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 (Medsafe) 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 Bloods here.
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 Relief Habit
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:
These individuals drink to cope or resolve a negative experience and therefore a driven by negative reinforcement. As a group they present with more depressive features and have more anxious traits than those ‘reward drinkers’. So the key to managing these patients is to offer treatment that also appeases their negative physical and psychological experiences with sedation, anxiolytics, glutamatergic modulation. (Hint this is where Taurine really shines, in this group!!)
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? As a nation of over-consumers by nature, this is a question we need to ask all our patients
Mastering Mental Health: New Assessments and Management Resources in Your Clinic (2hrs)
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.
When a teenage girl presents seeking her first oral contraceptive pill (OCP) script, what information is she privy to that enables her to make an informed decision? Read the insert inside the box? Please. Which 50 year old, let alone 15 year old does that? Forget it! What might her doctor tell her? Perhaps about clotting risk, as part of their determination of the suitability of this form of contraception for her but is there any discussion about the potential for adverse mood effects? A recent study of over 1,000 teenage girls followed over more than a decade adds to other evidence that suggests this should be flagged as a consideration prior to the prescription being written.
Most integrative health practitioners not only know about the potential negative impact on mood from OCP use in women but we’ve observed firsthand the havoc it has wreaked in some teenage girls’ and women’s lives.
A very experienced practitioner I know says, ‘if I am hearing mood instability and then I see a significantly elevated serum copper and or cortisol in these girls that’s when I just say to have to say to them, you know I don’t think this is the best contraception for you!’
This latest study did not find higher rates of depression across all OCP users in this group of 16-25 year olds but when they looked at this at different ages they found its use increased depression scores and was associated specifically with more crying, eating problems and hypersomnia. The discussion around the enhanced vulnerability at this younger age compared with older girls centres on the relative immaturity of their CNS. But wait, I hear you critical thinking clinicians ask, perhaps those teenage girls had more depressive features prior to starting the OCP. Good thinking 99! And the answer is…maybe…but the relationship goes both ways: from the related Medscape Continuing Medical Educational Activity
“For 16-year-old girls, the association was weakened after adjusting for depressive symptoms before use of OCPs, but the findings remained significant. This suggests that the relationship between OCP use and depressive symptoms could be bidirectional…For instance, 16-year-old OCP users were more sexually active and had more stressful events, as well as more menstruation-related pain and acne, than their counterparts in the nonuser group. Analyses showed that all these factors weakened the association, although none diminished it.”
The commentary surrounding this latest study is essentially 1) this is not the first study to find an association and others have been more able to demonstrate that COCP use predated the mood disorder in those affected and 2) those exhibiting higher depressive scores did not actually score strongly for anhedonia or sadness which are the most typical features in adult depression – so perhaps we are missing some of these negatively impacted young women. Awareness regarding reproductive psychology is rapidly growing and in Australia we are fortunate to have emerging hubs to seek help and specialist advice in this area, such as the important work of Professor Jayashri Kulkarni and colleagues out of the Women’s Mental Health Clinic. I’ve referred patients, both when a patient’s mental health appears to be caused or aggravated by use of hormonal agents but which they can’t not use for various reasons and for those small number of women in whom I feel hormonal management may in fact offer a psychiatric solution. So again I am asking, while we know & mainstream medicine increasingly knows about this association…who’s telling these young women?
How many of your clients are on a combination OCP? Do you know the full extent of the physiological impact as a result and are you able to identify to key pathology indicators of the size of that impact?
We’re all aware that in theory OCP use correlates with a range of elevated risks but in reality many females will make the decision that the pros, in terms of contraception or control of acne etc., outweigh the cons. What if we could provide more individualised advice by looking to their pathology results and identifying and quantifying specific danger signs for each individual? This approach enables us to better support patients who chose this form of contraception and to accurately identify those that should be be encouraged to find other safer options more biochemically suited to them. Learn more here.
Stop press. No, seriously. This new research warrants the attention of every practitioner working with children & teenagers. In the largest paediatric study of its kind to date, which included 2,480 children aged 10-18yrs diagnosed with hyperthyroidism (Grave’s or otherwise), Zader & colleagues found
Double the rate of ADHD diagnoses
5 times the rate of Bipolar diagnoses (almost 7 times in males)
5 times the rate of suicidality
That’s what I said: in 10-18 year olds
What is most alarming of course is that these mental health diagnoses were made in half of these children >3 months prior to the diagnosis of hyperthyroidism. What does this mean? It means we are missing this critical biological driver in this patient group. We all recognise the potential for some psychological presentations people affected with thyroid conditions, however, perhaps we are more alert to this in adults and letting it slip off our radar in kids? There’s been renewed talk about the over- and mis-diagnosing of ADHD lately and given that research has found up to 80% of hyperthyroid children meet ADHD diagnostic criteria this is one of the 1st place arguably to look! It also means, as these researchers discuss in detail, these kids are being medicated with psychiatric meds that in fact may, at the least mask their abnormal thyroid, lead to the incorrect diagnosis of hypothyroidism (lithium & even stimulants for example) or exacerbate their hyperthyroidism (quetiapine). But wait there’s more and it’s essential to understand.
Zadar & colleagues note that while we can not be 100% clear about the direction of the relationship…e.g. were these children already at risk psychologically and the hyperthyroidism just exacerbated that, they note that correction of the TFTs does not always equate to ‘cure’ of the mental health issues. This is not entirely surprising of course. What the problem emerges via a combination of biology and psychology & we resolve or remedy the biology…guess what you have left? PLUS the learned behaviours etc from suffering from anxiety, impaired cognition, suicidality they’ve been battling at the hands of excess T3 and a subsequent tsunami of reactive oxygen species.
This is one of those papers we should all have to read top to toe and therefore ideally be able to access for free but alas 🙁 What you can read is the Medscape review of this, which is a reasonable summary but the full paper is worth it if you can. You know the other key take home here…the diagnosis of hyperthyroidism was only made with overt out of range TFTs… which begs the question what about all those subclinical hyperthyroid cases we know exist? Yes, no wonder this paper has RACHEL’ S FAVOURITE written all over it…paediatric thyroid assessment and missed biological drivers of mental health and the opportunity to get better at both…can my research reading get any better this week?!🤓
Do you know how paediatric thyroid assessment differs from adults? Thyroid Assessment in Kids & Teenagers – Why, When & How
Currently in Australia there is limited use of age specific reference ranges for thyroid parameters in children & teenagers yet they are essential for correct interpretation and diagnosis. Even doctors & specialists seem to be at a loss with diagnosing thyroid problems in kids unless they are extreme presentations. Subclinical thyroid presentations, however, are increasing in both children and adults. Many practitioners competent in adult thyroid identification & management are less familiar and confident with knowing when why and how to test in this population. Make sure you’re not missing thyroid imbalance in your paediatric patients…early detection makes treatment easy.
Our knowledge is subject to constant change, and it is oh so necessary to stay up to date in our field for a bazillion reasons, give or take a few 😉 So sometimes we can feel like we need eight arms (for the visual amongst us) to manage and keep up with it all. However, if we ‘use the force’ together we are stronger, learn faster and can stop with the whole ‘recreating the wheel thingo’ that so many practitioners find themselves doing out there in solo practice. Like, like…well, how confident do you feel about putting pen to paper? How good are you at your inter-professional communicating?
*Cue* the release of a brand spanking new version of our
“Dear Doctor – Upskilling in Referral Writing & Inter-Professional Communications”
Referrals and inter-professional communication are just lightly touched on in the current undergraduate degrees (if at all!). But it’s actually such an important way to grow your own professional reputation while simultaneously the credibility of our whole profession. One might even argue, a pillar that stabilises the castle of shared patient-centred care & the future of true integrative health. I hear from my “New Graduates” as well as seasoned mentees about the unease that starts to creep in at the thought of writing the dreaded referral letter. I’ve been writing referral letters for 20+ years and it’s given me a lot of time to think! And refine. And refine again! To make inter-professional care a positive experience for everyone, we need to correct some misperceptions and ensure that our patients are everyone’s priority. And to fulfil our duty of care, communicating with the other practitioners on your patient’s healthcare team is fundamental. Sometimes, as you’ll learn, it’s about modelling the best kind of shared care to boot and being the bigger person 😉
Better still, positive experiences of inter-professional communication will bring collaborators out of the woodwork. Medicos and other allied health professionals you may never have been aware of otherwise, with a desire and openness to shared care tend to rise to the surface.
To get you even more excited about referral letters (you didn’t think that was going to be possible, right?!) and unlearn that Pavlovian procrastination you may have developed, Rachel has completely redesigned an older presentation to ensure it’s truly reflective of the contemporary healthcare landscape (oh yes, RACGP position statement included!). Expect to roll up your sleeves and get seriously practical advice with loads of examples about how to medico-speak naturopathic concepts, explain your role in the patient’s care, provide rationale for consideration of investigations and present ‘red flags’ with punch but minus the sensationalism. And above all else, reveal yourself as the asset you really are to the rest of the healthcare team.
“Thank you so much for a wonderful presentation yesterday, Rachel. It gave me a new perspective on how it must feel as a GP to receive incessant demands from Naturopaths/Nutritionists to order pathology for their clients. I am in awe of your integrity, desire for patient empowerment, humility and respect for other professionals in the mainstream health arena. I felt that every single naturopath and nutritionist out in the big wide world ought to have listened to your insightful words of wisdom when it comes to shared care of our clients. We are blessed to have you as our teacher.” – Michelle Blum (Mentee 2019)
If you’re interested in integrative care, want to learn the language of letter writing and follow Rachel’s SMART objectives to craft your comms and communicate clearly then you should take a listen to “Dear Doctor – Upskilling in Referral Writing & Inter-Professional Communications”
Kupfernickel. It’s the original German name for Nickel and it literally translates to ‘Copper Nickel’ which inferred it to be the ‘Devil’s Copper’. There’s an interesting story behind this of course and lo and behold the explanation (as is often the case with minerals and metals) is revealed by looking at where Nickel sits in the periodic table. Haven’t heard me rave on before about how all the key nutritional relationships are illustrated in that cornerstone of chemistry?? Where have you been?! Nickel is a transition metal and that tells us many things – including that its key relationships and interactions are likely to be with Iron, Cobalt, Zinc and Copper. And guess what? It’s all true. Still, I’ve had another Nickel-centric chemistry lesson of late because I actually had not the slightest appreciation of how noxious this can make it for us humans.
It started with one patient then, as is always the way, I’ve had about 3 in the past few months: predominantly women, some with ‘known’ nickel allergies, in the form of jewellery-related dermatitis and sometimes not, many with significant gut disturbance (IBS like, non-infectious gastritis) and most with early or advanced autoimmunity.
And the vast amount of scientific literature on the prevalence of Ni allergy (conservative figures suggest 15% population with a very high female:male) and its capacity to go beyond the ‘cosmetic’ and trigger gross immunological aberrations in Th1 cells, well, the case for Noxious Nickel is one of those things that once you see it, you can’t ‘unsee’, ever. Think if you or your patients have never had an issue with wearing cheap jewellery we can rule this one out? Think again. While the jewellery reaction might be the helpful clue in some patients, there are also 3 other ways that the old Kupfernickel may be undermining your health. And yes! The fact that contact dermatitis to nickel-containing silver jewellery is such a common issue tells us straight up, that its absorbed via our skin, think: watches, mobile phones, e-cigarettes, hair clips, and…yes I am having another crack at these again…tattoos! We also inhale and consume it via a wide variety of food and drink we consume. Oh and did I mention dental interventions, yet? 👀 Sheesh….
So while we all accept humans have zero requirement for Nickel, it’s in us all the time and the question is (always) how each individual inner chemistry lab (!) is interacting with it and to what extent this may explain some pretty potent health problems, from GIT disturbance to Hashimotos and from skin conditions and alopecia to CFS & Fibromyalgia-like conditions.
My latest Update in Under 30: How Noxious is Nickel – highlights the fundamentals of Nickel in terms of our sources of exposure and who is most susceptible and just how this can play out as a driver of disease. Next month we move onto our testing options, drilling down into the myriad signs & symptoms and how to effectively manage the patient dancing with the Devil’s Copper. This one has been a real ‘sleeper’ for me, but it’s time to wake the beast for us all 👀
While nickel sits benignly among its mineral mates in the transition metals of the periodic table, it is a metal that humans are constantly exposed to yet have no need for. What could possibly go wrong? Well, a lot it seems. Nickel is the most prevalent metal allergen worldwide and beyond this there is strong evidence of its potential to trigger autoimmunity, major endocrine pathology and a raft of GIT problems that masquerade as other conditions like IBS & NCGS. This episode captures the dance we all do with the ‘Devil’s Copper’ and why some of our patients are likely to end up with a bigger dose and a much bigger disease picture as a result of noxious nickel.
Hear all about it by listening to my latest Update in Under 30:
For all Update in Under 30 Subscribers, it’s now available in your online account and if you are not a subscriber you can purchase this individually here.
Tonic. Homeostatic modulator. These terms and concepts, which have a long tradition in herbal medicine (and let’s be clear, were considered yet another example of the wishy-washiness of the modality) are being appropriated by some areas of mainstream medicine right now. Cheer up ‘leaky gut’, you’re no longer alone! And arguably misappropriated by the public’s very ‘lay’ interpretation of the science on medicinal cannabis and its subsequent elevation to panacea, of late.
“So many of my patients are telling me they’re taking Cannabis now, just as a tonic”, says yet another practitioner to me recently, “No, not for pain, they’re young and fit but they take it because it’s a homeostatic regulator!!”
The capacity to maintain homeostasis, and particularly in the face of adversity or imbalance, is a sign of the vitality of the individual, according to what I remember from naturopathic philosophy (and have truly taken on and observed firsthand)…so just back up there a tad and explain to me how this one herb proposes to do this for everyone on a one-size-fits-all-fashion? As confessed in an earlier communication, I am a cannabis convert. But only in the sense of appreciating the niche areas where it is likely to offer true therapeutic benefits. I still have the words of warning from the brilliant Professor Michael Lintzeris, the Director of the Drug & Alcohol Services, South East Sydney Local Health District; Conjoint Professor, Division of Addiction Medicine etc., ringing in my ears, pleading with health practitioners to not ‘fall’ for cannabis in the way we have previously ‘fallen’ (so far and landed so badly) for the panaceas of the past: opiates and benzodiazepines. Most notable major omission for me, in an otherwise rigorous scientific debate of late, is any discussion about its potential for impacting fertility.
I’ve been aware of the potential negative effect on male fertility, in particular, for over a decade and while we undoubtedly need more targeted research on this topic to reach a consensus, the evidence base to date points to lower LH +/- testosterone and impaired sperm quality and motility. Certainly not perhaps what tonic-seeking patients know they’re signing up for.
There is in fact evidence to suggest ‘sperm under the influence’…’lose their way’ and are less effective at finding and fertilising the egg. Sorry but the image always makes me chuckle…stoned sperm. ‘Hey, dude where’s my egg?!’ style. But it’s not funny when impaired fertility is a problem affecting so many these days, and we still are guilty of over-focusing on ‘her’ and under-assessing ‘him’…and lo and behold it could be his chronic cannabis use to blame. We had a case recently, years of unprotected sex, daily cannabis, no baby, no dots connected. We may think this is a handy incidental contraceptive for young men sitting on couches with cones (one mum recently said as much to me) but for the rest…?
Getting Men’s Hormones Right
As practitioners we should know as much about investigating and treating male hormone imbalances as we do female ones, yet this is often not the case. While we are increasingly aware of everyone’s exposure to lifestyle & environmental endocrine disruptors and the fragility of the HPO axis, we sometimes fail to recognise that the reproductive health of our male patients is equally under threat. This is clearly demonstrated by generally diminishing levels of testosterone amongst men and increasingly early onset of andropause. These issues then become barriers to achieving success in other health areas with your clients, mood, metabolism, fertility and beyond. Learn more here
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My current count is about 13. Lucky for some? Patient advocate, referral point, primary prescribing practitioner, behavioural change motivator, wise business counsel, good empathetic listener, fearless myth buster, researcher, head chef to a group of nats…that’s the toughest hat right there, right?! 🤣
While there is a concern in naturopathy and integrative health that we increase our own load due to our eclecticism – I see this as a strength & part of the appeal.
But it does warrant regular review.
I semi-regularly cry-out, “I just want a normal job, you know 9-5, clock on, clock off.” To which anyone who knows me tends to drop to the floor in a fit of uncontrollable laughter. They’re right of course, I do not have the temperament or the ability to be sufficiently single-minded to work at Coles. And the reality is I do feel privileged and satiated by wearing all my different hats bar just a couple…but this is par for the course and part of the important reflective process we should all continually undertake in our careers: Which hat no longer fits me? Which gives me a bit of headache? We can then re-orient our work and our businesses in a way that tries to reduce, or remove altogether, our time spent in these roles.
“I am completely over giving 101 dietary advice!” I wish I had a holiday for every time I’ve heard a nat with more than 10 yrs experience say that!
“Oh the never ending story of answering my inbox!!!!!!!!!!!!!!!!!!!!!!!” is another one on high rotation in our ranks.
These ‘lost loves’ and potential disproportionate time wasters should never be ignored & simply endured but should instead be met…head on. The more I hear about different practice models & observe my own business over 20+years, the more I can see that when a practitioner is losing too much time or job satisfaction, wearing some of these hats that no longer fit, the less financial growth and sustainability their practice model holds. I know…them’s fighting words! Anyway, I’ll be talking about this and the delicate balance of our mild super-powers V our soft underbelly at Vicherbs monthly meet-up Sept 26th if you live in Melbourne and want to come along the join in the conversation. I think it’s a good one that we need to keep having.
2020 Group Mentoring Program Applications Open in October!
The Group Mentoring program provides integrative nutrition practitioners with monthly sessions of the most accelerated form of post-graduate education and clinically relevant skill development. Join this online 12 month program of like minded professionals and work with Rachel through real clinical cases and questions presented by each member in a collegiate setting. If you know you want in for next year already, get ahead of the queue and email us: email@example.com
“Rachel’s mentor program is something I look forward to each month and I feel very privileged to be one of her mentees (or mintees as she likes to call us). Each session is action packed with so much information shared that my brain gets a lot of dopamine hits! Rachel has a rare talent of teaching in a way that makes the most complicated information easy to understand, and even fun! The learning doesn’t stop after each mentor session. The group, including Rachel, will share research and continue to follow the cases shared. Amazing value for money. I know this is something I will want to do my whole career…there is always something more to be learned.”
VINKA WONG | Clinical Nutritionist, New Zealand
Histamine, Oxalates & Nickel…any of which may be at fault when your patient reports they experience adverse reactions from eating them. The same can be said for legumes, with a few extra contenders thrown in like oligosaccharides for those farty on FODMAPs. Additionally, in either case, there could be a bona fide allergy (IgE) or an intolerance (IgG) at play. Tricky, right?
I hear from practitioners often, though, that their interpretation of food reactions like these are at risk of being 1 dimensional, like a food word association game: tomato = histamine; legumes = FODMAPS; gluten = NCGS.
The labyrinth of possible pathways for food reactions is just that, a labyrinth!! So, we have to always be on our toes and try and approach each case methodologically.
I outlined how to approach this in clinic in A Guide to Investigating Food Reactions, released earlier this year. We cover a lot in this 2hr recording, but let’s face it, it’s an area that needs yet more time and a field that we never stop learning in. Next week, as part of our UU30 series on Getting to the Guts of Joint Pain, we need to take a little scenic detour along Oxalate Boulevard! Keep your eyes open peeps, because our very own food prescriptions tend to be full of them!! Not naming any names….berries, green smoothies, sweet potato &…
Need to catch up on investigating adverse food reactions??
Elimination of suspected food 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 adverse food reactions landscape.
Integrative Psychiatry is an inspiring area to work in & its evidence base, acceptance and recognition of potency is rapidly growing & offering more patients, more. Going beyond the ‘neurotransmitter imbalance model’ for each presenting diagnosis helps us to see the unique mix of biological & psychological drivers in each individual who presents seeking our help. However sometimes I believe, we find ourselves falling into looking through the lens of just another short-list of alternate models: What kind of methylation imbalance does this person have? What sort of Zn, Cu issues?
While I am so grateful for having learned these tools and watched them be very successful in a portion of my mental health clients, they are simply not the answer for everyone. We need to keep our thinking and practices dynamic and up to date, to reflect the incredible increase in research in new areas of integrative psychiatry, such that more of our patients can benefit and that we can continue to think beyond the box…even if that box itself was originally so progressive!
What do you know, for example, about abnormal purine metabolism in mania and using serum urate as a BPAD prognostic marker in depressed patients? Think you can simply be guided by the reference range provided, think again. What could good old LFTs reveal about our patient’s mental health vulnerabilities and what have we potentially misunderstood about copper in this area, particularly in children?
I appreciate Zinc’s role in mental health as much as the next integrative practitioner. Okay, given my 20K word thesis manifesto, more. But increasingly I am seeing mental health patients who need treatment with different tools. This upcoming ACNEM Mental Health Module in Perth is on point: thinking outside of, outside the box!
While the above only speaks to what I’m presenting, I know Dr. Sanjeev Sharma will also be sharing his wealth of individualised management insights and he’s a big fan of addressing Chronic MIld Metabolic Acidosis as an early treatment objective. Maybe we all need to hear why? And I am so looking forward to getting a PTSD update from Christabelle and hear all about the research into therapeutic keto-diets in psychiatry from Cliff Harvey…haven’t read all those papers to know which conditions and when this approach shows merit? No, most of us haven’t. That’s the point of outsourcing our up-skilling to colleagues who we know are across these more than us and to boot have the clinical experience to ‘make real the research’. As I’ve said before, given the content of this upcoming ACNEM Mental Health program, I wish I wasn’t presenting really, so I could just kick back and take it all in, uninterrupted. But alas, I have some important new information on reading basic bloods through a mental health lens to share! I really hope to see you all there. Let’s get out of the rut of 3-4 nutritional approaches to mental health and make the most of the explosion of research and shared clinical experience.
ACNEM Face-to-Face Training
Fremantle, 27-28 July 2019 at the Esplanade Hotel Fremantle by Rydges
Oh and while you’re here…did you know the research into both beta-casomorphins and IgG casein reactions in relation to certain mental health diagnoses has taken some giant steps forward in the last couple of years? You should. Milk Madness is back and it’s via two distinct mechanisms – identifying which might be at play in your patients & correct management is now clearer than before. Want to get up to date in this area of mental health – check out our UU30 recordings: Milk Madness part 1 & part 2
Remember biochemical individuality folks? That great core underpinning principle of naturopathic & integrative nutrition. We should always keep this in front of mind, when something utterly fabulous for absolutely everyone pops its head up. Like every month or so, in the area of health, correct?
Fasting, in all its forms, is having a lot of time centre-stage right now. What a novel & truly prehistoric notion in this era of food 24/7! I get it and I agree, most of us would do much better by regularly moving out of the top paddock.
BUT…and there has to be a but…or we are no longer treating the individual…
Some of whom, due to specific conditions or biochemical tendencies, do utterly horribly with any sort of prolonged periods between feeds. I already have a hit-list of conditions where fasting and food restriction is a no-no…then I saw a set of labs the other day from a patient who self-initiates regular, 4-6 day fasts during one of said fasts,whose alarming results jumped out in bold, italicized CAPITALS, illuminated itself in neon pink and reminded me to remind you! This patient’s (extended) fasting labs went a little like this… total bilirubin 48 (normally 15 umol/L), bicarbonate 18 (normally 26 mmol/L), corresponding anion gap 20 (normally 12), uric acid 0.62 (normally 0.4 mmol/L). Are you thinking what I am thinking B1?
So here’s my hit-list of ‘fasting = foe’ for – still subject to case by case assessment (of course!! because we treat the individual, right?!)…but
- Any individual with a history of, or currently risk factors for, disordered eating, e.g. orthorexia, bulimia, binge eating disorder, anorexia
- Gilbert’s Syndrome
- Low T3 – thyroid ‘hibernation’
- Anxiety and PTSD
- Drug addiction
- Children, pregnant women, the elderly…of course!
In short: any patient whose condition or biochemistry may be too negatively impacted even in the short term by any of the following: higher cortisol release, significant slowing of phase II detoxification, or radically elevated acidosis, should step away from the fast and towards the fridge! 🙂 🙂
Got any you want to add to this list?
What’s this you say about a hibernating thyroid?
Thyroid hibernation produces a low T3 value coupled with a ‘lowish’ TSH and typically a clinical picture of hypothyroidism. As the practitioner we are faced with the conundrum of how to effectively ‘wake up’ the pituitary which appears to be sleeping on the job. This audio connects up the dots between this type of thyroid dysfunction, dietary patterns, restrictive eating (including a history of eating disorders), carbohydrate intake and disturbed iodine nutrition of the thyroid gland. This pattern is increasingly seen in practice and this audio is a must for anyone working in the area.
Do you know that saying, ‘mind your Ps and Qs?’ It basically means mind your manners and I heard that a lot as a kid 😉 But what we really need to hear now, as practitioners and promoters of healthy eating and wellness is really, Mind your P’s and P’s because a lot of biggest health consequences of any diet are determined by the balance or imbalance of two major players; protein and potassium. We’re always looking for simpler ways to enable patients and ourselves to be able to both recognise the strengths and weaknesses of their diets and, better still, apply a simple method to making better choices moving forward. Eyeballing the protein and potassium rich sources in any diet speaks volumes about other essential dietary characteristics and the likely impact of diet on health – and getting the relationship between these two right should be a goal for us all.
“World Health Organization (WHO) Dietary Targets for Sodium and Potassium are Unrealistic”, reads the recent headline from yet another study finding that humans would rather challenge the solid science of human potassium requirements than acknowledge the urgent need to turn this ship of fools around!
This large study, conducted over 18 countries, involving over 100 thousand individuals, reported that 0.002% met these targets. That’s 1 person in 50,000. Now, the researchers’ response to this is that we should lower our dietary potassium expectations….such that the targets are more achievable and so that (frankly) we are less perpetually disappointed in ourselves and our terrible food choices. Wha???? Back up there. The WHO guidelines, just like any other nutrition authority, derived these minimum amounts from a thorough review of the science that speaks to our physiological requirements and the level of nutrients that have been shown to be associated with health. Australia’s own fairly conservative NHMRC suggests even higher amounts for good health! Perhaps rather than revise the established dietary targets we should revise what we’re putting in our mouth!
So where does protein come into this? Well one of the most important and central nutrient dynamics is the balance or imbalance of our intake of both. And in this regard, yet again, we have a surprising lot in common with plants! Whether you’re trying to understand optimal nutrition conditions for growth (nitrogen alone won’t get a plant there, nor protein alone in a human) or the intricacies and nuances of finely tuning our physiological processes such as cardiovascular function, renal health, blood glucose management etc. the answer lies in a happy marriage between these two.
In this area of nutrition, we should be listening most closely in fact to renal specialists/researchers. These ‘undercover’ protein and potassium experts have been talking about this for a long time and in particular, in my humble opinion, Lynda Frassetto has lead that charge for decades. If you haven’t read much on this issue and want somewhere to start at least, jump into her pivotal paper from 2001 which eloquently explains why the human design can not shoulder a potassium shortfall…well not without causing real health problems…like the ones we’re seeing in record numbers currently and why the protein potassium balance of any diet is a major health determinant. That’s why giving ourselves and our patients the knowledge and the tools (yes lovely shiny meaningful infographics included!!), to quickly determine their protein potassium balance, are so necessary and important.
Thanks to Frassetto and many other researchers’ work, looking at food through this protein potassium lens has sharpened my focus and I think it’s about time we all took a good look 🙂
Check out the latest UU30 to hear the latest information…
The health consequences of any diet are largely determined by the balance or imbalance of two major players & proxy markers; protein and potassium. When it comes to this area of nutrition, we should be listening more closely to renal specialists whose research shows why the human design cannot support a potassium shortfall and the health consequences of this. Whether you’re trying to understand optimal nutrition conditions for growth (nitrogen alone won’t get a plant there, nor protein alone in a human) or the intricacies and nuances of finely tuning our physiological processes such as cardiovascular function, renal health, blood glucose management etc. the answer lies in a truly happy marriage between our intake of these two. These recording comes with a clinical resource tool to help you quickly identify the dietary protein:potassium balance for your clients.
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.
and watch this presentation now in your online account.
How long? How long must we sing this song? I’m feeling a bit 80s anthemic and righteous. It turns out that patients’ bowel movements could be improved by using a foot stool?!! Who said that??
Only every naturopath, ever. Right?
But now medical researchers are singing the praises of the Stool Stool too…sorry, I mean the ‘defaecation postural modification device’…because lo and behold a new study of over 1000 bowel movements revealed using a stool to elevate your feet while on the toilet improved the speed and ease, improved full emptying, reduced the strain etc of laxation, >70% of the time, even in ‘healthy, non-constipated patients’. There’s a quick video you can watch to get across this groundbreaking research, or you can read the full article here. I’ve been educating patients about this for about 20 years and it never fails to revolutionise their world!
It would seem that elevating your feet results in straightening “the unnatural bend in the rectum that occurs when sitting on the toilet by placing the body in the squatting position nature intended”…hang on a second…who’s calling what unnatural???…I think the highfalutin anti-anatomical bathroom contraption, we westerners call a toilet, wins the ‘unnatural’ crown!
Next thing you know there’ll be a study that tells us squatting to have babies makes more sense that lying on your back…right?! 🙂
Love talking all-things Stool?
Fabulous Farty Fibre is a previous UU30 recording. Rachel at her warmest and funniest reminds us that fibre is a critical component to good nutrition and is often overlooked, partly due to the popularity of paleolithic and no grain diets. This UU30 details the important functions of different types of fibre and therefore the importance and therapeutic applications for fibre diversity.
Forever fascinated by the neurobiology of various mental health presentations, addiction included, two medical news items caught my attention this week. If you’ve ever heard me speak on addiction, in somewhat simplistic terms, it is very much about the reward centre of the brain and how strongly all recreational drugs hit on this. Think rats tapping levers with their feet to continually self-administer cocaine…to the exclusion of all else….kind of magnitude of reward hits. You may have also heard me quote or misquote (!) someone famous who once said something to the effect of….and I am totally paraphrasing poorly here: if we can’t seek pleasure legitimately, we will seek it illegitimately.
So this story from ABC news about a Newcastle addiction group support program showing some early signs of greater retention and engagement and therefore potential success with addicts…because they incorporate prizes…well that makes so much sense!
The article is important to read in its entirety as it creates the context – especially for many people suffering from addiction who tell tragic stories of lives where the only rewards/prizes and even gifts they’ve ever known, being drug-related – even from a young age. So to normalise reward to some extent, and give individuals an experience of constructive legitimate versions of this, is actually desperately needed and ground-breaking.
How can we incorporate some element of this in our interactions with these patients?
The second ABC news item touts ‘a new generation drug that restores balance to the brain’ but is actually just a teaser about…wait for it…cue stage right…a not so old favourite…N-acetyl cysteine! Although this is effectively a recruitment drive for methamphetamine addicted individuals into a new 12 week trial of NAC, run by the National Drug Research Institute, taking place in Melbourne, Geelong and Wollongong, it gives NAC a great wrap and rationale for being a good adjunct in addiction, of course. Just a reminder folks that naturopaths belong on that multi-modality health care team for people struggling with addiction, and we do have some potent therapies to contribute.
A couple of years back I was asked to deliver an educational session to a group of hospital based mental health specialists on the merits of NAC. My favourite question/comment at the end of my detailed presentation from a very experienced psychiatrist was, “Well if N-acetyl cysteine is so good for mental health…why haven’t I heard about it before now?!”
I hope they follow the ABC news 🙂
Want to Get Up Close to N-acetyl Cysteine in Mental Health? Previous ideas regarding the pathophysiology of mental illness have been profoundly challenged in recent times, particularly in light of the limited success of the pharmaceuticals that ‘should have worked better’ had our hypotheses been correct. Novel drivers such as oxidative stress, inflammation and mitochondrial dysfunction are on everyone’s lips and N-acetyl cysteine is in prime position in this new landscape, to be a novel and effective therapy for mental illness. This presentation brings you up to date with the current NAC research in a large number of mental health conditions & translates this into the clinical context.
I was lucky enough to hear Jason Hawrelak’s excellent presentation at the Australian Naturopathic Summit last weekend, titled: A Case of Blastocystis Infection – Or Is It? Timely, highly valuable, immediately usable, provocative education (just how I like it 😉 ) on how perhaps often Blasto is playing the scapegoat for another condition/cause of patients’ GIT symptoms. During this case study, Jason detailed the shonky diagnostic work-up of his current patient by a naturopath 12 years prior…that naturopath was him.
There was so much to love about his telling of this case study and the discourse around it but here are my Top 3 Takes:
- None of us know everything or practice perfectly but rather we do what we do, until we know to do differently…even Jason 😉
- As there are 9 strains of B.hominis found in humans and many of these are in fact benign commensals, even perhaps important ‘apex predators’ for the microbiome, attributing someone’s health problems (digestive or otherwise) to the presence of this parasite should in fact be a diagnosis of exclusion…always asking yourself first, what else could it be?? e.g. coeliac, SIBO, food reactions etc etc
- The cost of being a ‘premature evaluator’, to your patients and to yourself, can be very high…
If you’ve not seen Kitty Flanagan’s skit on current coffee culture...it’s essential viewing. In true Kitty-fashion, she wants to simplify coffee ordering down to 2 basic lines – White or Black – says all our pretentious coffee orders; macchiato, skinny, decaf, half strength, latte etc can essentially be reduced down to a much faster 2 queue system. But she’s forgotten the line for taking your coffee rectally. Sorry – did I make you just spill your coffee? Knowing How across health trends Kitty is, she’ll add this 3rd queue soon, if the number of patients asking me about this or telling me they’re already doing it. Now, while enemas had a place in naturopathic history, my training never covered them and, consequently, I’ve never included them in my practice. But the more hype I heard around coffee enemas specifically, the more I thought we better find out as much as we can, so at least we can better inform ourselves and our patients. And of course the monkey on your back, called FOMO, jumps up and down, incessantly asking, “Are you (and your patients) missing out on an amazing therapy?”
The first patient who told me they were using coffee enemas daily was a celeb. A very anxious one. Who also told me she couldn’t possibly drink chai let alone coffee because of the caffeine. This had me a bit stumped…I knew she wasn’t inserting decaff up there and I thought…well given the colon is SUCH an absorptive surface surely this is why she reported feeling, ‘so energised, more clear headed’ etc. with every enema?
But I wanted to find out for sure (more…)
I’ve had my nose in all the research on Gilbert’s Syndrome again..watch this space…in the interim just thought I’d share this image and a couple of important details I may not have been able to convey when you last heard me talk (very fast!) about this important and common polymorphism:
- While the incidence is approximately 10% of Caucasian population, rates are heavily influenced by ethnic background and the highest rates (up to 1/4) are seen in Middle Eastern populations
- Gone are the days of thinking this condition only effects bilirubin levels and the enzyme responsible for its clearance – more recent research has shown over 3/4 of patients with Gilbert’s Syndrome have multiple SNPs that compromise clusters of enzymes within the glucuronidation pathway – with varying patterns – this goes a good chunk of the way to explaining the variability we see in bilirubin levels and symptom pictures across patients all deemed to have Gilbert’s Syndrome. This also explains why figures of reduced glucuronidation activity vary anywhere between 10% less to 90% less! It depends on your cluster..but the average reduction is around 50%
- UGT enzymes, the ones affected in Gilbert’s, are also expressed all the way down the GIT and constitute important food and drug handling. These UGTs are most active in the small intestines,as you can see above, but may explain why Gilbert’s patients are ‘more sensitive’ to medications than just paracetamol!
- And are you still thinking you need to run an $$$ gene test to confirm your Gilbert’s hunch in a client whose bilirubin sits consistently high normal or high? Think again… here’s a great little diagnostic short-cut that even the Royal College of Pathologists Australasia cites as sufficient evidence to confirm the polymorphism:
In the face of elevated total bilirubin levels and in the absence of liver pathology or increased haemolysis to explain this..”If the diagnosis is uncertain the serum bilirubin fasting level can be measured and should exceed the non-fasting level by >50%.”
Nice. So that means you only need to demonstrate that the patient’s fasting total bilirubin levels go up by at least 50% compared with their fed levels and BINGO you have your diagnosis. Much easier. Oh and this image comes from an interesting paper from Tukey & Strassburg 2001 – but is probably not for the faint-hearted 😉
Stay tuned for more 🙂
Just new to this condition and need a soft place to land with understanding Gilbert’s Syndrome? This previous UU30 is just the thing! Affectionately called Gilbert’s Girls because in particular it details a set of twins with this condition, this short audio explains the basics about this common polymorphism and why we tend to see a lot of patients who have this…even if no one has pointed it out to them yet! You could be the first to provide them with this important understanding about how genetics is impacting their detox pathways, changing their sex hormone handling and perhaps setting them up for both mental health issues and some serious upset guts! Better still, what to do once we have that diagnosis.