Do you know that saying, ‘mind your Ps and Qs?’ It basically means mind your manners and I heard that a lot as a kid 😉 But what we really need to hear now, as practitioners and promoters of healthy eating and wellness is really, Mind your P’s and P’s because a lot of biggest health consequences of any diet are determined by the balance or imbalance of two major players; protein and potassium. We’re always looking for simpler ways to enable patients and ourselves to be able to both recognise the strengths and weaknesses of their diets and, better still, apply a simple method to making better choices moving forward. Eyeballing the protein and potassium rich sources in any diet speaks volumes about other essential dietary characteristics and the likely impact of diet on health – and getting the relationship between these two right should be a goal for us all.
“World Health Organization (WHO) Dietary Targets for Sodium and Potassium are Unrealistic”, reads the recent headline from yet another study finding that humans would rather challenge the solid science of human potassium requirements than acknowledge the urgent need to turn this ship of fools around!
This large study, conducted over 18 countries, involving over 100 thousand individuals, reported that 0.002% met these targets. That’s 1 person in 50,000. Now, the researchers’ response to this is that we should lower our dietary potassium expectations….such that the targets are more achievable and so that (frankly) we are less perpetually disappointed in ourselves and our terrible food choices. Wha???? Back up there. The WHO guidelines, just like any other nutrition authority, derived these minimum amounts from a thorough review of the science that speaks to our physiological requirements and the level of nutrients that have been shown to be associated with health. Australia’s own fairly conservative NHMRC suggests even higher amounts for good health! Perhaps rather than revise the established dietary targets we should revise what we’re putting in our mouth!
So where does protein come into this? Well one of the most important and central nutrient dynamics is the balance or imbalance of our intake of both. And in this regard, yet again, we have a surprising lot in common with plants! Whether you’re trying to understand optimal nutrition conditions for growth (nitrogen alone won’t get a plant there, nor protein alone in a human) or the intricacies and nuances of finely tuning our physiological processes such as cardiovascular function, renal health, blood glucose management etc. the answer lies in a happy marriage between these two.
In this area of nutrition, we should be listening most closely in fact to renal specialists/researchers. These ‘undercover’ protein and potassium experts have been talking about this for a long time and in particular, in my humble opinion, Lynda Frassetto has lead that charge for decades. If you haven’t read much on this issue and want somewhere to start at least, jump into her pivotal paper from 2001 which eloquently explains why the human design can not shoulder a potassium shortfall…well not without causing real health problems…like the ones we’re seeing in record numbers currently and why the protein potassium balance of any diet is a major health determinant. That’s why giving ourselves and our patients the knowledge and the tools (yes lovely shiny meaningful infographics included!!), to quickly determine their protein potassium balance, are so necessary and important.
Thanks to Frassetto and many other researchers’ work, looking at food through this protein potassium lens has sharpened my focus and I think it’s about time we all took a good look 🙂
Check out the latest UU30 to hear the latest information…
The health consequences of any diet are largely determined by the balance or imbalance of two major players & proxy markers; protein and potassium. When it comes to this area of nutrition, we should be listening more closely to renal specialists whose research shows why the human design cannot support a potassium shortfall and the health consequences of this. Whether you’re trying to understand optimal nutrition conditions for growth (nitrogen alone won’t get a plant there, nor protein alone in a human) or the intricacies and nuances of finely tuning our physiological processes such as cardiovascular function, renal health, blood glucose management etc. the answer lies in a truly happy marriage between our intake of these two. These recording comes with a clinical resource tool to help you quickly identify the dietary protein:potassium balance for your clients.
How often were we told this in our training? And how often have we found this to be true in practice? And now suddenly, it seems, the medical researchers (at last!) are rapidly coming around to this core concept?? Our microbiome is suddenly the hottest property on the body block, and it seems every interested party is shouting, ‘Buy!Buy!Buy!’ As integrative health practitioners, of course, we had a major head-start, not just by appreciating the gut’s central positioning in the whole health story (iridology beliefs, maps & teasers aside!!) but also a heads-up about the damage the western diet, our medication exposures and lifestyle tend to wreak upon it. A favourite quote of Jason Hawrelak’s by Justin Sonnenburg, “The western diet starves your microbial self”, underscores the significance of just one element of this impact. And…are we all clear that the increasing number of patients reporting adverse food reactions, once again, overwhelmingly are a response to aberrant processes in the GIT?
Sounds silly it’s so obvious right, but it’s easy to get distracted & misattribute blame…for example, it’s the food that’s the problem. Well yes in a minority of situations interactions between someone’s genes, immune system and a particular food turns something otherwise healthy into something pathological, but for the majority, the food itself & in others is healthy, & could be beneficial to this individual, if only we could resolve their GIT issues…like FODMAPs for example.
Not the problem, just the messenger.
So if the ‘problem food’ is just the messenger, what’s the actual message we need to understand? Is it that this patient has medication, disease or otherwise induced hypochlorhydria, impairing ‘chopping up’ of potential antigens implicated in immune mediated food reactions? Or is that this person’s got fat maldigestion &/or malabsorption so that in addition to not tolerating fats, they may experience dietary oxalate intolerance to boot? Or are the food reactions the result of altered microflora changing what we can and can’t digest (via their critical contribution) & absorb?
So what message does the presence of IgG antibodies to consumed foods send us about the state of someone’s gut? It’s telling us 2 things: this individual exhibits abnormal intestinal permeability & currently in the context of this leaky gut, these foods may constitute a barrier to resolving this & other symptoms as well.
We’ve recently released the mp4 (that’s audio plus the movie version of the slideshow so grab your popcorn…that’s if you don’t have a corn issue!) of A Guide to Investigating Adverse Food Reactions – What’s IgG got to do with it? which details the science behind IgG, including debunking, the incorrect debunking of IgG food antibody testing!! But more than this, it overviews the whole maze of adverse food reactions, articulates a logical investigative path for practitioners through this maze, and helps us to really understand that finding the food(s) responsible for a patient’s symptoms is not the final destination..and can be in fact a distraction, if we don’t cut to the chase and find out the why…and funnily enough…my dear old iridology teachers and colleagues...it almost always comes back to the gut 😉
Confronted with the possibility of adverse food reactions in an increasing number of our patients can be an overwhelming prospect, in terms of accurately identifying and understanding the faulty mechanism underpinning these aberrant responses to healthy foods. Elimination of culprits in most situations is only a short term reliever, not an appropriate long term solution, so to optimise results we need to know the real mechanism of action. The majority of these, of course, stem from the gut, but being able to elucidate exactly which of the many things that can go wrong there, is going wrong and therefore what foods are problematic until we address this, is the key. This 2hr mp4 is all about the bigger picture and helping you find method in the madness that can be the AFR landscape. Along the way, we detail the science of where IgG reactions fit into this and it’s a fascinating story that just might be the missing puzzle in your leaky gut patients.
and watch this presentation now in your online account.
a. Some hip new (truly undanceable) track
b. Every herbalist’s jaw at my table at the NHAA conference gala dinner, when I got almost all my Latin binomials right during the trivia quiz?…and after some champagne, that’s a particular achievement
c. My jaw, when I saw firsthand how much those herbalists could drink of ye-not-so-olde herbal extracts!!
d. The latest Update and Under 30 – Milk Madness Part 2
e. All of the above
If you answered, ‘e’…. you must have been one of those herbalists at my table, otherwise you have way too much insider information! But yes you are correct on all accounts. So this latest UU30 is an extension of our discussion last month about the potential contribution from to mental health from dairy intake in a subset of patients. This whole topic, the research for which dates all the way back to the 70s, was too big to fit into one – given the current evidence base that now depicts at least 2 different mechanisms that might be at play, and the different types of mental health problems, each has been linked with. Last month was all about retracing the ‘dietary exorphin’ path, this month it’s about the propensity for some individuals to make antibodies to casein and the significant growing data that suggest this happens to a larger extent in patients with certain psychiatric diagnoses. More importantly, we talk about the ‘why’.
What compelled me to make time to look through all the literature on this was that there is some. No seriously. When I initially learned of the GFCF dietary approach to ASD patients I was told that in spite of a lack of supportive research, the empirical clinical evidence was irrefutable, which I later saw with my own eyes. In the couple of decades since, I only really heard about negative findings, short trials of the elimination diet specifically in ASD kids, that failed to produce significant change. Funny how the bad stories rise to the top, right? But when I spent the time doing a thorough literature review, I found these negative findings were far from the whole story. In fact, I was really surprised by the high level of evidence employed by researchers of late, who have repeatedly found associations between either exorphin or antibody levels and patients with particular diagnoses, in addition to really progressing our understanding of why these measurable differences (urinary exorphins, plasma IgG and to a lesser extent IgA casein antibodies) are meaningful. Do we know everything? What do you think? The answer, of course, is always no. But we know enough to consider this aspect in our comprehensive workup of mental health patients and all their biological drivers and we know dramatically more than anyone in mainstream medicine, or the dairy industry for that matter, is ever going to let on!
If you want to hear a synthesis of the casein antibody link with mental health then download the latest UU30 – Milk Madness – part 2. If you can’t go that far, then “do yourself a favour” and read a couple of seriously important articles on this topic – and why not start at the deep end with this study by Severance in 2015.
Could dairy intake in susceptible individuals be a risk promoter for mental health problems? In addition to evidence of the exorphin derivatives from certain caseins interacting with our endogenous opiate system discussed in part 1, we now look at the evidence in support of other milk madness mechanisms. Specifically, the IgG and, to a much lesser extent, IgA antibodies about what this tells us about the patient sitting in front of us about their gut generally and about their mental health risks, specifically. The literature in this area dates back to the 1970s but the findings of more recent and more rigorous research are compelling.
We’re not deaf…we heard that stampede of Iron-Inundated Practitioners!
Our recordings and clinical resources for improving your skill-set in all things iron including, your accuracy of diagnosing deficiencies, pseudo-deficiencies & excesses, plus radically rethinking the best treatment approaches for each scenario…have been some of our most popular. Because nailing iron (pardon the pun) is harder than we were all lead to believe and at least 1 ‘iron maiden’ or ‘iron man’ walks into our practice every day, right? So we’ve brought together 5 extremely popular UU30’s on Iron into one bundle for the price of 4! So if you’re more than ready to graduate from ‘iron school’, now’s your best chance!
1. So You Think You Know How to Read Iron Studies? (≤30 min audio + Cheat Sheet)
Overt Iron Deficiency Anaemia or Haemochromatosis aside…do you understand the critical insights markers like transferrin and its saturation reveal about your patients iron status? Most practitioners don’t and as a result give iron when they shouldn’t and fail to sometimes when they should. This audio complete with an amazing cheat sheet for interpreting your patients Iron Study results will sharpen your skills around iron assessment, enabling you to recognise the real story of your patients’ relationship with iron.
2. Pseudo Iron Deficiency (≤30 minute audio)
The most common mistake made in the interpretation of Iron Studies is this one: confusing inflammation driven iron ‘hiding’ with a genuine iron deficiency. Worse still, following through and giving such a patient oral iron – when in fact it is at its most ‘toxic’ to them.
This audio together with some key patient pathology examples will prevent you ever falling for this one! Learn how to recognise a ‘Pseudo Iron Deficiency’ in a heartbeat!
3. Iron Overload… But not as you know it (≤30 minute audio)
We’re increasingly seeing high ferritin levels in our patients and getting more comfortable referring those patients for gene testing of the haemochromatosis mutations; but, do you know how to distinguish between high ferritin levels that are likely to be genetic and those that are not? This can save you and your patient time and money and there are some strong road signs you need to know. In addition to this, what could cause ferritin results in the hundreds if it’s not genetic nor inflammation? This Update in Under 30 summary will help you streamline your investigations and add a whole new dimension to understanding iron overload…but not as you know it!
4. So You Think You Know How To Treat Iron Deficiency? (≤30 min audio)
And then you don’t. The reality is we all struggle at times with correcting low ferritin or iron deficiency anaemia – so what have we got wrong? In spite of being the most common nutritional deficiency worldwide, the traditional treatment approaches to supplementation have been rudimentary, falling under the hit hard and heavy model e.g. 70mg TIDS, and are relatively unconvincing in terms of success. New research into iron homeostasis has revealed why these prescriptions are all wrong and what even us low-dosers need to do to get it more right, more often!
5. So You Think You Know the Best Iron Supplement, Right?! (≤30 min audio + Iron Supplement Guide)
Iron supplementation, regardless of brand, presents us with some major challenges: low efficacy, poor tolerability & high toxicity – in terms of oxidative stress, inflammation (local and systemic) and detrimental effects on patients’ microbiome. What should we look for to minimise these issues & enhance our patients’ chance of success. Which nutritional adjuvants are likely to turn a non-responder into a success story and how do we tailor the approach for each patient? It’s not what you’ve been taught nor is it what you think! This comes with a bonus clinical tool, a fabulous easy reference guide – to help you individualise your approach to iron deficiency and increase your likelihood of success.
You’ll never look at iron studies or your iron-challenged patients the same way.
Listen to these audios straight away in your online account.
So this is not news to most people who know me but I don’t like taking things out of people’s diet. As a result, in a room full of naturopaths & integrative medicos, I might be voted the least likely to use the phrase, “No Gluten or Dairy for you!” [said with the Soup Nazi’s accent from Seinfeld]. I must have slept through that class when we were taught to do this for absolutely every patient. But seriously, I try not to remove or exclude foods without a very strong rationale and evidence-base that relates directly to the person sitting in front of me, for several reasons: 1) those seeds are powerful ones to plant in your patient’s mind…how do they carry that with them as they move through life, navigating food and social settings etc etc…all well and good if this is a proven life-long pathological provocation for them but otherwise… 2) dietary exclusion is stressful for families & in kids especially, can create disordered eating and a range of other psychological impacts and 3) GFDF diets are not necessarily healthier in the basic nutrition stakes…if you haven’t read Sue Shephard’s work on the deterioration of diet quality in GF patients…you should. It can be much healthier of course…but often the real-world application of the principle doesn’t always match the lovely ‘serving suggestion image’ on all the GFDF highly processed, packaged foods!!
So listen up people, because now I’m talking about when I would seriously consider joining in on the GFDF chant.
The one patient group I’ve never quibbled over the benefits of GFDF, has been the autistic one. I was taught the merits of this approach early on by a few fabulous courageous integrative doctors and paediatricians who came back from the front-line of their clinics, reporting good effects. I then had the important firsthand experience of unprecedented verabilisation in a non-verbal ASD child’ after excluding these foods. But what I’ve been thinking a lot (and reading a lot!) about lately is the possibility that these ‘dietary exorphins’ may have negative mood effects in other subsets of mental health patients. My thought process is like slow TV! That aside, there’s a lot to be said for taking the time to really getting across an issue – even if that involves reading papers from as far back as the 1960s when the idea of a negative role for dietary exorphins in schizophrenics was first floated by Dohan & colleagues.
Let me say, when you go back to the beginning it’s undeniably a shaky start for the exorphin evidence base, but as you read the studies that emerge from decade to decade until the noughties…it reveals a nagging research topic that won’t go away and a fascinating process of discovery.
So is the devil really in the (regular commercial cow’s) milk? Well I think for some patients it may well be a contributor – most notably those with features consistent with the pattern of excess opiate effects including a higher dopamine picture, regardless of the mental health label they’ve been given, although, more commonly seen in ASD, psychotic presentations etc. But how do we work out which ones, because none of the evidence points to it affecting 100% of these groups…well that’s where we need to go back and truly understand the structure of these dietary exorphins and just how they potentially wreak havoc in some.
The latest UU30 takes your through the story of BCM-7 with a summary of research compile over half a century in Under 30 minutes!
There is a well-rehearsed chant in the integrative management for ASD individuals, “Gluten free- casein free diets” is based on the dietary exorphin theory which suggests these foods generate bioactive peptides that act unfavourably in the brain. Where did this theory emerge from and how strong or weak is the evidence upon which this therapeutic intervention stands? Even more interesting, is there support of this theory in a wider range of mental health presentations such as schizophrenia, post-partum psychosis and depression. Is there such a thing as milk madness for a subset of our patients?
Let’s talk turkey about our pharmaceutical Pet Hates, mine are Proton Pump Inhibitors (PPIs). They irk me more than any other drug class. It’s not entirely rational. Let’s face it, they have some stiff competition but for some reason, in my mind, they almost always win: helping so little & at such a high cost to patients. What fuels my fire of course is their over-prescription, followed closely by the complete disregard for the prescribing guidelines which state:
“When clinically indicated, PPIs should be used for the shortest duration necessary and chronic use is not recommended except for treatment of pathological hypersecretory conditions including Zollinger-Ellison syndrome and maintenance healing of erosive oesophagitis.”
Sorry…did I hear you correctly? Chronic use is not recommended – yet this is one of the drugs most commonly on ‘set and forget mode’ in general practice. To boot, their chronic use has been associated with a number of serious concerns, which I’ve touched on before, from osteoporosis to increased rates of GIT infections. not to mention just the little ol’ detail of malabsorption of multiple nutrients! But this week, yet another health concern has popped up and into my inbox…and well..I found myself shouting at the medical newsfeed on my screen…[again] 🙁
“In their analysis, more than 42,500 adverse events reported to the US Food and Drug Administration by patients on PPI monotherapy were compared with more than 8300 reports from patients on histamine-2 receptor antagonists (H2RAs)….Patients on PPIs alone were 28 times more likely to report chronic kidney disease than those taking H2RAs, while the frequency of acute kidney injury reports was around four times higher…Reports of end-stage renal disease were 35-fold higher among PPI users, while reports of renal nephrolithiasis were three times higher”
To be clear, while these increased rates are TERRIBLE and unacceptable in the context of the ‘set and forget’ prescribing that seems it be rife in most countries, they still only effect a small % of patients e.g. approx 5% of patients had adverse renal effects on PPIs Vs 1% on the older generation H2 blockers for reflux but it’s yet another reason (like we needed more?!) to think twice before our patients are initiated on these meds, which are presented to patients as being benign. Typically with drug development, the older drugs in a class are superseded by newer ones that are ‘cleaner’, and therefore more effective with less adverse effects but this is one situation where if one of my patients really did need a med, I would say out with the new and in with the old!
One scenario where PPIs in combo with multiple antibiotics get routinely rolled out is of course H.pylori infections. But does this make sense??
For a bacteria identified just a few decades ago as being a cause of chronic gastritis, atrophic gastritis and gastric carcinoma, the escalation of number of antibiotics used to eradicate it (4 at last count + PPI) has been nothing short of breathtaking. A management approach more consistent with both integrative medicine and with an improved understanding of the delicate microbiome focuses on changing the gastric environment to ‘remove the welcome mat’. What do we know about how to do this successfully? It turns out…quite a lot. You can find out here with our previous UU30: H.pylori- Eradicate or Rehabilitate?
How long? How long must we sing this song? I’m feeling a bit 80s anthemic and righteous. It turns out that patients’ bowel movements could be improved by using a foot stool?!! Who said that??
Only every naturopath, ever. Right?
But now medical researchers are singing the praises of the Stool Stool too…sorry, I mean the ‘defaecation postural modification device’…because lo and behold a new study of over 1000 bowel movements revealed using a stool to elevate your feet while on the toilet improved the speed and ease, improved full emptying, reduced the strain etc of laxation, >70% of the time, even in ‘healthy, non-constipated patients’. There’s a quick video you can watch to get across this groundbreaking research, or you can read the full article here. I’ve been educating patients about this for about 20 years and it never fails to revolutionise their world!
It would seem that elevating your feet results in straightening “the unnatural bend in the rectum that occurs when sitting on the toilet by placing the body in the squatting position nature intended”…hang on a second…who’s calling what unnatural???…I think the highfalutin anti-anatomical bathroom contraption, we westerners call a toilet, wins the ‘unnatural’ crown!
Next thing you know there’ll be a study that tells us squatting to have babies makes more sense that lying on your back…right?! 🙂
Love talking all-things Stool?
Fabulous Farty Fibre is a previous UU30 recording. Rachel at her warmest and funniest reminds us that fibre is a critical component to good nutrition and is often overlooked, partly due to the popularity of paleolithic and no grain diets. This UU30 details the important functions of different types of fibre and therefore the importance and therapeutic applications for fibre diversity.
Virginal skin, as my sister calls it, is on the endangered list. She also predicts that as a result, it will be a highly sort after commodity in the future and I agree but our reasons are a little different. Hers are aesthetic and mine are well, health-based.
I dislike spreading fear in the wellness world, especially around the area of autoimmunity, which is already plagued with podcasting puritans, espousing the notion that people with autoimmune conditions need to give up every single source of joy in their lives and then, and only then, they will be healed
[Silent Scream !!!!!!]
The essential formula for autoimmunity is generally thought to be: genetic susceptibility + environmental trigger = Bingo! i.e. Hashimoto’s or Grave’s or AS or or or…There are already so many candidates, both confirmed and speculated, on the environmental triggers list, from individual nutrient deficiencies, to food groups, from infectious organisms to of course, the big monster under the bed and everywhere else (!), environmental toxins. But wait there’s one more.
“Black inks likewise have been shown to induce production of reactive oxygen species (ROS) such as singlet oxygen or peroxyl radicals, which are free-radicals that can steal electrons from neighboring molecules and damage cell constituents. One study by Regensberger and colleagues (2010) found that in the presence of ultraviolet light, some black inks reduced activity of the energetic powerhouses of the cell, the mitochondria, of human dermal keratinocytes, the type of cell that predominates in the outermost layer of skin”
Recently I was prompted to ask one of my mentors whether tattoo inks contained heavy metals. His reply, “I seriously doubt that heavy metal-free tattoo inks even exist.” Then someone on my team forwarded me this well referenced article that contains the above quote titled, Toxic Chemicals Found in Tattoos: Links to Autoimmune & Inflammatory Diseases. I haven’t had a chance to read their citations and understand the real implications of this very plausible biological threat and I can’t do anything about the skull & crossbones on my back but I can warn my kids, my patients and anyone else with virginal skin to rethink the ink.
It’s summer time for all of us in the southern hemisphere & that means….Slip Slop Slap?!
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 podcast, Should We Rethink High Dose Vitamin D, Rachel outlines the key unresolved vitamin D dilemmas that should encourage us to exercise caution with supplementation and outlines how adequate sun exposure is associated with improved health outcomes independent of the production and action of vitamin D.
Did you and all your patients survive Spring? Have you had a chance to restock the shelves with all the big-gun-Quercetin-products for the next allergy onslaught…or maybe for patients presenting with other conditions that respond well to this, like leaky gut, asthma, MCAS, Grave’s disease? Either way…can I ask you a Quiet Quercetin Question…how high do you go?
I ask this because I know myself to be pretty heavy-handed at times, especially in those severely affected by traditional allergies..and the results are so impressive for patients and practitioners alike, it’s easy to perhaps get very enthusiastic with this approach, with doses sneaking higher and higher… if a little is so good then a lot must be great!
“Severe eczema and allergic asthma – [Insert preferred big-gun-Quercetin-product] 2 three times a day – STAT!”
And we use it across all patients, right? I love it in kids, teens and adults, men and women. So I kind of stopped dead in my tracks when a colleague recently said…”I do the same…buckets of Quercetin especially over hayfever season but Rach, what about it’s phyto-oestrogenic effects? Should we be worried?” Ah…yup…that’s right…being a flavanoid…it has them. Now let’s be clear about one thing, unlike some practitioners I am NOT, I repeat, NOT against phytoestrogens nor even (ahem) soy 😉 but the question was great because it got me thinking…at high-end supplement doses we are producing levels in the body 100s if not 1000s of times higher than a fruit and vegetable rich diet ever can….is it time we knew a little bit more about what Quercetin does at this level, or is suspected of doing and not just the benefits. Therefore we can be more informed about who we should not be so generous or so long-term with our big Quercetin prescriptions?
So I started busying myself in the literature and it turns out THERE IS A LOT OF LITERATURE!
[Note to said colleague who asked me question, you owe me some sleep] But at least I got an answer!
If you want a bit of DIY drilling then this Andes et al paper is an excellent overview of quercetin supplementation safety concerns…but it doesn’t cover everything. We need to talk. We need to talk about that dang estrogen aspect but it’s bigger than that – you see Quercetin doesn’t just engage with oestrogen receptors like a ‘normal’ phytoestrogen…it messes with levels of this hormone via several other paths…and where does that lead us…? Listen in to the latest UU30 Querctin – Are We Pushing the Limits? and you’ll know exactly our destination. This is important for the Quercetin Queens (both male and female) among us…and that’s like…everyone…right? 🙂
Quercetin has become an absolute go-to treatment for many practitioners faced with patients affected with allergies and high histamine. It is in this context, that often we find ourselves using large amounts over long periods. Supplemental quercetin exhibits a 5-20 fold higher bioavailability than its dietary counterpart, therefore increasing body levels beyond what a diet could ever achieve. This introduces more potent novel actions: anti-thyroid, pro-oestrogenic, detoxification disrupting…are we pushing the limits of desirable effects and introducing some undesirable ones and who should we be most conservative in?
Hear all about it by listening by my latest Update in Under 30: Quercetin – Are We Pushing the Limits?
For all Update in Under 30 Subscribers, it’s now available in your online account and if you are not a subscriber you can purchase this individually here.
As Britney so famously put it, ‘Oops, I did it again!’ I remember the actions on my to do list but not the intended recipients! D.O.H. I was talking with a practitioner the other day who lamented that she had never really learnt about stats nor how to assess the quality of research in her undergraduate and could I point her in the right direction towards a resource that simply explains this increasingly important basic skill-set…well I would if I could remember who you were!! Anyhoo, I followed through in my usually dogged way to the bottom of my actions list and with the help of a lovely past-intern, got directed to these free BMJ resources on how to read research…G.O.L.D.
Papers that go beyond numbers (qualitative research) Trisha Greenhalgh, Rod Taylor
Papers that summarise other papers (systematic reviews and meta-analyses) Trisha Greenhalgh
Papers that tell you what things cost (economic analyses) Trisha Greenhalgh
Papers that report diagnostic or screening tests Trisha Greenhalgh
Papers that report drug trials Trisha Greenhalgh
Statistics for the non-statistician. II: “Significant” relations and their pitfalls Trisha Greenhalgh
Statistics for the non-statistician Trisha Greenhalgh
Assessing the methodological quality of published papers Trisha Greenhalgh
Getting your bearings (deciding what the paper is about) Trisha Greenhalgh
Anyway…while I continue to ponder who this was actually intended for… it dawned on me how many people would just LOVE these & benefit from them immensely in the meantime. Couldn’t most of us do with a little more research literacy? So I thought I’d share. Don’t you love it when we work as a team. Now…who can help me find my keys?! 😉
It’s starting to feel a lot like…that Update in Under 30 time of the month!
Update in Under 30 are dynamic power-packed podcasts that will help you keep abreast of the latest must-knows in integrative medicine. Focused on one key issue at a time, Rachel details all the salient points so that you don’t have to trawl through all the primary evidence yourself. All topics are aimed at clinicians and cover a range of areas from patient assessment to management, from condition based issues to the latest nutritional research. Most importantly, each podcast represents unbiased education that can contribute to your CPE points, so if you haven’t subscribed yet…what are you waiting for??!! 🙂
Never say never, right. Back in my old uni teaching days, I scorned the very notion of treating someone with ‘actual melatonin’. Always in favour of upstream approaches over downstream, I was keen instead to give patients the ‘ingredients & cofactors’ so they could whip the right amount up themselves. Well fast forward another decade in clinical experience, and research too, and while I refuse to give in with many other ‘replacement remedies’, melatonin, has snuck well and truly into my list of treatment considerations for some very specific presentations such as silent reflux, treatment refractory GORD and Barrett’s oesophagus, buoyed by some amazing clinical successes. So much so…that in fact I’ve embraced this replacement approach, whose results in this setting especially, can’t be replicated by treating with ingredients and cofactors. Turns out of course I am not alone – melatonin has won a lot of fans over the last decade.
A recent Australian article from 6 minutes revealed a significant increase in GPs prescribing melatonin for sleeping issues in children and then of course, there is its substantial use in cancer and typically at mega-doses that will make your toes curl.
But always in the back of my mind is the old me. Whispering things like, ‘ but melatonin isn’t a nutrient, nor a herb, so it’s not naturopathic’ – hence we can’t even prescribe it, needing to refer patients to others for access and yet more pressing, ‘what do we really know about the full implications of replacing such a potent and ubiquitous neurotransmitter?’ I know. This old me, she’s annoying, right.
But she’s also important.
So absolutely perfect timing then to hear about a homegrown (2 Aussie Naturopaths in fact) systematic review on the adverse effects & safety of melatonin which is full of important and surprising info and I think ….everyone…single…one…of…us needs to read it:
“While this review reveals a high degree of safety for melatonin with few adverse events that cannot be easily avoided or managed in most populations, it also reveals lack of clarity regarding melatonin’s relationship to endocrine processes, and its effect on hypertensive patients and potential drug interactions in this population.”
But the devil is in the detail.
So here’s a newsflash for you – 4 human studies found melatonin had negative effects on key aspects of reproduction, like sperm counts and ovulation and not at mega-doses my friends, no…at 2mg/d over several months. We shouldn’t be surprised, right, melatonin is critical to fertility cycles in all other animals…but how many health professionals know this, or not just know it…but make our recommendations with this in mind? Other studies reported fascinating impacts on insulin sensitivity (5mg) and amazingly, (or not being the king of all things circadian), opposing effects depending on the time of administration. Then there’s the drug interaction with anti-hypertensives…a negative one, I must add. No information still unfortunately about the impact of long-term replacement on our own endogenous production. Anyway…enough spoilers… READ THE ARTICLE. This hasn’t wiped melatonin off my list of potential recommendations all together but it has given me some serious food for thought and much greater clarity about in whom this suggestion should be off the menu.
‘Melatonin – Misunderstandings and Mistakes’ – this important 2017 clinical update about what we are getting right and wrong with Melatonin answers in particular, one of the most common sources of fascination & frustration for clinicians, the reasons behind the Melatonin non-responder. We’ve all encountered patients who have taken Melatonin for sleep problems and reported no benefit, or initially responded and then lost efficacy quickly, or even patients who experienced insomnia after taking. What does this tell you about your patient and what should you do to resolve this and better still, prevent it? This UU30 from 2017 reveals all!
While this ABC article is written for the public it’s a great checklist to have written up somewhere to prevent against placing your confidence in the wrong sources of info.
Just recently, I had a practitioner ask about the ‘risks’ of B12 dosing…& while B12 is considered to be free of a toxicity profile in just about any textbook or in-depth review paper you can find, a ‘methylation’ expert had made mention of there being demonstrated increased oxidative stress.
My response, ‘Have you checked their references?’
I get it, right, we’re all busy people and don’t have the time for a full literature review of every claim made by every educator, ‘expert’ or company… BUT sometimes a credibility check can be lightning fast!!!! As was the case in this instance.
I did check this expert’s reference (singular). I read the full article just out of interest but actually, I didn’t need to. I had my answer just by reading the title and abstract…the study was conducted in genetically altered rats made alcoholic and injected with B12 or something to that effect. Relevance?? Which is in stark contrast to the absolute consensus from 100s of human studies concluding that B12 toxicity is NOT a thing.
That also means this particular expert’s references probably need to be checked every time of course…until you can be more confident in the quality of their claims – tough but true. Below are the 7 top Qs to try and answer to determine the quality of any claim – and remember you rarely have to complete the list to get your answer…just start with reading the title of their key reference!!!
1. Who says? (….and what agenda/bias might they have)
2. Sample size ( a response rate of 20% might mean something in a sample of 10000 & nothing in a sample of 10!)
3. Lab-bench or real world
4. Correlation V causation
5. Statistically significant V clinically significant (…if something was shown to reduce people’s migraine pain by a rating of 0.5 – but most people rate their pain at 10/10…is it actually clinically meaningful?!)
6. Does the dose relate? (…watch out for animal studies where they are using doses at mg/kg body weight…that we could never match with oral dosing in humans because they would be eating buckets of the stuff!)
7. Got some time?…then dig a little deeper…if your article has passed all the above checkpoints and you’re still dubious (and this does happen!) check out who has cited this paper (easy via Google Scholar) and whether other researchers are in agreement or not with their findings. What’s been published in this area since then?
Oh and this article is also handy for the occasional misguided patient – who’s found some incredulous online info about something that contradicts your contrastingly well-sourced & quality-checked knowledge! 😉
Our new – New Graduate Mentoring Program kicks off in late January and offers an incredible opportunity for successful applicants to develop their core clinical competencies in record time during their transition into practice. Real world research cheat tips, is just one of the many practical competencies covered across the year’s curriculum. But if you’re interested in applying, jump onto it! Applications close on the 15th November
Finally a systematic review puts paid to the nonsense that ‘withdrawal from antidepressants’ is problematic only for a few, is ‘mild’ & ‘lasts only 1-2 weeks’ with no treatment necessary other than reassurance, which is still being perpetuated by current prescribing guidelines both here and overseas. In fact their review found that 56% of patients experienced problems with stopping antidepressants and the majority of these rated these as ‘severe’. Back in the good/bad old days when I worked for a pharmaceutical company who made psych meds the phenomenon of an ‘initiation phase’ during which time suicidal risk was heightened, was acknowledged and freely discussed…in-house at least. However, the concept of a ‘withdrawal syndrome’ was less clear. Anyone who has witnessed patients coming off ‘even the cleanest’ SSRIs will speak to a potential myriad of worrisome experiences including…
“Typical AD withdrawal reactions include increased anxiety, flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal. Dizziness, electric shock-like sensations, brain zaps, diarrhoea, headaches, muscle spasms and tremors, agitation, hallucinations, confusion, malaise, sweating and irritability are also reported (Warner, Bobo, Warner, Reid, & Rachal, 2006, Healy, 2012). Although the aforementioned symptoms are the most common physical symptoms, there is also evidence that AD withdrawal can induce mania and hypomania, (Goldstein et al., 1999; Naryan & Haddad, 2011) emotional blunting and an inability to cry, (Holguin-Lew & Bell, 2013) long-term or even permanent sexual dysfunction (Csoka & Shipko, 2006).”
Previously termed ‘discontinuation syndrome’ by expert panels – to distinguish these inconvenient effects from the more seriously viewed (read nasty) benzo-associated discontinuation problems – was an act of smoke and mirrors, according to this scathing and insightful review by Davies and Read, who argue strongly this is a clear cut withdrawal picture and it deserves as much consideration and concern. In particular they point out that of course, patients can experience these symptoms even without ‘discontinuation’ – but simply as a result of a delayed or skipped dose, an intentional dose reduction etc. And they provide the alarming context that one third of people in the U.K. (and likely similar developed countries) who take antidepressants for more than two years have no evidence-based clinical indications for continuing to take them. But wait..I’m just getting to the worst bit, this is the part that gets me personally…having been a peddler in the past of these meds and in certain patients still spruiking their benefits, I am in no disagreement about them being necessary, helpful & even life-savers in some patients…yes I have seen this too many times to ignore it…BUT…and now this is where I start raising my voice a tad….
Patients need to make informed choices, and having a clear understanding of what you are likely to experience on any given medication has been shown to improve outcomes but according to the 2 largest surveys conducted to date,< 2% of antidepressant users are being told any of this. Do you know why? Well, let’s start with the misleading guidelines… if the RACGP says it isn’t so…then can we expect their GP to know or say any differently?
Grrrrrrrr…. yes that’s me…not a wild animal in the room with you.
Because you know what happens in the absence of this?! And let me say I have also seen this too many times to ignore as well, people feel compelled to stay on them & this is truly heartbreaking to witness. The experience of a reduced dose or a period without is so terrifyingly disconcerting to that poor unsuspecting individual, and without explanation, is misinterpreted by them (and according to this review often by their doctor as well!!) as being either a sign of their inherent mental instability and need for ongoing medication, or misdiagnosed as a separate condition. Ok…apologies, this is over a decade of pent up frustration…resurfacing as a result of reading this incredibly important and disturbing review. I think I need a little lie down now 🙁
Helping patients off anti-depressants is a challenging and important function that must be initiated by the patient with the full support of the prescribing practitioner, however there’s a role for complementary medicine here too. Rachel walks you through a range of strategies and when you might consider each. Listen to the free sample here from the Update in Under 30 from 2013 – Leaving Anti-depressants Behind. Or perhaps you’re interested in all things Mental Health and should find out more about our specialist mentoring group running in 2019.
So we already know that thyroid problems can start in utero, right…but a recent Medscape review (the fountain of thyroid information that I frequently drinketh from 😉 ) on Hypothyroidism in childhood taught me a couple of big things I hadn’t known before!
The diagnostic criteria for subclinical hypothyroidism are raised TSH levels in combination with a normal concentration of free serum thyroxine (FT4) but because there are some differences between accepted ranges in TSH assays, high-risk groups should be screened, especially babies with malformations, whose mum received steroid treatment during pregnancy or in the neonatal period, or who had existing thyroid dysfunction, TFTs (or at the least TSH as part of what’s called the Neonatal Screening test) should be repeated 2 weeks later. But now comes the couple of big light-bulb moments: the incidence of eutopic thyroid in twin births is nearly double compared with singletons! As you know, I’m a mother of twins and I’m guessing at 18yrs old now (and multiple peachy TFTs 😉 ) the horse has well and truly bolted for my two but geez…I had no idea of the dramatic increase in risk. And it keeps going…monozygotic twins very commonly show a delayed TSH rise and those numbers are even more prominent in multiple births. The other not-so-fun-fact is the discovery that subclinical hypothyroidism in IVF babies is approx. 10% which is noteworthy considering none were observed in the control group.
This obviously left me thinking “W.H.Y?” And of course…the first place my head goes with the latter…is iodine.
Could this phenomenon in IVF babies be due ultimately to undiagnosed or poorly managed SCH in mum or even simpler still, just basic iodine deficiency, presenting as infertility?!
The reasons behind our increasing rates of thyroid dysfunction across the life-stages are multifactorial (and don’t get me started on the very real contribution of EDCs!) and how, in spite of iodine adequacy being the first thing on the checklist for thyroid health, so many health professionals ignore this, at their patients’ peril… But now at least we know that patients with IVF babies, twins, and preterm bub, who are currently not included in the prioritised screening groups should be…and of course we should keep asking the questions, “what are the mechanisms behind this, why is it so?”
So if this has made you even more curious about the incredible butterflied-shaped gland and you’d like to go for a stroll on the vast plains of “thyroidisms” you can click on this link Thyroid Assessment in Kids and Teenagers and get completely “thyroided” up. There is always more research to come our way so keep your eyes and ears peeled.
A few months back I seriously ‘blew over’. Not on an RBT but on a UBT (Urea Breath Test). In spite of it being not the kind of test you want to score top marks for, my result was in the high 2000s, when all I needed was around 800 to confirm, and anything over 50 to be suspicious, that Helicobacter pylori had taken up residence in my stomach lining. I tell you, I knew it when I blew it! 😉 After ingesting the radioactive urea and waiting to blow up my sampling balloon, I felt like I could still fill a room full of balloons with all the gas being produced in my stomach and those balloons, I imagined, would all rise to the ceiling as if full of helium! Yep…I burped all the way home, which was representative of what I’d been experiencing daily for a month beforehand and what lead me to get the test done.
But initially, it wasn’t so clear.
The very first symptom I experienced was a sudden onset of severe tightness around my throat that lasted for minutes but started to happen multiple times in a day. Yep..no one panic. Together with a strange sensation of ‘extreme emptiness’ in my stomach on waking or delayed meals, and then mild nausea both with an empty and full stomach…only some days or weeks later the fabulously-unprecedented-&-socially-adorable-burping started, proper.
So a month or so later, I’ve solved my own mystery. Happy? Not in the least…where the heck have I picked up H.pylori from? Yes…that’s what I said because it had to come from somewhere people…right? I think there is much we have misunderstood about this bacteria with an incredibly long and interesting human history. Animals don’t and can’t carry this bacteria. The evidence suggests that it can’t survive for very long in the environment either (approx 4 days) but that is long enough to get into our food and water and maybe even onto shared chopsticks…just saying (listen in to hear the lowdown on all these and more!) Essentially hoomans are the traffickers, people! In fact one of the things that surprises people the most is the very high prevalence in young children and the clusters of positive tests & identical strains within families…but once you learn a little more about this bacteria…it won’t surprise you at all. (more…)
As an avid reader of medical news I face a barrage of headlines both domestic & international everyday. I feel this is important for many reasons – not just so that I know what’s being said about their medicine but what they’re saying about ours as well! Anyone see the jaw-dropping headline last week: Could Probiotics be bad for your gut? Yep.
Now how many of you didn’t make it past the headline? It’s hard isn’t it.
There’s almost a reflexive shutdown for many of us to dismiss such a proposition as simply ‘ridiculous’, surely on par with our response to an article from a climate skeptic…as we shake our heads with ‘you gotta be joking right?’… but unless we read on, we’ll never know. (more…)
Too many times we see thyroxine treated patients on the ‘set and forget’ setting. Often, they’re taking the same dose they started on a decade or so ago, in spite of weight changes, ageing of course and new comorbidities. They’ve undergone limited monitoring, with just an annual in-range TSH viewed as confirmation of efficacy. But is it? Many patients’ re-emerging hypothyroid signs and symptoms would suggest not.
A recent Medscape review article of a large study by Gullo et al 2017, identifies another shortcoming in the rudimentary way we ‘replace thyroid hormone’, in all patients but especially in those who’ve had their thyroid removed. (more…)
I’ve had my nose in all the research on Gilbert’s Syndrome again..watch this space…in the interim just thought I’d share this image and a couple of important details I may not have been able to convey when you last heard me talk (very fast!) about this important and common polymorphism:
- While the incidence is approximately 10% of Caucasian population, rates are heavily influenced by ethnic background and the highest rates (up to 1/4) are seen in Middle Eastern populations
- Gone are the days of thinking this condition only effects bilirubin levels and the enzyme responsible for its clearance – more recent research has shown over 3/4 of patients with Gilbert’s Syndrome have multiple SNPs that compromise clusters of enzymes within the glucuronidation pathway – with varying patterns – this goes a good chunk of the way to explaining the variability we see in bilirubin levels and symptom pictures across patients all deemed to have Gilbert’s Syndrome. This also explains why figures of reduced glucuronidation activity vary anywhere between 10% less to 90% less! It depends on your cluster..but the average reduction is around 50%
- UGT enzymes, the ones affected in Gilbert’s, are also expressed all the way down the GIT and constitute important food and drug handling. These UGTs are most active in the small intestines,as you can see above, but may explain why Gilbert’s patients are ‘more sensitive’ to medications than just paracetamol!
- And are you still thinking you need to run an $$$ gene test to confirm your Gilbert’s hunch in a client whose bilirubin sits consistently high normal or high? Think again… here’s a great little diagnostic short-cut that even the Royal College of Pathologists Australasia cites as sufficient evidence to confirm the polymorphism:
In the face of elevated total bilirubin levels and in the absence of liver pathology or increased haemolysis to explain this..”If the diagnosis is uncertain the serum bilirubin fasting level can be measured and should exceed the non-fasting level by >50%.”
Nice. So that means you only need to demonstrate that the patient’s fasting total bilirubin levels go up by at least 50% compared with their fed levels and BINGO you have your diagnosis. Much easier. Oh and this image comes from an interesting paper from Tukey & Strassburg 2001 – but is probably not for the faint-hearted 😉
Stay tuned for more 🙂
Just new to this condition and need a soft place to land with understanding Gilbert’s Syndrome? This previous UU30 is just the thing! Affectionately called Gilbert’s Girls because in particular it details a set of twins with this condition, this short audio explains the basics about this common polymorphism and why we tend to see a lot of patients who have this…even if no one has pointed it out to them yet! You could be the first to provide them with this important understanding about how genetics is impacting their detox pathways, changing their sex hormone handling and perhaps setting them up for both mental health issues and some serious upset guts! Better still, what to do once we have that diagnosis.
With many of the mentoring sessions I run, I suspect there’s often a misperception that the learning is one way. Part of what thrills me about being a mentor is all the learning opportunities I am personally presented with.
Recently, I had an exceptional example. You see, I am privileged to have a colleague, Sonya Cacciotti, in one of my groups. She has worked for over a decade in tandem with an extraordinary doctor up here in Ballina, and they have had a particular long-standing interest in sleep quality, assessment and management. Consequently, her knowledge in this area is exceptional, particularly with regard to not just obstructive sleep apnoea (OSA) but the much more and often missed, upper airways resistance syndrome, that is especially common in women. She’s been in my ear on numerous occasions and during group sessions saying, ‘Watch out for this Rachel, it’s more common than we all realise and could be behind many people’s problems‘.
As luck would have it, I have seen a series of cases now within quick succession that all look suspiciously like undiagnosed apnoea or airways resistance. I was listening all along but now Sonya’s wise words and these conditions have my full attention. (more…)
Not long ago, Kathryn Simpson and I were sharing a hotel room on yet another work trip to somewhere. The lights were out, it was way past our bedtime and we were just gasbagging incessantly like a couple of teens, when a thought pops into my head:
“Hey Kathryn, back when you were my student, did you ever imagine this scenario in the future – you know us being colleagues and friends and having slumber parties full of laughing?”, she replied, “Well no, but you know what I REALLY never could have imagined in my wildest dreams…the Australian Naturopathic Summit and you inviting me to be a co-founder of something that’s had such a big impact! That one I just didn’t see coming!”
Well to be honest, neither did I but sometimes I just have an idea that won’t leave me alone and is too important and too promising to ignore. Three years ago when I shared one of these, the vision of a national naturopathic conference by naturopaths for naturopaths, that would lift us all professionally, offer collaboration over competition and provide us the highest level of non-biased education, with Nirala Jacobi, turned out she’d been visited by the same thought bubble. Then I approached Kathryn, who was working for me at the time and pretty fresh out of uni but full of passion and drive about building a better ‘new’ naturopathic career path, one that supported rather than splintered those emerging out of great courses into a harsh, challenging professional space.
Time-travel forward to now, we are just 10 weeks(ish) out from erecting the chai tent, marquees and lanterns, for the second inception of this extraordinary thing called the Australian Naturopathic Summit 24-26th August at Lennox Head.
This is the culmination of 3 years of work from us, one paid project manager and the exceptional generosity of over 25 of our naturopathic idols, thought leaders and torch bearers who are donating their time to present plenaries, workshops, case studies, panel discussions… because they believe so strongly in the cause and the need for such an event.
If you think I am running out of breath between all these words..I am. This thing…has taken on a shape and life much greater than even we had envisioned.
If you follow the work I do – you’ll know that I am passionate about collaboration over competition. I could never have come to this place in my career without the input of many (some who remain on speed dial even now!) and through my mentoring programs, the infamous RAN internship and hopefully times we’ve come across each other…I’ve encouraged you to do the same and by doing so, grow bigger together. So just imagine the value of collaborating face-to-face…over 3 days…at a festival in Lennox Heads… ? And not just for 1 hour, but for 3 full days with 100’s of other practitioners from all areas, specialities and locations. Oh and if you’re thinking you’ll just have to wait ’til the next one’…SPOILER…there is no guarantee of a next one! Being a passion project that we 3 donate our time to, for you, it requires your support to keep it going.
So with saying all that…..(cajon roll…that’s a drum for you non-hippies)….It is with great excitement and enthusiasm that today I can announce a special deal for RAN subscribers. Yes….that’s you! Just like myself you all see a need to grow and build skills, knowledge, competence and confidence in the practice of naturopathic medicine. Come join the very best of your profession and take up this special offer to attend the second independent Australian Naturopathic Summit held in Lennox Head on 24-26 August.
To get 15% off a full 3 day pass enter Festival at the checkout
Book your tickets before they run out at www.australiannaturopathicsummit.com.au.
For information or questions about this special email email@example.com.
This summit is unprecedented in Australia for the following reasons:
- It is free from commercial bias
- It is about professional development, improving our practices and career paths, not products
- The primary objective is to support the Australian Naturopathic community, celebrating our diversity and creating a platform for our own Naturopathic torch-bearers in various areas (Practice, Research, Herbal Manufacture, Corporate Health, Entrepreneurship etc.) to help light the way for the broader professional community
This year our theme for ANS 2018 is ‘Coming Together On Common Ground’
Naturopathy has many different practices and paths,
but we all work for the same purpose, guided by the same principles.
The ANS 2018 program has three distinct themes across the 3 days…
- Friday 24 August: Custodians of the Vital Force
- Saturday 25 August: Upskilling Your Clinical Practice
- Sunday 26 August: The Business of Business Development
The morning of each day consists of plenary sessions followed by a lengthy lunch break that allows for networking, beach walking, guided outdoor meditation, perusing the vendor village, or simply enjoying the festival atmosphere in the beautiful outdoor location that our summit is surrounded by OR for those die-hards some amazing case studies presented by the likes of Jason Hawrelak, Dawn Whitten and Sandra Villella. Afternoon sessions are workshop-style, designed to be more interactive. There are plenty of workshops to choose from to keep you riveted and inspired.
We have created a jam-packed program to do just that.
Download your copy of the full program here!
ANS 2018 – come join the very best of your profession.
Book your tickets before they run out at www.australiannaturopathicsummit.com.au.
To get 15% off a full 3 day pass enter Festival at the checkout.
For information or questions about this special email firstname.lastname@example.org