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.
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.
Did someone explain the kidneys are like a really important, not to be forgotten, under-estimated, ignored or under-valued kind of organ in your training as a naturopath?No, me neither. I mean I know Buchu and Uva and Zea (on a first name basis only, clearly!) and …no actually, I’m done. But seriously, it didn’t take too long in practice to stumble across a whole lot of bad when kidneys aren’t getting the attention they warrant and equally to develop a slight obsession with renal markers in all of my patients not just because of their incredible impact on whole health but also because of what ‘lay beneath’.
As you might suspect, I get sent labs all the time from practitioners. Stop no! That is not an invitation!
Often it’s client’s renal markers which I do appreciate because it tells me there is an increasing number of praccies that absolutely have done some post-grad DIY knowledge building about these bean-shaped babies and their critical contribution to health. The results might come with a question like, “What’s going on with their kidneys?!” [insert worried face emoji of choosing]
To which my reply is often… “not much but boy do we need to talk about your patient’s GIT microbiome! [or] mental health! [or] sarcopenia!”
Say what? Yes abnormalities within the renal markers: urea, creatinine and uric acid may be a reflection of renal issues. But if you know where each of these molecules enters the blood,exits the body and all the interesting good & bad they can get up to in between…then the patterns speak less (if at all in some instances) to what’s going down in the kidneys but instead give you an incredible insight into key issues all over the body: from the gut to the brain. But wait there’s more! Want to know what’s the latest and greatest in management of advanced renal disease? Treat the gut to lower the urea. What about managing mania? Add in a gout treatment to lower uric acid. Dang! This is holistic health at its best with those poor kidneys no longer being left out in the cold!
“Who knew urea, creatinine, GFR and uric acid could be such a Goldmine….Mind…officially…blown!” New Graduate Mentee 2019
Most practitioners graduated with not much more than a few ‘kidney’ herbs and an under-appreciation of the contribution renal health makes to wellbeing. It’s not just about waste and water. In reality, the kidneys are pivotal in just about every major element: blood, bones, pH balance, methylation, control of oxidative stress, the GIT microbiome and more! And we are seeing the impact of this in our patients in all sorts of subtle and not so subtle presentations. This new instalment in diagnostics, brings the renal system into the spotlight so we can confidently identify and better manage its critical contribution. In addition to this, just like with other routine labs such as LFTs, we unpack how these so-called ‘renal markers’ can flag a plethora of other insights into your patients, from reflecting (un)healthy muscle mass to calculating individual dietary protein adequacy, from key ‘danger and distress’ signals in response to disturbed metabolism, oxidative stress to certain types of GIT dysbiosis! We call this Renal Markers: Explained, Expanded and Exploded because these routine labs can deliver XXX sized insights into your patients.
How often were we told this in our training? And how often have we found this to be true in practice? And now suddenly, it seems, the medical researchers (at last!) are rapidly coming around to this core concept?? Our microbiome is suddenly the hottest property on the body block, and it seems every interested party is shouting, ‘Buy!Buy!Buy!’ As integrative health practitioners, of course, we had a major head-start, not just by appreciating the gut’s central positioning in the whole health story (iridology beliefs, maps & teasers aside!!) but also a heads-up about the damage the western diet, our medication exposures and lifestyle tend to wreak upon it. A favourite quote of Jason Hawrelak’s by Justin Sonnenburg, “The western diet starves your microbial self”, underscores the significance of just one element of this impact. And…are we all clear that the increasing number of patients reporting adverse food reactions, once again, overwhelmingly are a response to aberrant processes in the GIT?
Sounds silly it’s so obvious right, but it’s easy to get distracted & misattribute blame…for example, it’s the food that’s the problem. Well yes in a minority of situations interactions between someone’s genes, immune system and a particular food turns something otherwise healthy into something pathological, but for the majority, the food itself & in others is healthy, & could be beneficial to this individual, if only we could resolve their GIT issues…like FODMAPs for example.
Not the problem, just the messenger.
So if the ‘problem food’ is just the messenger, what’s the actual message we need to understand? Is it that this patient has medication, disease or otherwise induced hypochlorhydria, impairing ‘chopping up’ of potential antigens implicated in immune mediated food reactions? Or is that this person’s got fat maldigestion &/or malabsorption so that in addition to not tolerating fats, they may experience dietary oxalate intolerance to boot? Or are the food reactions the result of altered microflora changing what we can and can’t digest (via their critical contribution) & absorb?
So what message does the presence of IgG antibodies to consumed foods send us about the state of someone’s gut? It’s telling us 2 things: this individual exhibits abnormal intestinal permeability & currently in the context of this leaky gut, these foods may constitute a barrier to resolving this & other symptoms as well.
We’ve recently released the mp4 (that’s audio plus the movie version of the slideshow so grab your popcorn…that’s if you don’t have a corn issue!) of A Guide to Investigating Adverse Food Reactions – What’s IgG got to do with it? which details the science behind IgG, including debunking, the incorrect debunking of IgG food antibody testing!! But more than this, it overviews the whole maze of adverse food reactions, articulates a logical investigative path for practitioners through this maze, and helps us to really understand that finding the food(s) responsible for a patient’s symptoms is not the final destination..and can be in fact a distraction, if we don’t cut to the chase and find out the why…and funnily enough…my dear old iridology teachers and colleagues...it almost always comes back to the gut 😉
Confronted with the possibility of adverse food reactions in an increasing number of our patients can be an overwhelming prospect, in terms of accurately identifying and understanding the faulty mechanism underpinning these aberrant responses to healthy foods. Elimination of culprits in most situations is only a short term reliever, not an appropriate long term solution, so to optimise results we need to know the real mechanism of action. The majority of these, of course, stem from the gut, but being able to elucidate exactly which of the many things that can go wrong there, is going wrong and therefore what foods are problematic until we address this, is the key. This 2hr mp4 is all about the bigger picture and helping you find method in the madness that can be the AFR landscape. Along the way, we detail the science of where IgG reactions fit into this and it’s a fascinating story that just might be the missing puzzle in your leaky gut patients.
I became interested in working in mental health not entirely of my own free will. I guess you could say, it had made it’s way into my world via family members and friends as well as my own problems when I was younger. So when I was at uni and I came across any information about mental illness, whether it was pathology or prescription, it was when I undoubtedly resonated most strongly with what I was learning. I’ve had some great opportunities throughout my career to feed my interest, met some wonderful mentors and some other powerful teachers who were often my patients. It’s now become a running joke among my teenage children that all my friends are either psychologists or have some sort of mental health diagnosis, ‘…and what does that say about you?’ they love to add teasingly. Well it says a lot probably: that I enjoy people who are comfortable talking about the psychology of our lives and ourselves, that I deeply appreciate that to be human is to suffer and we all suffer it’s just a question of degrees and the bravest of us share that with others. Lastly, I think it tells you that I live in the real world with real people 🙂(more…)
As we head rapidly towards the change over of our calendars we would like to offer you a special on the very best educational recordings from 2014 – buy 2 CDs before Jan 31st and receive one complimentary Premium Audio Recording of your choice OR purchase 4 CDs and receive a 3 month Premium Audio subscription for free.
It’s been a busy year during which Rachel has delivered 7 very successful new seminars in the area of mental health and beyond, most notably fortifying her role as a leader in the field of diagnostics and pathology interpretation. This has included collaborations with ACNEM, Biomedica, Health Masters Live, MINDD and Nutrition Care, however, each recording is classic Rachel – full of fresh perspectives on diagnosis & treatment, colourful analogies & humour. In case you missed some of these this year or want a copy for keeps – here’s a quick summary of the 2014 recordings included in this end of year offer: (more…)
I’ve received so much lovely feedback (fan mail!) recently I just had to share some with you (note I look much more excited than Meg does when I get mine!). It’s so exciting to be a part of our burgeoning naturopathic & integrative network. From Alyssa Tait a Brisbane based naturopath, clinical nutritionist & physiotherapist: “I am so appreciative of your mentoring and your professional development (e.g. recent Health Masters Live webinars). You make me really enthusiastic about being in this field, and you actually help me feel like I sort of know what I’m doing…most of the time!!”(more…)