Are You A Finger-Pointing-Prescriber Or A Change-Maker?

Are we doing ourselves out of a job?  I’ve been talking treatment plans with my New Grads recently. Given, only recently these were major assessment items in their clinic units, they have been trained to create ALL-ENCOMPASSING (biopsychosocial) prescriptions and recommendations of utterly EPIC PROPORTIONS – to simply prove they know it all. Problem is this doesn’t work in the real world. 

Emailing your client multiple pages of advice that covers: a whole sizeable supplement schedule that only a military-training could nail (2 tablets 1 XTID 1 X BID, a liquid, a powder, some with food, some definitely not with food) plus dietary advice, plus hyperlinks to exercise advice, mindfulness exercises and a request for follow up investigations before the next appointment…is…a L*O*T!!

It is also ineffectual – because it completely disregards the human on the other end. Let me ask you this, how much change are you capable of between a first and second appointment, roughly a period of 2-3 weeks?  Personally, I gotta say not that much. It took my dentist years to get me just embrace flossing & I don’t think I am an exception! With all the knowledge we possess its hard not to see people as (a long list of) problems (& problematic behaviours) that we translate into, and solve via, a prescription.

Effectively we are saying to patients with this practice model, ‘Go change & come back when you’re done & then I’ll probably ask you to change some more!’
That’s both a big ask and a huge missed opportunity.

I hear from reliable sources over the ditch, that GPs are increasingly referring their patients to, or teaming up with health coaches, rather than naturopaths. Given what I’m observing, I get it.  Doctors on the whole only have time (and barely then) for a finger-pointing prescription – certainly not the time and touch-points required to actually support patients with the very difficult thing that is, behaviour change. Nor the skills to truly facilitate patients making the necessary and desired changes – so they outsource this role.  But we shouldn’t.

After all – I want to be on my patients’ support bench & health care team always – not a flash in the pan, that blinded them with science or my ‘smarts’ and proved to them in one over-stretching prescription – that naturopathy is not for them, or at least, they’re not fit for the task.

Compliance Changers – Strategies for Success

At the end of an information & insight heavy appointment, formulating a list of products and doses for our patients to take can feel like a bit of a ‘tada moment’, like a magician pulling a rabbit out of the hat.  “Here is the solution – now off you go!”  Research tells us, however, that treatment-plans that are a co-creation between you and your patient – evolving from a discussion that not only allows them a voice, but a major role in the decision making – are far more likely to succeed. While we are the authority on our medicines, our patients are the authority on what makes them tick & what’s likely to succeed, in terms of taste, texture, temperature & timing!  This is called Patient Centred Prescribing and together with some other tips tricks and hacks I share with you in this episode, can really increase patient buy-in, compliance and therefore bring your treatment plan to fruition and fulfilment!

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.

I’m Against Absolutes

And health, no matter which side you sit on, seems to be particularly plagued by them.  I (incorrectly) recall my 4 year degree as being a series of deep personal losses, some favourite food, then caffeine, then alcohol etc etc.😂 Likewise, I’m aware that naturopathy & integrative health’s ‘voice’ in the ‘conversation’, could arguably be perceived as mostly a negative one – as in, ‘No. Never. Not good. No, not even a little bit?!’  But I love both playing devil’s advocate & reading the research (ALL the research – even the stuff that doesn’t support my views and position GASP!~) so I am less in favour of absolutisms.  This came up recently when I suggested alcohol may improve iron uptake 😬

Practitioners’ responses were 1 of 2 types: humorous dismissal (“steak & beer for breakfast – at last a naturopathic prescription I can support!”) or horror. 
But why are we so attached to the absolutes in spite of contradictory evidence?

Let me ask you this: is coffee bad? Full stop? Period? The end? Or is it the most concentrated source of antioxidants consumed in the average Western diet? Does it improve bile flow, peristalsis and at higher levels actually protect the liver against damage? Clearly, we need to read all the evidence, including, the favourable and make individual decisions about ‘what serves and what sabotages’, for each patient. But do we? Or do we imagine we only get membership to the ‘Ultimate Integrative Health-club’ when we adhere to blanket bans? 

Similarly I, like many of you, see a LOT of iron deficient women –  & a fair chunk of these have been incorrectly labelled, ‘refractory’ because the conventional correction strategies (high doses everyday) don’t actually make sense. But like you guys too, I’m always on the hunt for new ways to improve iron absorption in these women, so I can hit them & their gut with less. That’s why I shared the research regarding alternate day dosing, and taking a supplement within an hour of exercise and now, I dare to ask if a tipple could be helpful?

While we know that both ‘GOOD’ (exercise) & ‘BAD’ (alcohol) health behaviours increase gut permeability, which sounds ‘BAD’, right?
But could this be ‘GOOD’ for some?

This has certainly been demonstrated in relation to exercise & iron but most of the research investigating how alcohol intake effects iron uptake and status is based on alcohol abuse. The study below, however, based on a large sample of non, mild, moderate & heavy drinkers captured in NHANES data – is a very well written and reasoned article, such that it can exclude liver damage, inflammation and HFE mutations as other explanations for the better iron status, in drinkers. And it found:

“Consumption of up to 2 alcoholic drinks/day seems to be associated with reduced risk of iron deficiency and iron deficiency anemia without a concomitant increase in the risk of iron overload” and “Any amount of alcohol consumption was associated with a statistically significant 42% reduction in the risk of iron deficiency anemia (OR, 0.58; 95% CI, 0.4–0.8).”
Ioannu et al 2004

   I challenge you to read it for yourself and challenge your absolutes!🤓

Oh and just in case you’re thinking, “Have we all misdiagnosed iron deficiency and it’s actually a Copper deficiency underneath?”  because last year the fashion was everyone was copper toxic and now this year someone’s making noise saying everyone is copper deficient !!! (Absolute? Anyone?!) Ah, no.  Copper deficiency, as a cause of iron deficiency and anaemia, has been around for about as long as nutritional medicine itself.  It is absolutely a thing.  But in the absolute minority of people.  And if you go back to some basic maths & compare and contrast Fe & Cu at each level: 1) requirements almost 20mg Vs < 2mg 2) average intake (inadequate Vs adequate) 3) bioavailability (Fe < 20% more typically < 10% in a modern low meat diet Vs Cu  is typically >50% ) and do some basic sums I call, ‘Menstrual Maths’ – You’ll likely deduce that inadequate iron intake and uptake, given our losses, is in fact the common culprit and a ‘coldie’ may be more beneficial than copper in most!  Can y’all stop asking me about that now – pretty please?

 

So You Think You Know How To Treat Iron Deficiency?

And then you don’t.  The reality is we all struggle at times with correcting low ferritin or iron deficiency anaemia  – so what have we got wrong?  In spite of being the most common nutritional deficiency worldwide, the traditional treatment approaches to supplementation have been rudimentary, falling under the hit hard and heavy model e.g. 70mg TIDS, and are relatively unconvincing in terms of success. New research into iron homeostasis has revealed why these prescriptions are all wrong and what even us low-dosers need to do, to get it more right, more often!

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Are You And Your Patients Stuck?

There are some things we say so often to patients we could record them and just press <PLAY>  Like this daily dogma: ‘When you’re under stress, your demand for Magnesium rises and then in turn that can make you more susceptible to further stress, so we’re going to give you some to support you’. But is this actually the whole story? You guessed it, no. (I know I am fairly predictable like that 😅) 

Recently, a personal new record – a patient reported ongoing daily use of a very high dose Magnesium ‘practitioner only’ product 8 years after it was prescribed by her then naturopath – and guess what, the patient still hadn’t reached nirvana*  
not the band! – a transcendent state in which there is neither suffering, desire, nor sense of self

Jest as I may – I think this raises some serious questions.  The pervasiveness of our prescriptions when patients are not given an end-date coupled with ongoing access. How (not) effective this intervention was if someone perceives ongoing undiminished dependency on it. And specifically with Magnesium – whether our prescriptions (form, dose, adjuvants, advice) are the problem? If stress is synonymous with a shortfall of this mineral then Magnesium is not a solution to stress itself but the amplified stress response and the stress still requires its own redress, right?  But do our patients hear this as well when we press <PLAY>?

Likewise – the BIG doses per serve being recommended might make sense for the minority (seeking potential NMDA antagonism) but are a real mismatch with the majority, who are just stuck in the stress loop and weathering a perfect storm of Magnesium under-supply and increased demand.

I love my minerals as much as, ok more than, the next practitioner but I’m always keen to refine my repletion approaches and oh yes, by the way, there is good data, a meta-analysis in fact, examining how long it takes to achieve repletion using oral Magnesium – and guess what, it’s not 8 years! The latest Update in Under 30 goes into all this and much MuCh MUCH more…you’re welcome 😂

Magnesium – Stuck In The Stress Loop

Practitioners working with nutrition appreciate that Magnesium is vulnerable to depletion by the stress response and that in turn, can make people more prone to stress & keep patients stuck in a so-called ‘stress loop’. But do we understand the intricacies of this and how we, as practitioners, can get stuck in another kind of loop – one of endless Magnesium prescribing without reaching repletion? We discuss ways to improve your Magnesium prescriptions – in particular, ‘doping Vs drip-feeding’ and other things to assess & address if the long road to repletion risks becoming an endless one!

 

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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.

 

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 🐶

 

B12…12kms?

Is it just me or do you view everything with a trained eye?   My son always laughed when I wrote him a shopping list: I would list items under each shop and I always wrote down our local supermarket the Independent Grocers Association, like this: IgA…you all see what I was doing, right?!! It’s actually known to everyone else as IGA…well truth be told, I didn’t until he pointed it out 😂 Then there’s this relic I regularly pass, as I walk through bushy parkland near my home, ‘Hmmmmmm, B12 hey?’, I’d muse. I’d be embarrassed to tell you exactly how long it was before I realised OMG it’s not  a shrine to the vitamin but an old road sign telling you…Byron 12kms!!! 

I preferred my take on it to be honest, because invariably once past this, the remainder of my walk was full of scintillating B12 banter. Just internally, people, no one panic, I don’t walk the streets of this town spouting out crazy random nutritional tidbits…although, let’s face it, I would be in good company in, the Byron Bay region!

I have a deep respect for B12 – weird but true. As a result of my clinical experiences helping patients who had a previously ‘unseen need’ for this nutrient and the significant improvements that come with its replenishment. Plus the deep dive I did into the science of the different forms and their actions last year. In particular, I now have 2 families where the TCNII SNP is evident in mum and all her children.  No gene testing necessary, the pattern is self-evident once you know what to look for and the clear ‘call to action’ – more B12 please! And just this month, a fresh aspect has come to my attention in regard some brand spanking new research on B12 and IBD and the microbial (im)balance of this vitamin as a pivot point for the pathophysiology. Wowza!  Early days, but I think we’re headed next level on this nutrient again! And I can’t say, I’m surprised.  For while I don’t think the CHOICE of the supplemental form for B12 is complex at all (hence why we need to separate the B12 from the B*S#!) I recognise it is a complex character far beyond what regular dietetics has reduced it to. 

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.

 

I Spy…

I say: Biotin, Broccoli Sprouts & Bone Broth
You say….?

If you said: ‘Sulphur’, go directly to the top of the class, passing ‘Go’ & collecting $200 on your way!🤓  If you nervously said…”I don’t know, they all start with ‘B’ ?”, you are not alone.  In fact, most integrative health professionals aren’t aware of the Sulphur Strategies they’re using, probably, everyday.  But it’s time we all were.

How about this list?
Glycosaminoglycans (GAGs for joint, gut etc tissue integrity),  Cerebroside Sulphate (Myelin),
Metallothionein, Glutathione, Hydrogen Sulphide (H2S), Co-Enzyme A, Lipoic acid, SAMe, are just some things Sulphur is essential for.

I could go on…and on and on.  You see Sulphur, in spite of being an essential macromineral (adult dietary requirements > 1g per day) and critical to health, remains largely unseen.  Often we don’t know when we’re writing patient prescriptions that actually we’re using a particular vehicle for Sulphur and therefore we’re also not able to discern which, of the very long list of options (dietary and supplements), makes the most sense in this patient at this time. We’re not to blame, not many ‘possess the power’ to see it, it seems. Por old essential, irreplaceable Sulphur doesn’t even have an RDI. But the time has come to take a good look.  We need to know how patients are able to meet their needs, who needs more and how, very commonly, someone who is seemingly ‘consuming enough’ may still exhibit a functional Sulphur deficiency with poor musculoskeletal tissue integrity, low white cell replication capacity or higher oxidative stress load etc and in those who do have a shortfall, how to treat successfully & safely.  Who needs a top down approach (more protein, methionine, cysteine, bone broth) and in whom would that be a risky path and using ‘downstream’ Sulphur products instead would be a better balance of pros and cons?

Because all Sulphur needs to be handled with care.

That’s right.  Like other highly chemically reactive minerals, with reactivity comes risk – a great potency that requires careful consideration of both form and dose, so that we can harness this power for good not…well evil’s a bit strong…but how about, for not-good.  I’m a bit of fan of Sulphur and using Sulphur strategies in my patients. I think it has interesting echoes with our past: the ‘healing’ waters of a Sulphur Spring and of course even further back the old ‘brimstone and treacle’ medicine of eons ago.  This paper by Nimni in 2007: Are we getting enough sulfur in our diet? got me thinking about Sulphur again in a contemporary context, over a decade ago, I’ve done a lot more thinking, researching and prescribing since then but it seems that Sulphur still remains ‘unseen’ by most. But with the rise and rise and rise of popular Sulphur-based supplements (alpha lipoic acid, GSH, N-acetyl glucosamine, Brassica & Allium extracts and concentrates, N-acetyl-cysteine etc) I think it’s time to talk.

Unseen Sulphur – Time to take a look

If you don’t have a clear picture of the gross daily requirements, determinants of altered individual needs, sources, regulation & associated deficiency picture of Sulphur, you’re not alone.  Turns out this essential macromineral remains ‘unseen’ by most, even though you’re probably writing prescriptions everyday that have Sulphur as their key component.  From the simple: Taurine, N-acetyl cysteine, Protein powders, to the sublime: Brassica extracts & concentrates, N-acetyl Glucosamine, Alpha Lipoic acid etc. In order to use these Sulphur strategies successfully and safely, however, we need to fill in the missing detail on its metabolism, the difference between the ‘organic’ and ‘inorganic pools’, how regulation regularly goes wrong, even in those seemingly consuming enough, and how to balance the risks of this reactive medicine with its substantial therapeutic value.  This recording comes with a great clinical tool to help you at last see the Sulphur strategy most indicated for your patient.

 

The latest Update in Under 30 has landed!!!

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What’s A Little Flesh Between Friends?

I talk so much about iron, I feel like I’m cheating on my life partner (Zinc)…but these two are arguably the main mineral deficiencies we encounter most consistently in our patients and, don’t tell Zn, but quite frankly, in terms of who’s more well recognised out there, Iron throws some serious shade!  But the truth is they’re a ‘twofor’, as a result of their similar distribution in food, with both demonstrating significantly better bioavailability (read: virtually double) from flesh foods etc, ‘Watch out, she’s on the attack again!’ I can hear the V’s (vegetarians and vegans) say and yes I think you see this one coming…but I think it’s possible to be pro moderate meat, without being, antiV.

Ethical and environmental aspects aside (just momentarily) it is hard to argue against the nutritional benefits from moderate meat for most patients. 

I tried, trust me.  Put my own body on the line (and my babies) to be a vegetarian for over a decade.  But as the wheels fell off for me, I noticed them falling off for so many others…and these were people who were educated, with a capital ‘E’ and putting serious ‘E for effort’ into substitution etc Not everyone of course – but a LOT of women and occasionally some men.  There was no denying their ‘iron hunger’ (high serum transferrin), their movement towards microcytosis (however slight that ‘smallifying’ may be…we don’t wait for anaemia, right?), their poor zinc status and more importantly, the clinical chaos of impaired immunity, some cognitive or mood issues that presented, as a result. I went back to the mineral manual, back to all the science that helps us to understand these minerals especially in a modern dietary context. 

Ah yes…meat has become marginalised in our diets compared to those of our yesteryear selves (ABS data) while our consumption of potential mineral inhibitors…you know, all the good, but bad, but good foods, like legumes and grains and green tea and and and…has risen…especially among the kind of clients who come to see us, right?

Which ultimately leads to a lower iron ‘income’ with the same outgoings, again especially for menstruating, pregnant & breastfeeding women.
The books don’t balance.
(So then…IV Fe to the Rescue???)

Bite me…it’s just science. There have been some wonderfully thorough studies on this very issue and thoughtful discussions. This study in particular, by Reeves et al, of Australian women in their 20s followed for 6 years to 2009, argues that just a 1mg/d increase in heme iron from flesh foods could reduce susceptibility to the subsequent development of iron deficiency amongst omnivores. So while the median daily intake of fresh red meat in these women was just 39g/d, their analysis found that an additional 70g of lamb or 60g of beef…or about 140g of chicken and 250g of fish if you prefer white over red, appeared to be the positive tipping point for women and their ability to stay iron-replete.  Well below ‘dietary guidelines’, nowhere near the scary cancer correlations (which of course may be more about fat or nitrates or ??).  Moderate meat intake, right?  Just saying. And don’t worry, I know.  The only thing worse than an evangelical ex-smoker is a rambunctious reformed vegetarian 😂

Need A Manual on Minerals? 

Minerals represent a critical tool in naturopathic nutrition and there has been an explosion of research in this area over the last 10 years. In order to optimise patient care, practitioners need to keep up with the constant stream of information, updating their previous beliefs and understanding in the process. This seminal 7hr seminar (!!)…yes…seriously..it’s THE MANUAL..is designed to facilitate and accelerate this process of review and re-evaluation via a fresh look at the key minerals iodineseleniumironcopperzinccalcium and magnesium.

At less than $10 per hour of recording, the real investment is your commitment to making the time for a mineral makeover.

 

 

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.

 

 

 

 

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.

 

 

Trends not Truths

Trends in mineral supplements are like music genres, you can pick which ‘decade’ they were formulated very quickly. But instead of going by clothes, hairstyles or even the style of accompanying  music video, it’s all about the form – the ‘thing’ the mineral is bound to, that gives the game away.  While mineral carbonates , sulphates and oxides seem to many of us contemporary clinicians, pre even MTV, amino acid chelates take me back to a time when I was wearing shoulder pads in everything, even my pyjamas. It was called power-dressing and needed to be adhered to 24/7, you see.  Then along came fancy forms like orotates, aspartates, hydroxyapatites as we moved confidently into the 90s…well, as confidently as you can, when the Y2K bug may ‘end life as we know it’ come NYE. The dawn of the new millennium saw us embracing picolinates and bis-glycinates in a big way and for the last little while, citrates have really been having their time in the sun.  But you know what…here’s a few things you MUST know…

  1. These are trends, not truths
  2. Every mineral has its Mrs Rights and Mrs Wrongs, in terms of chelates and ligands, and these are not the same from one mineral to the next e.g. Zn sulphate is a decent form of available Zn, Mg sulphate, an over-priced laxative
  3. In almost every case, there is simply NO strong consistent body of evidence that one form of a mineral is superior in terms of bioavailability, regardless of what companies tell you..go on I dare you…check their references and then do your own quick literature search away from the cherry picker
  4. Nor is there one mineral form that is above adverse effects in everyone

Brutal.  Welcome back to ‘tough talkin’ Tuesday’ 😉  But we have to state these facts because we need effective supplements for our patients and not understanding the different forms that are better (but not ‘best’) compared with those that are inferior (this we do have some evidence of) threatens the integrity and efficacy of an otherwise well thought out prescription.  So here’s where you might want to move into a room away from everyone and lock the door…because you’re likely to scream.  One of, if not the most commonly used single nutrient supplement almost across the world, is calcium.  After almost 30 years of studying supplemental forms side by side, can we conclude which form is best? No. How about ‘better’….hmmmmm yes…maybe…citrates look good going by some markers but not all and vice versa for other commonly seen forms.  I can say this, because I have followed the research over the decades, reading the primary papers, like this excellent one by Bristow et al from 2015 that should burst quite a few people’s ‘best!’ bubbles. Have you screamed yet? 

I scream. Often.

Because I am frustrated by the lack of research that we need, to be more certain of our preferred forms and then even more frustrated by companies’ claims that the evidence is already in, and guess what, theirs wins!

But it comes back to the same call to action for us – know your nutrients and specifically, where possible, get familiar with the Mrs Right and Wrong for each mineral! Know that the supplemental forms that work for zinc will not necessarily be a good match with iron, that any company that formulates their minerals in the vain of ‘one form for all’, be that glycinates, citrates, picolinates…well they’ve  probably got a good fit for some of those minerals and a shocker for others. And as always truly check efficacy with follow up bloods, if you had baseline deficiencies evident in lab tests.  I know, that’s not everyone’s model of practice right, or ideal but not always ‘real’, so alternatively, if you are prescribing based on clinical signs of mineral deficiencies that should respond quickly to repletion e.g. white spots on nails in the case of Zn deficiency, then ensure that they do!! If they don’t and your patient is compliant then consider switching form! When I see good practitioners’ prescriptions let down by poor choices of nutrient forms, well, that’s when I need to go into that separate room once more….can you hear me? Ooh that reminds me of something else dated by Mike and the Mechanics: Silent running “Can you hear me?!”😂

Mastering Micronutrients – Critical Pieces Of The Puzzle

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’.  And yes we even mention Mrs Right/Wrong forms for minerals. 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!

 

Click here to gain immediate access to Mastering Micronutrients – 4 hours & clinical tools that will seriously change the way you work in Nutrition

 

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.

 

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.

 

‘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.
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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.

 

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.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
**But if you’re just joining us & this important conversation now,
ideally get the basics and backstory first and purchase all 3 key episodes in
‘A Guide to Gilbert’s Package’
-Your RAN Online Account has a NEW LOOK!!-
Next time your log in, you will experience a more user friendly way to search, view, listen and download your resources. Find out what’s new here.

 

Too Simple To Be Sensible Science?

 

This year I heard a great quote that hit the spot for me: anyone who offers you a simple solution to a complex problem is lying or misguided, the solution to a complex problem will inherently be complex. Dang! I’m frequently reminded of this in relation to many different aspects of working in integrative health. Or even just answering work-related questions socially. Random-friend-I-haven’t-met- yet, upon finding out I work in nutrition, asks:  Is [insert any given food, beverage, macronutrient, micronutrient] good for you? In spite of over 20 years of this happening, I confess, the poker face still requires concentration.

The poker face is necessary of course to
a) conceal my amusement at how predictable humans are and
b) to cushion the blow for them as I tear down the delusion that real nutritional science is simple and can be served up in a soundbyte or
c) lie 
and infer that it is, just to get out of there faster!

But recently, I’ve had another reminder of that ‘in here’ rather than ‘out there’, about how even as practitioners we long for things to be simpler than they are. This month in mentoring I’ve been talking about the dark side of both zinc and Akkermansia muciniphila (I know wash my mouth out right?!) in neurological issues. What, but we had them on the good guys list?! Remember the answer to a complex problem (and human health surely owns this territory) will inherently be complex, right? Similarly, I’ve been digging deep in research about beta-glucuronidase, that enzyme that undoes our phase 2 detoxification of oestrogen, bilirubin and a long list of nasty xenobiotics, earning it the informal title of ‘bad ass biomarker’…scoundrel! And well, I’ve found some really nice things to say about it…like actually it extends the half life of most of our flavonoids such as quercetin, isoflavones etc etc and that’s a great thing for increasing their positive punch given that their rapid detoxification limits how much we can benefit from them.  Turns out, like everything else, even dear old beta-glucuronidase exhibits light and shade.

How I ended up losing a weekend to such papers was because I was trying to resolve some burning questions about Ca-D-glucurate (CDG) that I’ve had for as long as I’ve been recommending it to people who arguably could benefit from a little less beta-glucuronidase activity. 

My two most pressing ones were: How much is required to be effective & Where’s the evidence?

And that’s when the fight broke out [just in my head] You see every review I’ve read, every piece of product information too, repeats the mantra CDG 500mg TID but turns out this is based on…not much.  More uncomfortable still, is that even our assumption that we can convert CDG into its active form has been strongly challenged. The new research, which is not the work from the 1990s that everyone cites, is a must read…or if you actually have a life, and other ways to spend a weekend then maybe just spend 30 mins with me in my Update in Under 30 this month 😂 I wanted to keep it simple and neat and tidy. I tried I promise.  But in the end…wouldn’t you know it…it’s complex. 

So to bring everyone up to speed, including myself!, I recorded an UU30 on…

The ABC of CDG
We often identify patients who could do with a little glucuronidation first aid: marked dysbiosis, Gilbert’s syndrome, oestrogen excess, cancer risk (especially bowel, breast & prostate) and one of our nutritional go-to’s has typically been Calcium D Glucurate. While there is ample evidence that one of CDG’s metabolites : 1,4 GL – inhibits beta-glucuronidase, is an antioxidant, platelet activation inhibitor and generally all round good guy to have on board, new research strongly challenges that oral CDG will convert to this at levels sufficient to support our detoxification pathways.  Sounds like we’re overdue for an update on this supplement and when and where it might be useful in addition to how to find the real deal in real food!

 

You can purchase The ABC of CDG here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account after you have logged into your 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.

 

Iron – Another Important Discovery

Yet another super-helpful part of Iron-Land has been mapped!!  Ever struggled to correct chronic iron deficiency in athletes or even just weekend warriors?  Yep, me too. One of the key barriers being the 2-3 fold rise in hepcidin in response to exercise. Hepcidin whose day job is an inflammatory signal that two-times as an iron uptake blocking agent at the small intestine.  In addition to other exercise-induced factors that either reduce Fe uptake or increase losses, it really is no surprise that these cases can be hard to treat. However, a recently published small Australian study has brought to light some constructive new information. Similar to the often talked about ‘anabolic window of opportunity’ whereby we encourage people to consume protein +/- CHOs within a short time-frame post-exercise to optimise exercise outcomes and negate negatives, these new findings imply the same might be true for optimal Iron uptake. But only in relation to exercise done in the morning! 

The key finding was when individuals consumed iron after 90mins of exercise in the morning they exhibited higher uptake than both when they took the iron at the same time but didn’t exercise beforehand or took it after exercising at night.

This is a game-changer for potentially ALL our patients who struggle with iron absorption.  With the key take-home being…not just take your iron preferably in the morning which we already know (when hepcidin is naturally lower as part of its diurnal rhythm) but before you pop that pill, pop on your sneakers and get busy sweating! How on earth might this be working?  Well this study demonstrated that while hepcidin rises after exercise typically for up to 6hrs…it is not yet ‘up’ and blocking within the first hour – gotcha! But why would this mean an even greater uptake compared with the same iron at the same time in the same individual…but a resting version of themselves?  Because exercise may in fact cause a transient leaky gut post exercise & enhanced nutrient uptake may be its silver lining!  A small study that actually punches above its weight, this one is worth the read – via a great comprehensive summary on Medscape if you have it or you can check out the abstract.

Our ever-expanding Iron knowledge gives us great hope for the improved understanding we are likely to reach with all nutrients in the future.  Let’s not forget Iron has about a 70 year head-start on other microminerals such as Zinc and almost a century on Selenium, which was identified to be essential in just 1979! 

And the contrast is apparent anywhere you care to compare and contrast the ‘older’ with the ‘younger’ nutrients. Just look at iron studies. A personalised detailed account of each individual’s iron story: how much you’re consuming, how effective you are at absorbing what you’ve been offered, how hungry that makes you for more and what good stores mean to you (not some fictitious average male or female)!  All told through 4 distinct but inter-related markers: serum iron, transferrin, transferrin saturation and ferritin.  What can we glean from our current routine assessment of Selenium in contrast?  Their short-term Se intake…yep. Looking forward to the multi-parameter markers of each individual nutrient we just might have at our fingertips in the future, thanks to iron nutrition which continues to teach us how sophisticated nutritional physiology really is 🙂

We know the most about iron and yet we know there is always more to learn.  And who better to teach us this than our clients with iron deficiency or iron excess?  Need some help getting across the most important aspects of recognising and correcting each iron issue in clinic?  We released an Iron Package earlier this year for this very reason. It covers how to really read iron studies (with a great cheat sheet), how not to fall for a fake (deficiency) and what the best supplements and dosing regimes look like and how that differs in pregnancy, athletes, those with marked gut issues and other key groups. It’s your 1 stop iron shop.