A Diagnosis of Inclusion for all Women 35-65?

Any steps towards inclusivity in societal & cultural terms are cause for celebration but in medicine, that can come in the form of a ‘diagnosis of inclusion’, the opposite, of course, of a ‘diagnosis of exclusion’ and potentially as slippery and loose as it sounds.  That’s the somewhat precarious position we find ourselves presently in with perimenopause and menopause. With greater recognition of just how long health effects can kick in before there are any cycle changes [2-12 years for those of you playing along at home] and the widening lens now taking in the diversity of such health effects, women’s health has had a win. But, I would argue, this is not without a double edge.  After all, aren’t we, as a result, more at risk, as women, of having everything attributed to “just ‘the change’, love”, and, in turn, going to be offered sex hormones more often as the solution?
And I am not alone in my thinking on this.

(more…)

Unmasking Hyperparathyroidism: The Dark Side of a Superhero Second Messenger

https://unsplash.com/@actionvance

Let’s play a word association game of minerals & their major roles

I say, ‘Potassium’. Maybe you say, ‘Sodium Potassium Pump’
I say, ‘Magnesium’. You say, ‘Muscles?’
I say, ‘Calcium’. You say, “Bones’….

But I say, Second Messenger. And arguably the most pervasive & potent one, at that.  Remind you about second messengers?  Well, sure. They are the ones who get sh*t done. Not like a boss (i.e. hormone or neurotransmitter) who shout directives from above but never step foot inside the dirty guts of the engine room itself. It’s the second messengers who run these messages from the outside of the cell to the inside and the engine room, to ensure that the directive is actually actioned!  Amazing huh!  And free calcium in the blood is, as I said, really a superhero even among the second messengers – with its regular responsibilities including: Insulin, TSH, Adrenaline, Oxytocin, Serotonin receptor activation etc etc 

Does, it have a dark side?  Well, sure. Don’t most superheroes?

If the available Calcium in blood and the extracellular environment is too high then basically bad sh*t gets done. Including vasoconstriction, clotting, deposition of calcium in the wrong place like arteries and joints and etc etc.  That’s why the amount of Calcium in our blood is the MOST tightly regulated of all electrolytes and, in turn, has the NARROWEST of reference ranges. But will a Serum Calcium level always tell you when there is a problem with Calcium regulation? No.  You’d need to have measured the major regulator itself, Parathyroid Hormone (PTH). Wait, am I seriously trying to tell you, that Serum Calcium alone can look completely normal in spite of really damaging Calcium dysregulation underway – leading to accelerated BMD loss, increased cardiovascular and renal risks etc.? I most certainly am.

So do you know which of your patients’ really need PTH assessment and why 1 dominant group amongst those, is any woman leading up to and following menopause?

No? Well you better pull up a pew and have a listen and a watch then! Yes this latest Update in Under 30 episode even comes with a little video tutorial!🤓🤯

Unmasking Hyperparathyroidism – Menopause & More

Parathyroid hormone is a career criminal.  In addition to buoying dropping blood calcium levels via legitimate means, it illegitimately achieves this by stealing it from our bones. But you wouldn’t know it – because like all career criminals this occurs completely under the radar. Elevated PTH, however, constitutes the most modifiable risk factor for bone mineral density loss & fracture risk and offers the biggest BMD gains secondary to its normalisation. In addition to this, even within range but ‘high-normal’ PTH correlates with a range of other cardiovascular and urinary presentations & if combined with elevated serum calcium can become a multi-systemic presentation  (GIT, Mental health etc) frequently mistaken for other aetiologies. So how can we be alert to this ‘bone thief’? Which of our patients will benefit the most from PTH measurement and monitoring? This recording, resource & video tutorial on how to use a Ca PTH Nomogram answers all!

 

You can purchase Unmasking Hyperparathyroidism – Menopause & More 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 audios and resources here.

Thyroid V Virus – Not New Just Ask Fritz

Ever feel like the universe has been preparing you just for this moment?  Me neither really…but in this one weird way – yes!
So hear me out. 

Thyroid disease as a result of a viral infection was first described in 1902 by Dr Fritz De Quervain and of course he and his ego called it De Quervain’s subacute thyroiditis. For some historical context, this predates the recognised role of iodine deficiency in thyroid disease! Skip ahead almost a century to deep in the 1990s and mini-me was sitting in a uni lecture room [front row & wearing fluro of course🤣] and over hundreds of hours (no scrap that zillions*^# of hours) of lecture content I was exposed to, the description of De Quervain’s Subacute Thyroiditis stood out and stayed stuck to me.  I’ve brought it out for a twirl from time to time in the interim with some of my patients & in particular in correspondence with their docs. Skip ahead to the 2020s when we had this thing called. ‘a global pandemic’, and now everyone wants to talk viruses and their broader health implications & as a result, good ol’ Fritz, me and our buddy, De Quervain’s subacute thyroiditis, are all having a moment.

But just to recap – this is (clearly) not new.

What is new is the way this ‘virus of the moment’ has brought this Thyroid V Virus battle to the forefront.  We are living an important chapter in history where all the textbook entries on De Quervain’s Subacute Thyroiditis are madly being rewritten to reflect the veracity of this viral attack on the gland and the wide-scale & varied damage that ensues over the months and years that follow.  And so many of our patients are the walking embodiment of it – whether that be in the form of low or high thyroid hormones, nefarious changes to gland anatomy only evidenced on US. So what do we need to know? in short, that pathogens as goitrogens have never been more of an issue than right now for ourselves and our patients. And that compared with just our usual desire for comprehensive investigation of the HPT, taking a complete look ‘under the hood’, not only by way of a full TFT and Ab titres but also, wherever there is an additional suspicion – by way of a thyroid US – has become non-negotiable.  But regardless of what you find there, once you look, do you know what to do next?

ThyVIRoid

Biopsies and autopsies of diseased thyroid glands alike reveal the prevalence of many common viruses within, setting the scene perfectly for the Thyroid V Virus battle. So, what happens when a virus takes a specific liking to this gland? While there are several different possibilities, one brought to the forefront in recent years is viral thyroiditis wherein stage 1 is ‘spill’, stage 2 constitutes a gland that is now ’empty’ and while stage 3 is reported to be ‘recovery’, this is increasingly scarce – replaced with chronic or recurrent thyroiditis, relapses of previously remitted GD and a doubling of new AITD diagnoses – not to mention the wide variety of unfavourable anatomical changes being found on ultrasound. Comes with a great desktop reference with prescription examples.
You can purchase ThyVIRoid 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 audios and resources here.

Individualising Adiposity

The debasing of BMI as a stand-alone assessment of weight is long overdue given its significant limitations and lack of meaningfulness with respect to overall health. This coincides with a bigger societal and cultural shift towards inclusivity which involves redressing bias against people with diverse body sizes and compositions.

And how do we, as integrative health professionals, continue to uphold our principles of prevention and treating the cause when excess adiposity may be a very real contributor? While ensuring we ‘see’ and treat each individual in front of us, not our assumptions about adiposity, not our body size bias nor blind spots?

One part of the answer: read and be led by their lab results – because pathology is nothing if not personalised. (more…)

More Histamine Intolerance? Really?! 🤐

I can barely bring myself to write the word given how overused it has been of late 🤐🙄😯😕🙃 But I gotta say something!  If we have found ourselves currently in a place where every second (or indeed single!) patient has a ‘histamine issue’ then I am afraid that it is we, that have an issue.  (more…)

Another Iron Question For Us All

What level of Serum Ferritin represents ’empty’?  As in complete depletion of iron stores?

Is it any value below the minimum of the reference range? e.g. < 30 mcg/L
Or does the bottom of the reference range allow for a buffer and ’empty’ is substantially lower than this?
Could patients actually be ’empty’ but still have Serum Ferritin values within the normal range?
Could the same Serum Ferritin value occur in one patient on ’empty’ but with adequate stores in another?

(more…)

Everyday Q&As – More Postnatal Iodine (Not) Fun

Rachel: And sometimes emails from practitioners provide me with both the question and their own answer to their question even!
Cameron Barker’s (Ex-student long-term learner & mentee) email arrives titled: Unexpected Source of Iodine in Placenta Caps?!
A 32 yo female with a 12-week-old daughter came to me as she was not feeling well, in particular, she reports fatigue, racing heartbeat, anxiety and loss of appetite. Previously, 2 years ago, I had helped her with her Hashimoto’s. I did not hear from her for a year or so and she fell pregnant and was recommended to take a well-known iodine-containing pregnancy multi.

(more…)

Ever Met A Set Of Thyroid Results You Didn’t Like?

Ever met a set of thyroid results you didn’t like? Because you couldn’t work them out?  Because they defied your expectations, & therefore your understanding, of how they should look in this patient given their weight, nutrition, meds, diagnoses? Yeah – me too.

In simple terms this is because we are taught ‘perfect patterns’ in thyroid interpretation:
* Iodine deficiency produces HN (high-normal) TSH and a shift towards T3
*Inflammation produces low TSH and T3 with a shift towards rT3
*Viral attack of the thyroid itself causes HN levels of both T4 & T3 due to spillage of preformed hormones, & secondary suppression of TSH

So can I ask: What about the patient who has a virus that is causing significant inflammation, attacking the gland directly but has a pre-existing Iodine deficiency?
Seriously.  What would you expect to see as the HPT responds to all of these concurrent disruptors?
(more…)

An Obese Individual Walks Into Your Clinic

This is not about body shaming nor body positivity.  I understand the crudeness of the body mass index, as a measure of (un)healthy weight – let alone (un)healthy muscle mass, so I don’t use this as a stand-alone assessment of weight, nor rigidly adhere to the categories it allocates individuals.  With only minor recognised racial adjustments for BMI, I also recognise our concept of ‘healthy weight’ is incredibly whitewashed with minimal regard and consideration for clear ethnic and racial differences in physique. Patient’s lab results tell the real story.  It’s in their results that we can discover someone is thin-on-the-outside-fat-on-the-inside (TOFI) or FOTI. These are patients whose BMI, WC,WHR, Body fat% etc identify them as obese – yet there is not a whisper of what I call ‘Adiposity Patterns’:  no subclinical inflammation, no reduced glucose tolerance or actual IR, no raised transaminases that we expect to correlate with girth and the corresponding fatty infiltration of their liver.  In this, as in so many other aspects of clinical practice, we are reminded to see each individual, individually.

AND if we adhered to this always, listening unfiltered to the whole health story and letting the labs speak, we would not miss those patients in whom unhealthy weight really is the most important underpinning, & all impacting, issue.
And we are not doing our job, when we don’t.

I mean – we all know the detrimental effects of excessive adiposity – that’s like Pathology Unit 1 topic 1, right? I know we know it. Yet there are so many reasons why we might down-play, step-around, or even ignore its enormous contribution in our patient work-up and certainly the discussion that follows with our patients.  That too is a no-brainer. Who wants to say to someone whose come seeking your help, as an explanation for their complex health concerns,  ‘There’s no zebras here just a horse – one really over-weight horse!’ Knowing too that unhealthy weight results from the most complex constellation of factors (biopsychosocial) unique to each individual and that change in this health determinant, is arguably the slowest and hardest to sustain.  But how are we serving our patients if we don’t?.

A practitioner presented this case of a 48yo F seeking help with the work-up:
Self-reported inability to lose weight after 1st pregnancy = ‘obesity’ ongoing – now BMI 33.1
–> 25yo Reflux & Hiatus hernia Tx Omeprazole initiated – ongoing
–> 26yo Depression Tx Venlafaxine initiated – ongoing
–> 30s Back and other musculoskeletal injuries Tx Surgery & Opiates – ongoing
–> 40s Hypertension & elevated resting HR
–> Last 12mo – changes in Mx cycles suggestive of perimenopause & substantial weight gain

This patient didn’t ‘have’ any lab results but I think I can make an educated guess about how they would look and in particular whether they show the characteristic ‘adiposity patterns’ I mentioned before.  What was my first thought about the most impactful element of the case? Obesity.  What was my second thought? Where is all the weight (diet & intervention) history that would help us to understand how she is where she is, right now? We didn’t have any.  The practitioner informed me that the patient was ‘not very interested in talking about her weight’ –  in fact, according to her, it didn’t seem like losing weight was one of her goals.  Now this could be several things: the fear of judgement, even her own self-loathing, the paralysing awareness of the enormity of such a goal, the dashed hopes of the past, or it could just be that her weight, as the key negative determinant of the majority of her health concerns & quality of life, has just never been brought to her attention, nor the connections explained to her in simple accessible language.  So over to us, right?

There were other health determinants at play in this patient but the centrality of the adiposity was undeniable & the practitioner said this was the greatest take-home.  She’d been ready to don some jungle gear and go hunting some zebras – but there was a horse right here in front of her and that could not and should not, ever be ignored.

What else became apparent was the lack of knowledge & skills regarding how to take a comprehensive weight history & why this is crucial. Not only for this type of unhealthy weight, the underweight require exquisite attention, as do those with a more labile weight than expected as an adult. This brilliant article by Kushner et al from 2020 is a total gift in that regard and a must-read for every clinician.  We feel uncomfortable asking about certain things when a) a patient feels uncomfortable which is usually because b) we are uncomfortable and this ultimately comes from not being clear about WHY this information is so important and HOW this will ultimately enable us to better help THEM.

Take a read and let me know your thoughts

Advanced Thyroid Assessment + Adrenal Bonus (10hrs)

This is the very latest, comprehensive review of the key aspects of thyroid assessment that will revolutionise your understanding of thyroid markers.  Gain a clear understanding of how to provide the best, most individualised, thyroid management by learning to read the real story in each patient’s pathology patterns.  Boost your knowledge and confidence looking at TFTs, rT3, thyroid antibodies & related nutrient patterns, as well as AITD, environmental EDCs, HPA driven HPT issues, thyroid nodules, the impact of dietary macro- & micro-nutrient imbalances and much more!

This 4 part series provides over 10 hours of the very latest research & findings, punctuated with real case studies, that will both contemporise and deepen your understanding of all things thyroid, with a bonus recording on Adrenal Assessment.

 

 

 

The Fig Fix for Potassium Goals?

My lord I can go on, I know.

And for weeks now I’ve really been banging 🥁🥁
The 1st drum was me making us all salivate & suffer through my month-long Mediterranean feast
The 2nd, my ongoing incurable fixation on the ‘Power of the Ps’ – Protein & Potassium, not just individually, in terms of meeting optimal requirements for each, but relationally,  as in, the (im)balance between them & the clear goals that have come from research for best health outcomes.

Maybe now you can hear the individual drumbeats merging to form some sort of chorus rather than a cacophony?! I can🎶 And largely that’s because I decided to put the Ps & Ps principles (Total Protein:Potassium < 1; Animal Protein:Potassium <0.6 etc) into practice, entering my own meals into software to see how often I kicked each goal and how often I missed (& [ouch] kicked myself).  Personally, I think thirty years in the game can lead to some laziness around looking in depth at our own dietary habits.  As in, I know the ‘rules’ right, back to front, so I’ve told the ref to have the rest of the season off! My meals are both mantra and memory foam.  There’s a lot of eat and repeat.  Like my heavy lunchtime reliance on my ‘protein power pack’: 2 XL soft boiled eggs on 1 piece of  avocado paleo toast and a bunch of asparagus. My (in)famous buckwheat breakfasts loaded with nuts, yoghurt & fruit.  My bulk-cooked plant protein heavy, animal protein light, stews, sauces and soups. Even, what I considered my laziest but luscious organic farmers market meal, pan fried lamb rump steak, steamed fresh new season potatoes & a bunch of asparagus. So which of these would you have put your money on for the most Ps& Ps goals kicked? 🤓🤯

 

The Lazy Luscious Steak & Veg Meal Wins with…
Total Protein : Potassium of 0.56!
Animal Protein : Potassium of 0.41
Btw that’s because of the Potassium-punch of Potatoes [>2200mg!] and the finale of Figs & dark chocolate [329mg]!
Animal Protein : Vegetable Protein of 2 : 1 (ok so you can’t win everything!)

 

Now obviously I am just looking at each meal individually, but the Protein & Potassium goals are really daily ones, however, I, like most people, don’t lay out the totality of my ideal food intake for the day and then think, now how do I make this all edible?!  I think in meals not metadata! So this little exercise was already incredibly rich in insights, checking my assumptions and snapping me out of some misguided mental calculations into the real world, placing a ref back on the pitch! I’m not ditching any of these favourites – just more mindful of what meal goes with others across the day, for better balance. Now all this analysis is time-consuming of course and while various software will do the macro and micro crunch, as far as I know, you still need to do all the Protein and Potassium calculations by hand, Ah yup.  So, 1) I’m stopping now & 2) I’m thinking about creating a little spreadsheet that auto-calculates a lot of these targets once you’ve obtained that basic elemental data to input, for easier use in the future – would you use it?? [insert answer here 🙋‍♂️]

And then you can show me your kick arse protein/potassium combo!
Because clearly even us ‘experts’ apparently need data to double-check our assumptions!

Now where’s the other 🥁 in all this, that Mediterranean one, I hear you ask? It’s in the figs!  My lamb dinner actually just missed reaching the targets for protein and potassium balance…until my fig finale! And remember, what the Greeks say, ‘A  few figs a day keep the chronic-mild-metabolic-acidosis at bay!’ 😂 Just jokes…

The Protein & Potassium Riddle of Ageing – Muscles and Bones

To prevent or minimise our slow but steady march towards sarcopenia, the need for dietary protein adequacy to fuel muscle maintenance is a no-brainer – but how does ageing affect this?  We get less bang for our buck. We have to eat more, to get the same ‘amount’ but do you know why this is?  Add to this, that also as we age, we experience a greater acid burden from a lower acid dietary load. And given that a higher acid load (PRAL), has been shown to have a negative effect on muscle and bone markers in the past, clearly to ensure optimal health of our bones and muscles as we age, we have a riddle, or two, we need to solve. How do we use Protein and Potassium intakes to benchmark our patient’s diet quality and musculoskeletal risks and can we modify their consumption of either, to drive therapeutic gains in terms of both BMD and muscle?

 

 

You can purchase The Protein & Potassium Riddle of Ageing – Muscles and Bones 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.

Suboptimal Thyroid Function? Could It Be Their Psych Meds?

Gone are the days, thankfully, when we could all easily identify any individual taking an antipsychotic 1) because they were the marginalised ‘mad’ and 2) stigma and shame were rife. With the seismic shift that has occurred both in psychiatry & society we now know so many of the people we live or work with just might be taking ‘something’ & under any number of diagnostic labels. And increasingly the ‘anti-psychotics’ are not reserved for the psychotic nor the ‘mood stabilisers’ for the manic.  Which can complicate things – especially when it comes to their thyroid.

You see it’s a mistake to think that only Lithium spells trouble for thyroid function

The latest piece of evidence from a study of over 25K BPAD patients in the US tells us this common misunderstanding makes us prone to not recognise all the other patients in whom their psych meds are disrupting and in fact driving thyroid (dys)function.  Though Lithium carbonate remains the most noxious goitrogen due to its multiple disruptive mechanisms – the rest of a large group of Psych meds (yes even antidepressants!) are impacting to the point of effecting the thyroid function test results you are likely to see in patients taking these.  And this is something we need to be alert to – these medications are essential, non-negotiable in most scenarios, but a secondary hypothyroidism is not their intended goal and can make matters worse.

Cue our growing understand of psychoneuroendocrinology, of course.
Your HPT is influenced by your mood & vice versa
I told you I’ve rekindled my love and passion for thyroid pathology and this is one of the many elements I got to include in our latest updated training * Advanced Thyroid Assessment* and the upcoming MasterCourse. But I just had to hit record on this one aspect immediately – because if we don’t recognise the cause we are likely to be throwing all the wrong things at the thyroid – to no avail.  This kind of subclinical or overt hypothyroidism is not due to nutrition per se, or due to some other kind of HPT re-setting influence like inflammation…it’s the meds & that necessitates different solutions & a much bigger conversation…so join me…
Many of us recognise the bidirectionality between thyroid function and psychiatry wherein ‘stress’ and mental illness can produce a predictable pattern and shift in TFTs and vice versa but regarding the question of psych meds as potential goitrogens, many of us are mistaken in thinking this issue begins and ends with the use of Lithium carbonate.  As it turns out, an increasing number of these pharmaceuticals are recognised to disrupt thyroid health & activity via a variety of mechanisms both centrally and peripherally & as a result many patients may get stuck in a vicious loop of worsening thyroid function and mental wellbeing. – until someone calls it – someone like us.
You can purchase Psych Meds & Sick Thyroidshere.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.

The 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 – so too a child at any weight.

And we expect a higher value as well in our elderly clients too and this level there may be, in fact, increased mortality.

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

Realising the full value of any test result in terms of what it reveals about the person sitting in front of you, requires these more thinking and more thoughtfulness. Unfortunately,  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 concede, much of my 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..this next MasterCourse series is focused on revolutionising your understanding of thyroid, adrenal, HPT & HPA markers based on the very latest research & findings & marry these together with everything you learned in MasterCourse I (ELFTs, FBE, Lipids & Glucose) to understand the ‘whole story’.

…an absolute treasure trove of free integrative health information about your patient!

DEEP DIVE INTO REAL CASE STUDIES TO DEMONSTRATE EACH PATHOLOGY PATTERN IN ACTION. ]\

There are limited places. To sign up for Rachel’s LIVE Series – MasterCourse II: Thyroid & Adrenal Diagnostics
and for more information click here.

MasterCourse II

13 years ago I was first asked to contribute to ACNEM’s thyroid training 
8 years ago I put together a little Masterclass on Diagnostics & 6 years ago co-created another one on Thyroid
2 years ago I dived deep into new literature to update my ideas & my teaching for ACNEM again & reinspired by all I had discovered
1 year ago I promised a new MasterCourse, for all those eagerly awaiting the next instalment: Thyroid & Adrenals
Now it is about to land!

Across this time I have fallen in and out of love with this topic. ‘In’, in the early heady days of learning some great tricks and tools, ratios and relationships between thyroid parameters (T4:T3, rT3:T3 etc) to aid interpretation but then ‘out’, when I discovered in my own patients and many others, that while this solved some thyroid patient puzzles, it left the curlier ones with questions remaining. I became unsatisfied with the simplistic stereotyping of the thyroid hormones (T3 important & always good, T4 not, rT3 never) and frustrated by the misapplication of ratios & lazy labelling of the thyroid as the ‘problem’. All of these things I intrinsically knew didn’t make good scientific sense and actually revealed a lack of depth in mine & our understanding. So I re-immersed myself in the very latest research and, wouldn’t you know it, in the time between there’s been a  mini-revolution taking place in relation to our understanding of the HPT axis and the other endocrine circuits that manage it! Thank goodness for science!!

As a result, not a slide, possibly barely a dot-point remains from what I wrote back in 2009 and not a great deal more from 2015 even.
That’s how far the research has revolutionised my ideas & understanding.

Some of the assay techniques & technologies are new, there’s a river of research  & a mountain of meta-analyses published in the time between & I have had the privilege of innumerable more clinical encounters in this space, to really nut out how all this translates into the real world.  And most importantly I can confidently say that this training and teaching reflects the truly integrative nature of psychoneuroimmunoendocrinology…did I just make up a word?! Basically, if you think that the hypothalamus and/or pituitary is the boss of the thyroid – we need to talk! There’s a lot I need to catch you up on.

So like our first MasterCourse in Comprehensive Diagnostics earned us a reputation for, we are going to leave no stone unturned – no difficult question – unanswered, like…

  • Can you list the critical roles in health of T4 that are independent of its precursor potential?
  • How about rT3 – what are the important health implications for us if we don’t have enough?
  • When shouldn’t the T4:T3 in the plasma be approximately 3:1?
  • When and why would a drop in TPO & Tg antibodies signal progression not remission of AITD?
  • In the absence of imaging, can you still be confident that thyroid nodules are the most likely differential in your patient?
  • What is the one test result that differentiates between Euthyroid Sick Syndrome and Central Hypothyroidism?
  • Exactly how low in Selenium, Iron or Zinc do you need to have a measurable impact on thyroid hormones and function?
  • Who escapes from the Wolff-Chaikoff effect and how long after iodine dosing can we be certain?

 

So stay tuned… and watch this space! We thank you for your patience and know it will be worth the wait…

“Absolutely loved this course, I’ve listened to each of the recordings at least 3 times now taking furious notes and am still picking up new gems. Love that it’s helping me build up my knowledge and confidence in such a fundamental area of practice. The case studies are super valuable as they bring the labs to life, I’d be keen for more of these!  Really appreciate all the extra PDFs / audios that have been added also. Eagerly awaiting MasterCourse II” – Naturopath | Australia

“Why wasn’t this content covered in medical school? As a psychiatrist,  I have greatly benefited from attending this course which comprehensively covers the ins and outs of interpretation of pathology labs and how this applies to clinical cases – many of which have both physical and mental health considerations.  I believe all doctors from general practitioners to specialists will gain from attending! ” – Psychiatrist | Australia

“Thank you so much for this course, it has been brilliant. It has ‘fuelled my practice’ and many people have benefited already – from such insights. It’s quite thrilling!!! I’ll definitely be signing up for the second course later next year” – Naturopath, Medical Herbalist | New Zealand

 

 

*NEW* Advanced Thyroid Training Coming Soon!

Overflowing Coffee

I’ve spent the best part of about 4 months recording my *NEW* Advanced Thyroid Assessment training. I told my team this would be easy and quick, given it was to be based on a great little 2-part, 2hr updated presentation I delivered just last year for ACNEM!!  Sixteen weeks (like seriously…most of it) numerous rewrites and retakes later, our final product is 4 parts that goes for over 12hrs in total & has a bonus Adrenal recording! And yeah my team are impressed but unimpressed too if you know what I mean?!🙄🤪

Every time another, ‘Oh wow!’, or ‘No way!’, escaped my lips, it was a source of personal celebration, as another deeper layer of learning revealed itself.

But to the wonderful, somewhat weary and definitely wary Sally, who does all my powerpoints, it was met with, ‘Oh boy!’, because it meant many multiple new slides to build full of visual metaphors, animation acrobatics, if not an entire new Part!*#@^

Her sage advice along the infinite research road I’ve been travelling was : ‘Stop. You’re going to have to stop.’ 

So I did but now I am this meme. Everything I see currently through the lens of thyroid health, I talk in tongues TFTs and my brain is one giant neural network of integrative endocrinological circuits! I have fallen in love with this topic, this neuroendocrine axis and its ‘first responder’ role all over again!  Hence our little thyroid character below – all ‘antennaed’ up – is one of the many tools we’ve developed for this training, to teach us that ‘bad thyroids’ per se are extremely rare – but bad scenarios are common (too much or too little of any macronutrient, key micronutrients, a change in the internal or external environment etc etc) and this little fellow and his board of directors (no – not the hypothalamus or pituitary!) – well it’s their job to ‘read the room’, right?!

In the absence of this key understanding we risk:
A lot of lazy labelling in thyroid health – ‘You have a bad thyroid – that’s why you…[can’t lose weight, feel tired, have SIBO etc]’
Misdirected treatment & especially a tendency to overload the butterfly with ‘thyroid’ nutrients – which can do more harm than good

I’ve said many times, ‘perfect number pathology is a myth’ but it runs rife in practitioners’ beliefs about TFT results with complete disregard of the person those labs belong too! Did you know, for example, that your TFTs should all be higher if your BMI is? That your T4:T3 ratio should never be 3:1 if you are on replacement, have hot nodules, are pregnant or are acutely unwell etc etc etc? How about how low your Selenium or Iron levels need to be before this factor will influence the actual levels of thyroid hormones measurable – & what the impact of these deficiencies are well before then that is far more sinister and serious?  Yep…you see here I am, pouring just some of the tiny take-homes of Advanced Thyroid Assessment ALL over you! 

Watch this space my new Thyroid training is just around the corner!

 

Are You Running Hot & Cold on Thyroid Nodules?

An increasing number of our patients have thyroid concerns but unbeknown to many of us the most likely explanation of all is thyroid nodules, whose incidence is on the rise globally. The development of nodules has always been primarily viewed as a nutritional disease. Traditionally attributed to chronic iodine deficiency but recently novel nutritional causes have emerged. Benign nodules come in 2 flavours: hot and cold and while patients can present with a mixture, it is the presence or absence of a hot nodule that radically changes what complementary medicines you can and can’t use and what an effective treatment plan looks like. The pointers, as is often the case, are there for us in the patient’s presentation and pathology, so knowing the difference is no longer a guessing game. This UU30 comes with a great visual clinical resource and includes key papers on the nutritional management of nodules.

Keeping Things Real & Representative

 

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

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

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

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

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

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

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

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

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

 

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

The GREAT Cortisol Capture! 35K Aussies Get Tested

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

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

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

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

Cortisol – Have you been caught out?

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

 

More FODMAP Fails

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

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

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

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

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

 

When is IBS BAD?

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

You can purchase When is I.B.S. B.A.D? 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.

Last Words for 2021

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

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

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

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

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

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

Urinary Iodine Curveball Corrected!

Example 1:

Example  2:

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

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

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

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

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

RAN Patient Pathology Manager

Increasingly our patients are coming armed with lab results and this cumulative data helps us to clearly see their ‘norms’ (as opposed to textbook ones) and therefore be alert to any changes. However, results from different labs at different times, and even the same lab, are unlikely to be presented side by side for easy comparison.  They certainly don’t come with all the important information about what was happening for that patient at each time point – important details pertaining to the blood collection itself (fasting, inflamed etc) which can profoundly alter results or the broader context: menstruating, breastfeeding, losing weight, on meds and supplements.

The Patient Pathology Manager retains all the results for you, including the critical contextual elements, helping you to keep more accurate records to make the most correct interpretation. It also assists you to monitor changes related to various interventions.

Previously, the RAN Patient Pathology Manager has only ever been available to clinicians who participate in Group Mentoring but due to frequent requests for access, we thought it was time to share this great tool for those wanting a foot up with some better systems in their practice. 
This provides you with a template that can be used an infinite number of times plus a short training tutorial.

Functional Medicine Falsehoods ⛔️

Functional Medicine Falsehood

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

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

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

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

[Rant over🎤💧]

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

Mastering Micronutrients

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