pave your way to a sustainable TOMORROW
I do not think it requires a paid business coach. I am a little horrified to see we are already being preyed upon by coaching businesses wanting us to invest more at this financially fickle time to be ‘shown the way to emerge triumphant from this’. That gives me the creeps. Enough said.
But I do know burying our heads isn’t the answer. In fact, that is probably the best way to bury your business for good. From connecting with hundreds of practitioners regularly I can confirm there is a trend emerging that many of us had absolutely predicted: some reduction in return appointments (patients not yet shifting to online or deprioritising long-standing health concerns and prioritising panic instead) and a much more worrying, more financially impacting, bigger drop in new patient bookings. We will only have this unprecedented run on ‘immune herbs and supplements’ for so long. We all need to do the maths…and fast.
Most of us know well enough the bare bones of our business to know this spells income trouble in terms of right now: via a lower hourly fee and moving forward, in terms of loss of expected growth of client base, in a nutshell a process of ever diminishing returns.
Wringing our hands and worrying is not dedicated directed thought. Which is instead about taking business advice from established experts (who have global experience in previous major financial crises) that is already out there for free and just committing the time to reading it and applying it to your own circumstances. The best I’ve found so far featured in Forbes Magazine…and no I have never read this mag before in my life either, only ever bought it for the pictures 🤣😂 BUT this article contains the essentials of what you need to consider right now and you can use it to form the basis of your planning, decision making and actioning. It applies to business generally and some of it is bit hard to translate out of CEO-speak but I’ve put my hand to it here for you. Please look at this, take the time to ask yourself these important questions about what may happen and how you could improve the outcomes of each new challenge. And if you find that still too difficult on your own, grab a couple of practitioner pals online and see if by putting your heads together you are better able to answer the questions this poses. If we learned anything from our horrendous fire season, it was, hopefully, that plans are meant to be made in advance…not when the flames are beating at your door. I recommend you make one, now.
To make it easier for you (and you know how I love creating resources!!), I have extracted and reproduced a table from this article – Forbes’ Business Strategies for 4 Phases of COVID. I’vejust modified it for you to download and use to create positive business strategies and vision for your future. You can download it here.
What does lockdown look like for you? More time spent…
A) Learning or B) Losing sleep over things outside of our control or C) Losing days just watching Tik Tok
I’m choosing ‘A’ and I know I’m keeping good company because last week many of my ‘nearest and dearest’ gathered on 2 occasions for some serious extra brain gym. The first was the ACNEM Fellowship Community of Practice that I had the privilege to co-chair with Dr. William Ferguson. A fantastic new initiative by @ACNEM to offer more hands-on mentoring and support to their doctors.
The second, our own Give-back-Gratitude Live Q & A for our Update in Under 30 Subscribers where I used the time to check-in and see if we could further the learning offered by our monthly audios and clinical tools.
Having all of those who attended, in my ‘home’ was a fabulous contrast to our social distancing ‘new norm’, and seeing all those lovely faces and buzzing brains behind them, warmed the cockles of my cortex!
For those of you that couldn’t make our UU30 date, I wanted to share a few things we learned in lockdown this week:
Copper can be absorbed through the skin and penetrate to deeper layers potentially increasing serum levels butthe degree of uptake is highly variable and more likely with prolonged contact e.g. jewellery and pastes not showers etc
Just like the Zn:Cu, when reviewing patients’ albumin:globulin, we must first look at each value individually and consider causes and consequences of low or high values, otherwise we can ‘miss the message’
When understanding labs of anybody who is not a couch potato we need to ditch reference ranges based on the general population because they essentially are…couch potatoes and ask ourselves 3 questions: 1) Whois this person outside of being ‘sporty’2) Whatis the nature of their sportiness because exercise ain’t exercise in terms of physiological effects and 3) When are the tests being done in relation to any exercise
On that last note, I am so thrilled to be able to share my brand spanking new presentation The Impact of Exercise on Pathology Tests – Beyond Artefact to Understanding which I put together B.C. (Before COVID19) for a NZ speaking engagement. This actually has been one of the most satisfying areas of research to expand my own knowledge in…explained a LOT about what labs go whacky (and why and how to navigate around and through this) not just in what you might call ‘real athletes’ but in weekend warriors, crossfit crazies, MIL (men in Lycra) and the increasing number of middle-aged or older women who just love pounding the pavement. Know the types? Our clinics are full of them…it is time to learn their labs properly.
Overwhelmingly when we look at our patients’ labs we compare their results with a reference range derived from ‘the general population’ aka couch potatoes! Therein lies our first problem. Exercise is recommended for health but we don’t know what this ‘looks like’ in terms of labs. The reference ranges reflect and assume ‘average’ muscle mass & haemodynamics & ‘average’ nutritional requirements in people consuming the SAD (standard Australian diet) none of which apply to the exercise enthusiast, weekend warrior, least of all the professional athlete! Given an increasing number of our patients are embracing exercise, this is an important instruction in what healthy looks like, how to make meaning of otherwise meaningless comparisons and ultimately enable you to distinguish between what is healthy exercise-induced adaptation, an artefact and an actual aberration that flags possible negative impact of emerging pathology for other reasons.
Click here to add The Impact of Exercise on Pathology Tests to your online RAN Library.
For all UU30 Subscribers the full Live Q&A Recording is now available in your ‘active content’ of your online account.
We’re keen to keep a bit of normal in all the noise. Are you? Here’s another way to keep your collegiate connections connecting and your brain blossoming! Our monthly podcasts are 30 minutes of jam-packed information and here is your opportunity to get more bang for your buck and expand on those 30 minute downloads with some serious drilling down! Keep the conversation going and get your questions, answered…
Rachel will be running a FREE 1-hour live Q &A to answer UU30 Subscribers questions about the first three episodes that have been released in 2020 (see the list below).
The live Zoom session will start at 6 pm (Syd time) on the 2 April.
Let us know you will join us so we can email the Zoom link on 1 April to you directly.
You are invited to pre-submit questions to [email protected] by noon 31 March.
We have extended this pre-submission due to the current circumstances. Rachel will do her very best to answer the ones that are the most common and/or offer the best-extended learning for everyone and, as many as possible.
What kinds of questions CAN you ask?
Specific topic-related short questions😊
“What’s is the copper (Cu) absorption rate like through the skin? I’m thinking of a couple of patients where Cu is high in bathing/showering water but it’s filtered from drinking water. Just curious about absorption rates through the skin with water as the medium, versus through ingestion/food/drinking water etc.”
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Here are the three episodes you can submit questions on. As a subscriber – you will find all these episodes in your ‘active content’. If you can’t make it, please still submit your questions as we will be adding this free bonus to your subscription account.
JANUARY: COPPER IN KIDS Copper, as a kingpin in angiogenesis, brain & bone building & iron regulation is a critical mineral during paediatric development. So much so, the kind of blood levels we see in a primary schooler might cause alarm if we saw them in an adult. So too their Zn:Cu. But higher blood Copper and more Copper than Zinc are not just healthy but perhaps necessary during certain paediatric periods. This recording redefines normal, low and high with a great clinical desktop tool to help you better interpret these labs, as well as reviewing the top causes and consequences of both types of Copper imbalance in kids.
FEBRUARY: YOUR MASTER INFLAMMATORY MARKER Patients’ labs lie, not often, but sometimes and the inflammatory markers performed routinely like CRP and ESR have been known to tell a few. Like when everything about a case screams inflammation but both of those say there’s none there. Why do they miss it?…well basically it’s not their lot. CRP and ESR have specific signals they only respond to and therefore reflect only certain immune reactions and at specific stages of that response. But there’s a nifty little calculation you can perform with all of your patient’s labs and suddenly see the immune activation, inflammation and oxidative stress that was lurking beneath.
OUTRUNNING ‘ATHLETE’S’ ANAEMIA Persistent ‘hard-to-resolve’ anaemia is a common presentation for anyone participating routinely in sport and that can be at any level, not just among the professionals. From our lovely ladies who take up running or Crossfit in their middle-age to our MIL (men in Lycra) and ‘weekend warriors’, they may love it but their haemoglobin and their iron doesn’t! Anaemia equals reduced oxygen-carrying capacity, a concern for anyone interested in optimising their performance but equally relevant to patients just trying to manage their energy throughout the day. In this important episode, we identify 4 different types of anaemia seen in patients as a result of exercise, incorrectly lumped together as ‘Athlete’s’ Anaemia.
JOIN RACHEL LIVE ON 2ND APRIL AT 6PM (NSW TIME) Make time to connect with like-minded practitioners to hear what they are asking about these topics and/or have your questions answered too.
This is a special bonus for our current premium subscribers only, so if you are not a UU30 Subscriber yet, you can sign up here.
TAKE UP THIS OPPORTUNITY!! RESERVE YOUR SPOT AND SUBMIT YOUR QUESTIONS BY 31 MARCH AT 12PM Email [email protected] so we can send you the link to join the meeting.
Yes, the news is – the current regulations may last for a while and as the social-distancing and best-to-stay-at-home message is slowly but surely sinking in. If you’re like me, more time ‘not out in the world’, means more time to get my creative thinking going and put my mind to how to sustain our humanity, sanity, professional and financial viability.
We have put together a few tips on how you can best support your clients, your community, yourself and your business.
PERSONAL
Look after yourself, both physically and emotionally. For most of us this is in fact an opportunity for more of this.
1. Build your benevolence muscle! Foster a rescue animal. Check-in on your elderly neighbours, family members, new mums – maybe trade a roll of toilet paper for a cup of rice or the other way around LOL
2. Keep some structure in place and your brain active. Can you use this opportunity to catch up on all the things you’ve always wanted to do but never really had time to? E.g get stuck into some of the online training, webinars, podcasts, papers, books etc. that you’ve never managed to watch, listen to, read about…the enormous library of ‘Medscape Fast Fives’ alone should see you through til August!
4. ‘Follow a routine’- this may include exercise (if you used to go to a gym maybe go for a walk outside), get ‘dressed for work’ as if it was a casual day in the office… etc. My team and I have independently established that our work gets done a little slower and our minds get a little sloppier (!) when we are wearing UGGs or slippers …so beware!!!
5. Keep connected with your support networks. Social distancing does NOT equal social isolation. Just take it online if you can (thank you technology!)… Your weekly book club, fortnightly visits at your aunty’s aged care facility, religious meetings, etc. It can all still happen.
BUSINESS
Stay dynamic, creative, and open-minded. Our profession requires us to come up with individual treatment plans for each patient so thinking outside of the box and on the spot is nothing new to us…Yet, it can be challenging when the structure as we’ve known it for so long is becoming more dynamic. So, what can we do in amongst all this…?
1. Shift to 100% online or phone consultations and offer smaller acute care-type appointments to reduce the costs for clients who are currently not able to afford comprehensive consultations
2. Consider further reduced-prices for so many people who are currently facing financial uncertainty – offer this online letting people in your community know about the kind of support you CAN (and can’t offer)
3. Put a few extra safety measures in place if your business includes a dispensary: Get clients to pre-order and pay via phone so that they can pick up their order when it’s ready (they could even wait in the car if preferred). Let any “walk-ins” wait outside, better still encourage them to call and pay over the phone instead and pick up the order when it’s ready.
4. Or use patient ordering systems more often and stay right out of the handling for the time being. Lessen your capital risk etc
5. Buyer beware of ‘CORONA CAPITALISM’ which is already afoot. Remember post-bushfires when every possible business’ marketing message became suddenly fire-friendly?! Well, there are plenty of businesses already rubbing their hands together over this pandemic 🙁 so stay smart and discerning. Only buy what you truly need personally and what you really can be certain of selling, professionally, and don’t over-commit because the true financial fall-out will not be felt for some time to come 🙁
6. If you are still treating people in clinic, introduce extra safety measures such as phone screening them (OS travel, current URTI sx) before even allowing them to present in person, getting your clients to wash their hands before entering, keeping a safe distance, and clean all clinic surfaces thoroughly every night.
Feel free to post any further tips and tricks on our RAN Facebook page, stay safe, learn lots and above all – stay connected!!!
Rachel will be running a FREE 1-hour live Q &A to answer questions about the first 3 episodes that have been released in 2020 (see the list below). Here is your opportunity to debrief and ask any questions you may have after you’ve listened to Rachel’s pearls of wisdom on these episodes. This is a special bonus for our CURRENT PREMIUM SUBSCRIBERS only. SAVE THE DATE AND GET YOUR UU30 SUBSCRIPTION NOW. The live Zoom session will start at 6pm (Syd time) on the 2nd April. You will be invited to pre-submit questions and Rachel will do her very best to answer the ones that are the most common and/or offer the best-extended learning for everyone and, as many as possible. Here are the three episodes you can submit questions on. Please note the March episode – Outrunning ‘Athlete’s’ Anaemia – will be released early on 24 March so you can listen before the live session.
Listen to me, I’m sounding all sporty 😂. I’m not though, just in case you suffer misguided visions of my virtues! But it’s not just the self-declared serious athletes that we need to have on our radar in relation to optimising their oxygen carrying capacity (aka window to winning). Our clinics are full of people, regularly running, doing triathlons for fun (!), riding vast distances clad in Lycra to drink coffee in other town’s cafes etc. etc. whose FBE might be feeling the pinch! That’s right! All these individuals, depending on the frequency and intensity of their exercise, could have the so-called, anaemia of an athlete.
Long gone is the idea that exercise-induced changes to your haemoglobin and red blood cells and perhaps even your iron, would only affect the ultra-marathon runners among us. It’s the swimmers, the cyclists, the Roller Derbyists, the CrossFitters, the basketballers, the Gym Junkies, the lawn bowlers..ok I may have gone too far now…they all are at increased risk.
Why? Isn’t exercise good for you? You know I so want to say, ‘Surprise! It’s not!’ but alas. Of course it is good for us BUT there are some fascinating challenges regular exercise can throw at your dear old blood and its bestie, iron. These challenges are incredibly dynamic – having one effect during exercise, a different one immediately following, and yet another in the days of rest in between. And sometimes, in fact, often, our patients can end up on the wrong side of these seismic shifts. Here’s how the story usually goes
“Oh yeah..I’ve had anaemia for ages! You know and it doesn’t matter how much Iron I take or how I take it – it never budges. But I’ve been told to stay on the Ferrograd anyway”
Typically, being told it’s ‘Athlete’s Anaemia’ is the first, in a series, of many many errors to follow. Because in fact, there is no such thing. That’s right. Anaemia is a symptom not a disease and exercise induced anaemia comes in 4 common flavours: Dilutional, Heamolytic, Iron Deficient & Acute Anaemia of Exercise, and knowing the difference is critical to correct management. Only 1 of them will reliably improve with iron and it needs to be prescribed in a totally novel way. Others will get worse with more iron. Yep. And one is a complete illusion. So when we don’t make the right diagnosis, which of the 4 types your patient actually has, we fail to find the fix. And while all of our patients may not be overly obsessed with improving their performance or even winning, let’s face it, they all want to achieve their PB, that’s why they came to see you. So can you tell the difference?
WARNING: I got so enthused about this topic that I went over. The current ‘Update in Under 30’ is a ‘serving suggestion’ only! And you may need to speed up your playback to squeeze in another bonus 10 min, if you can only afford your usual 30 min car trip to listen!
Outrunning ‘Athlete’s’ Anaemia
Persistent ‘hard-to-resolve’ anaemia is a common presentation for anyone participating routinely in sport and that can be at any level, not just among the professionals. From our lovely ladies who take up running or CrossFit in their middle-age, to our MIL (men in Lycra) and ‘weekend warriors’, they may love it but their haemoglobin and their iron doesn’t! Anaemia equals reduced oxygen carrying capacity, a concern for anyone interested in optimising their performance but equally relevant to patients just trying to manage their energy throughout the day. In this important episode we identify 4 different types of anaemia seen in patients as a result of exercise, incorrectly lumped together as ‘Athlete’s Anaemia’. Each type is easy to recognise once you know how and effective treatment of each is remarkably different. This summary and the super handy clinical resource that accompanies it will help you and your patients absolutely outrun it, at last.
For all Update in Under 30 Subscribers, you will find it waiting for you in your online account and don’t forget the **EXTRA BONUS LIVE CALL WITH RACHEL.
**This live Zoom call with Rachel is for current Update in Under 30 Subscribers ONLY. A Q&A session for subscribers on the UU30 episodes released in 2020. Contact the RAN Team to reserve your spot!
It is a challenging and confusing time for everyone.
Yet, as healthcare practitioners, we are needed more than ever, by our clients and our community, to do what we do best *educating *advocating * providing access to medicines * supporting
Our friends and esteemed peers down at Gould’s Apothecary’s (TAS) have shared some great tips on Facebook and honestly, they couldn’t have done a better job! Let’s look after ourselves and each other and collectively calm and curtail this.
The Naturopaths and Herbalists Association of Australia (NHAA) also suggests as follows: “For those of you who want or need to move consultations to an online or phone format, this is a valid option to protect yourself, your staff and your patients during the current pandemic.” Check with other associations if you are a member of these to see how they recommend you approach consultations while minimising risk.
Below is the Gould’s post and well, we couldn’t have said it better and thought this may also be something you want to share with your patients to let them know you’re well informed and you’re there for them.
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We’ve put together a list of simple steps you can take at this time to take care of yourselves and your loved ones.
Our list of suggestions below has been compiled with the intention of providing you with simple steps for actions you can take at home, or recommendations for things that you can access fairly easily. These treatments have the potential to support your general health and immune resilience, but to be clear, none of them have any proven action in preventing or treating coronavirus infection.
Gargle and drink GREEN TEA. Consuming green tea, in particular gargling it, has been shown to reduce the risk of contracting influenza and the common cold. The tannins in green tea have been shown to have broad antiviral effects topically. In one study, residents in an aged care facility gargling the equivalent of ½ cup of green tea three times daily were more than 15 times less likely (OR 15.7) to catch the flu https://www.ncbi.nlm.nih.gov/pubmed/?term=16970537
Take a Vitamin D supplement. Living in Tasmania is known to increase our risk of having low vitamin D. A number of studies have shown that taking vitamin D, particularly in people who are vitamin D deficient, reduces the chances of developing acute respiratory infections including influenza. Most studies reviewed used adult doses ranging from 2000IU to 4000IU a day, which is known to be safe to take long term even in the absence of deficiencyhttps://www.ncbi.nlm.nih.gov/pubmed/?term=30675873
Eat probiotic foods daily. Consuming probiotic foods regularly or taking a probiotic supplement has been shown to reduce the risk of developing an upper respiratory tract infectionhttps://www.ncbi.nlm.nih.gov/pubmed/?term=25927096You can consume probiotics through foods such as probiotic yogurt (Vaalia has 3 well researched viable strains in therapeutic amounts), sauerkraut or kimchi, in addition to many others. All of these can be consumed on a daily basis. If you would prefer to take a supplement, talk to us at Gould’s about the most ideal one for your situation.
Eat plenty of raw crushed GARLIC. We don’t care if you stink, we can all stink together! Garlic is one of nature’s best antimicrobials, and it is quite amazing in that it appears to be selective in its action – it doesn’t wipe out your good bacteria. Local organic garlic is best if you can access it, but don’t worry if you can’t – eat what you can find. Ensure you are eating raw garlic according to your own tolerance as not everyone can stomach it. We find that adding crushed garlic to a meal just before consuming it, or having it with avocado on wholesome bread, improves tolerability.https://www.ncbi.nlm.nih.gov/pubmed/?term=PMC4103721
Keep any medicines you regularly use in stock and within date. This includes pharmaceuticals (check your scripts are also in date), herbal remedies and nutritional supplements. At Gould’s, we have taken measures to ensure we have enough immune and respiratory herbs in stock to get through the winter season, and while we encourage you to be prepared, we emphatically ask that you don’t stockpile herbs, so that we can continue to serve the community through the winter period. Tinctures are also not something we can accept returns for, so please think about how much you realistically need. We are setting a limit of 500ml per person for respiratory and immune mixes, and while we won’t be policing repeat visits, we ask that everyone be mindful of others within the community also having access to herbal medicines.
Keep your home above 16°C. Having a cold home reduces respiratory resilience and increases susceptibility to and mortality from respiratory tract infections. This is especially important for people who are elderly, asthmatic or have other chronic/recurrent respiratory conditions.http://www.instituteofhealthequity.org/…/the-health-impacts…
Eat a healthy well-balanced diet. Eat an abundance of plant foods, high antioxidant foods (especially berries, kiwifruit and purple grapes), fresh local fruits and vegetables, nuts and seeds, and plenty of legumes. These help to feed your beneficial gut bacteria, which will assist you with immune resilience. They also ensure you have a healthy intake of vitamin C along with other nutrients important for immune health.
Don’t overindulge with alcohol. Binge drinking is bad for your gut flora, and also impairs immune function and increases the severity of respiratory tract infectionshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590612/
Get enough sleep, maintain a healthy exercise regime, and try to keep stress levels in check. We understand that these things can be easier said than done, but all three of these are integral to your immune system working well. So take the opportunities that present to take care of yourself.
If you do get sick, don’t panic, but please minimise your contact with other people, and follow the guidelines about self-isolation.
SELF ISOLATION IS RECOMMENDED IF:
● You have returned from or transited through any high-risk countries within the last 14 days. (It appears prudent to extend this to moderate risk countries also.) At the time of writing this post (12th March 2020) the following countries are considered high and moderate risk: Mainland China; Iran; Italy; South Korea; Cambodia; Hong Kong; Indonesia; Japan; Singapore and Thailand. It appears that USA may soon be classed as moderate risk also.
● You have been in close contact with anyone who has recently transited through these countries.
● You have been in contact with anyone who has confirmed coronavirus or is suspected to be at risk of being exposed to the virus.
● You have recently returned from anywhere overseas and have even mild cold or flu symptoms.
As a thank you to our current subscribers of Update in Under 30s, Rachel will be running a FREE 1 hour live Q &A to answer questions about the first 3 episodes that have been released in 2020 (see the list below). Here is your opportunity to debrief and ask any questions you may have after you’ve listened to Rachel’s pearls of wisdom on these episodes. This is a special bonus for our CURRENT PREMIUM SUBSCRIBERS only. SAVE THE DATE. The live Zoom session will start at 6pm (Syd time) on the 2nd April. You will be invited to pre-submit questions and Rachel will do her very best to answer the ones that are the most common and/or offer the best-extended learning for everyone and, as many as possible. Here are the three episodes you can submit questions on. Please note the March episode – Outrunning ‘Athlete’s’ Anaemia – will be released early on 24 March so you can listen before the live session. If you are not a premium subscriber yet, you can subscribe here https://rachelarthur.com.au/product/12-month-subscription-to-rachels-premium-audio/
Can you hear that? No it’s not some weird raucous bird-call. That’s me. A fabulous colleague of mine who also happens to be a Master MindMapper (yes it’s an official club now😂) , told me a couple of weeks back that practising naturopaths who don’t use this incredible tool for their case work-up typically say, “Oh, I’ve internalised that!” Well we laughed and laughed and yep even as I write this the giggles are back. You see between the two of us we have almost half a century of combined clinical experience between us (no telling on who has the bigger share!!) and WE haven’t managed that feat…so we’re wondering what we’re missing (bigger internalised RAM?) or indeed, what they are?! And naturally, I’m leaning towards the latter.
‘I practise holistically. I am truly integrative’, you say, ‘I consider all levels of evidence in patients, from their narrative to their neurologist’s report – from their bloods to their B vitamin SNPS – from their detailed diets to their social (dis)connections”
And I know you do.
But how on earth amongst all the information overload, that deafening white noise & distractions, can you always see the root cause and every connection?
Because for me, spending the time practising due diligence with the creating a MindMap, after I see every patient, is my reliable path to achieving this. Not just settling for the reflexive related systems that become well trodden paths in our minds…Gut to Brain (walked that track a million times, right!)…but step by step deepening my understanding of the case, adding layers I couldn’t see or hear at first, to reveal other critical connections that were unexpected. Gut to Kidney –> Kidney to Brain. It’s that time of the year when I’ve (clearly) been talking about MindMapping with my mentees and accordingly, I’m all juiced up! And my love of this process and skill-set is also getting more layers! I’ve realised that of course, beyond summarising the case in a truly integrated way, it helps me sift through my differentials, creating effectively a to-do-list about what things need follow-up assessment via questions, validated surveys, or testing. It also keeps me (and patients) accountable moving forward, as I come back to this over months and years while they remain in my care and I have to answer the question: did we address that?
This Master MindMapper Mate – she’s gone 1 GIANT step further, dedicating (virtually) the next few years of her life to writing a thesis on Complexity Science and, in part, how holistic medicine has now finally found its friend in science via this progressive model.
And MindMapping, and timelines and other key tools for genuinely integrated patient work-up, are the things that enable us to consistently uphold our holistic principles and practices and keep pace with the scientific progression. So if you wanna join our club 😂 because you’re already a MindMapping enthusiast don’t forget to contact [email protected] to find out about and ideally participate in her study. And if you’re feeling like the words MindMapping are Martian-speak for something you know nothing about 😥 …then maybe you should check this out.
As integrative health practitioners, we pride ourselves on taking in the ‘whole health story’ as a means to accurately identifying all the contributors & connections to each patient’s presenting unwellness. In the process, we gather a wealth of information from each client – pathology, medical history, screening tests, diet diaries etc. that borders on information overload and often creates so much ‘noise’, we struggle to ‘hear’ what’s most important. The management of complex patient information and the application of a truly integrative approach, requires due diligence and the right tools. Mindmapping and Timelines are two key tools to help you go from vast quantities of information to a true integrated understanding of what is going on in the case and the more time we spend learning and applying these tools, the more they will write the prescription for you. Not just for today but for the next 6-12mo for that patient.
Ever suspect you’re being gaslighted by your patients’ results? Especially when their CRP result says, ‘nothing to see here’! But every other piece of information and every one of your senses tell you they’re inflamed and their immune system is up to something!!Me too. You probably then look at their other results, their ESR or their white cell count searching out something that supports your hunch, but they too can look disappointingly unremarkable. That’s the moment when you wish life was like a televised sports match and you could check the video evidence rather than believe the mere mortal (and clearly blind!!) man in white on the pitch. Well guess, what…you can.
Albumin
÷
Globulin
As long as you know how to divide one figure by another using a calculator. I’ve found it requires the same digital dexterity as pushing the ‘on’ button’ on my blender…so if you can make a smoothie, you’re sorted! So while almost every lab routinely reports these two as separate parameters that are also routinely in range…I haven’t seen many that actually do the calculation for you and give you the Albumin:Globulin (AGR) on a platter. Yet this one step maths transforms the mundane into magic and can reveal almost all to you regarding your patient’s level of immune activation, inflammation and oxidative stress, from the largest number and variety of drivers. That’s why I call it, 📣The Master Inflammatory Marker 👑
When factoring in your patients pathology results is at its best – it makes the invisible suddenly visible to us. We could have sat and eyeballed that patient all month and never suspected that their Hcy was too high, or they had antiphospholipid antibodies or, or etc.
But the albumin to globulin ratio goes one step further & trumps the other inflammatory markers we’re so familiar with, because it even sees what they can’t!
And a low AGR (≤1.2) signals just that to you. So when the patient with joint pains, or just a little bit of belly fat or an emerging yet unnamed autoimmune condition presents exasperated saying, ‘but apparently I’m not even inflamed!’…you can let them know you do see it, and it’s just that others weren’t looking in the right place, then get busy rolling your sleeves up to move those markers! That’s right, a low AGR is a clear call to action for practitioners engaged in risk minimisation, prevention and for working towards best outcomes in established disease and monitoring a patient’s AGR is a series of clear sign-posts about whether you’re leading them in the right direction or not. There’s a lot more to say on this this third umpire & ripper of a ratio – about kids, the contraceptive pill, confounders, a role in cognitive impairment prevention and what optimal might look like but hey…the cricket’s back on…gotta go 😂
Patients’ labs lie, not often, but sometimes and the inflammatory markers performed routinely like CRP and ESR have been known to tell a few. Like when everything about a case screams inflammation but both of those say there’s none there. Why do they miss it?…well basically it’s not their lot. CRP and ESR have specific signals they only respond to and therefore reflect only certain immune reactions and at specific stages of that response. But there’s a nifty little calculation you can perform with all of your patients labs and suddenly see the immune activation, inflammation and oxidative stress that was lurking beneath. It’s called the albumin to globulin ratio and it’s going to change your understanding of what’s going on in your clients and your ability to monitor the efficacy of your management.
Sometimes I think I must be psychic..or is that psychotic? Don’t answer that, it’s a bad Byron Bay in-joke. I had literally just recorded my Update in Under 30 Copper in Kids and this excellent new study was published that same week, assessing and comparing trace minerals in age-matched ADHD and neurotypical kids. Snap! ✨ First, a moment of panic…because believe it or not, there are very few rigorous studies that have looked into this and so I had already read them all cover to cover and could confidently say, I had a grip on the literature. Gasp…’ will it have a different finding and challenge the much broader story about the excessive demonising of this mineral in kids health?’ Everyone take a big breath out…no.
But if you’re someone who thinks you’re seeing Copper toxicity in kids, you can keep taking a big breath in and while you’re at it a huge bit of new information:
Copper Excess is Normal in Children.
Every investigation of blood Copper levels in kids has reached the same conclusion and this latest one by a Russian group of researchers renowned for their work in Copper agrees. So the ideas that we have about optimal in terms of mineral balance for adults may stand, but can not and should not be applied to children. The elusive 1:1 relationship between Cu and Zn, for example, considered aspirational in optimising the mental health of big people, is absolutely not desirable or even healthy, in little ones. Why is it so? I hear you ask (…because you loved those old Cadbury chocolate ads with the crazy Professor as much as I did) Well, essentially because kids need more Copper than us, as a simple result of their increased growth requirements: blood vessels, bones, brains…Cu is a critical player in them all and more. And while we (and when I say ‘we’ I mean ‘I’) may be passionately passionate about Zinc’s importance, turns out, in paediatrics, it really does play second fiddle to Cu and should.
This new contribution to the Cu & Zn in ADHD kids debate did find that compared with neurotypical kids, their Cu:Zn was higher BUT – **and this is the really important bit **- as has been shown in a similar cohort before, the shift in relationship between the two was due in fact to lower Zinc levels NOT higher Copper.
So, I guess when you think about it…Zinc perhaps really does still deserve all our loving attention we give it 😂…we just need to rethink the whole negative attention we tend to mistakenly give Copper!
Copper, as a kingpin in angiogenesis, brain & bone building & iron regulation is a critical mineral during paediatric development. So much so, the kind of blood levels we see in a primary schooler might cause alarm if we saw them in an adult. So too their Zn:Cu. But higher blood Copper and more Copper than Zinc are not just healthy but perhaps necessary during certain paediatric periods. This recording redefines normal, low and high with a great clinical desktop tool to help you better interpret these labs, as well as reviewing the top causes and consequences of both types of Copper imbalance in kids.
The latest Update in Under 30 has landed. You can purchase January’s episode, Copper in Kids here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
-Your RAN Online Account has a NEW LOOK!!-
Next time your log in, you will experience a more user friendly way to search, view, listen and download your resources. Find out what’s new here.
While we may not all be pathology proficient, overwhelmingly we do take or record blood pressure, right? It’s such an easy but essential inroad to understand something more about patients’ cardiovascular system, and indeed their nervous system, when prone to the so-called ‘white-coat syndrome’. And it never fails to amaze me how the ‘numbers’ are so abstract and cryptic to the average patient. They’ll tell you things about previous BP readings like, ‘it’s normally fine I think, you know, like a 40 and maybe a 160, does that sound right? Ahhhhh…not quite. But of course these two numbers are not cryptic to us. And like all patient results, rather than our response being a simple, binary, GOOD/BAD one, we should be asking ourselves: What does this actually mean? What is it telling me?
Consequently, I’ve been interested in the blood pressure battle going on in America. Having traditionally placed the greater significance on a patient’s systolic pressure with comparatively little attention paid to the diastole, there have been lots of ruffled feathers following the redefined cut off for hypertension, which now flags any diastolic pressure over 80mmHg.
An unhealthy high systole of course is undeniably the most meaningful in terms of short term cardiovascular consequences and we are in no doubt that lowering this is critical for risk reduction BUT a new longitudinal study of over 13,000 UK citizens just published in the Journal of the American Heart Association, suggests that perhaps patients’ high or high-normal diastole in mid-life was in fact the earliest warning sign of poor cardiovascular health in the future. This comprehensive study followed participants for 8.5 years and essentially found that a rise in diastole in their mid-life (ahem, that’s our 40-50s 🙄) predicted the progression of arterial stiffness more strongly than any other measure. Additionally, while diastolic blood pressure tends to decrease as we move into our 6th decade and beyond, those individuals in mid-life with higher DBP –> more arterial stiffness were same people in whom their DBP drops the most significantly later in life. What a guise!! So, in a nutshell this substantial study teaches us:
“Prevention of arterial stiffening and the associated transition to a late-life hypertensive phenotype of falling diastolic BP is likely to depend on effective control of midlife diastolic BP in particular.”
Fortunately, the people we see are more in their mid- than late-life, which this new understanding speaks directly to, presenting the greatest window of opportunity for prevention in terms of modifiable risks for chronic disease, especially CVD, dementia and renal disease which arterial stiffness is such a major risk for. This extraordinary separate longitudinal study following individuals born in 1946 also suggests mid-life BP(both systole & diastole) is the major modifiable factor for later brain volume, integrity and function. Maybe we need to keep our eyes on that lower figure and our ears more closely peeled to hear what in fact it’s telling us 😊
Increasingly our patients are coming armed with lab results and this cumulative data helps us to clearly see their ‘norms’ (as opposed to textbook ones) and therefore be alert to any changes. However, results from different labs at different times, and even the same lab, are unlikely to be presented side by side for easy comparison. They certainly don’t come with all the important information about what was happening for that patient at each time point – important details pertaining to the blood collection itself (fasting, inflamed etc) which can profoundly alter results or the broader context: menstruating, breastfeeding, losing weight, on meds and supplements. The Patient Pathology Manager retains all the results for you, including the critical contextual elements, helping you to keep more accurate records to make the most correct interpretation. It also assists you to monitor changes related to various interventions.
Previously, this tool has only ever been available to clinicians who participate in Group Mentoring but due to frequent requests for access, we thought it was time to share this great tool for those wanting a foot up with some better systems in their practice.
Copper deficiency happens in kids, so does copper toxicity and both are serious concerns, but do we know when to accurately call either? First, we have to know ‘normal’. If we know what normal Serum Copper values look like in children, then we can easily spot those falling below or above this, right? That’s the first hurdle we tend to knock over and break a toe on! Being a mineral whose levels vary widely in soil from country to country, globally, the differences in reference ranges are breathtaking & absurd. Add to that, that copper is a key mineral in kids, driving huge demand for it during key periods of development, so the range for pre-schoolers isn’t the same as the primary or high schoolers – not that your lab is flagging that. Unhelpful? Yes. Dangerous, even? Potentially.
To diagnose ‘Copper Excess’ in a child is a big call to make.
One, because most practitioners are unaware just how much Copper a child really needs at each age & two, high copper is often a messenger for something else going on and then three, the primary objective based on this diagnosis becomes to lower their Copper but we could be either shooting the messenger or missing the mark all together…right?
Copper excess does happen but not nearly as often as practitioners believe it does. And in kids, the fall-out from such misdiagnosis is bigger. And missing a Copper deficiency? (because we’re not as well-trained to recognise it and because Copper has been sadly demonised) Likely to have myriad negative impacts at this vulnerable age…almost none of which generate symptoms or a distinct clinical picture e.g. secondary iron deficiency, low neutrophils without necessarily compromised immunity. But what about the holy grail get-out of jail adjective: ‘relative’. You know, ‘this is at least a Copper excess relative to their Zinc?’
Well, to form this opinion you’re likely calculating the Zn:Cu ratio and applying an ideal adult value of 1:1 but show me the primary evidence that supports this for kids…anywhere? The Zn & Cu relationship shifts as we move through life-stages and in fact Copper is supposed to dominate through a lot of our childhood so…ummmmm…no.
HTMA Copper side-steps all of this?..double no.
I used to make the same mistake re Zn:Cu, I may have even taught you this?!🤦♀️ But as so often happens, a week spent in all the original scientific data and I’ve emerged a changed practitioner! Having been part of perpetuating this problematic premise in the past, I am determined to get the correct message out there to as many practitioners as possible. So help me spread the word on Copper in Kids – by telling others that this mineral is so critical to kids compared with adults, they will often have higher levels than ‘us’ and that until you’ve applied the right age-appropriate reference range and ruled out confounders you can’t possibly make a call on Copper. I mean, we kind of knew this all along, with healthy pregnancy Copper values being exponentially higher being a giant clue. Turns out kids’ ‘Copper Age’ extends way beyond the womb.
Copper, as a kingpin in angiogenesis, brain & bone building & iron regulation is a critical mineral during paediatric development. So much so, the kind of blood levels we see in a primary schooler might cause alarm if we saw them in an adult. So too their Zn:Cu. But higher blood Copper and more Copper than Zinc are not just healthy but perhaps necessary during certain paediatric periods. This recording redefines normal, low and high with a great clinical desktop tool to help you better interpret these labs, as well as reviewing the top causes and consequences of both types of Copper imbalance in kids.
The latest Update in Under 30 has landed. You can purchase January’s episode, Copper in Kids here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
-Your RAN Online Account has a NEW LOOK!!-
Next time your log in, you will experience a more user friendly way to search, view, listen and download your resources. Find out what’s new here.
When you start doing this with your patients’ pathology results, you know your client records are turning into a big hot mess and more importantly your ability to see the wood for the trees is seriously under threat! Private labs don’t play nicely with one another and if your patient has been to more than 1 pathology provider you lose an enormous amount of their potential value, blindsiding you to their patterns, & the most accurate interpretations. I have a saying when it comes to getting the most out of pathology in your practice: Cumulative Data is King & Context is Queen.
Increasingly we’re in in the fortunate position of patients taking responsibility for their health and coming armed with lab results – this cumulative data helps us to clearly see their ‘norms’ (as opposed to textbook ones) and therefore also any noteworthy variations.
But even in this luxurious position of multiple results across a variety of time points & stages of their life – our ability to derive the greatest understanding from these is greatly stunted if we don’t have the context.
For example: if he was ‘cross-fit-keto-crazy’ at the time, if she’d stopped being pregnant & started breastfeeding, if in light of a major shift in thyroid hormone results, they were on biotin, or iodine, or changed their dose of thyroxine or were drinking straight from the udder of a soybean (!) these all seem like fairly critical contextual details to be across, right? All of these factors: diet, acute health context, medications, reproductive state, even season… impact the lab results we expect to see and therefore should be captured and considered to form the most accurate interpretation. But how do we pull it all together in a systematic way that SAVES us time and SAVES your sanity and can keep growing alongside your ever-growing patient notes? Cue the: RAN Patient Pathology Manager!
Systems for sorting through huge amounts of patient information help us make sense of what we’re seeing…and help us spot the source & solutions.
Systematised patient timelines for a better overview of the chronology of any case, the RAN Patient Pathology Manager not only holds all the data for you, helping you keep more accurate records & make the most correct interpretation from these, but also maps and monitors changes related to various interventions. Lastly there’s my old BFF, Mindmaps and Timelines not ancient torture tools of clinical supervisors (!) but rather what distinguishes us as integrative, enabling us a to work up a case in a truly holistic fashion instead of: symptom–> solution, symptom –> solution. These are the 3 key clinic systems I really wished I’d had from the get-go…so, me and my team created them! We’ve re-crafted them with each year and this year our RANPatient Pathology Manager has undergone a significant evolutionary leap and it comes with a comprehensive video explaining how to easily get the most out of this resource for all your patients. We always share these tools with all our mentees but we’re frequently asked how others can access them so this year we thought those of you out there just wanting a foot up with some better systems might like to get your hands on them too! Maybe this is one very practical part of the ‘new year new you’?
Do you know this saying but the other way round? My dad said it often enough and always with such an exasperated tone that it’s got its own dedicated lobe in my brain. Almost. Lately, however, I’ve been reflecting on how much I learn from people younger than me, both patients and practitioners and think we need to flip it! I love the way that young people (oh lordy I just used the term, ‘young people’!!) can be incredibly solution-oriented, seemingly undaunted by the perceived barriers that tend to affect us older folk. A perfect example of this really is a young naturopath who previously worked for me, an absolute gun who seemed fearless in the face of any challenge who used to say, “my real super-power is forming the perfect Google search term” 😂 Of course this was totally under-selling her cleverness but I take the point that this is skill-set that us older peeps may be a little short on!
I really enjoy my consults with my Gen Y patients too for similar reasons. Check out this recent exchange with a 20 something female when I asked about her supplement compliance:
“Yeah, I use an app to remind me to take all the supplements and that gives me a weekly report so I know I’m usually about 80% compliant. I’ve dropped off a lot over the holidays but I’m getting back into it now. So I’ll wait til I’m back up to 80% to do these next bloods, right, because that would be pretty representative and show us the effect of what I am actually taking”
Are you hearing this?! How incredibly clever! One: she found an app (Medisafe) because she knows herself and she knows apps work for her! (and by the way, she said…yeah so the government probably now has this data as well but really, they had it anyway!) Two: she knows that it’s not human nature to be consistently consistent with compliance with anything, so more importantly she aims for doable, sustainable and therefore representative!! I myself even find myself delaying the pathology sometimes, erroneously thinking, oh I wasn’t at my absolute best this week!! 🤦♀️Dang, I wish I was that smart in my 20s. I may have saved a lot of sun-damaged skin, some serious $ and my dad many many headaches!
And my New Grad mentees, not all of them young by the way (!), but all new to the profession, when you check out their social sites, their business models and hear the life experience/past work they’re bringing together for exciting new hybrid offerings, it’s a quick reminder that wisdom isn’t a one-way street!
Want to know how else we can get smarter regarding your patient’s pathology?
As my patient points out, we should never put off getting labs done, waiting for 100% compliance. It may never come and if it does…it’s likely only fleeting and therefore any results in this context will be too! What are you and your patients missing in relation to their blood tests – like when to have the blood tests done in relation to food, exercise, alcohol etc Beware of Bad Bloods! Occasionally, the fault of the pathology company but much more often the fault of the patient and the referring practitioner, who has not educated the patient correctly about what to do and not do prior to blood collection for certain tests. This recording clearly describes the 7 classic give-away patterns of ‘Bad Bloods’ which will enable you to spot them fast in the future. In addition to this. while we are unlikely to know the idiosyncrasies of very lab our patients will ever have done, knowing the ideal collection times and conditions for the most common ones assists you and your patients to avoid any in the future – handy clinic resource included.
You can hear all about it and download the resource when you purchase Beware of Bloodshere.
It’s like that split-second you close the door and realise you’ve locked the car with the keys still inside, or the whole reason you rang someone pops back into your head just after you put the phone down. Yes after the opportunity to draw breath over the break I went, ‘Doh! …I forgot to mention manganese!!’ So some of you may already know I am not a super fan of manganese. Well actually, that’s not accurate, I am perhaps just less of a fan than the people who are formulating a lot of our supplements! A place for everything and everything in its place. While this saying is completely foreign to my office, my house, my domestics and the rest of my life, it is a mantra I abide by with all micronutrients. Having enough of each micronutrient is good, having optimal (if we know what that is, which often we don’t) is wonderful but an excess is bad news.
And as I’ve spoken to before, with our increasing use of multi-nutritional formulas and the frequent inclusion of significant amounts Mn somewhere towards the bottom of those long ingredient lists…we very much run this risk with patients who are taking multiple supplements, at which point Manganese can become a serious meddler.
There’s a short list of patients for whom I am particularly conservative regarding their Manganese exposure and near the top of that list is those with Gilbert’s Syndrome. Do you get my ‘Doh!’ moment now? Because at the end of last year I released the Gilbert’s Syndrome: New Goals & Good News Update in Under 30…only to realise after ‘I’d put the phone down’ that I’d left this important one out of the dos and don’ts of managing these patients. So why am I saying no to chronic routine use of Manganese in those with GS? Well here’s the deal…
That’s why we need to be clear to cap the Mn for these patients as part of being across the cumulative subtotals of all micronutrients. While there is no established Upper Tolerable Limit (UL) set for Mn, adequate intake has been determined as 5mg/d for an adult. I agree, this is probably inadequate for some but I’ve seem individual patient prescriptions with cumulative Mn totals over 20 and 30mg per day! In spite of being generally regarded as having a low acute toxicity profile there is increasing research documenting Mn as a meddler when it comes to thyroid function in particular. So who else is on my watch and wait list for Mn excess? You’ve probably got some ideas…
The latest Update in Under 30 has landed: Gilbert’s – New Goals and Good News and my team has gone all out in producing a brilliant desktop reference to go with this recording that aids better understanding and clear treatment aims for your GS patients.
You can purchase Gilbert’s: New Goals & Good News here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
**But if you’re just joining us & this important conversation now,
ideally get the basics and backstory first and purchase all 3 key episodes in ‘A Guide to Gilbert’s Package’
It’s that time of year when we tend to set our intentions both personally and professionally. For me, between the many meals, pressies and dunks in the river, I slip into some ‘silent work’. In particular, I find myself flagging a couple of key areas that I want to sharpen my knowledge in this year. I’ve already picked mine…have you identified yours?
For many practitioners if there is one topic in nutritional medicine that seems to be more generous than any other it would have to be iron: Iron gives us patients…loads of them! Patients who present with deficiency, with overload, with something in between but still noteworthy, or on iron and that’s causing them all sorts of problems.
But Iron’s generosity doesn’t end there.
It also tends to give a lot of practitioners a bit of a headache!
That’s because a) we were mistakenly taught about iron as if it were just another one of the mineral mob and accordingly allocated grossly inadequate time to do more than scratch the surface of what we need to know and b) what we need to know, thanks to it being the most researched mineral, has undergone a couple of major revelations and revolutions since then anyway! So we can benefit from Iron’s generosity most and leave its other unwanted pressies (the headaches, confusion, frustration & suboptimal management of patients) under the tree – we just need to give iron the real attention it deserves, filling in the gaps in ours and many people’s knowledge about this critical nutrient. And boy, do we (and I mean everyone!! including doctors, midwives, pharmacists…anyone who has ever called iron deficiency on a client!!) need to learn how to correctly read iron studies!!!
Because iron also gives us much needed insight into other micronutrients and just how exquisitely sophisticated their roles & regulation can be. Thanks to it being one of the ‘older minerals’ we know more about it than any other and in turn we have the most advanced assessment methods: Iron studies, a collection of 4 parameters, like 4 chapters in a book or 4 key characters in a play, that need to be viewed separately and then together to understand the whole story.
Yes it’s true the learning doesn’t ever end and as I’ve continued to learn about new iron research I’ve added to our one-stop-iron-resource-shop..the Iron Package. Our very latest edition? A new clinical cheat sheet with some other important numbers on there you want to have at your fingertips whenever you read iron studies. So if you’ve already purchased and have access to the Iron Package…SURPRISE! 🤩 Go back and look again and if not, there’s never been a time like now. Oh iron, you’re sooooo generous!! 😉
Listen to these audios and download the resources straight away in your online account.
If you’ve already purchased ‘Update in Under 30: How to Read Iron Studies’ or ‘Iron Package’ you will find this new clinical cheat sheet available with these audios when you log in to your account.
I know, timing, huh?! It’s almost like I’ve been sniffing around your recycling bins but I didn’t need to of course, at this time of year it’s a fairly safe bet you’re madly winding it back a tad from your most outrageous annual alcohol imbibing. And so are all our patients. To me, extracting accurate information succinctly from patients regarding their alcohol use can be one slippery little sucker. It’s one of the questions people tend to give you a very tidied up answer to, or in fact they’re in such denial they can’t be considered a reliable witness. Think about it. Being a non-habitual drinker myself, I can appear almost saintly when reporting my daily consumption, “None”…but that omits the ‘other me’ that might show up at a conference gala dinner or some live music event, with my volume controls adjusted significantly up…ergh…firsthand accounts anyone? And how often does that happen? Well anywhere between 4 times a week and once a month. See what I mean?
While I’m sure you’ve probably heard me say before, I ask every patient who does drink, what kind of drunk they are because it can hint at their underlying neurobiology, there is a new study that suggests, using a very short 4 item UCLA RRHDS survey, we can categorise patients alcohol use and misuse into 3 types:
Reward ReliefHabit
and in doing so, also be better able to identify the best way to manage them as well.
I’ve been interested in addiction neurobiology for a long time and very much resonate with the work of Koob, which in layman’s terms proposes that we seek intoxication initially for the ‘high’ and then with dependence, we continue to seek it to appease the terrible lows of withdrawal. It has long been known that alcohol use disorder is heterogeneous – there are different types and accordingly the kind of generalised treatment of these individuals proves extremely hit and miss. But articulating the different types and their distinct drivers and solutions has been fraught. Like what makes one alcoholic the functional type who in addition to their long-lunches is a CEO and the one who can’t keep their job? Is it just socioeconomic context or something more? Why are some types of alcoholism deemed also to run more in families and while others aren’t? There are clearly major difference in pathophysiology but what are they? More recently these 3 groups have emerged and this recent study confirms the value particularly in the distinction between those who drink driven by reward and those for relief + habit. It’s a great read but here are some key take-homes:
ReliefHabit
Relief/Habit: You predominantly drink to cope with, or resolve a negative physical and emotional experience (negative reinforcement). You have more depressive features and have more anxious traits than those ‘reward drinkers’.The key to managing this type of pattern is to target negative physical and psychological experiences with ‘downers’ (they calm down an overactive brain that’s on ‘alert’) such as sedatives, anxiolytics, and glutamatergic modulation. (Hint for practitioners: this is where Taurine & Glycine really shine)
Reward
These individuals drink to feel good so they are driven by positive reinforcement and therefore the approach to the helping them should be quite different, with lifestyle recommendations that offer other options for mood elevation such as exercise etc as well and herbal and nutritional approaches.( Hint hint…not the key group for Taurine, more like Tyrosine and Saffron etc)
So…back to my question…what kind of drunk are you & what drives you to drink? As a nation of over-consumers by nature, this is a question we need to ask all our patients
Rachel introduces you to new clinical tools that has been developing to help us all better master the maze of mental health. With so many possible biological drivers: from methylation to inflammation and from gonads to gut, these tools can help you quickly identify those most relevant to each patient and also outline the strategies necessary for redressing these. This presentation comes with an extensive library of resources including pdf of Assessments Tools and Case Study Notes.
Earlier this year at a Mental Health Training for IM doctors, 3 practitioners (myself, a doctor & a psychiatrist) walked into a bar…not really, but we did each present a case study of challenging patient & in whom we had some great outcomes. All 3 patients presented happened to have Gilbert’s Syndrome. Just in case you’re wondering if there was a secret Gilbert Syndrome Conference you didn’t get an invite to, no. Or that perhaps there was premeditation and intention on the organisers behalf for a bit of sub-theme and focus, no. While this was purely coincidental it does speak rather loudly to a couple of things though.
Patients with Gilbert’s syndrome are likely to be over-represented in our client base especially among those presenting with psychiatric and/or gut issues (and both presentations frustratingly for them, very hard to diagnose, define, pigeon hole etc) and secondly, even though their genes underpin their biological susceptibility to such health problems, great outcomes are really possible.
One of the challenges comes from the medical dismissiveness of this genetic issue as simply ‘benign hyperbilirubinemia’. This has lead to a lack of diagnosis in patients affected and when it is incidentally picked up on routine bloods, a lack of follow up education about what having approx. 30% less phase 2 glucuronidation activity, in their gut and their liver, is really likely to mean, not to mention radically altered bile composition and digestion (!) and how they can make better choices in light of this. Similarly this year in our Mental Health Specialist Mentoring Group, the issue of reduced efficacy and tolerance of psychiatric medications, in those with Gilbert’s, raised its head over and over again. Given that so many drugs within the psychiatric class add at the very least to the ‘substrate load’ of the UGT system, if not frankly inhibit some members of this enzyme family, as this paper (check out Table 2…superb!) shared by my colleague, Kate Worsfold, points out, it actually shouldn’t come as a surprise.
But there is a change a’coming with an influx of research leading to improved understanding of this seemingly mercurial malady, resolving many riddles, identifying new key ways to help these patients and at last….some exceptionally good news for those with Gilbert’s.
For example, when I started this conversation back in 2013 with the Update in Under 30 Gilbert’s Girls, that was in response to seeing so many women at the time presenting with significant imbalances in both their sex hormones and their neurobiology as a result of their UGT impairment. But of course it was never meant to imply GS is just a girl thing! In fact there is a 3:1 dominance of men with this condition and some very good reasons as to why: more red blood cells and more testosterone…the former being the primary source of bilirubin and the later a terrifically powerful UGT inhibitor. The news from the research frontier is nothing short of thrilling, rewriting our thoughts on what medications and supplements (!!) are the most problematic, improved dietary management, how to track their progress more accurately and why completely normalising their bilirubin is not the goal…hey did someone say…longer telomeres?! 😉
The latest Update in Under 30 has landed: Gilbert’s – New Goals and Good News and my team has gone all out in producing a brilliant desktop reference to go with this recording that aids better understanding and clear treatment aims for your GS patients.
You can purchase Gilbert’s: New Goals & Good News here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
**But if you’re just joining us & this important conversation now,
ideally get the basics and backstory first and purchase all 3 key episodes in ‘A Guide to Gilbert’s Package’
-Your RAN Online Account has a NEW LOOK!!-
Next time your log in, you will experience a more user friendly way to search, view, listen and download your resources. Find out what’s new here.
Turn-up the sound, lean back (as there are quite a few names here) and watch it all the way to the end!, Click here and enjoy our little video to honour each of our mintees (aka mentees) in 2019.
Use the force…… well, maybe force isn’t quite the best word, but use the knowledge, the skills and the collective minds. Take what you’ve learnt and go forth into the world, into 2020 knowing that you have evolved as a practitioner!
Congratulations on completing your full year of group mentoring –
and if this is your 2nd, your 3rd even your 4th year then I bow to you even more deeply.
Thank you for including me on your support team and entrusting me with helping you grow & develop as exceptional practitioners.
You should be celebrated for your commitment to your own learning & your endeavour to always improve your knowledge and skills.
So if your name is not on this year’s Honour Roll – (apologies to all those practitioners who do private individual mentoring with me on a regular basis…the list just got too long but this applies to you as well!) – take a good look at whose is – I am sure you know someone here and perhaps now knowing about their commitment to their own development might help you to understand why they stand out not just for how good they are but how they continue to challenge themselves and strive to be better.
Oh and psssst…..if you want to be in the 2020 honour roll and you forgot to sign up, there may be some spots left in some groups (but not many). If you want to grab one email us quick at [email protected]. Or save your spot for 2021 and join the waiting list, send an email.
We’re keen to keep a bit of normal in all the noise. Are you? Here’s another way to keep your collegiate connections connecting and your brain blossoming! Our monthly podcasts are 30 minutes of jam-packed information and here is your opportunity to get more bang for your buck and expand on those 30 minute downloads with some serious drilling down! Keep the conversation going and get your questions, answered…
