Those ‘still-believers’ look away now. One of the great myths, misconceptions and misunderstandings in nutritional medicine is that supplementation with specific nutrients will produce change specifically in one system, or pathway, which just happens to be the one that the practitioner has determined would benefit most/is targeting. Let me explain myself a bit better. When we give patients any nutrient, in the cases where it’s not simply to correct a global deficiency & therefore improve levels all round, it’s typically on the basis of a specific desirable therapeutic benefit, e.g. some magnesium to help their GABA production…, additional B3 would improve their mitochondria. Beautiful on paper…but like sending a letter to Santa in reality (I did warn you!)
Truth Bomb No.1: There are nutrient distribution pecking orders that have nothing to do with who you ‘addressed’ it to
This dictates that when something is given orally, for most nutrients, the gut itself has first dibs. So the cells of your digestive tract meet their needs before any other part of your body gets a look in. Sometimes the digestive system’s needs can be quite substantial and leave little for any other part of the body…not mentioning any names (ahem) Glutamine!
Truth Bomb No.2: En route to the ‘target’, these nutrients get delivered and distributed to many other tissues – with possibly not so desirable or intended effects!
You may determine that a patient needs iron because their ferritin hasn’t got a pulse…so you keep giving them daily high dose oral iron to ‘fix’ this…not realising you’re making their GIT dysbiosis and gut inflammation worse in the process. Or you feel their mysterious ‘methylation cycle’, happening predominantly in the liver and kidneys, could do with a folate delivery…perhaps ignoring the very worrying fact that their colon may have already had a ‘gut full’. Literally. Hence the concerns and caution against supplementing with folate in patients with established colorectal cancer. So is bypassing the gut via IM or IV nutrients the answer…well yes and no…but mostly no. Read on…
Truth Bomb No.3: Those pathways that use the nutrient you’re supplementing, that are most active in the patient’s body currently – which is determined by many factors (genes, physiology, feedback circuits, pathophysiology) and rarely simply by the availability of nutrients – will take take the next lion’s share of that nutrient
Wanting to nutritionally support someone’s thyroid, you know tyrosine is the backbone of the thyroid hormones, so you include this in the hypothyroid prescription. Will it help? Who knows? Being a non-essential amino acid the body exhibits very complex regulation of its distribution and use – with thyroid precursor availability being only one job on a very long list! And if this was in a patient who is regularly smoking cannabis, due to upregulation of the tyrosine hydroxylase enzyme – there is likely to be more of the supplement headed for even more dopamine production and very little or none reaching in fact your intended target. And don’t get me (re)started on Glutamine – supplements of which in an anxious and glutamate dominated patient will make…G.L.U.T.A.M.A.T.E…right…not GABA! 🙁
Sorry, I know, it hurts right? But these are essential teachings, that tend to have been over-looked or under-played I find, in nutrition education, regardless of training: nutritionists, naturopaths, IM doctors, dual qualification practitioners remedial therapists. Nutritional medicine is a wonderful and potent modality when it’s done well…but we need to revisit some core truths and principles that many of us have missed out on, to ensure we’re not writing letters to Santa.
Want to revisit your core nutritional knowledge which will cover this and much much more?
Let’s start with Micronutrients. Let’s talk 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 felt well trained – will find a lot in this critical review that is new, insightful and truly practise-changing!
So we already know that thyroid problems can start in utero, right…but a recent Medscape review (the fountain of thyroid information that I frequently drinketh from 😉 ) on Hypothyroidism in childhood taught me a couple of big things I hadn’t known before!
The diagnostic criteria for subclinical hypothyroidism are raised TSH levels in combination with a normal concentration of free serum thyroxine (FT4) but because there are some differences between accepted ranges in TSH assays, high-risk groups should be screened, especially babies with malformations, whose mum received steroid treatment during pregnancy or in the neonatal period, or who had existing thyroid dysfunction, TFTs (or at the least TSH as part of what’s called the Neonatal Screening test) should be repeated 2 weeks later. But now comes the couple of big light-bulb moments: the incidence of eutopic thyroid in twin births is nearly double compared with singletons! As you know, I’m a mother of twins and I’m guessing at 18yrs old now (and multiple peachy TFTs 😉 ) the horse has well and truly bolted for my two but geez…I had no idea of the dramatic increase in risk. And it keeps going…monozygotic twins very commonly show a delayed TSH rise and those numbers are even more prominent in multiple births. The other not-so-fun-fact is the discovery that subclinical hypothyroidism in IVF babies is approx. 10% which is noteworthy considering none were observed in the control group.
This obviously left me thinking “W.H.Y?” And of course…the first place my head goes with the latter…is iodine.
Could this phenomenon in IVF babies be due ultimately to undiagnosed or poorly managed SCH in mum or even simpler still, just basic iodine deficiency, presenting as infertility?!
The reasons behind our increasing rates of thyroid dysfunction across the life-stages are multifactorial (and don’t get me started on the very real contribution of EDCs!) and how, in spite of iodine adequacy being the first thing on the checklist for thyroid health, so many health professionals ignore this, at their patients’ peril… But now at least we know that patients with IVF babies, twins, and preterm bub, who are currently not included in the prioritised screening groups should be…and of course we should keep asking the questions, “what are the mechanisms behind this, why is it so?”
So if this has made you even more curious about the incredible butterflied-shaped gland and you’d like to go for a stroll on the vast plains of “thyroidisms” you can click on this link Thyroid Assessment in Kids and Teenagers and get completely “thyroided” up. There is always more research to come our way so keep your eyes and ears peeled.
That’s me…always questioning the ‘status quo’ and Iodine is the perfect example! The interview I did on this important subject with Andrew Whitfield-Cook from FxMedicine, covers a lot of key areas of confusion & underscores why it’s so critical all health practitioners get clarity on this topic. ‘It’s just a matter of geography’.
You know, I say to people, we can make vitamins ourselves, we can get all sorts of other organisms including animals, bacteria and plants to make vitamins for us, and then eat those…but minerals…our source of minerals…well it all comes down to the rocks and the soil our food itself is grown or fed on. And iodine is profoundly influenced by these factors. (more…)
“Researchers followed more than 500 women trying to conceive over about five years and found that, overall, those with moderate to severe iodine deficiency had 46% lower odds, per cycle, of becoming pregnant.”
All researchers dream of generating the kind of results that are ground-breaking but sometimes you read about the latest study’s findings and you think, ‘Really, you spent all your time & cleverness for years on this and that’s all you have to show for it!’ Like the study that finally confirmed dog’s can feel empathy (at last thank goodness …phew…cos I had my doubts until they crunched the numbers!)
So too a study published this month on the possibility that iodine deficiency is common in women trying to conceive in developed countries and may be connected to increasing fertility issues.
Stop press! I know…that made you spill your coffee! (more…)
Another young female presents in my clinic with a newly diagnosed thyroid cancer and has been recommended urgent thyroidectomy. Her story is increasingly common. If you’re not seeing it in your clinic, you will, because thyroid cancer, and almost exclusively papillary thyroid carcinoma (the form my patient and most young patients have), is dramatically increasing. Since the 1970s there has been a 67% increase in the incidence in women and a 48% increase in men documented in 5 continents (Peterson et al 2012). Australia, though less up to date with its data collection, found a similar increase between 1982-1997 (Burgess 2002). The question begging to be answered is why.
Increased screening and more effective detection of smaller tumours was the going theory for years. New research rejects this absolutely and concludes instead this is a ‘true increase in occurrence’. Increased radiation exposure? Mutation studies say no. Many researchers are pointing to is a ‘new environmental chemical and/or dietary factor’ and EDCs (Endocrine Disrupting Chemicals) that target the thyroid such as perchlorates, phthalates, parabens and phenols are the likely suspects. And, more than likely, with iodine deficiency to explain the increased susceptibility to these EDCs.
But wait there’s more. These ‘new goitrogens’ aren’t only implicated in thyroid cancer, a large number of human studies confirm the higher your urinary metabolites of these, the lower your thyroid function. More worryingly is that they might be doing this ‘without a trace’. With myriad impacts at the receptor level, altered hormone excretion rates, impaired peripheral conversion etc. the data to date suggest these patients TFT results might only look ‘slightly low’ or even ‘normal’ but the reality is they are suffering hypothyroidism. Sound familiar?
There is a HUGE body of scientific evidence we can pull from to understand the role of EDCs in thyroid problems in our patients, how to maximise prevention and minimise impact – even when your patient, like mine, is perhaps already in the full grip of the consequences. I’ve read all the papers and summarised them in this 30min recording: Hypothyroid without a trace – the role of EDCs.
Have you got patients with hypothyroid symptoms but normal results? Or results that suggest the HPT axis just seems to be broken? Could it be the result of a combination of Endocrine Disrupting Chemicals (EDCs)? How do you assess for these ‘new goitrogens’, which act more potently and more insidiously, inducing hypothyroidism ‘without a trace’. How do you maximise prevention for all of your clients and the most at risk sub-populations or minimise impact for those already in the full grip of their consequences.
This latest Update in Under 30 audio comes with 3 key related scientific articles and a bonus larger powerpoint presentation that Rachel presented at the ASLM 2017 conference.
Let’s play a little word association game:
I say ‘Fibroids’ – you say, ‘Oestrogen’.
I say ‘Cyclic Breast Pain’ and you say, ‘Ouch!’ [because it just slipped out] but then you say, ‘Prolactin’, right? Me too.
Prolactin driven breast pain’s most characteristic form is the premenstrual ‘oh my goodness get these off me!!’ kind, with patients experiencing anything from burning, aching, bruised feelings and acute hypersensitivity to touch, which builds in intensity for days leading up to their bleed. Of course cyclic mastalgia can progress to being full-time mastalgia in women whose breasts start to exhibit structural tissue change in the form of cysts, fibrosis and ultimately fibrocystic breast disease. If you’ve ever experienced even a day of mastalgia it is truly hard to conceive there are so many women (about 50% of premenopausal women!!) living with it daily.
Adding to our concerns about this so-called ‘benign breast disease’ (BBD) is that researchers are now certain it’s a significant risk factor for breast cancer, with women with any form of BBD experiencing at least a doubling of risk of a subsequent breast cancer diagnosis, while those women with proliferative BBD exhibiting a risk of 3.5X that of women without BBD. Castells et al 2015 (more…)
While I did diagnose this one correctly, I didn’t get 100% in this quiz – Can you? Speaking of the devil, Medscape, has this great little visual quiz to test your knowledge about physical signs & other hidden clues of nutritional deficiencies.
While we all know there can be a lack of specificity when it comes to some deficiency signs…like glossitis…eyeyiyi..naming a nutritional deficiency that doesn’t include this sign would be a tougher question 😉 but what a great reminder of some quirky things you may have forgotten or in fact deficiency features you may not have even known about.
A gem I love and apply frequently, is about zinc the ALP levels…watch out for the that later in the slideshow quiz.
Also note the distinct difference in opinion when it comes to vitamin D adequacy – with Medscape citing blood vitamin D result < 75 nmol/L unequivocally associated with osteoporotic change…in contrast to the …’anything over 50 nmol/L is a bonus’ line we’re being fed here in Aus and NZ! While we may not ever see some of these severe deficiency presentations walking through our doors – you can’t be so sure…given the reported resurfacing of scurvy in good ol’ Sydney just last year!
Is it just me? I love going back to nutrition 101. So tomorrow with your cuppa…test yourself and then let us know how you go 😉
Are you keen to keep developing your naturopathic knowledge in areas of diagnostics and nutrition? Rachel has a range of services that can help accelerate your learning. From the long list of great downloadable recordings in the store, that help fill your ‘knowledge potholes’ in a fun and engaging way that really brings these topics to life, to our Update in Under 30 Subscription: 30 mins of power-packed up-skilling delivered to your inbox every month, as well as our individual and group mentoring programs! There’s content galore and a delivery format to suit every clinician – come check out what’s on offer.
Whenever I talk to practitioners about thyroid health, like I recently did at MINDD, I can guarantee I’m going to get 2 questions:
- Shouldn’t we aim for the high iodine intake of Japanese?
- Can we use the patch test for testing iodine levels in our patients?
I am so glad you asked. The answers are no and no.
I am a nutter for minerals and iodine just won’t go away right now. Too little = a problem, too much = often the same problems. To boot we are faced with radically contrasting views on assessment and dosage and just about everything iodine related. It’s not you – it’s iodine. Trust me it’s a complex little mineral that requires some extra thought and caution. If you imagine the Japanese have no thyroid problems – correct that big myth right now by reading this scientific paper that refers to health problems that result from too much dietary iodine. It also explains that the typical first step in treating hypothyroidism in Japan is to reduce their iodine intake! (more…)
Got any patients on Natural Thyroid Extracts (NTE)? Me too…and I am finding it’s on the increase. What’s the deal? What do we need to understand about this form of thyroid replacement therapy to best monitor and manage those patients already on it or contemplating taking it? Does it really offer advantages to all hypothyroid patients or just to a subset of those and how would we recognise these people who might benefit the most?
NTE are marketed as being superior to synthetic thyroxine primarily based on the fact that they provide the patient with some T3 as well as T4 and in addition to that, being extracts of pig thyroid glands, there are other thyroid and iodine based actives e.g. mono and diiodotyrosine, present in the extracts. So in essence this is giving us more iodine and more of the other ingredients we need to make our own thyroid hormones. Based on this, many proponents of NTE say this is a major advantage over synthetic thyroxine replacement because it is more ‘holistic’ and it supports the patient’s gland in its own hormonogenesis. (more…)
I just want to scream with joy…and then keep on screaming with utter frustration! Last week I presented the culmination of months of work looking into the extraordinary manifold relationships between thyroid health, fertility, pregnancy & post-partum health for mum and bub.
The findings are breathtaking: whether it’s about being able to put thyroid Abs firmly on the ‘Must Screen’ list for preconception care, given their ability to double-quadruple the rate of early miscarriage or their propensity for triggering post-partum thyroiditis in 50% of women who possess them or being able to state emphatically that maternal low iodine (prior to conception as well as during pregnancy) remains the number one risk for the thyroid’s healthy transition to pregnancy. The evidence is overwhelming that we need to pay very close attention to the thyroid. (more…)
Have you still got some thyroid patients that don’t fit any sort of traditional thyroid disease model and are difficult to get results with? Oh yes me too… and watch out…I’ve been spending the last few weeks with my nose firmly embedded in hundreds of articles digging around for more answers. As I am presenting on thyroid conditions for ACNEM in Adelaide March 18-19th, I couldn’t resist going back to the literature to see if by delving a little deeper again I could come up with some more answers to these weird, wacky and hard to treat thyroid presentations that we’re increasingly seeing and guess what…I think I’ve found a few gems. (more…)
Howdy hard working praccies 🙂 well I received a very interesting email this week from someone asking me if I thought her urinary iodine result was accurate or if, as I have written about previously (https://rachelarthur.com.au/concentrating-concentration-getting-urinary-iodine-right/), it needed to be corrected for the creatinine content of her urine. Her raw iodine result was 24ug/L which suggests severe iodine deficiency. Her referring doctor however had also asked for creatinine and applied the creatinine correction formula I have previously described:
Iodine (mcg) ÷ Creatinine (mmol) X 8.85 = Corrected Iodine – which changed her result to 265 mcg/gCR which suggests she is NOT iodine deficient at all
She then asked another doctor to review the result who had told her 24ug/L was correct in the first place as ‘pathology companies automatically correct for the concentration of the urine’. Naturally the individual found the difference in opinions and results absolutely striking and ultimately disconcerting so she thought she’d ask me.
It was good to get this email because it made me go and check my facts, get in touch with all the major mainstream pathology companies we deal with and ask their labs ‘Do you or do you not automatically correct for creatinine when you report urinary iodine results?’ I was worried I had given you guys some bad advice 🙁 …here’s what I found out: (more…)
I’m only human & there are some questions that do make me silently groan & invisibly (I hope!) roll my eyes. One is the old chestnut: “but the Japanese consume on average 7mg of iodine a day!” which is typically offered up as a rationale for the need for mega dosing of iodine in everyone. This is of course only a partial truth & the missing bits make all the difference! The Japanese have some of the highest rates of thyroid disease in the world & this is in part, attributed to their high iodine exposure. Secondly, it’s simplistic & flawed to isolate one characteristic of a whole diet & not appreciate that its effect or impact is mitigated by the context of the entire diet & lifestyle of that population. In the case of the Japanese, for example, this includes relatively intake of isoflavones, key goitrogens which will reduce the bioavailability of the iodine both within the gut & at the thyroid. Harrumph! I love iodine & am frequently suspicious of a deficiency in my clients, however, like many nutrients feel that our ultimate objective is for optimal nutrition…not excessive.
Am I just a conservative scaredy cat perpetuating fear around this topic in the industry? Well…..no. There is accumulating international evidence of big spikes in autoimmune thyroid disease diagnoses following the introduction of iodine fortification programs in previously iodine deficient countries such as Greece, Turkey & Brazil. There is of course evidence as well that iodine supplementation in Grave’s & Hashimoto’s disease can lead to delayed recovery or worsening of the condition. (more…)
Like all thyroid disease, post-partum thyroid conditions seem to be on the rise – and often they rewrite the rule book when it comes to thyroid pathology & its management. Therefore for many of us it can add an extra element of uncertainty about how to help these clients.
One of our graduate practitioners has a great example of this, a 33yo female who developed late gestational diabetes and is now struggling with a new baby and an autoimmune thyroid disease! What would you do? Does post-partum thyroiditis have unique triggers/drivers that require specific treatment? What can you/should you be doing differently because she is still breastfeeding? What’s the likely progression/prognosis?
This is your invitation to come along and find out the answers to these questions and more. During our live graduate mentoring session on Monday 15th June at 3.30pm AEST we’ll work through all aspects of the case, from history to presentation and from looking for clues in her pathology results to where to start with treatment. (more…)
As we head rapidly towards the change over of our calendars we would like to offer you a special on the very best educational recordings from 2014 – buy 2 CDs before Jan 31st and receive one complimentary Premium Audio Recording of your choice OR purchase 4 CDs and receive a 3 month Premium Audio subscription for free.
It’s been a busy year during which Rachel has delivered 7 very successful new seminars in the area of mental health and beyond, most notably fortifying her role as a leader in the field of diagnostics and pathology interpretation. This has included collaborations with ACNEM, Biomedica, Health Masters Live, MINDD and Nutrition Care, however, each recording is classic Rachel – full of fresh perspectives on diagnosis & treatment, colourful analogies & humour. In case you missed some of these this year or want a copy for keeps – here’s a quick summary of the 2014 recordings included in this end of year offer: (more…)
Apologies for having a one-track mind currently but yes I’m still banging on about the thyroid this week. You see, this year in my own clinic I connected up some dots I hadn’t connected before via a series of young female patients. Each of these women presented with some hypothyroid features, most notably, low basal body temperatures, fatigue and weight gain and while their thyroid hormones (TSH, T4 and T3) were all technically ‘within range’, their T3 levels were very low (low 3s) and the TSH seemed to sit low as well (<1.5). Normally of course, when T3 levels drop we expect TSH secretion from the pituitary to rise in response, as a means to correcting this dip, however, this part of regulation appeared ‘blunted’ or even ‘broken’ in these women.
So why would their pituitary be sleeping on the job, allowing them effectively to experience long term suboptimal thyroid function? (more…)
Recently in our group & individual mentoring sessions we’ve been looking at lots of patients’ urinary iodine results. Many of you will know that I’m a bit of a fan of doing spot urinary iodine testing to gain some understanding about patients’ iodine, in spite of several well-documented limitations of the test. The first thing to remember is that urinary iodine has a diurnal rhythm, parallel to the rhythm seen with the thyroid hormones, so urinary values will fluctuate throughout the day. We can get around this by always asking patients to collect the sample at the same time – preferably a fasting early morning urination, which represents the lowest iodine concentration in a day. That way we know we’re always comparing apples with apples. The second limitation and frequent cause for misinterpretation of results is not allowing for the concentration/dilution factor of the urine sample. (more…)
Also presenting at the Science of Nutrition in Medicine Conference this year was Professor Eastman who is a world-renowned Australian endocrinologist with a primary interest in global iodine deficiency. He is also Deputy Chairman elect of the International Council for the Control of Iodine Deficiency Disorders (ICCIDD) and is frequently consulted by Australian health authorities and medical groups on the issue of iodine deficiency in Australia. Boy did he have some things to say…and it kind of went like this:
- Substantial epidemiological research has shown that 95% of euthyroid patients have a TSH between 0.04-2.5 mIU/L (note the current reference range suggests results < 4 mIU/L are okay, Eastman strongly refutes this)
- The mean TSH in a disease free population is actually 1.5 mIU/L
- In fact Professor Eastman was emphatic that the mean TSH in iodine replete individuals is actually 1 mIU/L
- While acknowledging the limitations of spot urinary iodine testing for the assessment of individual iodine status, he genuinely seemed at a loss to understand GPs reluctance to refer for this test when patients exhibit risk factors for hypothyroidism and in his article (Screening for thyroid disease and iodine deficiency. Eastman CJ. Pathology. 2012 Feb;44(2):153-9.) he argues strongly for screening of all mature age women, pregnant women (1st trimester) and school children, using the urinary iodine and TSH together
- And while we’re stirring the pot how about this: Professor Eastman says that hyperthyroid individuals who have a low urinary iodine result should still be given judicious iodine! Such sacrilege!!
- But wait…before you get too excited and join the ‘too much iodine is never enough… just look how much the Japanese eat’ camp…I was very relieved to hear Professor Eastman remind the audience that while the Japanese diet does provide substantially more iodine than the Western one, it is not without problems, with very high rates of thyroid disease especially thyroid cancer and in fact, Japanese health authorities are concerned about excessive intake and are currently investigating ways to cut back. And lastly, if you’re not convinced by this, he says perhaps you should talk to one of the many litigants in the current class action against Bonsoy, who developed severe thyroid diseases thanks to excessive iodine exposure from the milk (7.5mg/cup)!
So keep arguing for urinary iodine assessment and for addressing individuals with ‘within range reference results’ for TSH that are clearly not healthy ones. Check out Professor Eastman’s article, there’s a goldmine of information in there and while we’re talking about incredible resources in nutritional medicine – take a moment out to thank Dr. Tini Gruner (previously from Southern Cross University) for her significant contribution to naturopathic nutrition education in Australia. She was a mentor and inspiration to me and many others. She sadly passed away this week and we will miss her dearly.