Keeping Things Real & Representative

 

Any pathology test is only of value if the result produced is ‘real’, or, representative of that individual, right? So the timing of the test is a major pivot point then: do I tell my patient to present for the test, or collect the sample themselves, on their ‘best’, their ‘worst’ or their ‘average’ day? 🤷‍♀️  Well, that all depends on the question you are trying to answer.

Whenever we reach or refer for a test, we have a question in mind we’re seeking an answer to. But the question always comes in two parts, at least.

Part 1: How much progesterone is she making?
Part 2: …When she’s ovulated & her corpus luteum should be most productive?

A third might refine the question you’re answering further by adding another contextual clarification

Part 3,4,5: …When she’s eating her regular diet, not exercising excessively or under extreme stress

Without these other parts – the answer to the first one: How much progesterone is she making (full stop), is hard to correctly interpret, right? By refining and expanding on the full extent of our question, we can be clear about which elements of this patient’s life the result likely reflects. We might say that for her, this time-point, or set of collection conditions, is a ‘real reflection’ of her generally and therefore, representative.  But what if she does occasionally undertake a 5 day fast, or train for & compete in marathons? If we were to specifically test during these times, we answer a different question, right?  Likewise every time we instruct a patient to present for their blood tests (routine or fancy schmancy): Fasted, Rested, Hydrated and off their supplements – is this sound advice or a misdirection?  Well it depends on the individual in front of you and the real question you want answered about them 🤓

Ahhhhh I love rules: both the making of them and the subsequent breaking of them 🦜🏴‍☠️

Fasted, Rested, Hydrated & Unsupplemented? Exceptions to the rule

The collection conditions for any pathology test – can refine or ruin the question you were hoping to have answered about your patient but is it always appropriate to ask everyone to ensure their preparation for the test was ‘ideal’? What if their real life is far from ‘ideal’ and contrasts dramatically with these ‘conditions’ e.g. they forget to drink water but never alcohol! Or do they run 20km every weekday and 40 on weekends?  And why would we tell some patients to stop their supplements prior to a blood-test and not others? If our goal is to ensure any pathology test answers the question we need answered we need to know how to respond to these and other scenarios.  This new update is all about keeping results ‘real’ & representative.

 

You can purchase Fasted, Rested, Hydrated & Unsupplemented? Exceptions to the Rule here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.

The GREAT Cortisol Capture! 35K Aussies Get Tested

And all 35K results have been collated, analysed & made available so we can be better informed regarding expected Cortisol values based on sex (spoiler alert: women win & when I say win I mean track higher generally🤷‍♀️), age & life-stage. This month in our Mental Health Primer program I’m talking about how to look at labs through a mental health lens – from the most routine (ELFTs, FBE etc) to those 2nd tier assessments that we might sometimes recognise to provide essential information about our patients.  HPA assessment is such a big one in mental health and depression, specifically, because of the 2 major subtypes: typical (can’t sleep, can’t eat) and ‘atypical’ (over-sleeps, over-eats).   We all know that in ‘typical’ depression – the subtype we tend to over-focus on due to its dominance (and sometimes therefore miss the atypical patient at our own peril),  there is most characteristically a hyper-cortisolism, with poor negative feedback at the HP, allowing for these higher circulating levels. But is your depressed patient with sleep disturbance experiencing higher than healthy or expected cortisol release?  No, not necessarily.

You see even the 2 subtypes can have sub- sub- types.  Patients can have a diagnosis of either form of depression but have PTSD features or other psych and non-psych comorbidities that make it more probable that their adrenals and Cortisol are turned to ‘low’.
As in unhealthily & unhelpfully low.

And that would then necessitate a very different approach to treatment – a different choice of herbs and nutrients etc., right? As we’ve discussed before, accurately capturing cortisol is a task not for the faint-hearted!  Cortisol demonstrates such dynamism – not just regarding time of day and pre-test and test exposures & experiences, but also your geographical location in the world (!), not to mention choice of medium and which aspect of the HPA story that specifically reflects.   But for some patients it is essential for best management that we ‘feel the fear & undertake an assessment of their HPA function anyway’! But we need to ensure we get results we know how to accurately interpret.

I use different cortisol captures (saliva, urine, blood) to answer different questions – but if I want to understand the HPA functionality and performance and feedback…then measuring cortisol alone is not adequate – and we are back at blood, which offers us, as always, to go beyond a simple numerical: ‘adrenal output’ & also answer the question: “What were the adrenals TOLD to do?” aka where does any actual mismanagement lie & likewise, the key to correction.

Cortisol – Have you been caught out?

I have!  And just recently a stark contrast between the results from 2 different methods of cortisol capture in the same patient illustrated just how likely this is. How do we ‘capture’ something so ‘dynamic’ and interpret anything of substance from a ‘static’ assessment technique?   But rather than throw up our hands and throw out the whole attempt to measure cortisol, we can improve the rigor, reliability, and real-world meaningfulness of our patients’ results by refining our timing of tests, choosing the medium wisely & manipulating test conditions to answer specific questions about their HPA function.  Great ready reference resource included!

 

More FODMAP Fails

Last week, yet another patient with refractory diarrhoea, up to 10 stools a day, Bristol type 5-7, for 3 decades following a diagnosis of Crohn’s at 16 years old. A range of specialists have thrown everything at ‘it’ – single & combination immunosuppressants, TNF alpha blockers, buckets of sulfasalazine and bathtubs of antibiotics – she’s been gluten and dairy free for years, trialled strict diets that are FODMAPs free, low histamine etc etc etc. She’s even had 50cm of her terminal ileum removed & the diarrhoea continues unabated – perhaps even worse than before…& therein lies a major clue.

 1/2 patients with Crohn’s exhibit bile acid malabsorption –> diarrhoea but with terminal ileum resection this jumps to > 90%

This is Type I BAD (Bile Acid Diarrhoea) & is the easiest to spot, being the result of anatomical change.  You remove the section of the small intestines responsible for 95% of the reabsorption of bile acids…a LOT of bile acids are going to be present in the colon where they act as potent osmotic laxatives, right? But there are 3 other types which are a little trickier to identify – including one that affects up to 50% of IBS-D patients. 

Being a child of the 80s⚡🎹 (ok a teen of the 80s but who’s counting?!) and a personal fan of fat, I NEVER thought I would EVER be recommending a ‘low fat’ diet to ANYONE🤐

But hey, that’s another ‘absolute’ that needs challenging, right? I mean this is the primary, almost only, dietary change these patients need to make and as a stand-alone intervention, is highly effective for many. We’ve had several patient successes in the last year – a total game-changer for patients in similar situations where all kinds of  ‘restriction’ had brought zero joy and reward for all their ‘good (dietary) behaviour’. While sequestrants (like cholestyramine) are recommended in BAD, and are certainly worth a trial at least, patients have very mixed results – for some, in combination with the low fat diet it’s a winner – for others these meds cause GIT upset all on their own and actually undo the good of the fat restriction. Being able to identify the true reason for their loose stools and stop them going down endless rabbit holes of ..is it? is it? is a great way to re-empower people who’ve been bossed and bullied by their bowel for far too long 🤓💪🧻

 

When is IBS BAD?

This is not a trick question. Up to 50% of all patients diagnosed with IBS-D actually have bile acid diarrhoea (BAD) underpinning their digestive complaints as well as some patients with non-resolving diarrhoea post-cholecystectomy and gastro.  Knowing which ones do and how to manage this, which requires distinctly different approaches from our general management of IBS, is the key.  As always, good lessons come from those we learn in the clinic and this story starts with a patient and how we came to recognise the BAD in her belly.

Where Is That??!!!

Ever been guilty of having a ‘man’s look’ for something?  I have. Particularly when it comes to the online omniverse! I can be a bit flaky at finding things right there on the page…allegedly! So for those of you who have a similar experience with my website & endless educational offerings, I FEEL YOU! We do have a tonne of training options and a whole lot of (love 😉 couldn’t resist the Led Zepplin reference)… lab & diagnostics resources!  This has come up in conversation a lot recently, following the release of our RAN Student Pathology Hub, for example: “I’ve done your MasterCourse in Diagnostics, does this cover something different?” or “LOVED😍 this new hub its *$@# incredible resources & extra training vids but I also wished it included your take on… [insert your pick from infinite list: thyroid, cortisol, zinc etc etc etc]

So here’s a Dummies Guide:
How to Find the Help you Need in Diagnostics

  1. If you are just starting out on your path to pathology & true lab literacy & want an accelerated way to ensure you are starting this journey on solid ground and you have the most called-upon skills you’ll need in clinic today, then the RAN Student Pathology Hub is your perfect match. NOTE: this is not limited to actual students but anyone who considers themselves, like us, a life-long learner! This 12 part module includes some small core components of our MasterCourse, a few expanded episodes from our Update in Under 30, plus unique short training videos, covering tests and topics including: Iron studies, B12 assessment methods, Coeliac screening & much more
  2. If you’re seeking the immersive experience – you want to maximise your competence and confidence & forge your path as a true Diagnostic Diva or Divo then look no further than our ‘mothership’, the MasterCourse in Comprehensive Diagnostics  which now has a part payment option.  This really is the most seminal training we offer, taking the time to dig deep into the science behind all the ‘signposts’ our patients’ results are pointing to. A big commitment for a big reward. It comprehensively covers all the routine labs you will see everyday:  LFTs, Renal markers, Glucose and Lipids, FBE & WCCs & is loaded up with case illustrations for each key pathology pattern – that many practitioners say was an absolute highlight
  3. Just have a specific question or need for upskilling in Cortisol assessment?  Zinc or Zonulin? It’s probably in our vast Update in Under 30 library!  Yes, with more than 100 episodes in there and my penchant for pathology…you’ll find something, if not in the UU30 episodes, then somewhere else on my website.  You know how in pdfs ‘Control + F’ is a god! Ok on my site it is this fella 🔎  You can use this to search my whole site to find free information on the topic (blogs) or manifest the same magnifier🔎 magic once you have clicked ‘Catalogue’ on the top right of the tool bar on any page, to locate any specific educational offerings. Remember with the UU30, you can purchase single episodes or subscribe and get access to the whole shebang.

And for those of you primed praccies, patiently waiting for our MasterCourse II to land?  Well about that…did we mention we got hit with a flood? Twice? And then got covid?  Two of us? And have our beloved Nina about to depart to become a mumma!!! Yeah, so our plans to have this up and ready for May changed to Mayhem, real fast 🙄🤪 We will definitely keep you posted on any developments and new timeframes but for now we can only apologise for the delay and will do our best to get back on track with this, at the earliest opportunity. In the meantime maybe a little review of some of MasterCourse I is in order?  I refer back and re-listen all the time, myself!!😂

RAN Student Pathology Hub

Being a practitioner who is able to read labs will set you apart in practice. For your patients this flows from your ability to form a more sophisticated understanding of what’s happening for them, enabling you to better individualise treatment and deliver superior outcomes.  Amongst other health professionals, it will attract positive regard and an increased willingness and enthusiasm for sharing the care of patients with you. Learning to be lab literate could take a lifetime…or you can enter the expressway from the very outset! We have curated the content to reflect the most essential elements, to help you hit the ground running in the shortest period of time. Spread across 12 modules which can be consumed as monthly instalments or, as an all-in-one experience for those wishing to waste no time. The teaching points, tips and tools make the complex simple, engaging, even fun!

Developed, designed and delivered with students of any health discipline in mind.

Meet My Alter Ego

Impact of drugs on mental health

Did I say, ‘Our Brain’? 🙄 Maybe it really should be, ‘Their Brain…on Drugs: what recreational substances reveal’. While infinite self-analysis is an occupational hazard for health professionals, when we use our detective powers for good not evil, our patient work-up benefits.  But of course, it is impossible (and not desirable) to avoid all self-reflection.  Let me introduce myself: I am a high dopamine gal.  How do I know?  Because a valid accurate test of my neurotransmitters told so? Heck no – outside of lumbar puncture there isn’t one! Because my reactions to recreational drugs did.

A self-proclaimed ‘cheap date’, with amplified & protracted intoxication experiences from small amounts of any psychoactive & no, sadly, not always pleasant.  I specialise in visual trails, a known trademark of dopamine surges, when under the influence of even just a few drinks – much to the bewilderment of my loved ones.

Some even famously once questioned whether I was, in fact, safe to ride a push-bike 500m on Lord Howe Island after 2 glasses of prosecco. Stop! I heard that murmur, this has nothing to do with my liver & its handling of such substances. [How rude!😆] I can cite ample other evidence in support of this. This is also not simply due to being a teetotaller and therefore having not (yet) developed tolerance.  This high dopamine diva-stuff is echoed by my non-intoxicated ‘normal’: vivid dreaming, impulsivity, and bankable bad reactions to Vitex: ANGER (capitals intended). TMI? 🙄🤐

When you know the questions to ask, the answers to lean in further to, and then the way it can all come together, to create a neat little trail of breadcrumbs we can follow all the way to our their neurochemistry…you can find the gold.

The thing is – and I remain annoyed and frustrated by this to this day – our ‘schooling’ was not very ‘sex, drugs and rock’n’roll’. New grads tell me nothing has changed. In fact, these kind of topics were absolutely omitted, in spite of the claim we consider the ‘whole patient’, the whole health story! Interesting, hey? Nod to those working on the ‘sex’ bit in holistic health: Moira Bradfield-Strydom, Sage King, Monica Francia, Daniel Robson…love ya work!  Now for the drugs! Do you know what recreational substances can reveal about your patients’ neurochemistry?

Finding out about your patient’s historical or current psychoactive appetites and adventures (and yes that could be as commonplace as alcohol), is not purely for the purpose of collecting yet more data on their ‘health behaviours’. Nor yet another cue for casting judgement! It is an opportunity to take a can-opener to their cranium, open that baby up & take a look inside.  Without making a single incision!

But there’s a bunch of background knowledge you need to polish up on re psychoactive MoA and what each part of your patients’ experience (1st vs subsequent exposures, threshold for intoxication, the nature of the intoxication itself, & the possible aftermath) can reveal – as an inventory of their CNS materials and machinery.  All the while having a process to follow to ensure your evidence is leading you to the right and reasonable conclusion. Come with me and let’s follow the trail of breadcrumbs your patients recreational substance experiences have laid out for you…🐓

 Our Brain On Drugs – What Recreational Substances Reveal Part 1

Ever wondered why not everyone loves MDMA given it’s the ultimate love drug? Or why some of your clients are exquisitely sensitive to the aftermath of psychoactives and routinely, reliably experience ‘rebound’, in the following days while others ‘bounce’ seamlessly from a big night into the boardroom the very next morning?  What do these things tell you about the state of play of their neurotransmitters & their neurochemistry? So much more than you expect and given the only validated accurate assessment of an individual’s neurotransmitters is via lumbar puncture…with far less pain and inconvenience.  This is the first of a 2 part discussion.

&

Our Brain On Drugs – What Recreational Substances Reveal Part 1 Part 2

The 2nd part of this discussion goes into the detail of the MoA of each recreational drug class and what our patients’ encounters with these reveal about their neurochemistry. It also includes a resource we’ve developed to help you follow a process, in your review and rate the quality of evidence you have, to ensure your extrapolation and interpretation are well-founded.  **WARNING OVERSIZE LOAD AHEAD** There is a bonus case discussion that puts into action everything outlined in both parts and the process of qualifying the evidence. 

 

You can purchase individually Our Brain on Drugs – What Recreational Substances Reveal Part 1 here and Part 2 here
or become an Update in Under 30 Subscriber to access both episodes plus the entire library (100+ episodes) of Update in Under 30 audio’s and resources here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.

That ‘Throat Feeling’

Is my sore throat COVID-19 or not? | OSF HealthCare

“My 7yo daughter was frequently distressed, telling me she had that ‘throat feeling’.”

As you can imagine, mum offered up a smorgasbord of suggestions to help her try and describe it: Can you swallow ok? Does it burn or taste funny? Where is it? Is it hard, soft, moving, give me a rating out of ten….so many, but she just couldn’t. When it was really bad, her daughter said she also felt it in her sternum. The first doctor attributed it to ‘stress’ & mum understood why. Her 7yo is a bit of a worrier and while the ‘throat feeling’ was distressing, stress, itself, seemed to also perhaps bring this on. But by the time they made an appointment with their regular family GP, mum had noticed her daughter’s sx were worse with heavy, fatty, high meat meals & that she was burping excessively especially with the night time meal also. So, when their switched-on doctor heard these very careful observations, he referred her for a urea breath test (UBT) for H.pylori.

‘Miss 7’ blew 1200 on the UBT
the decision limit is 200, to confirm the presence of the bacteria in significant amounts

As I’ve said previously, there are (sadly for ‘Miss 7’ & myself) no prizes for the highest score on this particular test.  In fact, I spoke with a gastroenterologist last week who said, really it remains so debateable about the significance of the overall result (?size or virulence of colony) that results should probably be more considered like a pregnancy test: a simple yes or no!  But this together with her sx was a clear yes. GP recommended triple antibiotic therapy which sadly produced vomiting in Ms 7 within a few days. GP contacted paediatric gastroenterologists to get some advice, which was: don’t treat unless symptomatic. Back to square 1.

“In the meantime, I had done Rachel’s two UU30 episodes on H.pylori, so I told him what ‘we’ would do (polyphenols plus cranberry juice plus Zn carnosine plus deal with the hypochlorhydria). GP  says. “Ok, then let’s do it and then let’s breath test again in 3-6 months.

She has now breath tested at 200 and symptoms are non existent!”

Mum contacts me to relay the success story & give me the credit but mum is completely minimising her extraordinary actions that produced this outcome. Firstly, not resting with the ‘stress’ diagnosis. I have seen several children who present in very similar ways to Miss 7, YES! they are anxious, YES! parents might tell you they are the ‘worrying-type’ but when combined with these upper GIT sx I have found they test positive for H pylori more often than they don’t.  And how clever is this mother’s medicine?

“I recognised it was worst after birthday parties where she has eaten too much and done cartwheels or run around (we now talk about recognising when she has a ‘full bucket’. We talk about the fact that her tummy takes a little bit more time to process food it means her bucket fills and she needs a bit of extra time to let it do it’s job before she adds more food to the bucket otherwise it spills over and she feels rubbish. She finds that analogy useful as she can feel her bucket getting full at birthday parties and when she gets the feeling, she knows why and doesn’t freak out.”

 

H.pylori – Eradicate or Rehabilitate?
For a bacteria identified just a few decades ago as being a cause of chronic gastritis, atrophic gastritis and gastric carcinoma, the escalation in the number of antibiotics used to eradicate it (4 at last count + PPI) has been nothing short of breath-taking.  A management approach more consistent with both integrative medicine and with an improved understanding of the delicate microbiome focuses on changing the gastric environment to ‘remove the welcome mat’. What do we know about how to do this successfully? It turns out…quite a lot.

What Good Can Come From ‘Getting on the Gear’

When was the last time you ‘got on the gear?’. Wait, am I showing my age?🙄  The afore mentioned ‘gear’ could be beers or GnTs, weed or hooch, eccies or pingers, ‘nose candy’ or blow. I could keep going! While, anything beyond alcohol, might be purely a historical tale for many of us – during a [ahem] ‘very different phase of our lives’, Australian research tells us that the patients who come to see naturopaths are just as likely to drink alcohol as those that don’t and are in fact about 40% more likely, to have used marijuana or other illicit drugs in the past 12mo.  And this was the women in their 30s!  You heard me.

Now, this is not a call to action, to dob in a dabbler. 

This is instead a wake-up call for all of us, regarding the best insight into our patient’s neurochemistry, that is right there in the patient’s psychoactive substance encounters.

Because let’s get 1 thing clear, straight up – the ONLY valid, accurate, reliable pathology test for the measurement of neurotransmitters is a lumbar puncture.  Correct. And anyway, if you’ve been following psychiatric research this millennium, you’ll know that the belief that neurotransmitter quantities are the whole story (or even main players) in neurochemistry, is fatally flawed.  So, whether your patient’s ‘alcohol or other’ is purely in the past or in the present, this line of questioning and what it can reveal to you about their neurochemical nuances (high or low dopaminergic tone, shortfall in serotonin, high or low histamine etc) is gold. 

Because no recreational substance BYO

Instead they raid your stocks and supplies, get your brain to develop ‘bigger ears’ for some signals over others.  Their effects are purely a manipulation of the patient’s existing materials and machinery. And accordingly, here is the great reveal. So, a 30 something patient of mine reports dabbling in all sorts during her teens and twenties. She relays pretty ‘expected experiences’ with each substance – remember these psychoactives are known quantities, we know a lot about which buttons they push and I so I concur that her responses were anticipated & typical. Maybe if anything, she is able to recognise that she had a lower threshold for intoxication compared with other first time users.  “But MDMA,” she says, “I don’t get it and boy I tried! Several times!” So, while everyone else felt the love in the room, danced all night to the fantazzmical beats and the orgasmic-optic light show…she felt like she’d taken nothing at all.  Aha! This of course would prompt me to ask more questions to help clarify both her serotonergic tone & other instances where she might have encountered oxytocin.  And the real insights about her neurochemical milieu (strengths, weaknesses, balance and imbalance) start to form, so too the best way to support her. Don’t miss the real reveal in your patient’s story – that offers to lift the lid on their cranium and let you take a look inside.

Our Brain on Drugs – What Recreational Substances Reveal Pt 1

Ever wondered why not everyone loves MDMA given it’s the ultimate love drug? Or why some of your clients are exquisitely sensitive to the aftermath of psychoactives and routinely, reliably experience ‘rebound’, in the following days while others ‘bounce’ seamlessly from a big night into the boardroom the very next morning?  What do these things tell you about the state of play of their neurotransmitters & their neurochemistry? So much more than you expect and given the only validated accurate assessment of an individual’s neurotransmitters is via lumbar puncture…with far less pain and inconvenience.  This is the first of a 2 part discussion.

 

You can purchase Our Brain on Drugs – What Recreational Substances Reveal Pt 1 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.

This

There’s probably some poignant lines from a rap song everyone knows that I could insert here but, alas, Gold FM doesn’t play anything produced after 1999, so I’m none the wiser. What I’m trying to bring to mind, is the potential clash between our reality & our response: we’re not all gonna get instafamous, so the majority of us should probably curb the buy-now-pay-later spending and establish some contingency plans.  And while it might seem like I’m just picking on the young folk, this can happen at any age and stage of life. These, in psycho-speak are called Positive Illusions, and are one of the concerns psychologists have about the potential impact of exclusively focussing on ‘the positives’, aka Positive Psychology (PP). 

Cue: ‘Strengths wheels’, Goal Visualisations, Gratitude journals etc etc

There’s a lot to like about this Gen Z offspring of psychology.  And perhaps, as integrative health professionals, a ready-made romance, given both tribes (them & us) believe in health being something beyond the mere absence of disease. That and the fact they give due recognition to the role diet & exercise play in our mental wellbeing…how truly thrilling! Over the last 20 years PPIs (Positive Psychology Interventions not the other ones!) have become so pervasive: schools, workplaces, we’re in an age of the National Happiness Index, we’re overflowing with positivity, spilling over the lip of your coffee mug, emblazoned with ‘You’re Awesome!’ or ‘You’ve Got This!'(Just in case we forget momentarily) But we need to explore the science for and against, to better discern when these messages and tools are a help in clinic and in our patients, and when potentially a hindrance, worse still, a harm.

😁POSITIVITY😁
is extremely popular right now, but an obsession with it & rejection of all things negative (thoughts, feelings, experiences pasted over by something nicer and brighter!) is not necessarily a balanced recipe for mental wellbeing, according to the science.

PP has made a wonderful contribution to how we think and talk about our mental wellness as opposed to just our mental illness. However, there is a critical context in here that’s important for clinicians to understand, in order to use it well, and some thought-provoking criticisms and counter-balances that will help us all avoid becoming as (in)effective as a slogan on a coffee mug.  Oh and guess what guys?  Assessment first 🤓💪 this takes the guess work out of whether your patient is a good candidate for PPIs and we’ve included two in this latest Update in Under 30 – even a validated mental health screen that only uses positive language for those averse to those nasty negative thoughts and feelings!

 

UU30 Positive Psychology Its likability & limits
The ideas behind Positive Psychology may resonate deeply with integrative health professionals, for good reason.  We have in common a belief that ‘the absence of disease’ does not constitute health & that prevention is better than cure.  And PPIs have become so popularised they have permeated into schools, workplaces and most people’s therapeutic interactions, e.g. gratitude exercises, identifying our strengths via a strengths wheel, self-compassion. But do we know the limits of positive psychology? Do we know who it works for and what it means when it ‘doesn’t deliver’  mental wellness?
You can purchase Positive Psychology Its likability & limits 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.

Nutritional Neuropathies & Much More

Burning, tingling, crawling, buzzing, humming, zapping, pins & needles, numbness: our patients often tell us about strange sensations they have in various parts of their body. It’s typically not their major concern, but they mention it as an aside, a curiosity, ‘another weird thing I get’. While they may have trivialised this, relative to their ‘real issues’ [insert gut, hormonal, mental health] we should do the opposite and bring this concern to top of the list to correctly identify the cause.

If bilateral sensory nerves are mis-messaging it typically means 1 of 2 things:
1. Nerve damage is occurring – and if allowed to progress this can become irreversible or extend to motor and central deficits
2. Nerves are irritated or impaired – and this tells you something ‘systemic’ is out of whack and these sensations are often the only alarm bell

The top cause of paraesthesia, falls into the first category and is of course diabetes – and yes even now diabetics will walk into your clinic not knowing they have this (a good old HbA1c should be routine to rule this out).  Second on the list is alcohol dependence. The third most likely explanation for the patient with paraesthesia is nutritional.  And in contrast to what many of us might incorrectly think, there is a long list of nutritional imbalances that can be responsible for either, nerve damage or irritation, and B12 deficiency is not in fact the most likely.

That’s right all you nutritional ninjas🐱‍👤  – that makes the correct identification of the cause & the solution our bag, right?
I mean who else is going to do this, accurately?

Asking the right questions about these sensations helps you to quickly confirm when a nutritional cause is likely.  From there we need to know how each single micronutrient excess or deficiency or in the case of some, ‘sort of single’ nutrients (we all know people who sit in this category, right?! So why not nutrients 😂) are likely to present, via ‘easy-to-spot’ key characteristics that cover: pattern of distribution, speed of onset and progression, risk factors, accompanying features etc.  In our final New Graduate mentoring session for 2021, a practitioner presented her patient who rated her concerns as 1) Fatigue 2) PMS 3) GIT issues & 4) Tingling & crawling sensations across limbs, face, lips and tongue…and I was like, whoa stop right there, you might just have given us the answer to all of the above~!~! Seriously. Here’s a clue: it wasn’t oral allergy syndrome and it wasn’t B12. Can you pick it?🤓 

The Patient with Paraesthesia – Part 1
Patients often mention experiencing peculiar sensations: crawling, tingling, burning, as an aside, as a ‘oh and by the way’.  But while it may not be their top priority – it should be ours.  That’s because nutritional imbalances are the 3rd most common cause of these and timely treatment is essential to prevent progression to more serious issues.  The list of potential nutrient deficiencies and excesses behind these, is long, but this recording, the first part of 2, will help you narrow the differentials, nail the diagnosis & the solution.

The Patient with Paraesthesia – Part 2
In this continuation of this topic, we discuss several less talked about nutrients whose deficiencies drive potent pathology for the nervous system & move onto a cluster group of minerals, whose imbalances create functional irritation rather than organic change. This episode includes a range of excellent resources from videos demonstrating in-house tests you can perform to aid diagnosis, as well as our own Ready Reference which assists correctly categorising the different paraesthesia patterns and the nutrient issues behind them

You can purchase The Patient with Paraesthesia Part 1 here and Part 2 here.
BUY PART 1 & PART 2 TOGETHER AND RECEIVE 10% DISCOUNT BY USING CODE BUNDLE12
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.

 

Last Words for 2021

I’m ready to zip my lips 🤐 and ride off into the sunset of silly season. But first I wanted to tell you about the BIG PLANS we have ON THE BOIL!  Noticed a bit of a thyroid theme of late?  Last month I presented training in thyroid assessment for the 4th time for ACNEM but not a slide, possibly barely a dot-point remained from the original one I wrote back in 2009.  That’s how much my ideas & understanding have changed.

Some of the assay techniques & technologies are new, there’s a river of research  & a mountain of meta-analyses published in the time between & I have had the privilege of yet more clinical encounters in this space, to really nut out how all this translates into the real world.

There’s a lot I need to catch you up on.  And as I start creating our new MasterCourse II in Comprehensive Diagnostics…which will include 🥁…you guessed it…the humongously hardworking HPT, I’m just about bursting at the seams! And will those four little friends of every good practitioner, that sit superficially atop the ‘butterfly’, make it into our MCII?? I hope so because a) they should be our besties – being the director of Ca Mg D & P regulation and b) research tells us that where we find, ‘thyroid’ dx we should have another good hard look for ‘parathyroid’ dx and vide versa and c) over the last few years it has become increasingly apparent to me that this is one incredibly common source of ‘medical mysteries’  in our patients – remember the ‘Bones, Stones, Abdominal Groans & Psychic Moans’ catch-cry?  Yep, that’s the patient who typically finds their way to us, with pervasive but hard to pinpoint gut issues (often misdiagnosed as SIBO, FGD, IBS -D or C), some significant stress perhaps even depression and insomnia and, if someone bothered to look, premature bone demineralisation.  What other pathology panels and parameters will we be able to squeeze into our MasterCourse II?

Our current plans are to deliver the MCII live from May but just a reminder, because this next instalment assumes you have the exquisite foundational knowledge we laid down in the MCI – this is a pre-requisite for attending the MCII.
So if you’ve been putting off your pathology apprenticeship now you have a hard deadline to work to!

And finally the last, last words. On topic because they came from someone who specialises in thyroid, did the original thyroid training with me, way back when, and last month was my fellow presenter & panellist on all things thyroid for ACNEM:

I’m sure I’m the 1 billionth person to reflect this back to you but I’ll do it anyway because I think we all need reminders sometimes – you have a truly special gift in critical thinking, discernment, and most importantly passing on complex knowledge in a very digestible way without making anyone feel silly for asking questions or not getting something the first (or fifth time…no, just me?). The endless analogies are a teaching tool you’ve well and truly nailed and boy am I grateful because it speaks to my way of learning very well.
So, a big thank you! Endless gratitude for your brain, passion and generosity with your time/knowledge/resources.
Natalie Douglas
Here’s to another great year of learning, teaching, sharing & mentoring in 2022 – 1 billion and counting I hope 🌟🌈😂

Urinary Iodine Curveball Corrected!

Example 1:

Example  2:

We love hearing from our fellow fearless friends on the frontline – working with lab results & pathology providers – everyday.  We recently received an SOS! from the Francesca Naish over yet another iodine assessment issue that you may need to also be alert to:

“Ever since you first drew our attention to the need to correct urinary iodine results, I have used your formula for all my patients’ results. Thank you for this.  As most GPs don’t seem to be aware of the need to do this, I find it essential to warn my patients to wait for my interpretation before acting on their doctor’s advice! For a while now, Laverty have started giving the corrected result, which complies with the calculation you recommended. However, very recently Douglass Hanly Moir have started to give a corrected result on their  result sheets, but it does not tally with the calculation I have been using (the one you recommended) and generally gives a lower figure.”

Well, as always, cluey people ask cluey questions…and this did take some back & forth with DHM to solve.  Increasingly, all the major pathology companies are coming around to the essentiality of urinary iodine correction, something I’ve been banging the drum 🥁 about now for….yikes…7 years..no wonder I’m going grey! This is a mathematical formula applied to any raw score for urinary iodine to account for the dilution/concentration of the given sample, because, as we all know, hydration status varies widely between individuals and even within an individual at different times – and this is something that can wildly lead you astray in your thoughts about their iodine status, if not accounted for. Some companies are now employing the formula we use: Iodine (mcg) ÷ Creatinine (mmol) X 8.85 = Corrected Iodine in mcg/gCr which is wonderful to see.  But DHM have taken a different path, strangely enough, using this formula BUT rather than using the patient’s own reported urinary creatinine they instead use a ‘median creatinine’ 

Which…I am going to say it… MAKES NO SENSE!^%@* aka we WILL correct this iodine for hydration status – but we’ll correct it for someone else’s no yours! – Ms/Mr average…ok?
Ahhhh no.
Just look at the difference this makes in a patient with very dilute urine, in example number 2 above!!

So Francesca & all of you on the frontline, can be assured, if you’re using the formula above – it is correct – keep up the great work and know that it is often better to do something yourself than blindly trust a 3rd party when it comes to pathology…unless that 3rd party is our RAN Patient Pathology Manager template which calculates this perfectly of course!

RAN 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, the RAN Patient Pathology Manager 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. 
This provides you with a template that can be used an infinite number of times plus a short training tutorial.

Functional Medicine Falsehoods ⛔️

Functional Medicine Falsehood

An ideal T4 is 15
An ‘anti-aging’ DHEAs must be >7
A ferritin of 100 is optimal for women…

I’ve heard it all, probably you have too, and far too often & too recently from practitioners who should have rationalised & researched their way beyond these functional falsehoods, by now.  I bought into these ‘optimal wellness truths’ hook line & sinker early in my career and proceeded to even propagate a few but with (not much) more experience in clinic, I had to seriously question this pursuit of ‘perfection’ & ‘perfect pathology’…in favour of reality & scientific evidence!  They didn’t add up.  Not with my patients – even the healthiest ones, in fact some of the really unwell ones occasionally had these kind of high-normal results and they were part of the problem!. ‘But that’s because no one is truly healthy outside of those seeing a functional medicine practitioner & supercharged on supplements & hormone replacements!!’ came the counter-argument.  Ahhh, really?

How then do we reconcile this with the following:
Individual genetics & biochemistry
Our biological resilience
Healthy & appropriate senescence
Large datasets of mixed race populations from other comparable first world countries…where these figures denote the statistical outliers?

I mean, if the 50th centile value for ferritin for actual living, breathing, bleeding, women in the US, Canada, Australia etc etc is 30-40 ng/mL and the 95th centile is 126 ng/mL and the WHO says that in fact, anyone menstruating with a ferritin > 150 ng/mL should attract suspicion for iron overload….but functional medicine men (mostly…sorry but it has to be said!) say 100 IS OPTIMAL FOR EVERY WOMAN #@^*…please tell me in which women, consuming what kind of diet, where in the world, & based on what improved or better health outcomes?
And while you’re there can someone please support this bold claim with a scrap of high quality evidence??

[Rant over🎤💧]

The falsehoods of functional medicine include the blanket belief, ‘more is better’ (ahhhhh not when it comes to many things, including iron where women’s lower levels have been found to be an evolutionary advantage…guys). But you know what, we’re better than that! We see each individual, recognising all the factors at play that make for their uniqueness, help to define what ‘healthy’ looks like for each person and don’t fall for one-size-fits-all claims without any evidence nor common sense even, to support them. What do you think?

Mastering Micronutrients

Let’s make sense of the over-arching nutrition principles, that will profoundly change your understanding and application of this modality  Truly understanding the ‘big’ concepts, so often overlooked, or incorrectly taught, ensures you get the critical ‘small’ detail in your nutritional prescriptions right. In this 4 hour recording, together with key clinical tools, we talk about the tough stuff: dose-response curves, active versus passive stores and excretory pathways and ooh lah lah…the myth of taking ‘activated vitamins’.  Even those who feel satisfied with their original training – will find a lot in this critical review that is new, insightful and truly practise-changing!

 

When CKD C(omes) K(nocking) at your D(oor)

And it will.  It knocked again on a practitioner’s door last week.  She in turn knocked on mine. It turned out to be a very familiar story:

Firstly: Patient presents distressed – recently a nurse applied the term ‘Chronic Kidney Disease’ to HER (note no one has ever mentioned this diagnosis)
Secondly: She is in stage 3 of 5
Then: This practitioner is left to have ‘the conversation’ but wants to know where to start, ‘What do I say?’
Next up: And what else can I do for her – are we really able to make a difference?

Familiar to you too? So,1st & 2nd: Yes, this is not uncommon we would have to say and even with age-appropriate reference range adjustment, her GFR consistently in the 50s,  flags premature decline.  Then: What DO you say?  Well this clearly is a delicate area, not only because of the level of patient distress and concern but because, at this stage the practitioner knows nothing more than what the patient tells her and her ELFTs over the last 2 years.  This is not enough information, right? Chronic Kidney Disease is a heterogeneous condition, with many different causes, manifestations, comorbid conditions, and factors affecting prognosis (Levey et al., 2009) So while most individuals certainly progress from stage I to II and II to III the rate at which they do this differs dramatically.

Two years of data is not long enough for us to appreciate the trajectory of her CKD & means we are unable to provide the patient with any kind of perspective:
‘With no further decline in GFR or progression in stages over 5 years, you’re doing well, so keep doing what you’re doing!’
Vs
‘Ok, I can see what looks like a little period of accelerated decline – let’s review what’s been happening and how we can turn this around”

“Please sir can I have some more?’ Yes, back to her primary carers to request more information to fill in the gaps, and ideally more labs to calculate & observe the trajectory for yourself.  Next Up: What do we have to offer the patient with CKD stage III? Soooooooooooooooooooooooooooooooooo much!! When is adequate hydration helpful?  Always, except Stage V! (and these patients are not coming to see us) What are our treatment objectives & our evidence backed medicines to meet these? Hcy lowering (note often referred to as ‘folate refractory’ in renal dx), vitamin D adequacy, lowering the acid load, supporting the microbiome & in turn the Renal-GIT axis…hang on, got to go…someone’s knocking 😅 but hopefully we all can see, when they present to us, they are indeed knocking on the right door ✊

Nutritional Interventions in Renal Impairment – Place & Potency

Nutritional or naturopathic support for the kidneys tends to have been over-looked in our training and yet research suggests there is much in our tool kit that can make an enormous difference to this system, in particular, slowing the progression of chronic kidney disease in patients.  Rachel talks about what these key evidence based interventions are and also gives you the tools to identify the early pathology markers of renal impairment – the earlier the recognition, the earlier we can make a start on the remedy.

Water & Our Kidneys – Helping or Harassing?

It seems almost farcical to question the merits of hydration for our renal health but is this actually the truism we have been lead to believe?  Where does the recommendation of ‘8 glasses a day’ come from and what is the level of evidence to support it and in whom?  Or should we in fact be setting our sights on output ie. 24 hr urinary volume, over input. Do all kidneys love water – or does this relationship change with the progressive impairment seen in CKD which affects up to 30% of our middle-aged population?  When does hydration become harassment?

Renal Markers – Explained, Expanded and Exploded 

Most practitioners graduated with not much more than a few ‘kidney’ herbs and an under-appreciation of the contribution renal health makes to wellbeing. It’s not just about waste and water.  In reality, the kidneys are pivotal in just about every major element: blood, bones, pH balance, methylation, control of oxidative stress, the GIT microbiome and more!  And we are seeing the impact of this in our patients in all sorts of subtle and not so subtle presentations.  This new instalment in diagnostics, brings the renal system into the spotlight so we can confidently identify and better manage its critical contribution.  In addition to this, just like with other routine labs such as LFTs, we unpack how these so-called ‘renal markers’ can flag a plethora of other insights into your patients, from reflecting (un)healthy muscle mass, to calculating  individual dietary protein adequacy, from key ‘danger and distress’ signals in response to disturbed metabolism, oxidative stress to certain types of GIT dysbiosis!  We call this Explained, Expanded and Exploded because these routine labs can deliver XXX sized insights into your patients.

 

It Could

You know when you learn about a ‘new’ dis-ease driver and then you actually have to stop yourself from diagnosing every patient with it? I’ve done this dance with Gilbert’s Syndrome for over a decade, so too maybe have some of you?  And while there have been many, many occasions when I’ve been certain it’s Gilbert’s (clear robust & reproducible patterns of high bilirubin without other explanation) there are other times when I’ve been left wondering, and with questions.  Like – what about a fluctuating pattern – sometimes ‘within range’ sometimes above or at least high-normal – with no other explanation? What about the patient whose symptom-story is a perfect fit – prone to nausea, early satiety, gut issues, food reactions and anxiety all worse for increased oestrogen…but the total serum bilirubin is 14 micromoles/L? I mean, 14, right? that’s well below the top of that range, but remarkably higher than the majority of women of the same age, eating the same diet. And you ask yourself…could it…be??

It could.

The latest UU30 offering on Gilbert’s Syndrome constitutes a complete overhaul of everything we’ve previously been told about how to recognise and diagnose this polymorphism & it’s going to answer a lot of those ‘could it be’ questions we’ve all had!  Known also as familial non-haemolytic jaundice and episodic hyperbilirubinaemia under stress – is everyone with Gilbert’s prone to jaundice? Uh, no. Total bilirubin levels typically have to get to 45 micromoles/L to evoke this effect – many of our GS patients won’t ever get there, some will with increased illness or other stress and may yellow a tad (like a fading bruise), while other patients of mine routinely have a bilirubin at this level but won’t experience jaundice unless they impair their UGT further via doing what they know they shouldn’t: extreme exercise or excess alcohol. The latest deep dive into GS diagnostics 

But as much as we don’t want to miss this diagnosis we don’t want to mis-diagnose patients with it either!

Can you spot the difference?  Don’t forget total serum bilirubin levels are the net result of haem catabolism – so you need to account for rate of blood production, destruction and of course rule out any biliary dx before you can take a guess at Gilbert’s.  Oh and watch out for expected high bilirubin values in the fasting fan(atic)s!

Living on Gilbert Street

For those people living with Gilbert Syndrome at last the research world & the real one are uniting – with greater detailed documentation of how this very common polymorphism presents and the mark it may make in their health story. However, given only 1/5 with Gilbert’s syndrome actually know they have this condition, who are we missing?  This latest instalment rewrites our diagnostic criteria and corrects our past misunderstandings based on the very latest science, while shedding further light on what it’s like to live in Gilbert St.

 

If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can purchase Living on Gilbert Street here
OR 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.

I’m Using My Inside Voice 🙄

Maybe it’s tax-time, just my wintery whinge or a tirade triggered by missing my twins’ 21st birthday due to border restrictions 😶 but I’m sorry for all the shouting of late…about interpreting iron studies, about the copper misinformed etc etc. and my gorgeous new grad mentees copped a full monologue, with links to articles, recordings & the Coeliac Society, when they asked me to expand on why we must exclude coeliac disease before removing gluten from anyone’s diet.  I was so glad they asked though!  I’m now using my inside voice.  

But I don’t want my message to be misdirected and I fear it might be.
It’s not you and it’s not me

‘We’ are doing our best.  We are working in a field that demands us to be across soooooo many domains of knowledge and information, from the basic & not-so-basic medical sciences, to pathology interpretation, nutrition, herbal medicine and beyond.  It’s a lot.  None of us are across it all. I’m certainly not.  And I’m aware, that the frustration I feel at others’ misunderstandings sometimes is unfair, because I’ve benefited from excellent early teachers all the way through to having a job now, that keeps my head in the research daily. And even still, without a doubt, the gaps & shortfalls I observe and criticise in others, I could have made of myself, earlier in my career. We don’t know what we don’t know, until we know better, right.

It’s them

Who is this ‘them’ of which I speak? Well, 25 years ago when I completed my under-graduate (and walked 10 miles to school in the rain, without shoes or breakfast 👵) I believe I received the training required to be the naturopath that I needed to be. Safe, effective, knowing my scope – which was basically coughs. colds, atopy and risk mitigation for future chronic disease.  I never saw a lab test during my under-grad. I would have read a set of iron studies badly and something like ELFTs, like it was Latin. I wasn’t made aware by my lecturers of the critical part I could play in my patients’ lives, either by advocating and advancing correct diagnosis or by obscuring, confounding and delaying it (sorry, still thinking about the gluten debate!).  But back then, I think this was appropriate for the time, the state of play of our collective medical knowledge and for the role naturopaths were playing in the health landscape. Not any more.

If you haven’t had a chance to read the extensive research about ‘us’ (Australian nats, nuts & herbalists) published of late,  who we are, what we do, how we are viewed and what our patients expect, then you could be in for a surprise.

We’re perceived by many, if not most, of our patients to be a primary health care provider – either flying solo or co-piloting with the patient’s GP (& no auto-pilot function!!!) and as clinicians for chronic comorbid cases not the acute cold. My how times have changed and the question is – has the knowledge and level of competency of those in educational roles & the quality of what they deliver a good fit? Sorry, but if the majority of a large new graduate cohort have left their training with a mantra of ‘we must not diagnose’ and INTSEAD are likely to advocate a gluten free diet RATHER THAN Coeliac testing with the patients doctor first – then we’re falling at the first: Primum non nocere. Sorry,I forgot, inside voice 🙄🤐

Closing the Gap on Coeliac

This Update in Under 30 recording speaks to the seriousness and primacy of identifying Coeliac Disease in any patient reporting a suspected reaction to gluten and takes you through the latest evidence on the best screening protocol.  With an increased understanding about the strengths and limitations of gene testing, serology and biopsy, we have a clear map to follow now.  Along the way Rachel outlines 3 additional potential mechanisms for ‘gluten’ reactions amongst our patients, what to look for and how to tell the difference. 

Elders & Young’uns – Best Of Both Worlds

Last week I had my say about acknowledging our elders & mentors, this week I want to speak to the power of the young peeps.  Just like a younger sibling, nipping at your heels can act as a great motivator to move faster, or having children can inspire us to do more to improve the ‘world’ we’re welcoming them into, my interactions with naturopaths, nutritionists & herbalists of the younger generations generally effect both responses in me! The best of these come from cluey ‘youngsters’ (mature-age-second-career-new-nats included!!) who ask the most difficult questions & show dogged determination in getting answers to these either via me or in spite of! 

This is exactly what’s been in play over the last few years (yes, you heard me…years) while I’ve been under the watchful gaze of Jostling Josh Weymouth! He’s a youngun’ – it’s all relative right – who has kept us both on the straight and narrow writing: The accuracy and interpretation of plasma selenium in our patients: a literature review, which has just been published in the the Australian Journal of Herbal & Naturopathic Medicine.

At the outset I was able to hand over a substantial selenium research hoard I had obsessively compiled, Josh was able to build on this, refine some fledgling theories I had and then completely redefine my appreciation & understanding of how chronic over-treatment (not toxicity…) is so deleterious to human health.  Check this out:

When Selenium (Se) saturation point occurs in plasma, there is a potential reduction in health protection… Se will progressively pool within plasma non-specifically as SeMet in lieu of regular, sulphur containing methionine, in albumin and other proteins…inducing oxidative stress via a complex disruption of cell reactions/signalling
This is likely to be how Selenium over-treatment increases the risk of both CVD and T2DM

Many of you may ‘Know Your Numbers’ when it comes to Serum Se targets in thyroid health or just generally know how to Stay Safe with Selenium Supplementation because I’ve spoken extensively about these in the past and you will be relieved to know neither my ‘numbers nor my message’ have changed BUT I encourage everyone to read this new article because Josh has added so much more, including the interplay between our microbiota and our individual selenium needs, handling and tolerance and and and….I could go on but…what I really want to say is, thanks Josh for your academic rigor, your firm determination & diligence and for nipping at my heels all this time. This important piece of work just wouldn’t have happened without it 🐶

 

Slippery Little Sucker Indeed!

[Ahem] Ok let me explain…Several catch-cries from Australian ads have earnt themselves a lifelong place in my head and heart, taking up space where something more important should be, no doubt, but does anyone remember this SPC canned fruit (REALLY showing my age now!!) one, where the little boy chases the grape around the bowl and declares it a, ‘Slippery Little Sucker!’? Ok so this little boy is every one of us when we’re trying to ‘capture someone’s cortisol’ and just like the boy we will eventually achieve a ‘result’ – get a ‘number’ but what in fact does this mean in relation to your patient’s HPA axis, stress perception, responsivity, recovery etc etc?

Recently I was presented with 2 cortisol results for a patient taken within the same 24hrs – her blood am result was above range, while her 24hr urine flagged under-functioning of her HPA axis generally.
Both were accurate.

Had I have only have seen one, I would have formed the wrong opinion and only gleaned part of her overall HPA story.  Every different type of cortisol capture – from different mediums: blood, saliva & urine – to different collection conditions: time of day, fasting V fed, specific stressor exposure etc answers a different question about our patient’s HPA axis.  So to use any form of cortisol assessment well we need to start with 2 understandings: 1) it is a slippery little sucker indeed and no one test can answer all our questions – or as Miller & colleagues more eloquently put it, “Remember, all models are wrong; the practical question is, how wrong do they have to be to not to be useful” and 2) be clear about the most important question you have about your patient you are trying to answer and that will make your choice of test (& timing & & &) patent. But do you know enough about cortisol regulation to be clear about the ‘sweet spot’ of each test?

The Cortisol Awakening Response has understandably attracted the bulk of the research focus over the last decade and accordingly has risen in popularity in practice & while it remains a very valuable way to answer certain questions about patients, our understanding of its limitations continue to grow.  For example there is a disconnect between CAR & diurnal cortisol secretion – so in essence your CAR can look woke but your ‘Slope’ may be broke!  If you’re a fan of this method, make sure you catch up on the CAR-Expert Consensus Guidelines by Stalder et al and if you’d like to get clear about which test and when, when it comes to all the key options for Cortisol Capture..
then let’s dive in together with my latest Update in Under 30 instalment

 

Cortisol – Have You Been Caught Out?

I have!  And just recently a stark contrast between the results from 2 different methods of cortisol capture in the same patient illustrated just how likely this is. How do we ‘capture’ something so ‘dynamic’ and  interpret anything of substance from a ‘static’ assessment technique?   But rather than throw up our hands and throw out the whole attempt to measure cortisol, we can improve the rigor, reliability and real-world meaningfulness of our patients’ results by refining our timing of tests, choosing the medium wisely & manipulating test conditions to answer specific questions about their HPA function.  Great desktop reference included!

 

You can purchase Cortisol – Have You Been Caught Out? 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.

What’s happening with Lucy’s Labs?

What’s your knee-jerk response to 52Y Lipids Lucy & Liver, whose ALT & AST suddenly jumped above range when she was put on statins?  They’re damaging her liver?  You’d be wrong.  One of the practitioners who undertook the MasterCourse in Comprehensive Diagnostics just graduated with flying colours when she was able to correctly identify the true cause of this patient’s LFT abnormalities, can you? 

[Cheeky hint: there is more than one explanation/process at play]

This naturopath now knows her pathology patterns.  She knows the interpretation of any liver enzyme must also take into account the movement in other markers, to make meaning of the whole.  Because so-called ‘liver enzymes’ are never exclusive to the liver.  They are expressed in multiple other tissues and organs – sometimes at equal concentrations to their liver-level (e.g. ALP and bone). For some, even referring to them as a ‘liver enzyme’ is a mislabelling of sorts, with minimal expression in the liver itself compared with ubiquitous distribution all over the body (e.g. GGT & LDH).  Of course this is both a blessing and a curse.  A curse if you make the mistake of only interpreting their levels through a ‘liver lens’…a blessing if you know when they are flagging problems elsewhere through the specific pattern recognition.  So back to Lucy – the statins had induced a rhabdomyolysis not hepatocellular damage. The clues?  Significant AST dominance over ALT, above range CK and LDH.

So if the statins weren’t causing increased hepatocellular damage what is that increasingly high-normal ALP pattern all about?

Bones. And again, this practitioner picked it.  And then got to win herself some pretty BIG credit and credibility points with all the other health professionals sharing care of this patient by suggesting that they clarify and confirm this by referring her for an ALP bone isoenzyme assay, which answers the question: is the elevated ALP originating from the liver, the intestines or from the bone? Bingo, bones it is!  Or was, because this practitioner was able to alert not only the patient but all the other practitioners treating her to the increased bone remodelling taking place, independent of the statin reaction, but part of her perimenopause. Left unchecked this would escalate further of course at menopause and leave her bones in bad shape. This is just one illustration of how we can show ourselves the be the incredible one we are on the shared-care team. 

Being lab literate and pathology proficient, sets you apart from the rest and enables you to practice truly preventative medicine.
How else would we have known she was experiencing increased BMD loss that may be the start of something truly tragic?

 

Realise the true value you can extract from the most commonly performed labs.
Join Rachel Arthur LIVE on the MasterCourse I: Comprehensive Diagnostics WATCH PARTY
This skill is the biggest ‘game-changer’ in Integrative Medicine!
Want to know more? Head over to my website here and check out more of the great benefits and bonuses of joining this program
This course is a fantastic learning opportunity to identify the many intricacies in cases that have previously been missed.

Every Woman & Her Dog

The average woman & her dog (& likely every other member of her household, be they furred or otherwise), can tell you that sudden changes in sex hormones can undermine, derange, psychopathise, impact her mind and mood.  Hey, for me most days reverse parking is my mild super power, the envy of all, but on day 26 of my menstrual cycle, I can struggle with a ‘nose-to-kerb’! But if we are quick to attribute this to the fluctuating sex hormones produced by our ovaries, alone, we’d be making a mistake.  A portion of these peripheral steroids do cross the BBB and act in our brain, so changes to these levels during any kind of transition: follicular to luteal, pregnant to post-partum, menstruating to menopausal, early adulthood to andropause, will be ‘felt’ but the sex (hormones) we have on our brains at any given time, are far more abundant, potent and complex than this, thanks to the brain’s ability to make its own.

So in fact, the amount of sex hormones active in the brain represent an intersection between peripheral and central steroidogenesis. 
These Neurosteroids, made ‘on site’, are as much produced in response to our mood, our neurobiology, our psychological and environmental stress, to help us navigate these, as they are the creators of mood itself.

Yes, these particular sex hormones, due to their actions in our brain, belong to that growing list of CNS celebrities: the Non-Classical Neuromodulators.  Which, for the otherwise neurotransmitter-centric & obsessed among us (that’s everyone), makes mental health and illness much more complex than ‘serotonin deficiency’ or ‘glutamate excess’ and a whole lot more real.  We now need to consider other entities like: ‘suboptimal LDLs’, 5 alpha reductase over or under-expression & ‘xs inhibitory tone via progesterone’.

The ‘sex on the brain’ of any patient therefore is impacted by both their Endocrine (ovaries, testes, adrenals) and Synaptocrine (neural) contributions – and these demonstrate some shared dependence (for cholesterol & healthy mitochondria etc) and independence.

We all know the depressing stats in support of the ‘ovarian withdrawal hypothesis’ and the risk to women’s mental health with each reproductive transition, and also in andropause in men, but the time has come to now deepen our understanding and to recognise  we can have an imbalance of ‘sex’ on the brain – regardless of the ‘balance’ we might see in the periphery and put our thinking caps on about the options we have to address steroidogenesis either side of the blood brain barrier.

When it comes to a modern take on how sex hormones impact both the structure & function of our CNS, we need to blend the ‘old’ with the ‘new’.  The ‘old’ tells us, production of sex hormones is in the gonads and action at a distant target anywhere else in the body, including our brain. And the ‘new’ is in the form of the ‘Synaptocrine’ – where production of these sex steroids is actually within neural tissue itself and their immediate actions occur close-by, in the synpase and at the post-synaptic neuronal membrane. These two contributive pathways show some shared dependence but also independence from one another and the balance of both has now been recognised to be integral to the overall health of the nervous system.
You can purchase Sex (Hormones) On The Brain 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.

 

Present But Not The Problem

Something’s just come up today again and I think we need to talk about it.  A positive result on a stool PCR microbiome test for H. pylori, understandably, might be heard as a clear call to action to go in guns blazing with an eradication approach.  But is it?  Trust me, I’ve had more than my fair share of battles with this bug & can understand being keen to have it be gone BUT first things first, let’s be clear about what the result speaks to.  

Does it say, “Here!  Look over here!  Here’s the source of your patient’s GIT distress,”  or even, “Here’s a pathogen that has taken up residence in their GIT and is a risk for future dx!”

No, not necessarily. It speaks to its presence.

And that may be only fleetingly, as it passes through.  I’ve seen it before and so have many other experienced practitioners: a positive stool PCR that is at odds with the results of gold standard H.pylori testing, the UBT, faecal antigens or blood serology, all freely available through the GP.  And the reality is, if you have a negative UBT, there’s no urease production, the trademark trouble-making of this bug. If you have negative blood serology, your immune system has never ‘met’ this bug or, in the minority of cases, you’ve tested in that brief early exposure window prior to antibody production (2wks) so you should retest within the month, to confirm or refute. And if you don’t have any faecal antigen…it ain’t in da’ house…so to speak 😅 If there’s something new here, then have a quick read of Medscape’s great work-up summary.  So, clearly we need to confirm before we open fire.

 We (me included) have been so single-minded about increasing the ‘sensitivity’ with our testing methods, we may have left ‘specificity’, in broader sense, behind & that creates a new problem.

This leads us and the patient down the garden path of false attribution and time and money wasted ‘treating’ a ghost gut issue. And no one wants to be put on a pylori protocol when they really didn’t need to.  Trust me 🙄 But if someone does come back confirmed, well then…

H.pylori – Eradicate or Rehabilitate?

For a bacteria identified just a few decades ago as being a cause of chronic gastritis, atrophic gastritis and gastric carcinoma, the escalation of number of antibiotics used to eradicate it (4 at last count + PPI) has been nothing short of breath-taking.  A management approach more consistent with both integrative medicine and with an improved understanding of the delicate microbiome focuses on changing the gastric environment to ‘remove the welcome mat’. What do we know about how to do this successfully? It turns out…quite a lot.