Well, obviously(!)…this has been a year heavy on pathology interpretation for me and the huge number of practitioners who’ve just spent the last 6 months taking that learning journey with me. I celebrate and congratulate them all for their commitment to their own professional development and also their investment, in what is arguably, the most potent yet overlooked set of skills of any health professional… the ability to read bloods. Basic bloods. Mainstream labs. No…but to really read them. Backed by all the scientific understanding about what these parameters actually are, how they perform and what they (dis)prove e.g. subclinical inflammation and ramped up oxidative stress – not an informed guess but mappable…right there but where no one else can apparently see it! But I digress!
Actually what I wanted to discuss was the whole erroneous notion of ‘normal’.
No, I am not speaking from the heart about my personal quirks, sense of humour or dress sense but rather the incorrect assumption that a reference range defines ‘normal’ and that our answer for each patient and each result is, a Yes or a No!
In this brilliant article by Whyte & Kelly published in the BMJ they spell out this falsehood succinctly. They note that the term ‘normal range’ has slipped into medical language from the misunderstanding that all lab results follow a Gaussian (aka bell shaped curve & later referred to as ‘normal distribution’) pattern but many simply don’t. So for some parameters a result near the ‘middle of the reference interval’ constitutes aspirational whereas for others it spells danger. Add to this, that these reference intervals are mathematically determined to reflect the expected values of 95% of your patient population (mean +/- 2 SD either side) so…that means the chance of a YES…”Your patient’s results are ABNORMAL!”… is just 5%. And hey…who said all the values within the reference range are all equally “normal” or better yet, healthy?! Not these authors, nor I, nor the praccies who’ve just done our course. So while, in many regards, these goalposts are too wide, they are also too narrow – typically only representing a subset of adults age-wise and Caucasians, yes they are both ageist and racist (yep, I said it!). And if our practitioners have learnt anything it’s about keeping an ol’ eagle eye on the sneaky intra-individual shift! Only spotted, of course, if you know your patient’s normal (not theirs compared to anyone else…just theirs) and then spot a shift. [I can hear they’re shushing 🤫me…they’ve got it already, alright!!]
So this is music 🎻to my ears, from Whyte & Kelly: “The intraindividual variation in laboratory values is usually much smaller than the interindividual variability (ie, the variation in the population). Variation in the concentration of an analyte, if significantly outside of a patient’s usual values (but still within the reference interval), could be a sign of early or latent disease”
ps I know your type and know that is EXACTLY the kind of weird nerdy thing you have planned for your break…you should see my summer fun list!!! 😅
MasterCourse 1: Comprehensive Diagnostics is a self-paced online program due for release in December. The course has pver 18 hours of video presentations plus 2 free bonus sessions 1) Accurate Pathology Interpretation Starts Here and 2) Patient Pathology Manager and access to resources and tools within, for your own use. This is a pre-requisite for MasterCourse II that will be delivered live in 2021.
This skillset has been found by many to be biggest ‘game-changer’ in Integrative Health You can view the full course outline here.
I talk so much about iron, I feel like I’m cheating on my life partner (Zinc)…but these two are arguably the main mineral deficiencies we encounter most consistently in our patients and, don’t tell Zn, but quite frankly, in terms of who’s more well recognised out there, Iron throws some serious shade! But the truth is they’re a ‘twofor’, as a result of their similar distribution in food, with both demonstrating significantly better bioavailability (read: virtually double) from flesh foods etc, ‘Watch out, she’s on the attack again!’ I can hear the V’s (vegetarians and vegans) say and yes I think you see this one coming…but I think it’s possible to be pro moderate meat, without being, antiV.
Ethical and environmental aspects aside (just momentarily) it is hard to argue against the nutritional benefits from moderate meat for most patients.
I tried, trust me. Put my own body on the line (and my babies) to be a vegetarian for over a decade. But as the wheels fell off for me, I noticed them falling off for so many others…and these were people who were educated, with a capital ‘E’ and putting serious ‘E for effort’ into substitution etc Not everyone of course – but a LOT of women and occasionally some men. There was no denying their ‘iron hunger’ (high serum transferrin), their movement towards microcytosis (however slight that ‘smallifying’ may be…we don’t wait for anaemia, right?), their poor zinc status and more importantly, the clinical chaos of impaired immunity, some cognitive or mood issues that presented, as a result. I went back to the mineral manual, back to all the science that helps us to understand these minerals especially in a modern dietary context.
Ah yes…meat has become marginalised in our diets compared to those of our yesteryear selves (ABS data) while our consumption of potential mineral inhibitors…you know, all the good, but bad, but good foods, like legumes and grains and green tea and and and…has risen…especially among the kind of clients who come to see us, right?
Which ultimately leads to a lower iron ‘income’ with the same outgoings, again especially for menstruating, pregnant & breastfeeding women.
The books don’t balance. (So then…IV Fe to the Rescue???)
Bite me…it’s just science. There have been some wonderfully thorough studies on this very issue and thoughtful discussions. This study in particular, by Reeves et al, of Australian women in their 20s followed for 6 years to 2009, argues that just a 1mg/d increase in heme iron from flesh foods could reduce susceptibility to the subsequent development of iron deficiency amongst omnivores. So while the median daily intake of fresh red meat in these women was just 39g/d, their analysis found that an additional 70g of lamb or 60g of beef…or about 140g of chicken and 250g of fish if you prefer white over red, appeared to be the positive tipping point for women and their ability to stay iron-replete. Well below ‘dietary guidelines’, nowhere near the scary cancer correlations (which of course may be more about fat or nitrates or ??). Moderate meat intake, right? Just saying. And don’t worry, I know. The only thing worse than an evangelical ex-smoker is a rambunctious reformed vegetarian 😂
Need A Manual on Minerals?
Minerals represent a critical tool in naturopathic nutrition and there has been an explosion of research in this area over the last 10 years. In order to optimise patient care, practitioners need to keep up with the constant stream of information, updating their previous beliefs and understanding in the process. This seminal 7hr seminar (!!)…yes…seriously..it’s THE MANUAL..is designed to facilitate and accelerate this process of review and re-evaluation via a fresh look at the key minerals iodine, selenium, iron, copper, zinc, calcium and magnesium.
When I deliver foundational nutrition training to GPs I talk tough. It’s a tough field, right? Compared with the relative certainty of pharmaceuticals, their established pharmacokinetics, their sophisticated delivery systems to ensure high bioavailability…trying to fix micronutrient deficiencies in patients can feel a lot like you’re trying to perform minor miracles. Take iron for something different, its homeostasis pivots on its tight regulation at the gut wall – and this is a wall that is very tight!! At best you get about 10% of a supplement taken up, at worst you get none and the harder you push & the higher you go with your dose…the lower the fractional uptake. Tough stuff, right?!
It’s about at this point in my talk I read their collective minds and say, “I know, you’re thinking, oral supplementation is for suckers – what about we bypass that road block and use IV?!” [Ok, I definitely use nicer words than this]
And then I put up a list of pros and cons about IV micronutrient repletion: ‘100% bioavailable’ & ‘Bypasses the body’s regulatory systems’, go on both! You see, time & time again we discover, when we think we’re outsmarting the body, it still manages to outsmart us. There are some exceptions to this – some nutrients (Vitamin C) and some contexts (late pregnancy iron deficiency) but the broader promise of ‘rapid replenishment’ for everyone, in your lunch break, via an IV infusion..is not realistic, responsible nor without risk. Don’t get me wrong, I am an advocate of appropriate IV Fe use and have encouraged a small fraction of my patients to take this path. However, given the dramatic rise in prescriptions for this since 2013, I think it’s time to stop and seriously review each element: In reality what does it achieve and in whom is it a responsible recommendation; Was a risk benefit analysis performed for & communicated to each individual & was the remaining risk mitigated?
Think anaphylaxis is the major concern? It might be the most lethal but there are more serious concerns due to higher incidence with newer preparations.
So, how well do you know your different IV iron forms, and their predilection for potential problems? And have your answers ready to all the questions raised above? In order for all involved to make an informed choice (both practitioners and patients), we must.
You’re welcome 😉 and hey welcome back to tough talkin’ Tuesday…
While rates of iron deficiency and related anaemia continue to grow, the increase in prescriptions of IV Fe have expanded exponentially in western countries. What is behind this change in practice regarding how we treat iron deficiency and does it match with responsible prescribing? Do the benefits always outweigh the risks? And while we’re on the topic, who is most likely to benefit and what are all the risks? In light of a current class action in the US, relating to a lesser talked about adverse event associated with IV Fe and recent complaints here in Australia against GPs, allegedly due to inadequate information to enable informed patient consent…it’s time to answer these questions and more. When is IV Fe a means of rescue and when is it a risky repletion strategy with no evidence of advantage?
As a health practitioner, you are always actively building: your reputation, your practice and your knowledge.There’s theoretical …and then there’s applied. Some of the biggest leaps we take forward as practitioners come with being shown how (rather than told) & then being forced to ‘do the work’ ourselves, rather than being exposed to simply more information, be that about pathology, patient prescriptions or practice structure! The slogan ‘Just Do It!’, might have already been nabbed and TMed by a huge corporate beast, but this doesn’t undo the universal truth of it! Prefer your mantras to come from mystical philosophers rather than monster multinationals? How about this then?
I hear and I forget. I see and I remember. I do and I understand. Confucius
This mentoring community that I am a part of, we are about applied learning. We learn by doing. We learn, not just through each individual’s patient encounters but through the collective clinical experience. We make what can otherwise be an isolating experience of constantly, seemingly, reinventing the wheel, if not many wheels (!), into one of collegiality and ‘using the force’. If you haven’t experienced Group Mentoring with me previously and are thinking about next year being your year (see below to find out more about our 2021 offerings), we put together this fun little video here to get across that mentoring isn’t about a conversation between just two people.
So….HoW dO YoU gET FroM HeRE tO tHeRe?
With Group Mentoring you’ll be learning, through the application of core clinical skills, improved patient questioning, methodical information gathering, evidence based answer finding & getting access to resources that you can apply in real-time in your own practice.
“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 Nats 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
We have a range of groups on offer to suit all levels and most types of integrative health modalities. Go to our Group Mentoring page to discover the groups and bonus extras on offer for 2021.
Going by the landslide registrations for 2020, our ongoing excellent retention rate of practitioners from year to year & our already overflowing waitlist for 2021, the reputation of RAN Group Mentoring is highly regarded and a popular choice.
So, if being part of our community excites you and if the thought of learning and applying collective knowledge from expertise outside of our own, now’s the time to put your hat 🎩 in the ring, put your hand up ✋🏼 & join the conversation 📣 through Group Mentoring.
I feel a bit Trumpy…because whenever someone says ‘N-acetyl cysteine’, I want to reply, “Big fan, I’m a big fan”. And yes that’s an uncomfortable awareness. But unlike he who shall not be mentioned, I can qualify my statement and provide supportive evidence, both of the research and real-world varieties. So, of course, can so many of you as well. I know of fertility specialists who place it in PCOS patients’ preconception prescriptions and respiratory specialists who regard it highly in COPD, CF and a range of other conditions. And I am a signed up supporter of its adjunctive use in many psychiatric conditions. Then there’s the biofilm-breaking buffs…
This is where non-believers might be tempted to call ‘Snake-oil!’
How can one very simple tricked-up amino acid possibly contribute to the health of so many systems? Oh, just via the chameleon qualities of its chemistry of course! As a rate limiting ingredient and precursor of GSH, as well as a potent mucolytic agent and and and…we get it. We surrender! But I want us all to back up here just a few steps. As a mucolytic agent…renowned for biofilm busting…hmmm. I prescribe a lot of NAC for a lot of people for a lot of days-weeks-months….because all the research in mental health points to it being a long-term intervention. I’ve heard Professor Michael Berk say, that patients still on it at 2 years had even more improvements than they had experienced at the 6 month mark and of course mental health, for most, is a chronic illness, so no one is surprised.
But we can’t contain its chameleon chemical qualities. Given orally, it will be having effects within the gut of these individuals on the way through…and not all biofilms should be busted, right?!
So what to do? Well thankfully, NAC is not something that patients rely on for short term acute effects, that would then make missing doses problematic – like pharmaceutical psychiatric medications, and some CAM options as well potentially, like SAMe and SJW. So a regular sNAC break is likely to be free from negative impact for those with mental health issues and in fact, beneficial long term. With all this in mind, we’re now using a dosing model of taking weekends off from this supplement – which works for most. Do we have any concrete research to say this makes sense and doesn’t compromise efficacy yet? Well no, and don’t hold your breath, because research can be very reductionistic (you heard it here first LOL) and there is a lack of consideration of the effects on an individual as a whole. The psych researchers are not measuring the impact of all interventions on the microbome of patients (yet!) and the gut researchers not always monitoring the mind. But we clinicians can pioneer the path, fuelled by two old buddies of mine: first do no harm & least medicine, best medicine, right?
Oh and has anyone managed to open a tub of NAC and not accidentally snort some?…I don’t have anything else to add or a solution, I am genuinely asking if this is humanly possible 😂
“There are few complementary medicines that come onto the market with such a bang, opening up genuinely new therapeutic options for the effective management of such a broad range of health complaints. N-acetyl cysteine stands out for this reason and has changed the way I practice” Rachel Arthur
We’ve been talking all about the dangers of excess fuel in our blood recently. You know, just like nature…too much fuel underfoot creates a fire hazard. So too in the bloods of our patients. The key fuels I am referring to, of course, are lipids (triglycerides & cholesterol) and glucose. Our tissues need ready access to both but Balanced Blood Supply & Mastery of Management is key.
In terms of excesses, lipids play the long-game…wreaking havoc over a long period primarily via their vulnerability to form peroxides, which in turn create a chain of oxidative stress and depletes our antioxidant artillery.
In contrast, even outside of insulin dependent diabetes, for the rest of our patients, glucose plays a fast and furious game, being a highly reactive substance capable of causing both glycation and oxidation. We describe even high-normal levels of glucose as something akin to the ‘Bull in the China Shop’, disrupting the function of the endothelial linings and damaging a variety of plasma proteins (not just haemoglobin) that float within them. But do we have a way to routinely measure the level of damage occurring in our non-diabetic but somewhat glucose intolerant patients? Sure! Just check the C-CCTV footage!
The extra C stands for ‘Carb’ and yes we can potentially check the Carb-Closed-Circuit-TV ‘tape’ in every patient.
It’s called HbA1c and measuring this provides us with an opportunity to review their personal ‘tape’ of the last 2-3 months for evidence of excesses.
Helpful, hey. But we actually have so many great tools through regular routine labs at our disposal to understand the glucose disposal or dys-disposal(!) at play in our patients! You’ve just got to know where to look (urate, triglycerides, insulin, HOMA-IR etc) and what each piece of information is telling you. We’ve had SO MUCH FUN with this particular topic in the MasterCourse this month…or is that just me 🙄 No, I know it was, because our live session chatbox was full of ‘blown brain emojis’!! 🤯🤯🤯 I can’t wait to share this course content far and wide at the end of year with those of you that missed out on attending live.
In the meantime if you want to learn more about glycation which is the new inflammation, out there in research-land, you know…the source of all evil including ageing itself(!!) then check this out…
Glycation is a normal physiological process that, just like inflammation and oxidative stress, can get out of hand, contributing to disease processes. Currently there is an explosion of correlational research suggesting relationships between higher levels of Advanced Glycation End-products (AGE) in individuals who have fertility problems, psychiatric conditions, osteoporosis, premature skin ageing, cancer…you name it! New research implicates diet heavily in the determination of individual’s levels of AGE but there is devil in the detail – there are ‘4 Ps’ of dietary AGE contribution that we need to be mindful of when we are giving dietary advice and trying to move patients towards wellness. This Update in Under 30 recording: Are You Feeling Your ‘AGE’ will open the lid on the ‘new black’ in chronic health & ageing.
I think I’m finally able to put my ‘late-90s-Creatine-frontline-trauma’ behind me. Back then, like many good nats in training, I was working the trenches of the health food stores and was faced on a daily basis with two types of men with two types of Creatine questions. The first type was scrawny and would ask, ‘will taking this help me build muscle?’, the second, built like the proverbial brick *&#@ house, asking, ‘will it help me build more muscle?’ Cue, eye roll. Come on… any of you current or ex apothecaries, pharmacy or retail assistants…you know exactly what I’m talking about!!! So deep was this trauma that I put Creatine as a supplement, into the ‘strictly sports folder’ in my brain (the bit in the deep dark back with other rarely accessed items) and never gave it much thought when I left retail and moved exclusively into private practice. Even back when I was a sub-editor for the Braun and Cohen 4th edition, it was apparently still too soon.
A great colleague of mine, Emily Bradley, had written the chapter on Creatine and, in doing so, presented compelling case to reconsider this supplement as offering great therapeutic potential well outside of the sports-field. That one was accidental 😂
I actually remember reading that chapter, especially the sections on Creatine supplementation for neurological & psychiatric conditions and thinking….WOW…who knew?! ??!! Well, clearly Emily for one 🙄 and also every author and researcher whose work she had read…so that made quite a lot of people actually! But another [ahem 😳] several years had to pass before the research into Creatine and the argument that this has been a grossly over-looked CAM option in mental health, beat down my door and finally got my full attention. Better late than never. And boy, do we all have some catching up to do!
Let’s start with 5 fun facts: 1. Creatine is critical for energy – like cellular currency it ‘tops’ back up our funds, after increased spending, everywhere, including the brain 2. The Brain consumes >20% of our resting energy expenditure & is fifth on the organ list in terms of highest concentration of this molecule 3. Creatine CNS depletion is a thing – and it happens in a wide variety of scenarios – from the seemingly benign (like chronic sleep deprivation) to the more sinister (neurodegeneration) 4. This then leads to higher Glutamate, Oxidative Stress & a spell of other sorts of ‘brain badness’ 5. Oral supplementation can cross the BBB and ‘refuel’ the brain and correct the Creatine deficit
Out of the thousand or so pages of research on this topic, I’ve just indulged in, there are several great reviews to pick from…it’s a tough call to make but perhaps this older one by Patricia Allen remains my favourite. This marks the beginning of a new era…I’m putting the trauma behind me & moving on & hope you’ll come along too!
When we recap the contemporary science of shared pathophysiology in mental health, we have: oxidative stress, impaired neurogenesis, monoamine deficits, glutamate excess, hypometabolism & mitochondrial dysfunction. When we ask researchers which of these supplemental Creatine might be able to assist with, we get hits at each and every point. Turns out, Creatine’s capacity for enhancing performance is not limited to athletes but can be capitalised on for anyone vulnerable to a CNS shortfall. Ignored for far too long, this economic and impactful brain nutrient is coming to the fore for psychiatric and neurological disorders.
The latest Update in Under 30 has landed!!!
You can purchase Creatine – The Brain Builder Part 1here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.
Did I mention my mentees ask the meanest (!) & most meaningful questions? Especially those early career practitioners engaged in our New Grads program! And it’s been almost a whole month minute since I’ve talked about iron, so I wanted to share this gem from Katherine Geary:
“Why are so many women seriously low in iron? Periods aren’t a modern invention and it seems a bit of a design fault to have half the population dragging themselves around with iron deficiency anaemia! So why is it so common, even in women who seem to have reasonable dietary intake and low/average menstrual blood loss?”
Well I am so glad you asked! And not because I or anyone has the definitive answer. But there are some excellent voices joining in this conversation about how iron nutriture has seemingly become the collective female Achilles and how, in fact, this might be, as opposed to a ‘design fault’…wait for it…an evolutionary advantage! Particularly hard to believe I bet for those of us ‘dragging ourselves around with iron deficiency anaemia’…to contemplate that this makes you, in fact, some kind of Superhero! But let’s back up there a bit. Firstly, in light of iron being the 4th most common element on earth and concurrently the number one micronutrient globally we struggle to stay replete in…the contradiction is striking. Add to this the fact that while women and children of developing countries experience higher rates of deficiency & IDA, those of us living the ‘good life’ in the top pastures of the developed ones, are still affected at strikingly high rates. Katherine’s right of course, periods are not new…so have the rates of iron deficiency always been so high, or if not, what’s changed?Well, a few things.
As so often seems to be the case 🙄 most of the finger-pointing is at the problem child period: the Agricultural Revolution. This radical shift in diet, away from meat towards cereals, is a clear contributor.
And then came the infections. Both the GIT ones, with bacteria (not naming any names, H.pylori!) parasites & helminths etc getting cosy and cohabiting inside no-longer nomadic humans (stealing even more of our precious iron) and then following on as well, the rise of infectious illnesses, flu, smallpox, malaria, TB, etc. [Ok this is the bit where you can don your cape!] If you have one of the latter, then having one of the former can be really handy! Let’s say this another way. Iron deficiency is considered protective against the infections that can kill.
That’s why we see that characteristic sequestering of iron during any significant inflammation in our patients – ferritin rises because in fact as much iron as possible has been removed from the blood…because our infectious foes are fans of ferrous (not Ferris..😳)
Authors like Denic and colleagues contend therefore that “humans may have ‘failed to adapt’, genetically and culturally, to continuous deficiency of iron because relative iron deficiency was protective against many infectious diseases”. So next time you find yourself cursing the ‘dragging feet deficiency’, perhaps rather than our Stone-Age genes we can blame the blinkin’ Agrarian ones! It’s food for thought. Add to that, other major changes in the lives of women over time, like more time menstruating, both with a tendency to earlier menarche and significantly less cumulative time pregnant over our lifetime but I am sure there are many other theories out there. Have you got one?
Love Getting Answers to the Iron Questions That Bug Us All? Us Too!
Hence, The Iron Package
That’s why we’re often adding new tools and resources to our Iron Package for that very reason! Already, this package provides you with an opportunity to take a significant step up with regard to identifying, lows, highs and everything in between of iron status, and how best to manage deficiencies..our number one bug bear (as per above)! So if you’re not already a proud (iron) package practitioner, maybe there’s no time like….now?
Now find a comfy spot everyone & I’ll tell you a story…’Once upon a time, a long long time ago, we lived our days out in the dark, regarding potential calcium dysregulation!’But ever since serum Calcium has become a standard lab included in most routine screening tests (General Chemistry aka ELFTs) abnormal calcium handling is no longer an ambush for patients of ‘stones, moans and abdominal groans’, as the saying goes in hyperaparthyroidism. A diagnosis historically only mad, when someone presented with this constellation of rather advanced symptoms. But actually being able to identify your patients’ typical blood calcium levels offer us so much more than just a heads-up re parathyroid disease
It may tell us something about their Magnesium status, cardio cautions, be a bit of ‘bone barometer’ and probably most immediately important, flag their suitability for calcium supplementation!
Yep…rather than the current-criminally-crude-calcium-checklist: 1. Patient is female 2. Patient probably doesn’t consume enough calcium 3. Patient may be at risk of osteoporosis (yup…that accounts for practically every woman, right there!)
But seriously, if you just do a full review of the vast literature on this topic, what?! Not enough time?! How about then, just skim read a couple of key papers? Still baulking at that?…maybe just a wafer-thing editorial (??!) will tell you that, consuming elemental amounts of calcium (> 250mg), that are beyond even the biggest Dairy Diva’s Diet Diary, may be deeply problematic for many. And guess what…this doesn’t pertain to supplements alone…even calcium fortified foods are not free from concern! But let’s not let yet throw all our calcium fortified foods in the same bin as the folate ones we did a while ago!! Let’s step out of the dark and into the light that shines upon us, care of fasting serum Calcium measurements, to help us recognise whether Calcium is the cause, the consequence, a cure or a curse for person sitting in front of you 🧐
The Calcium ConspiracyControversy Continued
The Calcium Conspiracy arises primarily from misperceptions about it being ‘the boss of bones’ but becomes more of a controversy when in spite of ongoing advice for broad-scale use we review the evidence and have to acknowledge that the recommendation to supplement post-menopausal women with large doses of Calcium, not only lacks strong evidence but may cause harm to some. In this detailed discussion of the two schools of thought – Rachel finds a position somewhere in between. Reinforcing the need for an individualised approach and personalised risk benefit analysis while teaching you how to undertake this in every client.
The latest Update in Under 30 has landed!!!
You can purchase The Calcium Conspiracy Continued here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.
Trends in mineral supplements are like music genres, you can pick which ‘decade’ they were formulated very quickly. But instead of going by clothes, hairstyles or even the style of accompanying music video, it’s all about the form – the ‘thing’ the mineral is bound to, that gives the game away. While mineral carbonates , sulphates and oxides seem to many of us contemporary clinicians, pre even MTV, amino acid chelates take me back to a time when I was wearing shoulder pads in everything, even my pyjamas. It was called power-dressing and needed to be adhered to 24/7, you see. Then along came fancy forms like orotates, aspartates, hydroxyapatites as we moved confidently into the 90s…well, as confidently as you can, when the Y2K bug may ‘end life as we know it’ come NYE. The dawn of the new millennium saw us embracing picolinates and bis-glycinates in a big way and for the last little while, citrates have really been having their time in the sun. But you know what…here’s a few things you MUST know…
These are trends, not truths
Every mineral has its Mrs Rights and Mrs Wrongs, in terms of chelates and ligands, and these are not the same from one mineral to the next e.g. Zn sulphate is a decent form of available Zn, Mg sulphate, an over-priced laxative
In almost every case, there is simply NO strong consistent body of evidence that one form of a mineral is superior in terms of bioavailability, regardless of what companies tell you..go on I dare you…check their references and then do your own quick literature search away from the cherry picker
Nor is there one mineral form that is above adverse effects in everyone
Brutal. Welcome back to ‘tough talkin’ Tuesday’ 😉 But we have to state these facts because we need effective supplements for our patients and not understanding the different forms that are better (but not ‘best’) compared with those that are inferior (this we do have some evidence of) threatens the integrity and efficacy of an otherwise well thought out prescription. So here’s where you might want to move into a room away from everyone and lock the door…because you’re likely to scream. One of, if not the most commonly used single nutrient supplement almost across the world, is calcium. After almost 30 years of studying supplemental forms side by side, can we conclude which form is best? No. How about ‘better’….hmmmmm yes…maybe…citrates look good going by some markers but not all and vice versa for other commonly seen forms. I can say this, because I have followed the research over the decades, reading the primary papers, like this excellent one by Bristow et al from 2015 that should burst quite a few people’s ‘best!’ bubbles. Have you screamed yet?
I scream. Often.
Because I am frustrated by the lack of research that we need, to be more certain of our preferred forms and then even more frustrated by companies’ claims that the evidence is already in, and guess what, theirs wins!
But it comes back to the same call to action for us – know your nutrients and specifically, where possible, get familiar with the Mrs Right and Wrong for each mineral! Know that the supplemental forms that work for zinc will not necessarily be a good match with iron, that any company that formulates their minerals in the vain of ‘one form for all’, be that glycinates, citrates, picolinates…well they’ve probably got a good fit for some of those minerals and a shocker for others. And as always truly check efficacy with follow up bloods, if you had baseline deficiencies evident in lab tests. I know, that’s not everyone’s model of practice right, or ideal but not always ‘real’, so alternatively, if you are prescribing based on clinical signs of mineral deficiencies that should respond quickly to repletion e.g. white spots on nails in the case of Zn deficiency, then ensure that they do!! If they don’t and your patient is compliant then consider switching form! When I see good practitioners’ prescriptions let down by poor choices of nutrient forms, well, that’s when I need to go into that separate room once more….can you hear me? Ooh that reminds me of something else dated by Mike and the Mechanics: Silent running “Can you hear me?!”😂
Let’s make sense of the over-arching nutrition principles, that will profoundly change your understanding and application of this modality Truly understanding the ‘big’ concepts, so often overlooked, or incorrectly taught, ensures you get the critical ‘small’ detail in your nutritional prescriptions right. In this 4 hour recording, together with key clinical tools, we talk about the tough stuff: dose-response curves, active versus passive stores and excretory pathways and ooh lah lah…the myth of taking ‘activated vitamins’. And yes we even mention Mrs Right/Wrong forms for minerals. Even those who feel satisfied with their original training – will find a lot in this critical review that is new, insightful and truly practise-changing!
Gotta love all the clever inquisitive minds among our integrative health practitioner community. I think each of us, as children may have been that one kid who just never stopped asking questions. What a great quality to have because it prompts us to think outside the box, then outside the triangle, then the hexagon and beyond! Simultaneously, busy minds that never stop questioning and never quiet down can also feel like a curse! None of us have the time to go find the answer independently to every single question that our patient, prescription & pathology encounters raise for us. We need to use the force. Our colleagues, our workmates, our informal and formal practitioner networks, our mentors, our associations, our educators etc.A lot of practitioners recently got some questions answered with the Update in Under 30: Separating the B12 from the B*S#!...and then guess what…they had some more B12 related questions 😂😂
Q: What might a normal or even high serum B12 together with low Active B12 combination flag in a patient?
A: Exclude COCP use, & gross liver pathology, refer for B12 antibodies if possible & review the case for other evidence of functional B12 deficiency, as TCII values are more specific and sensitive than serum
Q: What evidence do we have to use a higher cut-off value than the labs give us for Serum B12 (< 400 pmol/L), as a decision limit for follow-up investigation for B12 deficiency
A: Just the findings of some of the biggest studies on B12 assessment – correlating serum values and markers of functional deficiency such as Harrington et al 2017, Spence et al 2016, which flag that there is already metabolic impairment typically when serum values drop below 400, well before the classic features such as macrocytic anaemia
You’re welcome 🙂 It’s nice to be surrounded by like-minded curious kids (disguised in big people’s bodies!) I love playing my part in adding to the collective knowledge in different ways and for those of you who are our Update in Under 30 subscribers, and of course anyone that purchased this as a single download, well we’ve gone that extra step and put together a nice little pdf: A B 12 Assessment Decision Tree for you and added that in as a bonus to your Separating the B12 from the B*S#! episode. So go take a look now and hopefully that answers just a couple more questions and we can all have at least 1 good night’s sleep… before you come back with more 😉 🧐 😂
B12 is a routinely under-rated and recognised micronutrient, which is in fact in high demand by many of our patients. As nutritional research pushes back against defining adequacy as simply the prevention of the deficiency-associated disease (macrocyctic anaemia, irreversible neurological damage) we enter a new landscape of more individualised approaches where we’re better able to recognise and treat those at risk of falling below ‘optimal’. But how do we accurately identify this and then choose the ‘best’ B12 (methyl- cyano- adenosyl- hyroxo-) supplement? Does it need to be this complex? Time to sort the B12 from the B*S#!!
This recording comes with a bunch of great resources including a clever clinical tool.
And now a new one to boot!!
You can purchase Separating the B12 from the B*S#!here
If you are an Update in Under 30 Subscriber, you will find the new resource in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.
I don’t know about you but I don’t count myself among the conspiracy theorists. While I may have been partial to the occasional one over my lifetime, you have my word, I never inhaled. Or at least not since I learned the practise of scientific enquiry and the application of critical thinking to all evidence. The two together tend to put a dampener on the whole: earth is flat & the moon-landing was a hoax…kind of notions. But there is one conspiracy I think all of us in nutritional medicine have been the victim of: The Calcium Conspiracy.
Not in the vein of speculations regarding excessive lobbying & undue influence of the Dairy Corporation on dietary guidelines. Nor even arguments that this has gone so far as to inflate the RDIs for this nutrient. Nope, I am actually good with the RDIs for this mineral. High level evidence confirms that our intake of Calcium was enormous even before the Agricultural Revolution, and therefore BD (Before Dairy) 😂
Man, those roots and tubers and other bushfoods sure were nutrient dense, not like the stuff we consume these days!
No, the Calcium Conspiracy we’ve all been lead to believe is that it is the boss. The boss of bones. The boss of the parathyroid. The boss of the other minerals. And especially the boss of Magnesium. While you might have heard me describe Calcium as a ‘bully’ in the GIT (let’s call this the slide 😅) and I stand by that, it is far from being the boss of the rest of the playground! In fact its regulation is largely at the hands of other nutrients..not naming any names…[Magnesium😳] So while, all of us trained in nutrition have had the significance of the Calcium-Magnesium relationship & the mantra “2:1, 2:1, 2:1” drilled into us, which we repeat at night to get ourselves to sleep (or did they mean to take not just ‘talk’ these minerals, to help with sleep?!) Our teaching created this conspiracy – a misperception that Calcium is the boss and Magnesium its long-forgotten lackey. Well guess who’s really calling the shots and on whom?!
Have you ever heard the saying, ‘It can take Magnesium to fix a Calcium problem”? I’ve not just heard it but seen it many, many times in my patients.
But how do you tell which patients need both and which ones, just one? It comes down to understanding the exquisitely sophisticated way Magnesium lords it over Calcium – via the parathyroid and Vitamin D metabolism and how we can see this patently in the pathology (regular screening labs) of your clients. I think there is a bias in integrative nutrition – we favour Magnesium – it goes into our supplement recommendations for so many of our patients and while the rationale for this is valid – all dietary surveys show magnesium under-consumption to be rampant in the SAD – I don’t actually think all of us know 1) how much we should be giving (yes there is a limit) 2) how to discern who needs what, in spite of a lack of a good Magnesium assay and 3) the true potency in the prescription when we get these things right or wrong! This study by Sahota et al is so far my favourite for 2020..it’s 14 years old and the sample size is small but its methodology and examination of when Magnesium can fix a Calcium issue and when it can’t, is superb. Together with about 50 other papers I’ve just imbibed…they’ve refined my thinking, tremendously. There’s a Calcium Conspiracy, alright, but just throwing Magnesium at everyone in arbitrary doses is not the solution…. “2:1, 2:1, 2:1…..”😴
There’s a conspiracy going on regarding Calcium but it’s probably not the one you imagine. We have been lead to believe that Calcium is the boss: the boss of the bones, of the other minerals and certainly of its often over-looked lackey, Magnesium. But the truth is, we have it all the wrong way round. There is a sophisticated synergism between these two minerals but the brains and the brawn in this relationship are held by the latter and we need to understand how to recognise when Magnesium is ‘pulling the strings’, to produce low calcium, in our patients and how to find the sweet spot of their synergy. This recording comes with a great resource to use in your clinic, with explicit redefinition of ‘what healthy looks like’.
A 26 year old woman suffering years of fatigue from ‘persistent iron and B12 deficiency’ repetitively treated with both oral and IV, walks into a compounding chemist and finally meets her match 🐱🏍 A naturopath with years of experience working the frontline, used to dispensing iron galore (& to a lesser extent B12) to young women with similar stories. But this naturopath requests to see all her labs, she meticulously collates them and then she comes back to the client and deals the fatal blow: Has the iron or B12 ever made you feel any better? “No,” she replies.
“I didn’t think so,” says the Naturopath…”everyone’s been barking up the wrong tree all these years!” And she was right.
First glance at her blood results has all of us reflexively reaching for the same diagnosis everyone has made before – crikey that serum B12 is terrible! And then there’s the fuzzy family history of relations ‘needing’ B12 injections and some even with confirmed pernicious anaemia. But wait up…let’s keep our critical thinking hats on once you look over the rest of the lab you see there’s no evidence of functional B12 deficiency (no rise in Hcy, MCV even RDW) and then, the statement that seals the deal, ‘B12 injections have never made me feel any better’. This woman is not feeling the pinch of pernicious anaemia, not the crush of cobalamin clinical deficiency. In spite of being told that for almost a decade.
A low serum B12 value can of course flag a deficiency and we must never ignore it. But given the serum measures, in fact, predominantly Transcobalamin I (TCI), which is the carrier or taxi for B12 that almost ‘never drops its passengers off’, we are less concerned than when we see a low active B12 (TCII aka ‘the real deal’)
So what else could leave someone with less TCI, while not in fact creating a genuine functional deficit of B12? SNPs?🤧 Bless you!…Sorry that sounded like a sneeze and this retort, as we know is almost as common as the common cold! Sure…of course it could be sexy SNPs…but wait, what about something a little less ‘zebra’…a little more horse. The COCP…oh blooming heck..she’s spent the last decade on the COCP and guess what, its impact on B12 is thought to be principally a reduction in TCI! Oh and that iron story, that supposed ‘iron hunger’ we can see with her upregulation of transferrin? Well that’s an artefact of the COCP too, right? And BINGO was her name-O 🕵️♀️
B12 is a routinely under-rated and recognised micronutrient, which is in fact in high demand by many of our patients. As nutritional research pushes back against defining adequacy as simply the prevention of the deficiency-associated disease (macrocyctic anaemia, irreversible neurological damage) we enter a new landscape of more individualised approaches where we’re better able to recognise and treat those at risk of falling below ‘optimal’. But how do we accurately identify this and then choose the ‘best’ B12 (methyl- cyano- adenosyl- hyroxo-) supplement? Does it need to be this complex? Time to sort the B12 from the B*S#!! This recording comes with a bunch of great resources including a clever clinical tool.
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
I used to all the time. Especially when I noticed the Niagara-falls-sized gap between the doses I was using compared with my mainstream medico mates. I thought, hang on, for a patient with a baseline blood level of 40nmol/L, they’re recommending <1000 IU per day, but I’m thinking 5000 IU…which one of us is wrong? Then again, we might both be right!
The sexily simple formula as cited byAussie researchersis: for every 1,000 IU of vitamin D a patient takes a day, their blood level is likely to rise approx. 17 nmol/L over 2 months, at which point it plateaus. So the medicos’ 1,000 IU supplement would bring our patient’s blood level up to 57 nmol/L which, as far as the medico might be concerned, is ‘job done’ 👍👏
My dose would be viewed as excessive but clearly I am aiming for a different set of goals (optimal rather than simple prevention of deficiency)…oh and I insist on follow up testing to know when we’ve made it!!
I encourage my patients to get their Vitamin D retested 2 months into treatment to confirm 1) they have responded and 2) their response is loosely within this predicted performance. And how many times is it not? Often. Which got me to readjust the formula I use to something more akin to: for every 10 nmol I want their blood levels to rise, I will need to increase their intake by a 1,000 IU. Now am I just making big sweeping inferences from empirical experiences of a few (hundred) patients without additional backing….well so what if I was...this is a branch of the EBM family tree! But no! I have also actually read enough studies clearly documenting the individualistic response to vitamin D, as a consequence of different adiposity levels, genes, magnesium status etc. to know that, while I am very grateful to have any kind of formula to start my thinking from…I treat individuals and goshdangit#@! they keep insisting on individualised medicine!
The whole practise of identifying a deficiency, ‘treating it’ and yet never following up with repeat labs to confirm that you actually have…BLOWS MY MIND🤯
That’s not EBM, let’s face it. Not even a distant demented cousin who has fallen from the dizzying heights of that family tree.
The one lesson I’ve learned, more than any other over 20 years in nutritional medicine, is that the more questions we ask and the more we challenge ‘established truths’, the more we uncover something much more personalised and potent about each and every nutrient …and now as the days continue to shorten into smaller and smaller slithers of sunlight between ‘bed-ends’, this is probably also a good time to ask ourselves…
Vitamin D deficiency has been associated with a long list of major health conditions: from autoimmunity to mental health & almost everything in between. This has lead to many of us recommending high dose vitamin D supplementation for a large proportion of our patients but do we understand everything we need to to be certain of the merits and safety of this? In this provocative episode Rachel outlines the key unresolved vitamin D dilemmas that should encourage us to exercise caution and outlines how adequate sun exposure is associated with improved health outcomes independent of the production & action of vitamin D.
You can purchase this UU30 episode individually here or become a subscriber and gain access to this and over 65+ episodes plus new monthly releases for 12 months here.
If you are already an Update in Under 30 Subscriber, you will have immediate access to this episode in the ‘active content’ of your online account.
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:
What is this (metabolite, analyte, binding agent, plasma protein etc)?
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?
How have the reference ranges been determined for this lab – who am I comparing my patient to?
Therefore, what is the significance of a result that is: ‘normal’, ‘low normal’, ‘high normal’, below or above the range?
Does this value ‘fit’ with my patient?
What else could explain an unexpected result?
How strong is my level of evidence?
What do I need to do from here to confirm or refute this?
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.
Me neither. I value transparency in all things impacting my health. So when the ‘Colonel’ tells us the magic is in not knowing…I think….hmmmmmmm, no thanks!
Similarly, when the provider of a test tells us, ‘We’d like to give you independent scientific support for our markers and our method but we just can’t because it’s patented!’…well that’s as good as the so-called ‘Colonel’ and his mysterious unidentified herbs and spices, as far as I’m concerned.
It’s effectively like they have created for themselves a ‘Get out of jail free card’ but unlike in Monopoly, they can play it over and over again. Trouble is, as the referring or just ‘reading’ practitioner (many of my patients present with results of these tests in hand) you have to practice either utter blind faith and believe every word that report tells you or you feel like you have to disregard the entire thing because you don’t have the time to sift through every parameter, searching out any independent scientific discussion of their markers, to distinguish fact from fiction. Utterly exasperating. Because of course, a test that offers a huge panel of results may consist of both – some of high value, some utter nonsense and some somewhere in between.
There’s one 24hr urine test from an OS company that I tend to see increasingly and it purports to be able to assess just about everything from gut health, to neurotransmitter levels, to your antioxidant capacity, mitochondrial health and beyond! How is this even possible in one 24 hr non-preserved urine sample that goes off-shore to be analysed? Well they can’t say…it’s a secret. 🤐 Pu-lease!
To boot all the lights and sirens are on for this patient who appears to have such little vitamin C in their urine, they’re at risk of scurvy! That is except for the fact that Vitamin C readily oxidises in urine only to turn into….wait for it….Oxalic acid! So, anyone surprised to hear she is also reported to have an exceptionally high oxalate load?!
Secret herbs and spices? No thanks, I’d prefer science. As the saying goes, “Keep an open mind but not so open your brain falls out!” Sorry but tough-talkin’ Tuesday is back and it’s gotten all toothy!
Update in Under 30: Oxalate Overload – Assessment and Management
Oxalates are present in many healthy foods and in all healthy people, but when ‘normal’ levels are exceeded they can spell trouble in a whole raft of different ways due to their extensive distribution across the body. Some tissues, however, have more problems than others, especially the urinary system and soft tissue and joints but now there are also questions about oxalates’ relationship with thyroid and breast issues. We review the latest evidence about the health consequences, blow the lid on accurate assessment for oxalate excess and talk management in this jam-packed update.
Copper deficiency happens in kids, so does copper toxicity and both are serious concerns, but do we know when to accurately call either? First, we have to know ‘normal’. If we know what normal Serum Copper values look like in children, then we can easily spot those falling below or above this, right? That’s the first hurdle we tend to knock over and break a toe on! Being a mineral whose levels vary widely in soil from country to country, globally, the differences in reference ranges are breathtaking & absurd. Add to that, that copper is a key mineral in kids, driving huge demand for it during key periods of development, so the range for pre-schoolers isn’t the same as the primary or high schoolers – not that your lab is flagging that. Unhelpful? Yes. Dangerous, even? Potentially.
To diagnose ‘Copper Excess’ in a child is a big call to make.
One, because most practitioners are unaware just how much Copper a child really needs at each age & two, high copper is often a messenger for something else going on and then three, the primary objective based on this diagnosis becomes to lower their Copper but we could be either shooting the messenger or missing the mark all together…right?
Copper excess does happen but not nearly as often as practitioners believe it does. And in kids, the fall-out from such misdiagnosis is bigger. And missing a Copper deficiency? (because we’re not as well-trained to recognise it and because Copper has been sadly demonised) Likely to have myriad negative impacts at this vulnerable age…almost none of which generate symptoms or a distinct clinical picture e.g. secondary iron deficiency, low neutrophils without necessarily compromised immunity. But what about the holy grail get-out of jail adjective: ‘relative’. You know, ‘this is at least a Copper excess relative to their Zinc?’
Well, to form this opinion you’re likely calculating the Zn:Cu ratio and applying an ideal adult value of 1:1 but show me the primary evidence that supports this for kids…anywhere? The Zn & Cu relationship shifts as we move through life-stages and in fact Copper is supposed to dominate through a lot of our childhood so…ummmmm…no.
HTMA Copper side-steps all of this?..double no.
I used to make the same mistake re Zn:Cu, I may have even taught you this?!🤦♀️ But as so often happens, a week spent in all the original scientific data and I’ve emerged a changed practitioner! Having been part of perpetuating this problematic premise in the past, I am determined to get the correct message out there to as many practitioners as possible. So help me spread the word on Copper in Kids – by telling others that this mineral is so critical to kids compared with adults, they will often have higher levels than ‘us’ and that until you’ve applied the right age-appropriate reference range and ruled out confounders you can’t possibly make a call on Copper. I mean, we kind of knew this all along, with healthy pregnancy Copper values being exponentially higher being a giant clue. Turns out kids’ ‘Copper Age’ extends way beyond the womb.
Copper, as a kingpin in angiogenesis, brain & bone building & iron regulation is a critical mineral during paediatric development. So much so, the kind of blood levels we see in a primary schooler might cause alarm if we saw them in an adult. So too their Zn:Cu. But higher blood Copper and more Copper than Zinc are not just healthy but perhaps necessary during certain paediatric periods. This recording redefines normal, low and high with a great clinical desktop tool to help you better interpret these labs, as well as reviewing the top causes and consequences of both types of Copper imbalance in kids.
The latest Update in Under 30 has landed. You can purchase January’s episode, Copper in Kids here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
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It’s like that split-second you close the door and realise you’ve locked the car with the keys still inside, or the whole reason you rang someone pops back into your head just after you put the phone down. Yes after the opportunity to draw breath over the break I went, ‘Doh! …I forgot to mention manganese!!’ So some of you may already know I am not a super fan of manganese. Well actually, that’s not accurate, I am perhaps just less of a fan than the people who are formulating a lot of our supplements! A place for everything and everything in its place. While this saying is completely foreign to my office, my house, my domestics and the rest of my life, it is a mantra I abide by with all micronutrients. Having enough of each micronutrient is good, having optimal (if we know what that is, which often we don’t) is wonderful but an excess is bad news.
And as I’ve spoken to before, with our increasing use of multi-nutritional formulas and the frequent inclusion of significant amounts Mn somewhere towards the bottom of those long ingredient lists…we very much run this risk with patients who are taking multiple supplements, at which point Manganese can become a serious meddler.
There’s a short list of patients for whom I am particularly conservative regarding their Manganese exposure and near the top of that list is those with Gilbert’s Syndrome. Do you get my ‘Doh!’ moment now? Because at the end of last year I released the Gilbert’s Syndrome: New Goals & Good News Update in Under 30…only to realise after ‘I’d put the phone down’ that I’d left this important one out of the dos and don’ts of managing these patients. So why am I saying no to chronic routine use of Manganese in those with GS? Well here’s the deal…
That’s why we need to be clear to cap the Mn for these patients as part of being across the cumulative subtotals of all micronutrients. While there is no established Upper Tolerable Limit (UL) set for Mn, adequate intake has been determined as 5mg/d for an adult. I agree, this is probably inadequate for some but I’ve seem individual patient prescriptions with cumulative Mn totals over 20 and 30mg per day! In spite of being generally regarded as having a low acute toxicity profile there is increasing research documenting Mn as a meddler when it comes to thyroid function in particular. So who else is on my watch and wait list for Mn excess? You’ve probably got some ideas…
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’
It’s that time of year when we tend to set our intentions both personally and professionally. For me, between the many meals, pressies and dunks in the river, I slip into some ‘silent work’. In particular, I find myself flagging a couple of key areas that I want to sharpen my knowledge in this year. I’ve already picked mine…have you identified yours?
For many practitioners if there is one topic in nutritional medicine that seems to be more generous than any other it would have to be iron: Iron gives us patients…loads of them! Patients who present with deficiency, with overload, with something in between but still noteworthy, or on iron and that’s causing them all sorts of problems.
But Iron’s generosity doesn’t end there.
It also tends to give a lot of practitioners a bit of a headache!
That’s because a) we were mistakenly taught about iron as if it were just another one of the mineral mob and accordingly allocated grossly inadequate time to do more than scratch the surface of what we need to know and b) what we need to know, thanks to it being the most researched mineral, has undergone a couple of major revelations and revolutions since then anyway! So we can benefit from Iron’s generosity most and leave its other unwanted pressies (the headaches, confusion, frustration & suboptimal management of patients) under the tree – we just need to give iron the real attention it deserves, filling in the gaps in ours and many people’s knowledge about this critical nutrient. And boy, do we (and I mean everyone!! including doctors, midwives, pharmacists…anyone who has ever called iron deficiency on a client!!) need to learn how to correctly read iron studies!!!
Because iron also gives us much needed insight into other micronutrients and just how exquisitely sophisticated their roles & regulation can be. Thanks to it being one of the ‘older minerals’ we know more about it than any other and in turn we have the most advanced assessment methods: Iron studies, a collection of 4 parameters, like 4 chapters in a book or 4 key characters in a play, that need to be viewed separately and then together to understand the whole story.
Yes it’s true the learning doesn’t ever end and as I’ve continued to learn about new iron research I’ve added to our one-stop-iron-resource-shop..the Iron Package. Our very latest edition? A new clinical cheat sheet with some other important numbers on there you want to have at your fingertips whenever you read iron studies. So if you’ve already purchased and have access to the Iron Package…SURPRISE! 🤩 Go back and look again and if not, there’s never been a time like now. Oh iron, you’re sooooo generous!! 😉