When Your Day Ends On A Happy Note

A conscientious early career practitioner digging deep into GS research and upskilling, recently sent me a message to ask if I knew that the correct pronunciation of the condition was ‘Zheelbairs’…as in..imagine you’re French and say the word through  a pencil moustache and barely opened lips!  My answer? ‘Yes (or should that be Oui Oui!), but I gave up pronouncing it correctly when I realised no one in my very Aussie audience could make the connection between my fickle French impersonation and the word G-I-L-B-E-R-T-S on the screen”… 😂😂😂

Ok I know many of you imagine I read nothing else but  Gilbert’s Syndrome guff and that not a day would pass without those sweet words passing my lips!  But you know what? That’s not completely true 😂  But my series of mentoring sessions yesterday did end on another happy note, with both the final case presented being a Gilbert’s one (overt oestrogen excess, likely bile stasis etc)  and then stumbling across this paper that I hadn’t seen before a longitudinal study of 100 Egyptians with GS, tracking their bloods and health experiences.  I know you also imagine that I have a direct line with God in terms of receiving Gilbert’s research the second it gets published…again not completely  true 😂 and somehow I had missed this one!

It’s not the greatest research in terms of sample size and methodology but hey beggars can’t be choosers and when you’re a condition with whom the word BENIGN is so commonly associated…you’re always begging for something: attention, validation, research crumbs! 

So the practitioner presenting this case, actually asked a great question…”do I put these patients on everything you’ve talked about as having potential efficacy in GS and set and forget?”  The answer of course is no.  But it is good to clarify. The bulk of the heavy therapeutic lifting is always the education of these patients – what choices they need to make and perhaps make differently to get the best out of their body.  The non-negotiable for me, is the direct glucuronidation support which for me typically would be cruciferae based and then if needed glucomannan (I now use this as much as possible instead of Calcium D glucurate…missed the reason why?…check this out). The next treatment tier is dictated by how the GS principally presents for the patient in front of me: GIT – choose any additional treatments to work on this aspect of the disorder (motility agents, bile thinners, fat digestion support) or Psych: mitigating and managing the longer half life of both dopamine and oestrogen and the potential imbalances that ensue.   Throwing the entire dispensary at these patients (like any other) is often unpopular…especially when we know this is not something ‘solvable’ so in fact we need to aim for sustainable instead.  

But following this approach has brought so many of my patients long-lasting benefits and a far better experience of their health that they are super grateful for. Now that’s a happy note to end on 🙂

A Guide to Gilberts Package
It all started way back when with ‘Gilberts Girls’…then came ‘Gilberts Guts’ because that is such a common source of unexplained hard to define gut dysfunction in patients…then latest instalment was news from the research frontier in Gilbert’s Syndrome, which is nothing short of thrilling, rewriting our thoughts on what medications and supplements (!!) are the most problematic, significantly improved dietary management of these clients, how to track their progress more accurately and why completely normalising their bilirubin is not the goal…hey did someone say…longer telomeres?! 😉 Included are kickass desktop clinical reference that comes with this months UU30 that aids a better understanding and clear treatment directives in your GS patients.  All of these are combined for the newcomers in this Guide to Gilbert’s Package

A Guide to Gilbert’s package is 3 Update in Under 30 episodes combined into one
– Gilbert’s Girls; Gilbert’s Guts and Gilbert’s – New Goals & Good News.
If you are already an UU30 Subscriber you will already have access to these episodes in your ‘active content of your online’ account. Or you can purchase this complete package here

The ‘Perfect’ TSH?

Have you been told somewhere by someone that the ‘perfect’ TSH is 1.5 mIU/L?  This is a wonderful, terrible & wonderfully terrible example of ‘magical numbers medicine’.  As a push-back against the published reference ranges we’re given, that are so wide you could drive a truck through them, there has been an over-correction by some, leading to the myth of ‘magic numbers’.  We can narrow the reference range substantially for many parameters with good rationale, make no mistake about that but once we start setting ‘aspirational goals’ that are explicitly rigid…well we’ve done 2 things 1) forgotten about the patient to whom this result belongs and 2) disregarded viewing each result as part of a ‘pattern’, that we must piece together and make sense of.

Back to TSH then… if my obese patient had a value of 1.5 mIU/L this in fact would be woefully inadequate.

Also too low for any patient, no matter their size, if their T4 is low and we’d like a higher value as well for risk minimisation in our elderly clients too. 

But the same result would be excessively & worringly high in my patient who’s undergone thyroidectomy. 

Being given a list of ‘magic numbers’ will never replace learning labs correctly.   When we do this, we come to truly know that meaning can only be made of the markers when you can answer the following questions:

  1. What is this (metabolite, analyte, binding agent, plasma protein etc)?
  2. What do I know about its physiological and biochemical context – what is its role and regulation in the blood, what moves it and to what magnitude?
  3. How have the reference ranges been determined for this lab – who am I comparing my patient to?
  4. Therefore, what is the significance of a result that is: ‘normal’, ‘low normal’, ‘high normal’, below or above the range?
  5. Does this value ‘fit’ with my patient?
  6. What else could explain an unexpected result?
  7. How strong is my level of evidence?
  8. What do I need to do from here to confirm or refute this?
  9. And a few more 😉

 

Realising the full value of any test result in terms of what it reveals about the person sitting in front of you, requires these skills. Unfortunately, in contrast a list of magic numbers will often lead you astray.  And building your scientific knowledge about  labs will not only help you avoid the pitfalls of pathology but will strengthen your pathophysiology prowess in surprising ways, saving your patients a packet in terms of additional extraneous testing and help you truly personalise your prescriptions…because the ‘invisible (biochemical individuality, oxidative stress, genetic probabilities, subclinical states, imbalanced or burdened processes etc)  just became visible’.   I started requesting lab results early in my career and years later was lucky enough to be taken under the wing of Dr. Tini Gruner.  I found some of our shared notes, from 10 years ago, scribbled all over patient results recently and I was struck by just how lucky I was to have her encouragement to really pursue my interest and how she was a guiding force about learning to recognise pathology patterns over single parameters.  A decade on I can confess, much of clinical and educative success has come off the back of this foundational skill-set and I know, this is true for so many I’ve taught too.  

“The guidance I’ve received over the years from Rachel in relation to pathology interpretation has been one of the most valuable (and fascinating) investments I’ve made as a clinician. Her teachings have filled gaps in my knowledge base I never knew needed filling and have significantly enhanced my understanding of the inner workings of the body! Rachel has an incredible ability to make the numbers that patient’s so often present us with, both understandable and clinically meaningful. The knowledge I’ve gained by investing in this skillset has paid off in dividends and I’m certain will continue to do so into the future.”

Stacey Curcio – Cultivating Wellness

I hope you’ll join me for the most exciting up-skilling opportunity in learning labs yet. Oh…and all this talk about thyroid testing..that’s just a serving suggestion 😉 this year my MasterCourse is focused on the most routine labs of all: ELFTs, FBE, WCC, Lipid and Glucose Panels…an absolute treasure trove of free integrative health information about your patient!

This skillset has been found by many to be biggest ‘game-changer’ in Integrative Medicine!

There are limited places. To sign up for the MasterCourse: Comprehensive Diagnostics click here.
For more information about the program click here.

‘Copper Excess’ In A Child?!….Really??

Copper deficiency happens in kids, so does copper toxicity and both are serious concerns, but do we know when to accurately call either?  First, we have to know ‘normal’. If we know what normal Serum Copper values look like in children, then we can easily spot those falling below or above this, right? That’s the first hurdle we tend to knock over and break a toe on!  Being a mineral whose levels vary widely in soil from country to country, globally, the differences in reference ranges are breathtaking & absurd. Add to that, that copper is a key mineral in kids, driving huge demand for it during key periods of development, so the range for pre-schoolers isn’t the same as the primary or high schoolers – not that your lab is flagging that. Unhelpful? Yes.  Dangerous, even? Potentially.

To diagnose ‘Copper Excess’ in a child is a big call to make.

One, because most practitioners are unaware just how much Copper a child really needs at each age & two, high copper is often a messenger for something else going on and then three,  the primary objective based on this diagnosis becomes to lower their Copper but we could be either shooting the messenger or missing the mark all together…right?

Copper excess does happen but not nearly as often as practitioners believe it does.  And in kids, the fall-out from such misdiagnosis is bigger. And missing a Copper deficiency? (because we’re not as well-trained to recognise it and because Copper has been sadly demonised)  Likely to have myriad negative impacts at this vulnerable age…almost none of which generate symptoms or a distinct clinical picture e.g. secondary iron deficiency, low neutrophils without necessarily compromised immunity.  But what about the holy grail get-out of jail adjective: ‘relative’. You know, ‘this is at least a Copper excess relative to their Zinc?’

Well, to form this opinion you’re likely calculating the Zn:Cu ratio and applying an ideal adult value of 1:1 but show me the primary evidence that supports this for kids…anywhere?  The Zn & Cu relationship shifts as we move through life-stages and in fact Copper is supposed to dominate through a lot of our childhood so…ummmmm…no.

HTMA Copper side-steps all of this?..double no.

I used to make the same mistake re Zn:Cu, I may have even taught you this?!🤦‍♀️  But as so often happens, a week spent in all the original scientific data and I’ve emerged a changed practitioner! Having been part of perpetuating this problematic premise in the past, I am determined to get the correct message out there to as many practitioners as possible.  So help me spread the word on Copper in Kids – by telling others that this mineral is so critical to kids compared with adults, they will often have higher levels than ‘us’ and that until you’ve applied the right age-appropriate reference range and ruled out confounders you can’t possibly make a call on Copper. I mean, we kind of knew this all along, with healthy pregnancy Copper values being exponentially higher being a giant clue. Turns out kids’ ‘Copper Age’ extends way beyond the womb.

Copper, as a kingpin in angiogenesis, brain & bone building & iron regulation is a critical mineral during paediatric development. So much so, the kind of blood levels we see in a primary schooler might cause alarm if we saw them in an adult. So too their Zn:Cu.  But higher blood Copper and more Copper than Zinc are not just healthy but perhaps necessary during certain paediatric periods.  This recording redefines normal, low and high with a great clinical desktop tool to help you better interpret these labs, as well as reviewing the top causes and consequences of both types of Copper imbalance in kids. 
The latest Update in Under 30 has landed. You can purchase January’s episode, Copper in Kids here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
-Your RAN Online Account has a NEW LOOK!!-
Next time your log in, you will experience a more user friendly way to search, view, listen and download your resources. Find out what’s new here.

 

So, What Kind Of Drunk Are You?

I know, timing, huh?! It’s almost like I’ve been sniffing around your recycling bins but I didn’t need to of course, at this time of year it’s a fairly safe bet you’re madly winding it back a tad from your most outrageous annual alcohol imbibing. And so are all our patients.  To me, extracting accurate information succinctly from patients regarding their alcohol use can be one slippery little sucker. It’s one of the questions people tend to give you a very tidied up answer to, or in fact they’re in such denial they can’t be considered a reliable witness.  Think about it.  Being a non-habitual drinker myself, I can appear almost saintly when reporting my daily consumption, “None”…but that omits the ‘other me’ that might show up at a conference gala dinner or some live music event, with my volume controls adjusted significantly up…ergh…firsthand accounts anyone? And how often does that happen?  Well anywhere between 4 times a week and once a month.  See what I mean?

While I’m sure you’ve probably heard me say before, I ask every patient who does drink, what kind of drunk they are because it can hint at their underlying neurobiology, there is a new study that suggests, using a very short 4 item UCLA RRHDS survey, we can categorise patients alcohol use and misuse into 3 types:

Reward  Relief Habit

and in doing so, also be better able to identify the best way to manage them as well.

I’ve been interested in addiction neurobiology for a long time and very much resonate with the work of Koob, which in layman’s terms proposes that we seek intoxication initially for the ‘high’ and then with dependence, we continue to seek it to appease the terrible lows of withdrawal.  It has long been known that alcohol use disorder is heterogeneous – there are different types and accordingly the kind of generalised treatment of these individuals proves extremely hit and miss. But articulating the different types and their distinct drivers and solutions has been fraught. Like what makes one alcoholic the functional type who in addition to their long-lunches is a CEO and the one who can’t keep their job?  Is it just socioeconomic context or something more?  Why are some types of alcoholism deemed also to run more in families and while others aren’t? There are clearly major difference in pathophysiology but what are they?  More recently these 3 groups have emerged and this recent study confirms the value particularly in the distinction between those who drink driven by reward and those for relief + habit. It’s a great read but here are some key take-homes:

Relief Habit

These individuals drink to cope or resolve a negative experience and therefore a driven by negative reinforcement. As a group they present with more depressive features and have more anxious traits than those ‘reward drinkers’. So the key to managing these patients is to offer treatment that also appeases their negative physical and psychological experiences with sedation, anxiolytics, glutamatergic modulation. (Hint this is where Taurine really shines, in this group!!)

Reward

These individuals drink to feel good so they are driven by positive reinforcement and therefore the approach to the helping them should be quite different, with lifestyle recommendations that offer other options for  mood elevation such as exercise etc as well and herbal and nutritional approaches.( Hint hint…not the key group for Taurine, more like Tyrosine and Saffron etc)

So….back to my question…what kind of drunk are you? As a nation of over-consumers by nature, this is a question we need to ask all our patients

Mastering Mental Health: New Assessments and Management Resources in Your Clinic (2hrs)

Rachel introduces you to new clinical tools that has been developing to help us all better master the maze of mental health. With so many possible biological drivers: from methylation to inflammation and from gonads to gut, these tools can help you quickly identify those most relevant to each patient and also outline the strategies necessary for redressing these. This presentation comes with an extensive library of resources including pdf of Assessments Tools and Case Study Notes.

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

 

Earlier this year at a Mental Health Training for IM doctors, 3 practitioners (myself, a doctor & a psychiatrist) walked into a bar…not really, but we did each present a case study of challenging patient & in whom we had some great outcomes. All 3 patients presented happened to have Gilbert’s Syndrome.  Just in case you’re wondering if there was a secret Gilbert Syndrome Conference you didn’t get an invite to, no.  Or that perhaps there was premeditation and intention on the organisers behalf for a bit of sub-theme and focus, no.  While this was purely coincidental it does speak rather loudly to a couple of things though.

Patients with Gilbert’s syndrome are likely to be over-represented in our client base especially among those presenting with psychiatric and/or gut issues (and both presentations frustratingly for them, very hard to diagnose, define, pigeon hole etc) and secondly, even though their genes underpin their biological susceptibility to such health problems, great outcomes are really possible.

One of the challenges comes from the medical dismissiveness of this genetic issue as simply ‘benign hyperbilirubinemia’.  This has lead to a lack of diagnosis in patients affected and when it is incidentally picked up on routine bloods, a lack of follow up education about what having approx. 30% less phase 2 glucuronidation activity, in their gut and their liver, is really likely to mean, not to mention radically altered bile composition and digestion (!) and how they can make better choices in light of this. Similarly this year in our Mental Health Specialist Mentoring Group, the issue of reduced efficacy and tolerance of  psychiatric medications, in those with Gilbert’s, raised its head over and over again.  Given that so many drugs within the psychiatric class add at the very least to the ‘substrate load’ of the UGT system, if not frankly inhibit some members of this enzyme family,  as this paper (check out Table 2…superb!) shared by my colleague, Kate Worsfold, points out, it actually shouldn’t come as a surprise.

But there is a change a’coming with an influx of research leading to improved understanding of this seemingly mercurial malady, resolving many riddles, identifying new key ways to help these patients and at last….some exceptionally good news for those with Gilbert’s.

For example, when I started this conversation back in 2013 with the Update in Under 30 Gilbert’s Girls, that was in response to seeing so many women at the time presenting with significant imbalances in both their sex hormones and their neurobiology as a result of their UGT impairment.  But of course it was never meant to imply GS is just a girl thing!  In fact there is a 3:1 dominance of men with this condition and some very good reasons as to why: more red blood cells and more testosterone…the former being the primary source of bilirubin and the later a terrifically powerful UGT inhibitor. The news from the research frontier is nothing short of thrilling, rewriting our thoughts on what medications and supplements (!!) are the most problematic, improved dietary management, how to track their progress more accurately and why completely normalising their bilirubin is not the goal…hey did someone say…longer telomeres?! 😉

The latest Update in Under 30 has landed: Gilbert’s – New Goals and Good News and my team has gone all out in producing a brilliant desktop reference to go with this recording that aids better understanding and clear treatment aims for your GS patients.

You can purchase Gilbert’s: New Goals & Good News here.
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.

 

We Know – But Do They?

When a teenage girl presents seeking her first oral contraceptive pill (OCP) script, what information is she privy to that enables her to make an informed decision? Read the insert inside the box? Please. Which 50 year old, let alone 15 year old does that? Forget it! What might her doctor tell her? Perhaps about clotting risk, as part of their determination of the suitability of this form of contraception for her but is there any discussion about the potential for adverse mood effects? A recent study of over 1,000 teenage girls followed over more than a decade adds to other evidence that suggests this should be flagged as a consideration prior to the prescription being written.

Most integrative health practitioners not only know about the potential negative impact on mood from OCP use in women but we’ve observed firsthand the havoc it has wreaked in some teenage girls’ and women’s lives.

A very experienced practitioner I know says, ‘if I am hearing mood instability and then I see a significantly elevated serum copper and or cortisol in these girls that’s when I just say to have to say to them, you know I don’t think this is the best contraception for you!’

This latest study did not find higher rates of depression across all OCP users in this group of 16-25 year olds but when they looked at this at different ages they found its use increased depression scores and was associated specifically with more crying, eating problems and hypersomnia. The discussion around the enhanced vulnerability at this younger age compared with older girls centres on the relative immaturity of their CNS. But wait, I hear you critical thinking clinicians ask, perhaps those teenage girls had more depressive features prior to starting the OCP.  Good thinking 99! And the answer is…maybe…but the relationship goes both ways: from the related Medscape Continuing Medical Educational Activity

“For 16-year-old girls, the association was weakened after adjusting for depressive symptoms before use of OCPs, but the findings remained significant. This suggests that the relationship between OCP use and depressive symptoms could be bidirectional…For instance, 16-year-old OCP users were more sexually active and had more stressful events, as well as more menstruation-related pain and acne, than their counterparts in the nonuser group. Analyses showed that all these factors weakened the association, although none diminished it.”

The commentary surrounding this latest study is essentially 1) this is not the first study to find an association and others have been more able to demonstrate that COCP use predated the mood disorder in those affected and 2) those exhibiting higher depressive scores did not actually score strongly for anhedonia or sadness which are the most typical features in adult depression – so perhaps we are missing some of these negatively impacted young women.  Awareness regarding reproductive psychology is rapidly growing and in Australia we are fortunate to have emerging hubs to seek help and specialist advice in this area, such as the important work of Professor Jayashri Kulkarni and colleagues out of the Women’s Mental Health Clinic.  I’ve referred patients, both when a patient’s mental health appears to be caused or aggravated by use of hormonal agents but which they can’t not use for various reasons and for those small number of women in whom I feel hormonal management may in fact offer a psychiatric solution. So again I am asking, while we know & mainstream medicine increasingly knows about this association…who’s telling these young women?

What’s the OCP really doing? An update on the physiological impact 
How many of your clients are on a combination OCP?  Do you know the full extent of the physiological impact as a result and are you able to identify to key pathology indicators of the size of that impact?

We’re all aware that in theory OCP use correlates with a range of elevated risks but in reality many females will make the decision that the pros, in terms of contraception or control of acne etc., outweigh the cons.  What if we could provide more individualised advice by looking to their pathology results and identifying and quantifying specific danger signs for each individual?  This approach enables us to better support patients who chose this form of contraception and to accurately identify those that should be be encouraged to find other safer options more biochemically suited to them. Learn more here.

While You Were Sleeping

Remember the days when we had the brain all back-to-front & upside down?   Anatomy & physiology told us it was an island, completely protected by the blood-brain-barrier from pathology in the rest of the body, that it was incapable of regeneration after damage and that it didn’t have its own lymphatic system. All wrong. Which presents a problem, the CNS is absolutely in trouble if other parts of our body are (!), but also some solutions: plasticity and the brain’s own capacity for cleaning up after itself. New research has revealed more about this critical CNS cleansing and what is likely to get in the way of this

The latest Medscape update on this is quite poetic, speaking to the movement of body fluids like tides within the human body. 

“They found that the blood flow to the brain diminishes, allowing for an influx of cerebrospinal fluid (CSF), washing away the day’s detritus of proteins and other waste substances that might harm the brain if they aren’t cleared out.”

But these particular tide times are restricted to sleep – having never been identified during awake states & even more specifically only during our Deep Sleep, the period of slowest brainwave activity.  The speculation is, of course, given sleep issues predate or are a feature of neurological and mental health conditions, that perhaps this comes back to the impeded process of waste removal that accompanies this and how this may contribute to accelerated negative neurological change.  For example, beta-amyloid proteins are well known to be removed most rapidly during our sleep and this week I’ve been faced with a small mob of patients who have substantial cognitive impairment risk from a genetic standpoint (e.g. Apo E 4 carriers in families riddled with dementia) but their unmanaged long-standing insomnia plus or minus OSA is likely just AS risky.  So here we are again back at one of the key non-negotiables for health: Sleep.

I often say to my patients, ‘There is nothing I can give you in a bottle or a blend than can do one 100th of what healthy (quantity & quality) sleep can do for your wellbeing today or for preventing health issues for you in the future’ 

And then I say it out loud again when no one else is around just to ensure we’re all aware of that 😉

Want an Update on Inflamed Brain Science?

The brain is no longer considered an immunoprivileged organ separated from immune cells by the blood-brain barrier, with research revealing numerous interactions between the neurological and immune systems. A large body of evidence now shows that these interactions, in particular an imbalance in pro-oxidant & antioxidant systems, play a clinically relevant role in the mental health issues of our patients and may go some way to explain why patients with chronic inflammation frequently present with mood and cognitive issues.  Identifying and addressing the source of the inflammation (musculoskeletal, gastrointestinal etc.) therefore potentially addresses the underpinning cause and creates a ‘win-win’ scenario for patients. This updated recording aptly named: The Inflamed Brain, covers all this and more!

Does Holistic Health Include The Hardest Workers?

Did someone explain the kidneys are like a really important, not to be forgotten, under-estimated, ignored or under-valued kind of organ in your training as a naturopath? No, me neither.  I mean I know Buchu and Uva and Zea (on a first name basis only, clearly!) and …no actually, I’m done.  But seriously, it didn’t take too long in practice to stumble across a whole lot of bad when kidneys aren’t getting the attention they warrant and equally to develop a slight obsession with renal markers in all of my patients not just because of their incredible impact on whole health but also because of what ‘lay beneath’.

As you might suspect, I get sent labs all the time from practitioners. Stop no! That is not an invitation!   

Often it’s client’s renal markers which I do appreciate because it tells me there is an increasing number of praccies that absolutely have done some post-grad DIY knowledge building about these bean-shaped babies and their critical contribution to health. The results might come with a question like, “What’s going on with their kidneys?!” [insert worried face emoji of choosing] 

To which my reply is often… “not much but boy do we need to talk about your patient’s GIT microbiome! [or] mental health! [or] sarcopenia!”

Say what?  Yes abnormalities within the renal markers: urea, creatinine and uric acid may be a reflection of renal issues.  But if you know where each of these molecules enters the blood,exits the body and all the interesting good & bad they can get up to in between…then the patterns speak less (if at all in some instances) to what’s going down in the kidneys but instead give you an incredible insight into key issues all over the body: from the gut to the brain.  But wait there’s more!  Want to know what’s the latest and greatest in management of advanced renal disease? Treat the gut to lower the urea.  What about managing mania? Add in a gout treatment to lower uric acidDang!  This is holistic health at its best with those poor kidneys no longer being left out in the cold!

“Who knew urea, creatinine, GFR and uric acid could be such a Goldmine….Mind…officially…blown!” New Graduate Mentee 2019

Want an Opportunity for ‘XXX sized’ up-skilling in Renal Markers & Health?

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 Renal Markers: Explained, Expanded and Exploded because these routine labs can deliver XXX sized insights into your patients.

Group Mentoring…What’s it all about?

 

For all those Mentoring Virgins 😇 out there wanting a clearer understanding of what it’s really like to be part of my group mentoring, this video is a little snippet from a session with one of my groups. This year has flown by and I have thoroughly enjoyed working with each fabulous group of dedicated ‘life-long learners’.

OH YES!!…and the real announcement is…..(drum roll)…
It’s that time of the year….Applications open next week for GROUP MENTORING in 2020! 

As a result of the generous feedback and insights from our current Mentees, we are always fine tuning our program & level of service. Yep…it just keeps getting better and better every year!! We are keeping everything that so many practitioners have told us they love from the past 7 years (wow….have I been doing it for that long?!) and simply improving the already incredibly popular formula, with some great new features for 2020.

  • New 15min Follow up with one on one with me! via Zoom for those cases that have been presented in our group mentoring sessions.  This is a brand new format to follow up on how your client is going after the session – what’s working, and what’s happening now, what should you do next? Rachel will spend 15 mins with you on Zoom 1-2 months after you presented your client case.  The recording will then be uploaded to Basecamp so the whole group can catch up on the progress and extend our learning opportunities again.
  • We’ve expanded our mentees 30% discount to ALL Rachel Arthur Nutrition products on our website for 2020. When you join the Group Mentoring Program, you will receive a discount code that you can use for any and all purchases on Rachel’s website throughout 2020 – the Update in Under 30 subscriptions, Audio and Video recordings, Packages on Pathology, Thyroid, Iron.
  • Certificate for CPE Hours – we’ve done this for the last 2 years and will continue to do so to make your CPE easier at your end
  • General and Specialist Groups – we’ve had a great response to our specialist groups this year, and we are offering these again in 2020, so you can choose from:
    • General Group Mentoring –our regular case presentation groups, with practitioners taking turns to present a case, or just listen in. Yes, this ‘fly on the wall option’ which we’ve come to learn is preferred by some praccies (due to a lack of time, good cases or confidence) is finally getting formalised for 2020!
    • GP dedicated Group  – this depends on our final numbers of applicants for 2020.  This year we had a combined group of GPs and naturopaths with advanced standing, which has worked well.  Either way, we have a good track record in catering to the needs of doctors, medical specialists and dual qualified naturopaths (osteo, psychology etc).
    • New Graduate Groups –  great opportunity for New Grads to build confidence as they leap from student to practitioner, or for practitioners wanting to refresh their core clinical skills such as MindMaps, Pathology, Improved Case Taking etc.
    • Mental Health Primer Group –  topic based to build on your knowledge in the role of naturopathic medicine in Mental Health – from screening tools to key management issues, specialist diagnostics and beyond.
    • Mental Health General Group Mentoring – practitioners presenting their client cases with a focus on primarily Mental Health presentations.
“I believe the mentoring you are offering is allowing me to develop myself into the type of practitioner that I want to be.
I really aim to provide evidence based treatments, and wish to utilise pathology testing results as one of the major diagnostics in my practice. I can see that every mentoring session with you brings me closer to that, filling my knowledge gaps every time. You and your knowledge base is so inspiring, and I only hope that one day I will know close to some of what you know!” – Andrea Robertson

And don’t forget some of the offerings our Group Mentoring consistently delivers as part of your program – the opportunity to learn every month via high level applied knowledge not theoretical and to see it in action with tracking and updates on patient progress, our incredible online resource sharing platform for communication and support between sessions and the opportunity for sharing of pearls of knowledge from my 20+ years of experience and research together with the collective wisdom and know-how of each unique group.

“I am one of Rachel’s New Grad mentees. My first year out has been pretty overwhelming and I wanted to let Rachel know that I have been watching the zoom sessions and have learned so much to take my clinical confidence and practice to the next level.  She has an amazing gift of nailing the important aspects of practice and giving useful usable information that brings together the fuzz of everything you have learned and ties it all up with a neat bow with her pearls of wisdom every month. I plan to be a mentee again next year (and for many years I suspect)”  – Bek Di Mauro

 

REGISTRATIONS OPEN 14 October!

 To read more about the program click here.
Information on how to apply will be released on 14 October. Join the waiting list now so you won’t miss out by sending us an email on admin@rachelarthur.com.au.

 

Get Plugged Into The Brain’s Trust…

Forehead USB not required. Phew.  All that is required, is a real thirst for new knowledge, rapid development of your diagnostic skills and a willingness to commit an hour every month to tap into your new Brain’s Trust: Rachel and a collection of colleagues with a shared desire (general practice or mental health-focused) and similar level of experience to you – new graduate, medical, naturopathic or dual qualification.  And take one great leap forward closer to being the practitioner you want to be.

The Rachel Arthur Group Mentoring Program has the longest (7 years and counting!!) and most impressive track record of practitioner satisfaction for value for money and meeting clinician’s key learning outcomes.

And the long-awaited good news is…we will offer our New Graduate Program, which debuted this year to much critical acclaim, again in 2020!

Being part of the 12-month group program allows you to connect to a community of like-minded, similarly-skilled practitioners in a structured teaching environment either via case-based presentations (regular groups) or via an interactive curriculum (New Graduates, Mental Health Introduction). You’ll be plugged into 11 other practitioners and together with Rachel’s brain, you’ll receive the knowledge and confidence to assess, investigate and manage no matter who and what walks through the door. Our profession thrives when we thrive as individuals and central to this is building networks of ‘similar others’ in order to find your tribe and benefit from the ‘collective’.

“Rachel is a wealth of information, she has such a knack for breaking down cases. All case presentations no matter how complex are nicely deconstructed into bite sized bits of information that’s easy to digest and take away and put into practice. This mentorship program is worth its weight in gold, it shows you how to deconstruct cases, develop knowledge, gain greater clinical insights and you’ve got a fabulous base of other knowledge practitioners you can ask questions. Can’t wait for the rest of the cases! And you can count me in as a second year mentee next year.” – Megan

In Group Mentoring you’ll be learning core clinical skills that you can apply in realtime to your practice and be able to ask questions along the way. The most valued aspect of the mentoring is the ability to discuss practice experiences with the mentor and to hear and learn from all the group members, sharing experiences, knowledge and learning as we go during the sessions.The bonus of these sessions is you’ll find your tribe, gain support and radically build your toolkit.

I love witnessing every practitioner’s growth, I want everyone to find mentors to support them in their career in integrative health. – Rachel

“Having the group session each month, as well as having Basecamp to bounce ideas around in, is a reassuring connection to know is there if I need it. Having just started practice this year and working in an environment without other Nat’s around, I have noticed the occasional feeling of isolation. So having the monthly catch up keeps me feeling connected to other clinicians and gives me exposure to other cases and perspectives that I wouldn’t have otherwise had.” – Georgie

 

Going by the landslide of registrations for 2019, Group Mentoring is fast becoming a popular choice and could be an integrative part of your practice & your career progression.

So if being part of the community excites you and if the thought of learning and benefiting from a collective knowledge base that is strong and pulls on expertise outside of our own, now’s the time to join the conversation through Group Mentoring.

2020 Group Mentoring Program Applications Open in October!

Read all about it here or email admin@rachelarthur.com.au to let us know you are interested.

A Case of Stoned Sperm?

Tonic. Homeostatic modulator.  These terms and concepts, which have a long tradition in herbal medicine (and let’s be clear, were considered yet another example of the wishy-washiness of the modality) are being appropriated by some areas of mainstream medicine right now. Cheer up ‘leaky gut’, you’re no longer alone! And arguably misappropriated by the public’s very ‘lay’ interpretation of the science on medicinal cannabis and its subsequent elevation to panacea, of late.

“So many of my patients are telling me they’re taking Cannabis now, just as a tonic”, says yet another practitioner to me recently, “No, not for pain, they’re young and fit but they take it because it’s a homeostatic regulator!!”

Oh lordy…

The capacity to maintain homeostasis, and particularly in the face of adversity or imbalance, is a sign of the vitality of the individual, according to what I remember  from naturopathic philosophy (and have truly taken on and observed firsthand)…so just back up there a tad and explain to me how this one herb proposes to do this for everyone on a one-size-fits-all-fashion?  As confessed in an earlier communication, I am a cannabis convert. But only in the sense of appreciating the niche areas where it is likely to offer true therapeutic benefits. I still have the words of warning from the brilliant  Professor Michael Lintzeris, the Director of the Drug & Alcohol Services, South East Sydney Local Health District; Conjoint Professor, Division of Addiction Medicine etc., ringing in my ears, pleading with health practitioners to not ‘fall’ for cannabis in the way we have previously ‘fallen’ (so far and landed so badly) for the panaceas of the past: opiates and benzodiazepines.  Most notable major omission for me, in an otherwise rigorous scientific debate of late, is any discussion about its potential for impacting fertility.

I’ve been aware of the potential negative effect on male fertility, in particular, for over a decade and while we undoubtedly need more targeted research on this topic to reach a consensus, the evidence base to date points to lower LH +/- testosterone and impaired sperm quality and motility.  Certainly not perhaps what tonic-seeking patients know they’re signing up for.

There is in fact evidence to suggest ‘sperm under the influence’…’lose their way’ and are less effective at finding and fertilising the egg.  Sorry but the image always makes me chuckle…stoned sperm.  ‘Hey, dude where’s my egg?!’ style.  But it’s not funny when impaired fertility is a problem affecting so many these days, and we still are guilty of over-focusing on ‘her’ and under-assessing ‘him’…and lo and behold it could be his chronic cannabis use to blame.  We had a case recently, years of unprotected sex, daily cannabis, no baby, no dots connected.  We may think this is a handy incidental contraceptive for young men sitting on couches with cones (one mum recently said as much to me) but for the rest…?

Getting Men’s Hormones Right

As practitioners we should know as much about investigating and treating male hormone imbalances as we do female ones, yet this is often not the case.  While we are increasingly aware of everyone’s exposure to lifestyle & environmental endocrine disruptors and the fragility of the HPO axis, we sometimes fail to recognise that the reproductive health of our male patients is equally under threat.  This is clearly demonstrated by generally diminishing levels of testosterone amongst men and increasingly early onset of andropause. These issues then become barriers to achieving success in other health areas with your clients, mood, metabolism, fertility and beyond.  Learn more here

 

I’d love to continue this conversation with you… 
so join me and be part of my ongoing dialog on this and my other blogs by following my Facebook page.

 

 

When the Body Attacks the Mind

 

Following an important weekend of discussing mental health from a more balanced perspective (that’s my new less provocative term for ‘integrative’ or dare I even mumble…holistic) in Perth for ACNEM, I remain alert but not alarmed of how much is still to be revealed in this area.   Recently, for example, in our mental health dedicated mentoring group, we discussed a case of a somewhat atypical schizophrenia presentation in a middle-age female migrant.  Fortunately, I co-chair these sessions with an incredible clinical psychologist who was quick to pick up that no CNS auto-antibodies had been tested, and given the peculiarities of the case they should have. This is a relatively new area, in terms of more mainstream acceptance of this as a differential in some psychiatric presentations and provision of these tests now through mainstream labs, but it would appear it is far from common knowledge.   Then I read this brilliant article and…well I think we all need to read it.  Here are some snippets…

Scientists had previously noted that certain autoimmune diseases, such as lupus, were associated with psychosis. And they’d begun to suspect that some infections might, by activating the immune system, contribute to psychiatric conditions. But Dalmau provided meticulous proof that the immune system could attack the brain. The development of a test for the disorder, and the fact that very sick patients could recover with treatment, prompted a wave of interest in autoimmune conditions of the central nervous system. In total, scientists have identified about two dozen others—including dementia-like conditions, epilepsies, and a Parkinson’s-like “stiff person” syndrome—and many experts suspect that more exist…

Robert Yolken, a scientist at Johns Hopkins University, estimates that about one-third of schizophrenics show signs of immune activation (though he adds that this could be related to other factors, such as smoking and obesity). And autoimmune diseases are more common among schizophrenics and their immediate families than among the general population, which could hint at a shared genetic vulnerability.”

There are some potent practical take-homes in this article embedded especially within the story of an 11-year-old boy who was admitted to hospital with profound psychiatric features – initially misdiagnosed and managed as BPAD and later found to have autoimmune encephalitis.  First and foremost: psychiatric conditions develop gradually.  When there is an acute onset in the absence of an acute trauma – the possibility of a biological (esp autoimmune) driver should be elevated in your differentials. And the mother of this boy, now aged 21 and having undergone 5 relapses and recoveries in between, virtually echoes the thoughts and findings of Carl Pfeiffer half a century ago, when she says, “Too often, psychosis is seen as the disease itself but psychosis is like a fever, it’s a symptom of a lot of different illnesses.” Important for thought.

Milk Madness – Is it a thing?

Could dairy intake in susceptible individuals be a risk promoter for mental health problems?  In addition to evidence of the exorphin derivatives from certain caseins interacting with our endogenous opiate system discussed in part 1, we now look at the evidence in support of other milk madness mechanisms.  Specifically, the IgG and IgA antibodies about what this tells us about the patient sitting in front of us about their gut generally and about their mental health risks, specifically.  The literature in this area dates back to the 1970s but the findings of more recent and more rigorous research are compelling. Find out more here.

This Brain’s On Fire

I was at the Medicinal Cannabis (MC) in Mental Health Conference run by GHI on the weekend and I have to confess, I inhaled.  Seriously, deeply, inhaled. Just as I had hoped, this was a very high level of information on this important topic, delivered by outstanding presenters: from authorised Australian MC prescribers, to the head American researcher of the largest MC trial to be run in psychiatry – from brilliant pharmacognosists whose every day is spent immersed in complex cannabis chemistry to our very own national (naturopathic) treasure, Justin Sinclair.  I left there with thousands of words typed into my laptop, and about a thousand more in my brain, spilling out onto anyone who stood still long enough. Ahem…thank you my dear tolerant family & friends 😉

Let’s be clear. I am not in a position to prescribe medicinal cannabis.  Nor do I want to, right now.  But like me, patient purchases off the green market in response to DIY diagnosis and prescribing are on the up and up. I have felt concern and apprehension about this but not known enough to engage in any conversation. Now, watch out… I’m finding my words!

I left the conference with a much clearer sense of the patients and presentations for whom it may prove medicinal – most obviously for those conditions outlined in the WHO review including nausea and vomiting in cancer and pain refractory to other analgesics.  In addition to this, we were privileged to hear from a mum and son who have had to employ cannabis for the last half a dozen years following his diagnosis of an inoperable brain tumour, that originally robbed him of his literacy, his joy of reading and his overall quality of life, with high frequency seizures and intractable vomiting etc.  MC has remarkably given much of this back to him.  And I remain optimistic about future potential uses in psychiatry – especially within certain PTSD cohorts thanks to this small but promising study by Greer et al in 2014. Inspired by this paper and her extensive experience treating war veterans with PTSD, Dr. Sue Sisley, who spoke at the conference, executed a similar study of 6000 veterans for a MC inhalation trial.  I’ve got a spoiler for you…the study failed – publication pending.

But before you add 1 + 1 and get 3.879…let me tell you, there is nothing as powerful and revealing as hearing researchers talk firsthand about their trials. When Sue put up actual photos of the medicinal cannabis they were supplied with for this study…the room collectively let out a giant Gasp!

It was brown, full of stem and…wait for it…mould. Yup.  But that is what they, and as Sue poignantly pointed out, & what every other group of American researchers who run studies on MC as opposed to synthetics or extracts, have to use.  So…are any negative outcome a surprise? No.  But it will no doubt be interpreted as a sign that we shouldn’t pursue research in the area of MC and PTSD. We should. Have I completely ditched my concerns about negative mental health impact from cannabis? Absolutely not.  And Professor Michael Lintzeris, the Director of the Drug & Alcohol Services South East Sydney Local Health District; Conjoint Professor, Division of Addiction Medicine etc., spoke eloquently & comprehensively to this inherent duality of this herb in this regard. Even the most isolated and lauded (non-intoxicating) constituent of cannabis can be both help and hindrance to anxiety and depression sufferers and most clearly, Michael warned us not to make MC the opiates and benzodiazepine panacea promises of the past, buying the rhetoric of ‘no tolerance, no dependence, no risk’. How each individual’s mood and mental state responds to MC, whole plant, extracts or isolated constituents, from anxiogenic to anxiolytic and from depressant to antidepressant, has been clearly demonstrated to differ according to genes, ‘endocannabinoid tone’, route of administration and dose.  Seems like all roads lead to an individualised health care approach & prescription…yet again 😉

Need a road map to think your way through the integrative work-up of your Mental Health patients?

In Mastering Mental health: New Assessments & Management Resources in your Clinic, Rachel introduces you to new clinical tools that she has been developing to help us all better master the maze of mental health. With so many possible biological drivers: from methylation to inflammation and from gonads to gut, these tools can help you quickly identify those most relevant to each patient and also outline the strategies necessary for redressing these. This presentation comes with an extensive library of resources including pdf of Assessments Tools and Case Study Notes.

 

 

Thank You (ACNEM), Next!

Integrative Psychiatry is an inspiring area to work in & its evidence base, acceptance and recognition of potency is rapidly growing & offering more patients, more.  Going beyond the ‘neurotransmitter imbalance model’ for each presenting diagnosis helps us to see the unique mix of biological & psychological drivers in each individual who presents seeking our help. However sometimes  I believe, we find ourselves falling into looking through the lens of just another short-list of alternate models: What kind of methylation imbalance does this person have?  What sort of Zn, Cu issues?  

While I am so grateful for having learned these tools and watched them be very successful in a portion of my mental health clients, they are simply not the answer for everyone.  We need to keep our thinking and practices dynamic and up to date, to reflect the incredible increase in research in new areas of integrative psychiatry, such that more of our patients can benefit and that we can continue to think beyond the box…even if that box itself was originally so progressive!

What do you know, for example, about abnormal purine metabolism in mania and using serum urate as a BPAD prognostic marker in depressed patients?  Think you can simply be guided by the reference range provided, think again. What could good old LFTs reveal about our patient’s mental health vulnerabilities and what have we potentially misunderstood about copper in this area, particularly in children?

I appreciate Zinc’s role in mental health as much as the next integrative practitioner. Okay, given my 20K word thesis manifesto, more.  But increasingly I am seeing mental health patients who need treatment with different tools.  This upcoming ACNEM Mental Health Module in Perth is on point: thinking outside of, outside the box!

While the above only speaks to what I’m presenting, I know Dr. Sanjeev Sharma will also be sharing his wealth of individualised management insights and he’s a big fan of addressing Chronic MIld Metabolic Acidosis as an early treatment objective. Maybe we all need to hear why? And I am so looking forward to getting a PTSD update from Christabelle and hear all about the research into therapeutic keto-diets in psychiatry from Cliff Harvey…haven’t read all those papers to know which conditions and when this approach shows merit?  No, most of us haven’t. That’s the point of outsourcing our up-skilling to colleagues who we know are across these more than us and to boot have the clinical experience to ‘make real the research’.  As I’ve said before, given the content of this upcoming ACNEM Mental Health program, I wish I wasn’t presenting really, so I could just kick back and take it all in, uninterrupted.  But alas, I have some important new information on reading basic bloods through a mental health lens to share!  I really hope to see you all there.  Let’s get out of the rut of 3-4 nutritional approaches to mental health and make the most of the explosion of research and shared clinical experience.

ACNEM Face-to-Face Training
Fremantle, 27-28 July 2019 at the Esplanade Hotel Fremantle by Rydges
https://www.acnem.org/events/training

Oh and while you’re here…did you know the research into both beta-casomorphins and IgG casein reactions in relation to certain mental health diagnoses has taken some giant steps forward in the last couple of years?  You should.  Milk Madness is back and it’s via two distinct mechanisms – identifying which might be at play in your patients & correct management is now clearer than before.  Want to get up to date in this area of mental health – check out our UU30 recordings: Milk Madness part 1 & part 2

 

 

 

Look What’s Just Dropped!

a. Some hip new (truly undanceable) track

b. Every herbalist’s jaw at my table at the NHAA conference gala dinner, when I got almost all my Latin binomials right during the trivia quiz?…and after some champagne, that’s a particular achievement 

c. My jaw, when I saw firsthand how much those herbalists could drink of ye-not-so-olde herbal extracts!!

d. The latest Update and Under 30 – Milk Madness Part 2

e. All of the above

If you answered, ‘e’…. you must have been one of those herbalists at my table, otherwise you have way too much insider information!  But yes you are correct on all accounts. So this latest UU30 is an extension of our discussion last month about the potential contribution from to mental health from dairy intake in a subset of patients.  This whole topic, the research for which dates all the way back to the 70s, was too big to fit into one – given the current evidence base that now depicts at least 2 different mechanisms that might be at play, and the different types of mental health problems, each has been linked with.  Last month was all about retracing the ‘dietary exorphin’ path, this month it’s about the propensity for some individuals to make antibodies to casein and the significant growing data that suggest this happens to a larger extent in patients with certain psychiatric diagnoses. More importantly, we talk about the ‘why’.

What compelled me to make time to look through all the literature on this was that there is some. No seriously.  When I initially learned of the GFCF dietary approach to ASD patients I was told that in spite of a lack of supportive research, the empirical clinical evidence was irrefutable, which I later saw with my own eyes.  In the couple of decades since, I only really heard about negative findings, short trials of the elimination diet specifically in ASD kids, that failed to produce significant change.  Funny how the bad stories rise to the top, right?  But when I spent the time doing a thorough literature review, I found these negative findings were far from the whole story.  In fact, I was really surprised by the high level of evidence employed by researchers of late, who have repeatedly found associations between either exorphin or antibody levels and patients with particular diagnoses, in addition to really progressing our understanding of why these measurable differences (urinary exorphins, plasma IgG and to a lesser extent IgA casein antibodies) are meaningful. Do we know everything? What do you think? The answer, of course, is always no.  But we know enough to consider this aspect in our comprehensive workup of mental health patients and all their biological drivers and we know dramatically more than anyone in mainstream medicine, or the dairy industry for that matter, is ever going to let on!

If you want to hear a synthesis of the casein antibody link with mental health then download the latest UU30 – Milk Madness – part 2.   If you can’t go that far, then “do yourself a favour” and read a couple of seriously important articles on this topic – and why not start at the deep end with this study by Severance in 2015.

Update in Under 30: Milk Madness – Is It A Thing? Part 2 

Could dairy intake in susceptible individuals be a risk promoter for mental health problems?  In addition to evidence of the exorphin derivatives from certain caseins interacting with our endogenous opiate system discussed in part 1, we now look at the evidence in support of other milk madness mechanisms.  Specifically, the IgG and,  to a much lesser extent, IgA antibodies about what this tells us about the patient sitting in front of us about their gut generally and about their mental health risks, specifically.  The literature in this area dates back to the 1970s but the findings of more recent and more rigorous research are compelling.

 

 

A Dash of Milk Madness?

So this is not news to most people who know me but I don’t like taking things out of people’s diet. As a result, in a room full of naturopaths & integrative medicos, I might be voted the least likely to use the phrase, “No Gluten or Dairy for you!” [said with the Soup Nazi’s accent from Seinfeld]. I must have slept through that class when we were taught to do this for absolutely every patient.  But seriously, I try not to remove or exclude foods without a very strong rationale and evidence-base that relates directly to the person sitting in front of me, for several reasons: 1) those seeds are powerful ones to plant in your patient’s mind…how do they carry that with them as they move through life, navigating food and social settings etc etc…all well and good if this is a proven life-long pathological provocation for them but otherwise… 2) dietary exclusion is stressful for families & in kids especially, can create disordered eating and a range of other psychological impacts and 3) GFDF diets are not necessarily healthier in the basic nutrition stakes…if you haven’t read Sue Shephard’s work on the deterioration of diet quality in GF patients…you should. It can be much healthier of course…but often the real-world application of the principle doesn’t always match the lovely ‘serving suggestion image’ on all the GFDF highly processed, packaged foods!!

So listen up people, because now I’m talking about when I would seriously consider joining in on the GFDF chant.  

The one patient group I’ve never quibbled over the benefits of GFDF, has been the autistic one.  I was taught the merits of this approach early on by a few fabulous courageous integrative doctors and paediatricians who came back from the front-line of their clinics, reporting good effects.  I then had the important firsthand experience of unprecedented verabilisation in a non-verbal ASD child’ after excluding these foods. But what I’ve been thinking a lot (and reading a lot!) about lately is the possibility that these ‘dietary exorphins’ may have negative mood effects in other subsets of mental health patients. My thought process is like slow TV! That aside, there’s a lot to be said for taking the time to really getting across an issue – even if that involves reading papers from as far back as the 1960s when the idea of a negative role for dietary exorphins in schizophrenics was first floated by Dohan & colleagues.

Let me say, when you go back to the beginning it’s undeniably a shaky start for the exorphin evidence base, but as you read the studies that emerge from decade to decade until the noughties…it reveals a nagging research topic that won’t go away and a fascinating process of discovery.

So is the devil really in the (regular commercial cow’s) milk? Well I think  for some patients it may well be a contributor – most notably those with features consistent with the pattern of excess opiate effects including a higher dopamine picture, regardless of the mental health label they’ve been given, although, more commonly seen in ASD, psychotic presentations etc.  But how do we work out which ones, because none of the evidence points to it affecting 100% of these groups…well that’s where we need to go back and truly understand the structure of these dietary exorphins and just how they potentially wreak havoc in some.

The latest UU30 takes your through the story of BCM-7 with a summary of research compile over half a century in Under 30 minutes!

There is a well-rehearsed chant in the integrative management for ASD individuals, “Gluten free- casein free diets” is based on the dietary exorphin theory which suggests these foods generate bioactive peptides that act unfavourably in the brain.  Where did this theory emerge from and how strong or weak is the evidence upon which this therapeutic intervention stands? Even more interesting, is there support of this theory in a wider range of mental health presentations such as schizophrenia, post-partum psychosis and depression. Is there such a thing as milk madness for a subset of our patients?
Hear all about it by listening to my latest Update in Under 30: Milk Madness – Is it a thing?
For all Update in Under 30 Subscribers, it’s now available in your online account and if you are not a subscriber you can purchase this individually here.

 

No. 1 If You Are a Parent, Get Yourself a Team

Hear Hear…on all levels, right. But this is actually the first recommendation of an easy to read patient resource for families dealing with adolescent depression, that you and your patients can access here.  As lovely as the picture above makes parenting look, the one to one (or even 2 to 1) ratio isn’t realistic or necessarily optimal for anyone. I think we can all make a great addition to any parent’s team, especially given the emphasis these recommendations place on nutrition, sleep and exercise as being central to improving mental health…full-stop..and in this age group.

But while some things are the same between depressed adolescent and adults, there are important differences we need to be aware of: like the best assessment tools and the barriers for teenagers (and parents) in admitting there is an issue.  Think, parent guilt and over-attribution, standing defiantly on the top rung of that ladder!

They also mention different types of therapy for this age-group and I have to say the old CBT…oh yes it gets wheeled out yet again…really does offer something, given the kind of kids I’ve seen this work a treat on.  This is a developmental staged characterised by curiosity and a desire to understand more about the real stuff of life…rather than the soft focus lens we got them to look through in primary school.  I’ve seen teenagers benefit enormously from sitting with a good psychologist or GP who can explain the ‘brain mechanics’ of depression, or anxiety (amygdala activation that sends the frontal lobe executive control offline etc). They love the demystification and, in the best cases, feel re-empowered by this knowledge.  Not perfect for every teenage but it does work for many.  And then there’s the parental advice to discuss suicidal ideation.

Yes parents, even more than practitioners, fear the ‘planting of seeds’ when contemplating this topic with their teens but the opposite is true.  This paper is hot on the heels of an editorial, revealing that 50% of parents were unaware of their teenager’s suicidal thoughts.

There is much to be gained from the ‘knowing’ and so much to lose from avoiding this one. It’s the beginning of another school year (at any level) and with this can bring significant stressors and provocation for mental health challenges.  Let’s encourage every parent, to get themselves a team and take our own place in that invaluable roadside assist crew.

From the UU30 Archives: Investigating Paediatric Behavioural Disorders

This is a succinct recap of the many investigative paths we need to follow when presented with kids or teenagers with behavioural disorders.  From grass roots dietary assessment through to the key pathology testing that is most helpful in clarifying the role & treatment approach of integrative nutrition for each individual child.

Antidepressant Withdrawal is a Worryingly ‘Normal’ (Severely) Abnormal Experience

Finally a systematic review puts paid to the nonsense that ‘withdrawal from antidepressants’ is problematic only for a few, is ‘mild’ & ‘lasts only 1-2 weeks’ with no treatment necessary other than reassurance, which is still being perpetuated by current prescribing guidelines both here and overseas. In fact their review found that 56% of patients experienced problems with stopping antidepressants and the majority of these rated these as ‘severe’.  Back in the good/bad old days when I worked for a  pharmaceutical company who made psych meds the phenomenon of an ‘initiation phase’ during which time suicidal risk was heightened, was acknowledged and freely discussed…in-house at least.  However, the concept of a ‘withdrawal syndrome’ was less clear.  Anyone who has witnessed patients coming off ‘even the cleanest’ SSRIs will speak to a potential myriad of worrisome experiences including…

“Typical AD withdrawal reactions include increased anxiety, flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal. Dizziness, electric shock-like sensations, brain zaps, diarrhoea, headaches, muscle spasms and tremors, agitation, hallucinations, confusion, malaise, sweating and irritability are also reported (Warner, Bobo, Warner, Reid, & Rachal, 2006, Healy, 2012). Although the aforementioned symptoms are the most common physical symptoms, there is also evidence that AD withdrawal can induce mania and hypomania, (Goldstein et al., 1999; Naryan & Haddad, 2011) emotional blunting and an inability to cry, (Holguin-Lew & Bell, 2013) long-term or even permanent sexual dysfunction (Csoka & Shipko, 2006).”

Previously termed ‘discontinuation syndrome’ by expert panels – to distinguish these inconvenient effects from the more seriously viewed (read nasty) benzo-associated discontinuation problems –  was an act of smoke and mirrors, according to this scathing and insightful review by Davies and Read, who argue strongly this is a clear cut withdrawal picture and it deserves as much consideration and concern.  In particular they point out that of course, patients can experience these symptoms even without ‘discontinuation’ – but simply as a result of a delayed or skipped dose, an intentional dose reduction etc. And they provide the alarming context that one third of people in the U.K. (and likely similar developed countries) who take antidepressants for more than two years have no evidence-based clinical indications for continuing to take them. But wait..I’m just getting to the worst bit, this is the part that gets me personally…having been a peddler in the past of these meds and in certain patients still spruiking their benefits, I am in no disagreement about them being necessary, helpful & even life-savers in some patients…yes I have seen this too many times to ignore it…BUT…and now this is where I start raising my voice a tad….

Patients need to make informed choices, and having a clear understanding of what you are likely to experience on any given medication has been shown to improve outcomes but according to the 2 largest surveys conducted to date,< 2% of antidepressant users are being told any of this.  Do you know why?  Well, let’s start with the misleading guidelines… if the RACGP says it isn’t so…then can we expect their GP to know or say any differently?

Grrrrrrrr…. yes that’s me…not a wild animal in the room with you.

Because you know what happens in the absence of this?! And let me say I have also seen this too many times to ignore as well, people feel compelled to stay on them & this is truly heartbreaking to witness. The experience of a reduced dose or a period without is so terrifyingly disconcerting to that poor unsuspecting individual, and without explanation, is misinterpreted by them (and according to this review often by their doctor as well!!) as being either a sign of their inherent mental instability and need for ongoing medication, or misdiagnosed as a separate condition. Ok…apologies, this is over a decade of pent up frustration…resurfacing as a result of reading this incredibly important and disturbing review.  I think I need a little lie down now 🙁

Helping patients off anti-depressants is a challenging and important function that must be initiated by the patient with the full support of the prescribing practitioner, however there’s a role for complementary medicine here too. Rachel walks you through a range of strategies and when you might consider each. Listen to the free sample here from the Update in Under 30 from 2013 – Leaving Anti-depressants Behind. Or perhaps you’re interested in all things Mental Health and should find out more about our specialist mentoring group running in 2019.

 

 

Two Pointers for Addiction Management

Forever fascinated by the neurobiology of various mental health presentations, addiction included, two medical news items caught my attention this week.  If you’ve ever heard me speak on addiction, in somewhat simplistic terms, it is very much about the reward centre of the brain and how strongly all recreational drugs hit on this.  Think rats tapping levers with their feet to continually self-administer cocaine…to the exclusion of all else….kind of magnitude of reward hits.  You may have also heard me quote or misquote (!) someone famous who once said something to the effect of….and I am totally paraphrasing poorly here: if we can’t seek pleasure legitimately, we will seek it illegitimately. 

So this story from ABC news about a Newcastle addiction group support program showing some early signs of greater retention and engagement and therefore potential success with addicts…because they incorporate prizes…well that makes so much sense!

The article is important to read in its entirety as it creates the context – especially for many people suffering from addiction who tell tragic stories of lives where the only rewards/prizes and even gifts they’ve ever known, being drug-related – even from a young age.  So to normalise reward to some extent, and give individuals an experience of constructive legitimate versions of this, is actually desperately needed and ground-breaking. 

How can we incorporate some element of this in our interactions with these patients?

The second ABC news item touts ‘a new generation drug that restores balance to the brain’ but is actually just a teaser about…wait for it…cue stage right…a not so old favourite…N-acetyl cysteine!  Although this is effectively a recruitment drive for methamphetamine addicted individuals into a new 12 week trial of NAC, run by the National Drug Research Institute, taking place in Melbourne, Geelong and Wollongong, it gives NAC a great wrap and rationale for being a good adjunct in addiction, of course. Just a reminder folks that naturopaths belong on that multi-modality health care team for people struggling with addiction, and we do have some potent therapies to contribute. 

A couple of years back I was asked to deliver an educational session to a group of hospital based mental health specialists on the merits of NAC.  My favourite question/comment at the end of my detailed presentation from a very experienced psychiatrist was, “Well if N-acetyl cysteine is so good for mental health…why haven’t I heard about it before now?!”

I hope they follow the ABC news 🙂

Want to Get Up Close to N-acetyl Cysteine in Mental Health? Previous ideas regarding the pathophysiology of mental illness have been profoundly challenged in recent times, particularly in light of the limited success of the pharmaceuticals that ‘should have worked better’ had our hypotheses been correct. Novel drivers such as oxidative stress, inflammation and mitochondrial dysfunction are on everyone’s lips and N-acetyl cysteine is in prime position in this new landscape, to be a novel and effective therapy for mental illness. This presentation brings you up to date with the current NAC research in a large number of mental health conditions & translates this into the clinical context.

What’s Eating Gilbert Now?

 

I’ve had my nose in all the research on Gilbert’s Syndrome again..watch this space…in the interim just thought I’d share this image and a couple of important details I may not have been able to convey when you last heard me talk (very fast!) about this important and common polymorphism:

  1. While the incidence is approximately 10% of Caucasian population, rates are heavily influenced by ethnic background and the highest rates (up to 1/4) are seen in Middle Eastern populations
  2. Gone are the days of thinking this condition only effects bilirubin levels and the enzyme responsible for its clearance – more recent research has shown over 3/4 of patients with Gilbert’s Syndrome have multiple SNPs that compromise clusters of enzymes within the glucuronidation pathway – with varying patterns – this goes a good chunk of the way to explaining the variability we see in bilirubin levels and symptom pictures across patients all deemed to have Gilbert’s Syndrome.  This also explains why figures of reduced glucuronidation activity vary anywhere between 10% less to 90% less! It depends on your cluster..but the average reduction is around 50%
  3. UGT enzymes, the ones affected in Gilbert’s, are also expressed all the way down the GIT and constitute important food and drug handling. These UGTs are most active in the small intestines,as you can see above, but may explain why Gilbert’s patients are ‘more sensitive’ to medications than just paracetamol!
  4. And are you still thinking you need to run an $$$ gene test to confirm your Gilbert’s hunch in a client whose bilirubin sits consistently high normal or high? Think again… here’s a great little diagnostic short-cut that even the Royal College of Pathologists Australasia cites as sufficient evidence to confirm the polymorphism:

In the face of elevated total bilirubin levels and in the absence of liver pathology or increased haemolysis to explain this..”If the diagnosis is uncertain the serum bilirubin fasting level can be measured and should exceed the non-fasting level by  >50%.”

Nice.  So that means you only need to demonstrate that the patient’s fasting total bilirubin levels go up by at least 50% compared with their fed levels and BINGO you have your diagnosis. Much easier.  Oh and this image comes from an interesting paper from Tukey & Strassburg 2001 – but is probably not for the faint-hearted 😉

Stay tuned for more 🙂

Just new to this condition and need a soft place to land with understanding Gilbert’s Syndrome?  This previous UU30 is just the thing! Affectionately called Gilbert’s Girls because in particular it details a set of twins with this condition, this short audio explains the basics about this common polymorphism and why we tend to see a lot of patients who have this…even if no one has pointed it out to them yet!  You could be the first to provide them with this important understanding about how genetics is impacting their detox pathways, changing their sex hormone handling and perhaps setting them up for both mental health issues and some serious upset guts! Better still, what to do once we have that diagnosis.