The Clinical Knack of the NAC Break

I feel a bit Trumpy…because whenever someone says ‘N-acetyl cysteine’, I want to reply, “Big fan, I’m a big fan”.  And yes that’s an uncomfortable awareness. But unlike he who shall not be mentioned, I can qualify my statement and provide supportive evidence, both of the research and real-world varieties.  So, of course, can so many of you as well. I know of fertility specialists who place it in PCOS patients’ preconception prescriptions and respiratory specialists who regard it highly in COPD, CF and a range of other conditions. And I am a signed up supporter of its adjunctive use in many psychiatric conditions. Then there’s the biofilm-breaking buffs… 

This is where non-believers might be tempted to call ‘Snake-oil!’ 

How can one very simple tricked-up amino acid possibly contribute to the health of so many systems?  Oh, just via the chameleon qualities of its chemistry of course!  As a rate limiting ingredient and precursor of GSH, as well as a potent mucolytic agent and and and…we get it.  We surrender!  But I want us all to back up here just a few steps. As a mucolytic agent…renowned for biofilm busting…hmmm. I prescribe a lot of NAC for a lot of people for a lot of days-weeks-months….because all the research in mental health points to it being a long-term intervention.  I’ve heard Professor Michael Berk say, that patients still on it at 2 years had even more improvements than they had experienced at the 6 month mark and of course mental health, for most, is a chronic illness, so no one is surprised. 

But we can’t contain its chameleon chemical qualities.  Given orally, it will be having effects within the gut of these individuals on the way through…and not all biofilms should be busted, right?! 

So what to do? Well thankfully, NAC is not something that patients rely on for short term acute effects, that would then make missing doses problematic – like pharmaceutical psychiatric medications, and some CAM options as well potentially, like SAMe and SJW. So a regular sNAC break is likely to be free from negative impact for those with mental health issues and in fact, beneficial long term. With all this in mind, we’re now using a dosing model of taking weekends off from this supplement – which works for most.  Do we have any concrete research to say this makes sense and doesn’t compromise efficacy yet?  Well no, and don’t hold your breath, because research can be very reductionistic (you heard it here first LOL) and there is a lack of consideration of the effects on an individual as a whole. The psych researchers are not measuring the impact of all interventions on the microbome of patients (yet!) and the gut researchers not always monitoring the mind.  But we clinicians can pioneer the path, fuelled by two old buddies of mine: first do no harm & least medicine, best medicine, right?

Oh and has anyone managed to open a tub of NAC and not accidentally snort some?…I don’t have anything else to add or a solution, I am genuinely asking if this is humanly possible 😂

The Clinical Knack of NAC

“There are few complementary medicines that come onto the market with such a bang, opening up genuinely new therapeutic options for the effective management of such a broad range of health complaints.  N-acetyl cysteine stands out for this reason and has changed the way I practice”  Rachel Arthur

Want to learn more about its diverse applications? Check this out

 

The Underrated Art of Ancient Mastication

No, mastication.  I’ve touched on this before but I believe we need regular reminders.  Or maybe that’s just me? I am a fan of chewing.  I don’t profess to be good at it (I am a wolfer of food  tbh) but I see the enormous therapeutic benefits it has to offer.  Seriously.  Think I’m taking the mickey?  Here are some tasty brain bytes for you!

 Ancient Mayans – Chicle
Ancient Greeks –  Mastic Gum
Native Americans -Sugar pine and Spruce sap
Then there’s of course the Coca Leaves (South Americans) Betel Nut (Asians) etc

But putting aside those that come with a buzzy bonus🙄 …the tradition of chewing non-digestible substances between meals according to anthropologists and archaeological evidence dates back to the neolithic period.  Nowadays, of course, we barely break from constant feasting…but perhaps when we do, we should maintain the mastication?  There’s a lot to be said in favour of this.  From brain benefits to dental deterrents against plaque but of course the main gain for many – is the potential for better digestion. For GORD it’s the oldest trick in the book, right? The increased saliva generated by the process neutralises any untoward excess acidity in both the oesphagus and also the pharynx.  So naturally, not one to forget in Barrett’s oesophagus either and of course my beloved Silent reflux. While also producing greater amounts of salivary amylase to assist with CHO digestion and lingual lipase to kick off the first fat digesting process within the stomach.  But could it help beyond this?  Well, though the jury is out on this increasing the rate of actual gastric emptying (though still worth a crack in Gilbert’s Guts), it’s well regarded as being able to stimulate small and large bowel motility more generally. Some SIBO soothing in certain scenarios, perhaps?  So much so, it has been recommended post almost all types of surgery (GIT, gyne, renal etc) to ‘get things going again’.

And while this doesn’t have the highest quality evidence to support efficacy…encouraging people to trial chewing a natural gum – no pretend sugars, no  plastics & no PK for my patients (Sorry dad! ), is a recommendation that is accessible to just about everyone, easy to try and gives people a quick yes/no.

Yes I come from a long line of chewers. My dad chewed gum between meals and during them, he popped that piece behind his ear to ‘save for later’.  I swore there and then, as an offended on-looker that I would never be so disgusting. Well… I’ve finally turned into him and I think he might have been onto something 😉 [except the behind the ear bit…ewwwwwwwwwwww]

Is Silent Reflux Still Sneaking Under Your Radar?

Chronic dry coughs, rhinitis, postnasal drip, the sensation of ‘a lump in their throat’ or even asthma?  Have you ruled out silent reflux aka laryngopharyngeal reflux? This UU30 helps you to better recognise the myriad presentations of this condition, understand the latest about why it occurs and is on the increase & finally outlines my top & somewhat unusual interventions for management of these presentations that have proved highly successful in my own clients. Up-skill on this sinister ‘silent’ one, here!~

 

 

In Need Of Some Fuel Reduction?

We’ve been talking all about the dangers of excess fuel in our blood recently.   You know, just like nature…too much fuel underfoot creates a fire hazard.  So too in the bloods of our patients.  The key fuels I am referring to, of course, are lipids (triglycerides & cholesterol) and glucose. Our tissues need ready access to both but Balanced Blood Supply & Mastery of Management is key.

In terms of excesses,  lipids play the long-game…wreaking havoc over a long period primarily via their vulnerability to form peroxides, which in turn create a chain of oxidative stress and depletes our antioxidant artillery.

In contrast, even outside of insulin dependent diabetes, for the rest of our patients, glucose plays a fast and furious game, being a highly reactive substance capable of causing both glycation and oxidation.   We describe even high-normal levels of glucose as something akin to the ‘Bull in the China Shop’, disrupting the function of the endothelial linings and damaging a variety of plasma proteins (not just haemoglobin) that float within them.  But do we have a way to routinely measure the level of damage occurring in our non-diabetic but somewhat glucose intolerant patients?   Sure!  Just check the C-CCTV footage!

The extra C stands for ‘Carb’ and yes we can potentially check the Carb-Closed-Circuit-TV ‘tape’ in every patient.

It’s called HbA1c and measuring this provides us with an opportunity to review their personal ‘tape’ of the last 2-3 months for evidence of excesses.

Helpful, hey. But we actually have so many great tools through regular routine labs at our disposal to understand the glucose disposal or dys-disposal(!) at play in our patients!   You’ve just got to know where to look (urate, triglycerides, insulin, HOMA-IR etc) and what each piece of information is telling you. We’ve had SO MUCH FUN with this particular topic in the MasterCourse this month…or is that just me 🙄 No, I know it was, because our live session chatbox was full of ‘blown brain emojis’!! 🤯🤯🤯  I can’t wait to share this course content far and wide at the end of year with those of you that missed out on attending live.

In the meantime if you want to learn more about glycation which is the new inflammation, out there in research-land, you know…the source of all evil including ageing itself(!!) then check this out

Glycation is a normal physiological process that,  just like inflammation and oxidative stress, can get out of hand, contributing to disease processes. Currently there is an explosion of correlational research suggesting relationships between higher levels of Advanced Glycation End-products (AGE) in individuals who have fertility problems, psychiatric conditions, osteoporosis, premature skin ageing, cancer…you name it! New research implicates diet heavily in the determination of individual’s levels of AGE but there is devil in the detail – there are ‘4 Ps’ of dietary AGE contribution that we need to be mindful of when we are giving dietary advice and trying to move patients towards wellness. This Update in Under 30 recording: Are You Feeling Your ‘AGE’ will open the lid on the ‘new black’ in chronic health & ageing.

 

 

 

 

Hanging Out For The Histamine Handshake?!

Recently a mentee reported that when attending an in-person training event (remember those, everyone?!) she approached a sponsor’s stand, promoting practitioner training in the nutritional management of mental health, based on the pioneering work of American scientist, Carl Pfeiffer.  But when she and her nat buddy started asking questions, those manning the stand asked whether they were doctors and then, upon finding out they were naturopaths, encouraged them ‘to move along – this information isn’t for you then’. Or something to that effect…Ouch!

While I know a little about the decision behind offering this training only to doctors and specialists at this time, and I do understand that organisation’s reasoning, I also want to reassure you, this doesn’t mean that Pfeiffer’s important work, and the efforts of those that have followed him, is out of bounds to others.

No one can copyright cortisol or TM TSH, right?  Equally, Histamine is his own man.  Carl Pfeiffer and others brought histamine, the neurotransmitter to centre stage and many of us working in mental health remain eternally grateful for this.  But CNS histamine has come a long way since then…and is currently a very hot topic in modern molecular psychiatry where they are always looking for new drug targets, given shooting at the previous ones, risked taking ‘an eye out’! The recognition of histamine as a key player in mood, cognitive and behaviour has been long overdue but is absolutely here now!  Just give this search term a whirl in PubMed: histamine AND psychiatry, and you’ll be hit with quite the crush of citations!

An abundance of important info at your fingertips…no secret handshake required.

It was, in part, this story that inspired me to record an Update in Under 30 on Histamine Imbalance in Mental Health.  Just the proverbial straw on the proverbial camel really, after years of examining, experimenting and experiencing the incredible results some patients can achieve when this imbalance is identified and redressed. So I’ve done my darndest to pull together those years of hands-on helping histamine imbalanced patients with the latest literature in under 30 minutes!! Surprise! I failed! There is a lot to convey but you’ll also be surprised by what I don’t say…there’s no infinitely long list of personality peculiarities that fit with too much or too little. Nor is there a didactic discourse about absolute treatment dos and don’ts.  I’m communicating the common ground between the original evidence, clinical empiricism and contemporary neuroscience. So this month, consider the ‘under 30’ bit, merely a ‘Serving suggestion’…which would necessitate you playing it 1.5 X speed…go on, I dare you!!😅

Update in Under 30: Histamine Imbalance in Mental Health

About 15 years ago I was introduced to Histamine as a neurotransmitter. Not the allergy mediator or the ‘basophil baddy’ but rather this prolific and potent neurochemical we all produce in our brains which, in the right amount, regulates almost every biological rhythm, helps with memory and mood & much more. Being able to recognise excesses or deficiencies of CNS histamine in mental health presentations and, ever since then, fine-tuning my ability to support patients with these, has changed my practise forever and has been the key to some of my patients’ greatest recovery stories.  Forever grateful to the pioneers of this model, 70 years on, the model is ready for a mini-makeover, to bring it in line with the current scientific understanding of histamine, methylation, genes and much more.  This recording, together with a hugely helpful clinical resource, will give you the confidence to recognise and remedy this important imbalance in mental health. If you want to download this recording click here.

SSRIs – A Weight On Some Patient’s Minds

Given 1 in 8 Australians right now are taking an antidepressant, chances are you’re seeing a lot of clients on these, especially the SSRIs.  Erica McIntyre (fellow naturopath) and colleagues, found that in fact, mental health diagnoses affect about 43% of individuals who choose to seek help from a naturopath or herbalist, so clearly this is across all of our waiting rooms. Accordingly, by this stage in your clinical career you’ve probably seen more than 1 patient taking the identical SSRI – e.g. Citalopram (aka Lexapro or Cipramil)  Have you also by now, therefore come to ‘expect the unexpected’, when it comes to patients on the same prescription, in terms of ‘weight effects’? The majority not reporting this to be a major concern or issue but the occasional client, experiencing such significant weight gain, they may even have seen this as a reason to discontinue the medication.  So what’s up with that then?  Don’t we all wish we knew for certain!  But getting our heads around the potential mechanisms is important for our patients, in terms of making more informed choices, as well as offering us insight perhaps into their neurobiological nuances.

Some of you will know, this used to be my place of business.  

I have a background in the pharmaceutical industry, specifically psychiatric meds, more specifically SSRIs and even I find every time I duck-dive back into the literature I come up with more ‘fish’ – critical new information about mechanisms, secondary and unexpected actions, unforeseen benefits, barriers and yes, some sad or bad new detail.  Consequently, I always field lots of questions about SSRIs in our mentoring sessions & one that often comes up is why some patients gain weight on SSRIs. What’s most curious to many, is how the weight effects of antidepressants can be hard to predict.  There is not a consistent pattern across any specific antidepressant class, nor just 1 or 2 medications within a class, that will do it, while the others never will. This is in contrast to the many determinations and drivers for who will or won’t get discontinuation syndrome. So what mechanisms might be behind such an individualistic weight response and is there any way to predict or prevent this? 

Here we find ourselves again with the question that keeps all IM practitioners awake at night:
But why?
But why??
But why???!

A worthy question indeed. According to comprehensive reviews of this issue: there are still multiple candidates – one is the incidental histamine blocking that some SSRIs exhibit (could this flag someone low in histamine to start with??), while others still hold some suspicion over an old foe, elevated prolactin, that we can see in a minority of patients on these meds…easy to measure and confirm or refute, right?  But always ask your patients first, How has your diet changed over this same period?  How has your activity changed? You may of course find, you need look no further.  People can give you the answer on a platter with things like, “I just relaxed a lot more: about what I ate and my weight”…Bingo!  As always, the patient in front of you is their own little ultimate black-box…🧐

Leaving Anti-Depressants Behind

Never our call to make, but with 1 in 8 Australians at any time taking antidepressants, playing a supportive role for patients wishing to discontinue their antidepressant medication is common.  So what do we know, about how to really do this well, what to expect and how to perhaps mitigate some of the bumps that might lie ahead.  What in our artillery should we go in armed with either during the discontinuation or, better still, beforehand?  This Update in Under 30 outline the key principles of patient prescriptions in this context and may assist patients, in their desire to truly leave the antidepressants behind.

 

If you are an Update in Under 30 Subscriber, this is a previously release episode and you will need to search for it to find this in your library of UU30’s that are in your online account. 
Not an Update in Under 30 Subscriber? To access this episode and the entire library of Update in Under 30 audio’s and resources become a subscriber here.

 

Walk Towards The Light!

Now find a comfy spot everyone & I’ll tell you a story…’Once upon a time, a long long time ago, we lived our days out in the dark, regarding potential calcium dysregulation!’ But ever since serum Calcium has become a standard lab included in most routine screening tests (General Chemistry aka ELFTs) abnormal calcium handling is no longer an ambush for patients of ‘stones, moans and abdominal groans’, as the saying goes in hyperaparthyroidism.  A diagnosis historically only mad, when someone presented with this constellation of rather advanced symptoms. But actually being able to identify your patients’ typical blood calcium levels offer us so much more than just a heads-up re parathyroid disease

 It may tell us something about their Magnesium status, cardio cautions, be a bit of ‘bone barometer’ and probably most immediately important, flag their suitability for calcium supplementation!

Yep…rather than the current-criminally-crude-calcium-checklist:
1. Patient is female
2. Patient probably doesn’t consume enough calcium
3. Patient may be at risk of osteoporosis (yup…that accounts for practically every woman, right there!)

… and then the indiscriminate prescribing of calcium doses that could rarely be achieved in a single meal…(and hence run the risk of over-riding our critical regulation of this edgy electrolyte) we could…wait for it…individualise our approach!  I know, like a broken record 😂

But seriously, if you just do a full review of the vast literature on this topic, what?! Not enough time?! How about then, just skim read a couple of key papers? Still baulking at that?…maybe just a wafer-thing editorial (??!) will tell you that, consuming elemental amounts of calcium (> 250mg), that are beyond even the biggest Dairy Diva’s Diet Diary, may be deeply problematic for many.  And guess what…this doesn’t pertain to supplements alone…even calcium fortified foods are not free from concern!  But let’s not let yet throw all our calcium fortified foods in the same bin as the folate ones we did a while ago!!  Let’s step out of the dark and into the light that shines upon us, care of fasting serum Calcium measurements, to help us recognise whether Calcium is the cause, the consequence, a cure or a curse for person sitting in front of you 🧐

The Calcium Conspiracy Controversy Continued

The Calcium Conspiracy arises primarily from misperceptions about it being ‘the boss of bones’ but becomes more of a controversy when in spite of ongoing advice for broad-scale use we review the evidence and have to acknowledge that the recommendation to supplement post-menopausal women with large doses of Calcium, not only lacks strong evidence but may cause harm to some.  In this detailed discussion of the two schools of thought – Rachel finds a position somewhere in between. Reinforcing the need for an individualised approach and personalised risk benefit analysis while teaching you how to undertake this in every client.

 

The latest Update in Under 30 has landed!!!

You can purchase The Calcium Conspiracy Continued here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.

 

 

Is This You?

Gotta love all the clever inquisitive minds among our integrative health practitioner community.   I think each of us, as children may have been that one kid who just never stopped asking questions.  What a great quality to have because it prompts us to think outside the box, then outside the triangle, then the hexagon and beyond! Simultaneously, busy minds that never stop questioning and never quiet down can also feel like a curse!  None of us have the time to go find the answer independently to every single question that our patient, prescription & pathology encounters raise for us.  We need to use the force. Our colleagues, our workmates, our informal and formal practitioner networks, our mentors, our associations, our educators etc.  A lot of practitioners recently got some questions answered with the Update in Under 30: Separating the B12 from the B*S#!...and then guess what…they had some more B12 related questions 😂😂

Q: What might a normal or even high serum B12 together with low Active B12 combination flag in a patient?

A: Exclude COCP use, & gross liver pathology, refer for B12 antibodies if possible & review the case for other evidence of functional B12 deficiency, as TCII values are more specific and sensitive than serum

Q: What evidence do we have to use a higher cut-off value than the labs give us for Serum B12 (< 400 pmol/L), as a decision limit for follow-up investigation for B12 deficiency

A: Just the findings of some of the biggest studies on B12 assessment – correlating serum values and markers of functional deficiency such as Harrington et al 2017, Spence et al 2016, which flag that there is already metabolic impairment typically when serum values drop below 400, well before the classic features such as macrocytic anaemia

You’re welcome 🙂 It’s nice to be surrounded by like-minded curious kids (disguised in big people’s bodies!)  I love playing my part in adding to the collective knowledge in different ways and for those of you who are our Update in Under 30 subscribers, and of course anyone that purchased this as a single download, well we’ve gone that extra step and put together a nice little pdf: A B 12 Assessment Decision Tree for you and added that in as a bonus to your Separating the B12 from the B*S#! episode.  So go take a look now and hopefully that answers just a couple more questions and we can all have at least 1 good night’s sleep… before you come back with more 😉 🧐 😂

Separating the B12 from the B*S#! 

B12 is a routinely under-rated and recognised micronutrient, which is in fact in high demand by many of our patients. As nutritional research pushes back against defining adequacy as simply the prevention of the deficiency-associated disease (macrocyctic anaemia, irreversible neurological damage) we enter a new landscape of more individualised approaches where we’re better able to recognise and treat those at risk of falling below ‘optimal’.  But how do we accurately identify this and then choose the ‘best’ B12 (methyl- cyano- adenosyl- hyroxo-) supplement? Does it need to be this complex?  Time to sort the B12 from the B*S#!!
This recording comes with a bunch of great resources including a clever clinical tool.  
And now a new one to boot!!

________

You can purchase Separating the B12 from the B*S#! here
If you are an Update in Under 30 Subscriber, you will find the new resource in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.

 

Balancing Protein With Personalised Requirements

You guys know I can’t help myself.  For the last year or so I’ve been immersed in developing and redeveloping and redeveloping 🤓 [ahem apologies to my team!!] teaching tools for all practitioners to better understand what the routine renal markers can offer us in terms of understanding our patients…and it is far above and beyond renal function, promise.  Just one example of this, is the sophisticated yet incredibly simple urea to creatinine ratio calculation that I was originally taught by Professor Mel Sydney-Smith. In adults with preserved renal function, this is the key to the kingdom, in terms of being able to objectively quantify whether patients are truly meeting their own individualised protein requirements.  The Marvellous Mel (well he is, who can argue with that?!) added this one to my toolkit a long long time ago and in turn, I’ve been using it and spruiking it ever since. 

In fact, I just lost 30 mins of my life listening to myself (ewww) in an old Update in Under 30 from 2013 that I recorded on this very topic.

[Sigh] I sounded so youthful…and…about 7 years younger too in terms of experience with this crafty calculation in the hundreds of labs I have encountered since!

My reliance on this ratio has remained but my wisdom regarding how to apply it has widened….and so, as I prepare to initiate another hundred or so practitioners into this secret sect 😉 via our current MasterCourse in Comprehensive Diagnostics, I couldn’t help myself and decided to re-record this UU30 episode: Using Urea & Creatinine as Markers of Protein Adequacy and also throw in a new pdf resource to boot [once again, ahem,apologies to my team!!]  You see our ability to identify protein adequacy without this tool relies on the rather-rudimentary-‘rule’ that your protein requirements increase linearly with your weight…that’s the whole g/kg body weight thingo, right?  But what if your weight gain is ‘all adipose’ Vs ‘mega muscle’ – are the protein requirements really the same for both people? Absolutely, not!  This calculation enables us to step away from the rough approximation of the RDI and be able to determine if each individual is meeting their genuine requirements as driven by their own unique muscle mass hunger…oh and it reveals a few other very helpful things along the way to boot! 

But this simple calculation comes with some caveats: 1. there are people and presentations in whom this calculation is not appropriate or accurate 2. because there are no magic numbers, right, it is about matching your labs with the patient in front of you and 3. looking (as always) for patterns.

…and a word of warning to the uninitiated: You’re going to love it!

So for those of you who are already Update in Under 30 Subscribers…happy Wednesday!  Because you always benefit from any updated recordings etc.  you’ll find this rejigged resource is already in your Active Content and for those of you who may have purchased this as an individual recording in the past, the same applies.  And for anyone else keen to make some real meaning out of the most routine labs we see over and over again, and understand a whole world more about what they tell us about our patients’ muscle mass health, trajectory and the dietary protein piece of this puzzle…you might want to check this out too! And for those of you who think ‘total protein’ on a patient’s blood test results reflects ‘total protein’…boy have I got news for you!!

Out of the Archive – Rejigged & Re-resourced: Using Urea & Creatinine as Markers of Protein Adequacy

This comprehensive analysis of two standard indicators, urea and creatinine, that are often part of the patient’s standard blood chemistry tests. These commonly available results can provide insight into protein ingestion and uptake as well as muscle mass and, in extreme cases, kidney and liver function.

 

If you are an Update in Under 30 Subscriber, you can listen to the updated version which is waiting in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.

Calling Out The Conspiracy

I don’t know about you but I don’t count myself among the conspiracy theorists. While I may have been partial to the occasional one over my lifetime, you have my word, I never inhaled. Or at least not since I learned the practise of scientific enquiry and the application of critical thinking to all evidence.  The two together tend to put a dampener on the whole: earth is flat & the moon-landing was a hoax…kind of notions. But there is one conspiracy I think all of us in nutritional medicine have been the victim of: The Calcium Conspiracy.

Not in the vein of speculations regarding excessive lobbying & undue influence of the Dairy Corporation on dietary guidelines. Nor even arguments that this has gone so far as to inflate the RDIs for this nutrient. Nope, I am actually good with the RDIs for this mineral. High level evidence confirms that our intake of Calcium was enormous even before the Agricultural Revolution, and therefore BD (Before Dairy) 😂

Man, those roots and tubers and other bushfoods sure were nutrient dense, not like the stuff we consume these days!

No, the Calcium Conspiracy we’ve all been lead to believe is that it is the boss.  The boss of bones. The boss of the parathyroid. The boss of the other minerals. And especially the boss of Magnesium.  While you might have heard me describe Calcium as a ‘bully’ in the GIT (let’s call this the slide 😅) and I stand by that, it is far from being the boss of the rest of the playground! In fact its regulation is largely at the hands of other nutrients..not naming any names…[Magnesium😳]  So while, all of us trained in nutrition have had the significance of the Calcium-Magnesium relationship & the mantra “2:1, 2:1, 2:1” drilled into us, which we repeat at night to get ourselves to sleep (or did they mean to take not just ‘talk’ these minerals, to help with sleep?!) Our teaching created this conspiracy – a misperception that Calcium is the boss and Magnesium its long-forgotten lackey.  Well guess who’s really calling the shots and on whom?!

Have you ever heard the saying, ‘It can take Magnesium to fix a Calcium problem”?  I’ve not just heard it but seen it many, many times in my patients. 

But how do you tell which patients need both and which ones, just one?   It comes down to understanding the exquisitely sophisticated way Magnesium lords it over Calcium – via the parathyroid and Vitamin D metabolism and how we can see this patently in the pathology (regular screening labs) of your clients. I think there is a bias in integrative nutrition – we favour Magnesium – it goes into our supplement recommendations for so many of our patients and while the rationale for this is valid – all dietary surveys show magnesium under-consumption to be rampant in the SAD – I don’t actually think all of us know 1) how much we should be giving (yes there is a limit) 2) how to discern who needs what, in spite of a lack of a good Magnesium assay and 3) the true potency in the prescription when we get these things right or wrong! This study by Sahota et al is so far my favourite for 2020..it’s 14 years old and the sample size is small but its methodology and examination of when Magnesium can fix a Calcium issue and when it can’t, is superb. Together with about 50 other papers I’ve just imbibed…they’ve refined my thinking, tremendously. There’s a Calcium Conspiracy, alright, but just throwing Magnesium at everyone in arbitrary doses is not the solution…. “2:1, 2:1, 2:1…..”😴

The Calcium Conspiracy -Your Latest Update in Under 30

There’s a conspiracy going on regarding Calcium but it’s probably not the one you imagine.  We have been lead to believe that Calcium is the boss: the boss of the bones, of the other minerals and certainly of its often over-looked lackey, Magnesium.  But the truth is, we have it all the wrong way round.  There is a sophisticated synergism between these two minerals but the brains and the brawn in this relationship are held by the latter and we need to understand how to recognise when Magnesium is ‘pulling the strings’, to produce low calcium,  in our patients and how to find the sweet spot of their synergy.  This recording comes with a great resource to use in your clinic, with explicit redefinition of ‘what healthy looks like’.

 

The latest Update in Under 30 has landed!!!

You can purchase The Calcium Conspiracy here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.

 

Ever Wondered How Much D Will Get You There?

I used to all the time. Especially when I noticed the Niagara-falls-sized gap between the doses I was using compared with my mainstream medico mates.  I thought, hang on, for a patient with a baseline blood level of 40nmol/L, they’re recommending <1000 IU per day, but I’m thinking 5000 IU…which one of us is wrong? Then again, we might both be right!

The sexily simple formula as cited by Aussie researchers is: for every 1,000 IU of vitamin D a patient takes a day, their blood level is likely to rise approx. 17 nmol/L over 2 months, at which point it plateaus.  So the medicos’ 1,000 IU supplement would bring our patient’s blood level up to 57 nmol/L which, as far as the medico might be concerned, is ‘job done’ 👍👏

My dose would be viewed as excessive but clearly I am aiming for a different set of goals (optimal rather than simple prevention of deficiency)…oh and I insist on follow up testing to know when we’ve made it!!

 I encourage my patients to get their Vitamin D retested 2 months into treatment to confirm 1) they have responded and 2) their response is loosely within this predicted performance.  And how many times is it not? Often.  Which got me to readjust the formula I use to something more akin to: for every 10 nmol I want their blood levels to rise, I will need to increase their intake by a 1,000 IU.  Now am I just making big sweeping inferences from empirical experiences of a few (hundred) patients without additional backing….well so what if I was...this is a branch of the EBM family tree!  But no! I have also actually read enough studies clearly documenting the individualistic response to vitamin D, as a consequence of different adiposity levels, genes, magnesium status etc. to know that, while I am very grateful to have any kind of formula to start my thinking from…I treat individuals and goshdangit#@! they keep insisting on individualised medicine!

The whole practise of identifying a deficiency, ‘treating it’ and yet never following up with repeat labs to confirm that you actually have…BLOWS MY MIND🤯

That’s not EBM, let’s face it.  Not even a distant demented cousin who has fallen from the dizzying heights of that family tree.

The one lesson I’ve learned, more than any other over 20 years in nutritional medicine, is that the more questions we ask and the more we challenge ‘established truths’, the more we uncover something much more personalised and potent about each and every nutrient …and now as the days continue to shorten into smaller and smaller slithers of sunlight between ‘bed-ends’, this is probably also a good time to ask ourselves…

Should We Rethink High Dose Vitamin D?

Vitamin D deficiency has been associated with a long list of major health conditions: from autoimmunity to mental health & almost everything in between. This has lead to many of us recommending high dose vitamin D supplementation for a large proportion of our patients but do we understand everything we need to to be certain of the merits and safety of this? In this provocative episode Rachel outlines the key unresolved vitamin D dilemmas that should encourage us to exercise caution and outlines how adequate sun exposure is associated with improved health outcomes independent of the production & action of vitamin D.

 

You can purchase this UU30 episode individually here or become a subscriber and gain access to this and over 65+ episodes plus new monthly releases for 12 months here.
If you are already an Update in Under 30 Subscriber, you will have immediate access to this episode in the ‘active content’ of your online account.

Are You Thinking What I’m Thinking?

🍌 ‘Are you thinking what I’m thinking, B1?’

🍌‘I think I am, B2! It’s time to separate the B12 from the B*S#!’

Ok, if you’re reading this and you’re not from around here you have reasonable grounds to conclude I’m the one who’s gone 🍌 but if you grew up with a show all about 2 adults dressed up as bananas and creatively known as B1 and B2, then we’re all good!  Ok now for the next bit, you might need to sit down.  Nothing not everything in the wildly popular, and dare I say it populist, doco The Game Changers was scientifically rigorous.  I know, I’m loving the strike through a little too much today.

Goodness, when otherwise intelligent friends of mine forced me to watch this, they found the need for both restraints and duct tape over my mouth, to hear or see anything other than me jumping up and down, arms flapping, mouth yapping. People only tend to make this mistake with me once.

Among the many many dubious XXX was a terrible mis-truth about our ‘new modern reliance on animal food or supplements for B12’. Woah…back up there Game Changers Gang, say what?!  Does anyone on their research team read any research?  So that got me all motivated to go back to the books on our beloved B12, which is simply like no other micronutrient in human physiology or in nature, for many reasons…starting with 1) it contains a metal in the middle 2) it has dietary dopplegangers (plant forms that look just like it but actually are decoys that need to be actively removed from the body so as not to block its actions) and 3) has the most complex and sophisticated pathway for digestion and absorption, which surprising equates to brilliant average bioavailability (much better than most micronutrients)…until it doesn’t!  And that’s when the trouble starts.  Once you don’t have an intact IF absorption pathway, you’re down to picking up < 1% via simple diffusion, and suddenly we see why patients can be vulnerable to not meeting even the piddly required amount. Not to mention the vegans, of course. I’m on my best behaviour.

But the B*S#! about B12 is far from limited to the documentary.  It’s in the words of the Methylation Mystics, making methylation sound like rocket science and in the supplements we’re being sold.

But don’t get me wrong…effective B12 treatment in the right patient is a total wow moment. I’ve literally seen all the lights go on⚡ in some .  So what do we need to do to find our way out of the dark?  Go back to the solid science.   Come on. There’s nothing else you need to do and nowhere else you need to be… we all know it…so start by reading this and this.  There’s plenty more of course but these are excellent appetisers. And if you want to cut to the chase and get the lowdown on what’s B*S#! versus what’s the real magic of B12, you can always settle in and listen to my latest Update in Under 30 – complete with a very cool clinical tool to help you choose the best B12 for each individual, but spoiler alert, it ain’t rocket science.🤫

B12 is a routinely under-rated and recognised micronutrient, which is in fact in high demand by many of our patients.  As nutritional research pushes back against defining adequacy as simply the prevention of the deficiency-associated disease (macrocyctic anaemia, irreversible neurological damage) we enter a new landscape of more individualised approaches where we’re better able to recognise and treat those at risk of falling below ‘optimal’.  But how do we accurately identify this and then choose the ‘best’ B12 (methyl- cyano- adenosyl- hyroxo-) supplement? Does it need to be this complex?  Time to sort the B12 from the B*S#!!  This recording comes with a bunch of great resources including a very handy clinical tool
The latest Update in Under 30 has landed!!!
You can purchase April’s episode, Separating the B12 from the B*S#! is here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.

 

Are You A Sucker For ‘Secret Herbs & Spices’?!

Me neither. I value transparency in all things impacting my health.  So when the ‘Colonel’ tells us the magic is in not knowing…I think….hmmmmmmm, no thanks!

Similarly, when the provider of a test tells us, ‘We’d like to give you independent scientific support for our markers and our method but we just can’t because it’s patented!’…well that’s as good as the so-called ‘Colonel’ and his mysterious unidentified herbs and spices, as far as I’m concerned. 

It’s effectively like they have created for themselves a ‘Get out of jail free card’ but unlike in Monopoly, they can play it over and over again.  Trouble is, as the referring or just ‘reading’ practitioner (many of my patients present with results of these tests in hand) you have to practice either utter blind faith and believe every word that report tells you or you feel like you have to disregard the entire thing because you don’t have the time to sift through every parameter, searching out any independent scientific discussion of their markers, to distinguish fact from fiction.  Utterly exasperating.  Because of course, a test that offers a huge panel of results may consist of both – some of high value, some utter nonsense and some somewhere in between. 

There’s one 24hr urine test from an OS company that I tend to see increasingly and it purports to be able to assess just about everything from gut health, to neurotransmitter levels, to your antioxidant capacity, mitochondrial health and beyond! How is this even possible in one 24 hr non-preserved urine sample that goes off-shore to be analysed? Well they can’t say…it’s a secret. 🤐 Pu-lease!

But always HATING to be the one to throw the baby out with the bathwater, I lose hours of my time, over and over again, trying to determine the worth in this multi-paged report and salvage some value along the way, given these patients’ significant financial outlay.  So it’s handy when the test also professes to accurately determine whether these patients are nutritionally replete for basic vitamins.  Aha!  Now we’re talking! The science of nutritional assessment includes volumes and volumes of studies, reviews, discussion and luckily enough I happen to have a strong foundation in this area and read such research for recreation! Today I am looking at a patient’s results that flag profoundly low Vitamin B6.  Several hours of reading later I can call BS. Seriously. The marker used by the company is urinary pyridoxic acid which is 1) reflective of recent intake only, failing to reflect both tissue levels and coenzyme activity 2) needs to be reviewed in light of protein intake, as high protein produces lower excretion and B2 levels because B2 deficiency will produce a secondary abnormally low B6 in the urine. There’s zero mention of any of these limitations or considerations in the report, sadly 🙁

To boot all the lights and sirens are on for this patient who appears to have such little vitamin C in their urine, they’re at risk of scurvy! That is except for the fact that Vitamin C readily oxidises in urine only to turn into….wait for it….Oxalic acid! So, anyone surprised to hear  she is also reported to have an exceptionally high oxalate load?! 

Secret herbs and spices?  No thanks, I’d prefer science.  As the saying goes, “Keep an open mind but not so open your brain falls out!” Sorry but tough-talkin’ Tuesday is back and it’s gotten all toothy!

Update in Under 30: Oxalate Overload – Assessment and Management

Oxalates are present in many healthy foods and in all healthy people, but when ‘normal’ levels are exceeded they can spell trouble in a whole raft of different ways due to their extensive distribution across the body. Some tissues, however, have more problems than others, especially the urinary system and soft tissue and joints but now there are also questions about oxalates’ relationship with thyroid and breast issues.  We review the latest evidence about the health consequences, blow the lid on accurate assessment for oxalate excess and talk management in this jam-packed update.

 

Is Copper the Culprit in ADHD?

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.

 

Getting More Bang From Your Patients’ BP

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 😊

Have you also heard what’s totally NEW! for 2020 – Our Patient Pathology Manager!!

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 Excess’ In A Child?!….Really??

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.

 

In Need Of A Better System?

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 RAN Patient 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’?

 

Add this essential tool to your clinical toolkit by clicking here to purchase RAN Patient Pathology Manager
and watch this presentation now in your online account.

Putting Young Heads on Old Shoulders

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.

Ironing Out Some Old Misunderstandings

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.

So, What Kind Of Drunk Are You?

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:

Relief Habit

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!!)

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? 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.

New Goals & Some Good News (At Last!) in Gilbert’s Syndrome

 

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.
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‘A Guide to Gilbert’s Package’
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