We Need To Talk About Kevin…aka B3

Just like Kevin, ‘Niacin’ is profoundly misunderstood and consequently runs the risk of doing us harm. Unlike ‘Kevin’, we can’t watch the movie to see how this (our arguably excessive use of the wrong forms of B3 in supplements and fortified foods) is all going to play out, so that we can be suitably alarmed and start making some different choices. The risks that follow from our B3 ignorance are twofold:

One comes essentially from our gross under-estimation of this B vitamin – we’re stuck in the Pellagra Paradigm, believing that prevention of the 4 D’s is confirmation of adequacy.

The second, is our lack of discernment when it comes to the different forms or precursors of B3 & our unfamiliarity with their very specific physiological roles – good and bad.

In this regard we’re all likely to say, ‘Well back up there 1 second, we do know that Niacin (aka nicotinic acid) is different from the other forms!’  Producing flushing, yes.  Used as a lipid lowering agent in pharmacological doses, yes. But can you tell me, which serious concerns and biochemical disruption is shared between both gram doses of niacin and everyday ‘routine’ mg doses of niacinamide? Yep, that one, the so-called ‘safe’ one. Better still, can we all list the various B3 forms in order from most to least potent, in regard to their capacity for NAD+ promotion in the human body? 

Because this is now the definition of B3 ‘adequacy’ or ‘optimisation’ according to modern scientific understanding & it is a long long way from the absence of  Diarrhoea, Dermatitis, Dementia and Death!

In fact, the boosting and optimisation of NAD+ pools in the human body is key to life – a long and healthy one according to the current research consensus – and its depletion is akin to ‘death’, or a faster one, anyway.  From increased metabolic disorders, mitochondrial dysfunction, impaired gene stability (cancer, infertility etc) and higher rates of neurodegenerative disorders, just to start, these take up the lion’s share of our chronic health burden and battle that currently dominates the dis-ease landscape. And more niacinamide might just make that worse. 

I didn’t mean to to alarm you. I am alarmed.  Want to deep dive into this yourself?  Start with this older but still brilliant review article by Bogan & Brenner.  Want me to hold your hand while we jump off the high platform diving board together into this vastly different and powerful new understanding of B3?  Let’s do it!

The Balance of B3

Most of us have been taught to ‘balance the Bs’ when supplementing, which discourages the use of single B vitamins in case this interferes with the regulation and roles of others. In reality, outside of a couple of dynamic duos like B12 and folate, there is little concrete information & evidence of this. In the case specifically of B3, however, we now know, the risk of an excess of the most common B3 forms found in supplements and fortified foods, results not only in disruption of other nutrients but imbalanced B3 biochemistry itself. Given B3, in its coenzyme form NAD+, is regarded as highly valued currency in the prevention of many diseases, as well as the key to our optimal health and longevity, it’s critical to understand the different forms and functions of the various B3 sources.

 

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A Sprinkle Of Precursor & A Dash Of Co-Factor?

There’s enormous potency in nutritional medicine for mental health but it ain’t in the form of a ‘dash of precursor here and a sprinkle of co-factor there’, like some may have you believe.  Many nutritional prescriptions can look good on paper but that’s the extent of it, take the suggested use of glutamine for GABA production, for example.  Sure it can be said to be a precursor (so is glucose!) – so will higher intake of this equate to higher production of this neurotransmitter? Ah, no. The reasons relate to distribution and hierarchy of use for this amino acid, as well as determinants of glutamatergic neuron activity.

Why would we limit our prescriptions to precursors, anyway, when we have 2 amino acids at our disposal, whose oral supplementation is known to translate to higher CNS levels and their actions and efficacy as major inhibitors of neuronal firing (akin to GABA), involves no modification nor maybes?!

Hello, Taurine & Glycine, where have you been all this time?

While, many of us may have been using taurine in combination formulas for mood, chances are you’re not entirely clear why sometimes those work and sometimes they don’t.  The answer may be in the regulation of CNS taurine transfer & balance- sometimes the people who need it most, have the least capacity for its uptake across the BBB.  This is well-established in neurobiology, but news to many nutritional and integrative health professionals, who have been using it in patients where Glycine, in fact, makes more sense. So while taurine has myriad impressive strings to its bow in relation to mood-modulation and powerful protection of brain structure & function, Glycine, has an extensive network of receptors throughout the brain and spinal chord, enabling it to exert inhibitory effects, second only to GABA itself. And, most importantly, BBB transfer of this amino is not subject to the same impediments that we see with taurine.  These are two of my most frequent and favourite mood-modulators, affordable and accessible when used as single ingredients, for patients, with anxiety, addiction & sleep disorders etc but understanding how they work (and when they won’t) is essential in choosing which one to use, when. 

For example, do you know the Tmax for either of these oral supplements?  How long it takes, to create a spike in patients’ plasma, better still their CSF, and therefore speed of onset of action?  What about their elimination half-lives to guide your understanding their duration of action and therefore the timing of follow-up doses?

When we’re trying to realise the full potency of our medicines – these are important details to know that convert our ‘prescription potential’ into something powerful. Just like die-hard herbalists will tell you, its an art and a science and this is true in nutritional medicine as well.  Don’t skimp on the science!🤓

 

Both taurine & glycine have a claim-to-fame as amino acids that effectively calm an over-revving brain, via their net inhibitory actions within the CNS.  They achieve this via different means and while in some circumstances, one, either or both will is the result of differences in the regulation of their BBB transfer, pharmacokinetics, as well as add-on benefits or detractors, unique to each.  Learn how to use both of these powerful and affordable mood-modulators, to their fullest, and be more able to know ‘which one when’, by listening to this latest narrative review.

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I’m Gonna Take My Vitamins…They’re Good For You, They’re Good For You!

Don’t know this thrash anthem for all nutritional medicine practitioners written by Supernova about 20 years ago?  Do yourself a favour and check it out!! It makes me laugh to the point of tears every time.  What also got me giggling recently was a coffee catch-up with a fellow nat (relax, it was decaf people!) Both being active women approaching the half century we found common ground discussing our ‘war wounds’. She, an ankle injury, me, lax ligaments in my knee thanks to touch football minus any pre-season prep whatsoever. I was waxing lyrical about the wonders of swimming, which I’ve taken up to heal said gammy knee, at which point she asked, “What are you taking for it?” 

My mouth dropped open & nothing came out…because the answer was *!NOTHING!*😂
At which point, she mentions a couple of supplements I have *!ON MY SHELF!* that really helped her ankle 😂😂

I text her 3 days later with, “Man, our medicines really work!!”  You see, like the song says,  I do ‘take my vitamins’ and ‘they’re good for you! Good for you!’ – just this physician health yourself thing can be a blinking full time occupation sometimes! Anyway, it got me thinking about how we choose the products we do.  So turmeric caps are part of my new regime and they seem to be working a treat. I stock one brand only.  Now how did I come to that decision amongst an ocean of options?!  Well in this instance, I had asked a colleague who works OTC and dispenses a variety of turmeric products en masse – better still she sees those people come back either for more…or not.  I’ve found asking my well-placed peers about these kind of products invaluable!! But there are so many different ways each and everyone of us may have made product choices – ethical concerns, personal experience, research, a teacher, mentor or rep’s influence.  Anyone who has done the UTAS post-grad, of course, has exhaustively analysed the options, complete with comprehensive spreadsheets of all comparative products…god love these guys!! But for the rest of us mere mortals, how do we make such choices?

Let’s just talk turmeric for now, I’d love to know…

My gorgeous sister first brought this ditty to my attention & we’ve had a wonderful trip down memory lane today (with our elderly mother as our hostage as we both belt out the lyrics in laughter down the speaker phone)…she’d be cross if she didn’t get the credit here, rightly so 🤣

I’m gonna take my vitamins!
(Vitamins! Vitamins!)
You better take your vitamins!
(They’re good for you! They’re good for you!)

You better take your vitamins,
Two by two!
Two by two!

Someone Say Sulphur?

That’s not a word you hear often spoken by people practising nutritional medicine. Which is odd. I mean outside of the whole, ‘I’m not good with sulphites so I just have to add these magic drops into my glass of red so I can knock back my share,” often overheard at our conferences… it’s like this essential macromineral, pivotal to human health for things like barrier function, antioxidant defence and our basic ability to create the white cells for immune defence (for that matter), detoxification, musculoskeletal tissue integrity etc has just not received its due attention from us. Not entirely surprising given 1) there’s no RDI and 2) there’s no lab test to assess an individual’s status and how about 3) because we were never taught about it! 

But the biggest ‘call to action’ here is that, in spite of items 1, 2 & 3, we’re ‘prescribing’ Sulphur Strategies all the time!

Take one of my favourite examples; GAGs. Glycosaminoglycans like Glucosamine sulphate (not the crappy, found to be not as effective, other forms that we now see more commonly) hit the headlines back in the noughties as an effective arthritis remedy. This is one of the 100s of our body’s ‘end products’ of its endogenous Sulphur Stream.  We naturally make this in adequate amounts to ensure the integrity of our joints (and many other tissues of course!) when we have enough Sulphur in the ‘top pool’ (organic Sulphur) to trickle down to the 2nd pool (Inorganic Sulphur), therefore creating a constant essential supply of something known as ‘the universal Sulphur donor’ – ‘PAPs’, to its friends 😉 Like a waterfall, it helps to have a good flow from the top to increase the likelihood we’ll have anything to ‘show’ at the bottom. 

So when we give a patient Glucosamine Sulphate it may well help. Or not. But did we ‘treat the cause’ of their Sulphur problem? Should we have treated higher up, increasing the size of either the organic or inorganic pool to have improved and widened the benefits for their health? Or, as is equally common, actually identified why someone might need more Sulphur than most – due to increased demand and losses?

Herein lies my reason for liking this particular Sulphur story so much. The common medication that places the highest ‘demand’ on Sulphur (due to its need for detoxification) is paracetamol. There’s no debate regarding this – just absolute scientific consensus. NSAIDs and steroids also negatively affect the Sulphur status of individuals, as does Vitamin D deficiency and chronic mild metabolic acidosis. Now how commonly are these phenomena co-occurring in our patients afflicted with arthritis?  And traditionally of course, what was the remedy for arthritis? Sulphur springs.

Unseen Sulphur – Time To Take A  Look
If you don’t have a clear picture of the gross daily requirements, determinants of altered individual needs, sources, regulation & associated deficiency picture of Sulphur, you’re not alone.  Turns out this essential macromineral remains ‘unseen’ by most, even though you’re probably writing prescriptions every day that have Sulphur as their key component.  From the simple: Taurine, N-acetyl cysteine, Protein powders, to the sublime: Brassica extracts & concentrates, N-acetyl Glucosamine, Alpha Lipoic acid etc. In order to use these Sulphur strategies successfully and safely, however, we need to fill in the missing detail on its metabolism, the difference between the ‘organic’ and ‘inorganic pools’, how regulation regularly goes wrong even in those seemingly consuming enough and how to balance the risks of this reactive medicine with its substantial therapeutic value.  This recording comes with a great clinical tool to help you, at last, see the Sulphur strategy most indicated for your patient.

 

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I Spy…

I say: Biotin, Broccoli Sprouts & Bone Broth
You say….?

If you said: ‘Sulphur’, go directly to the top of the class, passing ‘Go’ & collecting $200 on your way!🤓  If you nervously said…”I don’t know, they all start with ‘B’ ?”, you are not alone.  In fact, most integrative health professionals aren’t aware of the Sulphur Strategies they’re using, probably, everyday.  But it’s time we all were.

How about this list?
Glycosaminoglycans (GAGs for joint, gut etc tissue integrity),  Cerebroside Sulphate (Myelin),
Metallothionein, Glutathione, Hydrogen Sulphide (H2S), Co-Enzyme A, Lipoic acid, SAMe, are just some things Sulphur is essential for.

I could go on…and on and on.  You see Sulphur, in spite of being an essential macromineral (adult dietary requirements > 1g per day) and critical to health, remains largely unseen.  Often we don’t know when we’re writing patient prescriptions that actually we’re using a particular vehicle for Sulphur and therefore we’re also not able to discern which, of the very long list of options (dietary and supplements), makes the most sense in this patient at this time. We’re not to blame, not many ‘possess the power’ to see it, it seems. Por old essential, irreplaceable Sulphur doesn’t even have an RDI. But the time has come to take a good look.  We need to know how patients are able to meet their needs, who needs more and how, very commonly, someone who is seemingly ‘consuming enough’ may still exhibit a functional Sulphur deficiency with poor musculoskeletal tissue integrity, low white cell replication capacity or higher oxidative stress load etc and in those who do have a shortfall, how to treat successfully & safely.  Who needs a top down approach (more protein, methionine, cysteine, bone broth) and in whom would that be a risky path and using ‘downstream’ Sulphur products instead would be a better balance of pros and cons?

Because all Sulphur needs to be handled with care.

That’s right.  Like other highly chemically reactive minerals, with reactivity comes risk – a great potency that requires careful consideration of both form and dose, so that we can harness this power for good not…well evil’s a bit strong…but how about, for not-good.  I’m a bit of fan of Sulphur and using Sulphur strategies in my patients. I think it has interesting echoes with our past: the ‘healing’ waters of a Sulphur Spring and of course even further back the old ‘brimstone and treacle’ medicine of eons ago.  This paper by Nimni in 2007: Are we getting enough sulfur in our diet? got me thinking about Sulphur again in a contemporary context, over a decade ago, I’ve done a lot more thinking, researching and prescribing since then but it seems that Sulphur still remains ‘unseen’ by most. But with the rise and rise and rise of popular Sulphur-based supplements (alpha lipoic acid, GSH, N-acetyl glucosamine, Brassica & Allium extracts and concentrates, N-acetyl-cysteine etc) I think it’s time to talk.

Unseen Sulphur – Time to take a look

If you don’t have a clear picture of the gross daily requirements, determinants of altered individual needs, sources, regulation & associated deficiency picture of Sulphur, you’re not alone.  Turns out this essential macromineral remains ‘unseen’ by most, even though you’re probably writing prescriptions everyday that have Sulphur as their key component.  From the simple: Taurine, N-acetyl cysteine, Protein powders, to the sublime: Brassica extracts & concentrates, N-acetyl Glucosamine, Alpha Lipoic acid etc. In order to use these Sulphur strategies successfully and safely, however, we need to fill in the missing detail on its metabolism, the difference between the ‘organic’ and ‘inorganic pools’, how regulation regularly goes wrong, even in those seemingly consuming enough, and how to balance the risks of this reactive medicine with its substantial therapeutic value.  This recording comes with a great clinical tool to help you at last see the Sulphur strategy most indicated for your patient.

 

The latest Update in Under 30 has landed!!!

You can purchase Unseen Sulphur – Time to Take a Look here.
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The Year For Iron & Gin

A few things really took up a disproportionate amount of our time & attention in 2020: Zoom, Mask Fashion & Gin based hand sanitiser. On a personal note I need to confess another: Iron. So while my one true (mineral) love remains zinc, iron answer hunting has infiltrated a lot of my days and some nights! There’s no hiding it…3 out of my 12 UU30 episodes this year have iron in the title 🙄 a sure sign its been on my and my mentees’ minds and sitting across the desk from a lot of health professionals in human form. And this affair I’ve been having, like most, started innocently… it started with a just a ‘quickie’, you know a quick question from a well meaning practitioner: “So, what’s expected in terms of ferritin levels across pregnancy?”

There are 2 answers to this.
The first reflects the practice guidelines for GPs and obstetricians in most western countries: > 30 mcg/L regardless of trimester
And then there’s another that is [ahem] evidence based, accounts for the essentiality of physiological anaemia in pregnancy &, naturally, trimester specific

There’s a big Fe-ar factor at play when it comes to answering the question, ‘Does this woman have enough iron for her and bub?’ Public health and practice guidelines appear to assume we are ‘guilty’ until proven innocent, patients are worried and health professionals are plagued with their own doubts about whether they’re ‘reading this right?!’  I’m sure we’ve all been in the situation where we feel our pregnant patient is doing well iron wise early in pregnancy, only for them to have that routine antenatal 28wk GP/Ob visit and discover a total panic has descended upon the patient and the rest of the health care team, with calls for ‘IV Iron STAT!’ But 28wks is the height of haemodilution right?  You know, that time when ferritin, Hb and Hct should look at their lowest, right?   There certainly is a limit to how low we want any pregnant woman to go – for her and her baby’s health but that limit is not the one routinely used and the truly evidenced based one is going to shock you. So what? What’s the issues if we are a little Fe-ar based about Fe, resulting in hypervigilance (calling a deficiency when there isn’t actually one) and giving them a ‘boost’ of more iron, surely this is good news ultimately for baby’s iron levels and for lactation and for…sorry what? No?

There’s a U shaped Curve for Iron supplementation & serum Ferritin levels in pregnant women?!!

Say it isn’t so!!  But I can’t.🤐

Pregnancy Iron Balance – Sorting the ‘Normal’ from the ‘Noise’

It starts with a simple enough question: What should women’s ferritin levels be in pregnancy? But the answer will surprise many. There are in fact two. The first reflects the practice guidelines for GPs and obstetricians in most western countries regardless of trimester and then there’s another that is arguably more evidence based, accounts for the essentiality of physiological anaemia in pregnancy & is also, sensibly, trimester specific. To challenge the ‘noise’ and have the confidence that ‘normal’ is ‘enough’,  we need to better understand the mother’s protective physiological adaptation of iron regulation and the intricate systems the foetus has to ensure its needs are met.  This of course is not without limit, so we need to also be clear about the maternal serum ferritin threshold for negative impact on the foetus and newborn. Getting the balance or iron right in pregnancy for both mother and baby, is perhaps easier than we have been led to believe. 

 

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IV Iron To The Rescue?

When I deliver foundational nutrition training to GPs I talk tough.  It’s a tough field, right?  Compared with the relative certainty of pharmaceuticals, their established pharmacokinetics, their sophisticated delivery systems to ensure high bioavailability…trying to fix micronutrient deficiencies in patients can feel a lot like you’re trying to perform minor miracles. Take iron for something different, its homeostasis pivots on its tight regulation at the gut wall – and this is a wall that is very tight!! At best you get about 10% of a supplement taken up, at worst you get none and the harder you push & the higher you go with your dose…the lower the fractional uptake.  Tough stuff, right?!

It’s about at this point in my talk I read their collective minds and say, “I know, you’re thinking, oral supplementation is for suckers – what about we bypass that road block and use IV?!”
[Ok, I definitely use nicer words than this]

And then I put up a list of pros and cons about IV micronutrient repletion: ‘100% bioavailable’ & ‘Bypasses the body’s regulatory systems’, go on both!  You see, time & time again we discover, when we think we’re outsmarting the body, it still manages to outsmart us.  There are some exceptions to this – some nutrients (Vitamin C) and some contexts (late pregnancy iron deficiency) but the broader promise of ‘rapid replenishment’ for everyone, in your lunch break, via an IV infusion..is not realistic, responsible nor without risk.  Don’t get me wrong, I am an advocate of appropriate IV Fe use and have encouraged a small fraction of my patients to take this path. However, given the dramatic rise in prescriptions for this since 2013, I think it’s time to stop and seriously review each element: In reality what does it achieve and in whom is it a responsible recommendation; Was a risk benefit analysis performed for & communicated to each individual & was the remaining risk mitigated?

Think anaphylaxis is the major concern?  It might be the most lethal but there are more serious concerns due to higher incidence with newer preparations.

So, how well do you know your different IV iron forms, and their predilection for potential problems? And have your answers ready to all the questions raised above? In order for all involved to make an informed choice (both practitioners and patients), we must. 

You’re welcome 😉 and hey welcome back to tough talkin’ Tuesday…

While rates of iron deficiency and related anaemia continue to grow, the increase in prescriptions of IV Fe have expanded exponentially in western countries. What is behind this change in practice regarding how we treat iron deficiency and does it match with responsible prescribing? Do the benefits always outweigh the risks?  And while we’re on the topic, who is most likely to benefit and what are all the risks? In light of a current class action in the US, relating to a lesser talked about adverse event associated with IV Fe and recent complaints here in Australia against GPs, allegedly due to inadequate information to enable informed patient consent…it’s time to answer these questions and more. When is IV Fe a means of rescue and when is it a risky repletion strategy with no evidence of advantage?

 

 

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Creatine Supplements: Brain Over Brawn

I think I’m finally able to put my ‘late-90s-Creatine-frontline-trauma’ behind me.  Back then, like many good nats in training, I was working the trenches of the health food stores and was faced on a daily basis with two types of men with two types of Creatine questions. The first type was scrawny and would ask, ‘will taking this help me build muscle?’, the second, built like the proverbial brick *&#@ house, asking, ‘will it help me build more muscle?’ Cue, eye roll.  Come on… any of you current or ex apothecaries, pharmacy or retail assistants…you know exactly what I’m talking about!!! So deep was this trauma that I put Creatine as a supplement, into the ‘strictly sports folder’ in my brain (the bit in the deep dark back with other rarely accessed items) and never gave it much thought when I left retail and moved exclusively into private practice. Even back when I was a sub-editor for the Braun and Cohen 4th edition, it was apparently still too soon. 

A great colleague of mine, Emily Bradley, had written the chapter on Creatine and, in doing so, presented compelling case to reconsider this supplement as offering great therapeutic potential well outside of the sports-field.
That one was accidental 😂

I actually remember reading that chapter, especially the sections on Creatine supplementation for neurological & psychiatric conditions and thinking….WOW…who knew?! ??!! Well, clearly Emily for one 🙄 and also every author and researcher whose work she had read…so that made quite a lot of people actually!  But another [ahem 😳] several years had to pass before the research into Creatine and the argument that this has been a grossly over-looked CAM option in mental health, beat down my door and finally got my full attention.  Better late than never.  And boy, do we all have some catching up to do! 

Let’s start with 5 fun facts:
1. Creatine is critical for energy – like cellular currency it ‘tops’ back up our funds, after increased spending, everywhere, including the brain
2. The Brain consumes >20% of our resting energy expenditure & is fifth on the organ list in terms of highest concentration of this molecule
3. Creatine CNS depletion is a thing – and it happens in a wide variety of scenarios – from the seemingly benign (like chronic sleep deprivation) to the more sinister (neurodegeneration)
4. This then leads to higher Glutamate, Oxidative Stress & a spell of other sorts of ‘brain badness’
5. Oral supplementation can cross the BBB and ‘refuel’ the brain and correct the Creatine deficit

Out of the thousand or so pages of research on this topic, I’ve just indulged in, there are several great reviews to pick from…it’s a tough call to make but perhaps this older one by Patricia Allen remains my favourite. This marks the beginning of a new era…I’m putting the trauma behind me & moving on & hope you’ll come along too!

When we recap the contemporary science of shared pathophysiology in mental health, we have: oxidative stress, impaired neurogenesis, monoamine deficits, glutamate excess, hypometabolism & mitochondrial dysfunction.  When we ask researchers which of these supplemental Creatine might be able to assist with, we get hits at each and every point.  Turns out, Creatine’s capacity for enhancing performance is not limited to athletes but can be capitalised on for anyone vulnerable to a CNS shortfall.  Ignored for far too long, this economic and impactful brain nutrient is coming to the fore for psychiatric and neurological disorders.

 

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Where Could Should Would All the Iron Go?

I love a good iron question.  It makes me emit a sound like Jack Sparrow might, when faced with something pleasingly piratey 🏴‍☠️  Lucky because I am asked SO MANY GOOD ONES, SO OFTEN!!  Being one of the earliest minerals discovered to be essential…we know so much more about it than the other latecomers but that ABSOLUTELY DOES NOT MEAN WE KNOW IT ALL!  Sorry…I also tend to shout with excitement when faced with a good iron question. Yes, run for cover, I do have an even higher volume setting 🙉🙉

Just this month, I received this little ripper:
I was wondering about the expected timeframe for iron supplementation to improve ferritin levels?  

Yes of all the nutritional answers we can quickly ‘google scholar‘ our way towards, actual realistic expectations for response to treatment, is rarely an easy find! And yet, this critical clinical detail seems to be the thing that can leave so many of us stranded at sea with our patient prescriptions. Did I give up too soon? Or should it have worked already by now?  Some of the best naturopathic approaches are easy to execute…but when those patients come back after maybe a few repeats & perhaps minimal change you realise, you have a major piece of information MIA: what to expect.  Rapid relief or a cure by Christmas?!  Aka, it won’t happen overnight but it will happen.  So, great, let’s talk ironing out our expectations around responses to iron repletion!!!

First – We need know where iron goes First!

So if your iron deficient individual is actually suffering from iron deficiency anaemia, no guesses who the VIP (very important priority) is during repletion! Consequently, you can throw lots of iron at somebody (oral or even IV) and find there’s limited increase in their ferritin initially, a rather ‘disappointing’  show actually but if you keep your other eye (Jack Sparrow style) on their FBE, you’ll see the iron is being funnelled into producing haemoglobin and red blood cells. Sneaky! And if sensible can ever be associated with sexy…this is it! Ferritin is for iron surpluses only and right now, we ain’t got none!  Medical texts advise that in these scenarios, confirmation of efficacy equals an increase in Hb levels of approx 10g/L a week. In reality, no one wants to turn patients into pin cushions (esp when we’re trying to build iron back up not keep springing leaks!) so we might retest in a month or more. But an increase in Haemoglobin of 40g/L per month sounds rather aspirational with oral iron, doesn’t it!!

If we bring in the personalised perspective here, we recognise that most of our anaemic patients may only be just on the wrong side of the line, with values at 110g/L and tbh we would be shocked and a little worried if this grew in a month to 150 in a woman! Erythropoiesis is not the result of iron alone!  But the point is, if the iron replacement is working well enough, you should be moving out of anaemia within a month not a millennium!

And only once this job is done will the ferritin start to build.

So what if your patient isn’t anaemic – just low in ferritin? Well then, if you’ve a) fixed the leaks (unintended or excessive blood loss anywhere Rectal, Renal, Repro) and b) buoyed bioavailability (HCl & prebiotics while minimising iron-blocking issues like excess Ca, tannins etc) and c) corrected for low intake via a sound supplemental approach (daily dosing for those not consuming much dietary iron and alternate days for the rest) you should be seeing ferritin increase within the month of at least 10mcg/L, but hopefully more.  And if it’s not? Go back to the beginning of this little to-do list…because it means we’ve missed something. Doh! 

The Iron Package

Yes it’s true the learning doesn’t ever end and as I’ve continued to learn about new iron research I’ve added to our one-stop-iron-resource-shop..the Iron Package.  Earlier this year we added a new clinical cheat sheet with some other important numbers on there you want to have at your fingertips whenever you read iron studies.   So if you’ve already purchased and have access to the Iron Package…SURPRISE! 🤩   Go back and look again and if the iron package is not already on your ‘bookshelf’ there’s no time to waste!  

 

You’ll never look at iron studies or your iron-challenged patients the same way.

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Walk Towards The Light!

Now find a comfy spot everyone & I’ll tell you a story…’Once upon a time, a long long time ago, we lived our days out in the dark, regarding potential calcium dysregulation!’ But ever since serum Calcium has become a standard lab included in most routine screening tests (General Chemistry aka ELFTs) abnormal calcium handling is no longer an ambush for patients of ‘stones, moans and abdominal groans’, as the saying goes in hyperaparthyroidism.  A diagnosis historically only mad, when someone presented with this constellation of rather advanced symptoms. But actually being able to identify your patients’ typical blood calcium levels offer us so much more than just a heads-up re parathyroid disease

 It may tell us something about their Magnesium status, cardio cautions, be a bit of ‘bone barometer’ and probably most immediately important, flag their suitability for calcium supplementation!

Yep…rather than the current-criminally-crude-calcium-checklist:
1. Patient is female
2. Patient probably doesn’t consume enough calcium
3. Patient may be at risk of osteoporosis (yup…that accounts for practically every woman, right there!)

… and then the indiscriminate prescribing of calcium doses that could rarely be achieved in a single meal…(and hence run the risk of over-riding our critical regulation of this edgy electrolyte) we could…wait for it…individualise our approach!  I know, like a broken record 😂

But seriously, if you just do a full review of the vast literature on this topic, what?! Not enough time?! How about then, just skim read a couple of key papers? Still baulking at that?…maybe just a wafer-thing editorial (??!) will tell you that, consuming elemental amounts of calcium (> 250mg), that are beyond even the biggest Dairy Diva’s Diet Diary, may be deeply problematic for many.  And guess what…this doesn’t pertain to supplements alone…even calcium fortified foods are not free from concern!  But let’s not let yet throw all our calcium fortified foods in the same bin as the folate ones we did a while ago!!  Let’s step out of the dark and into the light that shines upon us, care of fasting serum Calcium measurements, to help us recognise whether Calcium is the cause, the consequence, a cure or a curse for person sitting in front of you 🧐

The Calcium Conspiracy Controversy Continued

The Calcium Conspiracy arises primarily from misperceptions about it being ‘the boss of bones’ but becomes more of a controversy when in spite of ongoing advice for broad-scale use we review the evidence and have to acknowledge that the recommendation to supplement post-menopausal women with large doses of Calcium, not only lacks strong evidence but may cause harm to some.  In this detailed discussion of the two schools of thought – Rachel finds a position somewhere in between. Reinforcing the need for an individualised approach and personalised risk benefit analysis while teaching you how to undertake this in every client.

 

The latest Update in Under 30 has landed!!!

You can purchase The Calcium Conspiracy Continued here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
You can become an Update in Under 30 Subscriber to access this episode and the entire library of Update in Under 30 audio’s and resources here.

 

 

Trends not Truths

Trends in mineral supplements are like music genres, you can pick which ‘decade’ they were formulated very quickly. But instead of going by clothes, hairstyles or even the style of accompanying  music video, it’s all about the form – the ‘thing’ the mineral is bound to, that gives the game away.  While mineral carbonates , sulphates and oxides seem to many of us contemporary clinicians, pre even MTV, amino acid chelates take me back to a time when I was wearing shoulder pads in everything, even my pyjamas. It was called power-dressing and needed to be adhered to 24/7, you see.  Then along came fancy forms like orotates, aspartates, hydroxyapatites as we moved confidently into the 90s…well, as confidently as you can, when the Y2K bug may ‘end life as we know it’ come NYE. The dawn of the new millennium saw us embracing picolinates and bis-glycinates in a big way and for the last little while, citrates have really been having their time in the sun.  But you know what…here’s a few things you MUST know…

  1. These are trends, not truths
  2. Every mineral has its Mrs Rights and Mrs Wrongs, in terms of chelates and ligands, and these are not the same from one mineral to the next e.g. Zn sulphate is a decent form of available Zn, Mg sulphate, an over-priced laxative
  3. In almost every case, there is simply NO strong consistent body of evidence that one form of a mineral is superior in terms of bioavailability, regardless of what companies tell you..go on I dare you…check their references and then do your own quick literature search away from the cherry picker
  4. Nor is there one mineral form that is above adverse effects in everyone

Brutal.  Welcome back to ‘tough talkin’ Tuesday’ 😉  But we have to state these facts because we need effective supplements for our patients and not understanding the different forms that are better (but not ‘best’) compared with those that are inferior (this we do have some evidence of) threatens the integrity and efficacy of an otherwise well thought out prescription.  So here’s where you might want to move into a room away from everyone and lock the door…because you’re likely to scream.  One of, if not the most commonly used single nutrient supplement almost across the world, is calcium.  After almost 30 years of studying supplemental forms side by side, can we conclude which form is best? No. How about ‘better’….hmmmmm yes…maybe…citrates look good going by some markers but not all and vice versa for other commonly seen forms.  I can say this, because I have followed the research over the decades, reading the primary papers, like this excellent one by Bristow et al from 2015 that should burst quite a few people’s ‘best!’ bubbles. Have you screamed yet? 

I scream. Often.

Because I am frustrated by the lack of research that we need, to be more certain of our preferred forms and then even more frustrated by companies’ claims that the evidence is already in, and guess what, theirs wins!

But it comes back to the same call to action for us – know your nutrients and specifically, where possible, get familiar with the Mrs Right and Wrong for each mineral! Know that the supplemental forms that work for zinc will not necessarily be a good match with iron, that any company that formulates their minerals in the vain of ‘one form for all’, be that glycinates, citrates, picolinates…well they’ve  probably got a good fit for some of those minerals and a shocker for others. And as always truly check efficacy with follow up bloods, if you had baseline deficiencies evident in lab tests.  I know, that’s not everyone’s model of practice right, or ideal but not always ‘real’, so alternatively, if you are prescribing based on clinical signs of mineral deficiencies that should respond quickly to repletion e.g. white spots on nails in the case of Zn deficiency, then ensure that they do!! If they don’t and your patient is compliant then consider switching form! When I see good practitioners’ prescriptions let down by poor choices of nutrient forms, well, that’s when I need to go into that separate room once more….can you hear me? Ooh that reminds me of something else dated by Mike and the Mechanics: Silent running “Can you hear me?!”😂

Mastering Micronutrients – Critical Pieces Of The Puzzle

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

 

Click here to gain immediate access to Mastering Micronutrients – 4 hours & clinical tools that will seriously change the way you work in Nutrition

 

No One Does Nutrition Like We Do Nutrition

A 26 year old woman suffering years of fatigue from ‘persistent iron and B12 deficiency’ repetitively treated with both oral and IV, walks into a compounding chemist and finally meets her match 🐱‍🏍  A naturopath with years of experience working the frontline, used to dispensing iron galore (& to a lesser extent B12) to young women with similar stories. But this naturopath requests to see all her labs, she meticulously collates them and then she comes back to the client and deals the fatal blow: Has the iron or B12 ever made you feel any better? “No,” she replies.  

I didn’t think so,” says the Naturopath…”everyone’s been barking up the wrong tree all these years!” And she was right.

First glance at her blood results has all of us reflexively reaching for the same diagnosis everyone has made before – crikey that serum B12 is terrible!  And then there’s the fuzzy family history of relations ‘needing’ B12 injections and some even with confirmed pernicious anaemia.  But wait up…let’s keep our critical thinking hats on once you look over the rest of the lab you see there’s no evidence of functional B12 deficiency (no rise in Hcy, MCV even RDW) and then, the statement that seals the deal, ‘B12 injections have never made me feel any better’.  This woman is not feeling the pinch of pernicious anaemia, not the crush of cobalamin clinical deficiency.  In spite of being told that for almost a decade.

A low serum B12 value can of course flag a deficiency and we must never ignore it.  But given the serum measures, in fact, predominantly Transcobalamin I (TCI), which is the carrier or taxi for B12 that almost ‘never drops its passengers off’, we are less concerned than when we see a low active B12 (TCII aka ‘the real deal’)

So what else could leave someone with less TCI, while not in fact creating a genuine functional deficit of B12?  SNPs?🤧 Bless you!…Sorry that sounded like a sneeze and this retort, as we know is almost as common as the common cold! Sure…of course it could be sexy SNPs…but wait, what about something a little less ‘zebra’…a little more horse. The COCP…oh blooming heck..she’s spent the last decade on the COCP and guess what, its impact on B12 is thought to be principally a reduction in TCI!  Oh and that iron story, that supposed ‘iron hunger’ we can see with her upregulation of transferrin?  Well that’s an artefact of the COCP too, right? And BINGO was her name-O 🕵️‍♀️

Separating the B12 from the B*S#!

B12 is a routinely under-rated and recognised micronutrient, which is in fact in high demand by many of our patients. As nutritional research pushes back against defining adequacy as simply the prevention of the deficiency-associated disease (macrocyctic anaemia, irreversible neurological damage) we enter a new landscape of more individualised approaches where we’re better able to recognise and treat those at risk of falling below ‘optimal’.  But how do we accurately identify this and then choose the ‘best’ B12 (methyl- cyano- adenosyl- hyroxo-) supplement? Does it need to be this complex?  Time to sort the B12 from the B*S#!!  This recording comes with a bunch of great resources including a clever clinical tool.

 

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.

Ever Wondered How Much D Will Get You There?

I used to all the time. Especially when I noticed the Niagara-falls-sized gap between the doses I was using compared with my mainstream medico mates.  I thought, hang on, for a patient with a baseline blood level of 40nmol/L, they’re recommending <1000 IU per day, but I’m thinking 5000 IU…which one of us is wrong? Then again, we might both be right!

The sexily simple formula as cited by Aussie researchers is: for every 1,000 IU of vitamin D a patient takes a day, their blood level is likely to rise approx. 17 nmol/L over 2 months, at which point it plateaus.  So the medicos’ 1,000 IU supplement would bring our patient’s blood level up to 57 nmol/L which, as far as the medico might be concerned, is ‘job done’ 👍👏

My dose would be viewed as excessive but clearly I am aiming for a different set of goals (optimal rather than simple prevention of deficiency)…oh and I insist on follow up testing to know when we’ve made it!!

 I encourage my patients to get their Vitamin D retested 2 months into treatment to confirm 1) they have responded and 2) their response is loosely within this predicted performance.  And how many times is it not? Often.  Which got me to readjust the formula I use to something more akin to: for every 10 nmol I want their blood levels to rise, I will need to increase their intake by a 1,000 IU.  Now am I just making big sweeping inferences from empirical experiences of a few (hundred) patients without additional backing….well so what if I was...this is a branch of the EBM family tree!  But no! I have also actually read enough studies clearly documenting the individualistic response to vitamin D, as a consequence of different adiposity levels, genes, magnesium status etc. to know that, while I am very grateful to have any kind of formula to start my thinking from…I treat individuals and goshdangit#@! they keep insisting on individualised medicine!

The whole practise of identifying a deficiency, ‘treating it’ and yet never following up with repeat labs to confirm that you actually have…BLOWS MY MIND🤯

That’s not EBM, let’s face it.  Not even a distant demented cousin who has fallen from the dizzying heights of that family tree.

The one lesson I’ve learned, more than any other over 20 years in nutritional medicine, is that the more questions we ask and the more we challenge ‘established truths’, the more we uncover something much more personalised and potent about each and every nutrient …and now as the days continue to shorten into smaller and smaller slithers of sunlight between ‘bed-ends’, this is probably also a good time to ask ourselves…

Should We Rethink High Dose Vitamin D?

Vitamin D deficiency has been associated with a long list of major health conditions: from autoimmunity to mental health & almost everything in between. This has lead to many of us recommending high dose vitamin D supplementation for a large proportion of our patients but do we understand everything we need to to be certain of the merits and safety of this? In this provocative episode Rachel outlines the key unresolved vitamin D dilemmas that should encourage us to exercise caution and outlines how adequate sun exposure is associated with improved health outcomes independent of the production & action of vitamin D.

 

You can purchase this UU30 episode individually here or become a subscriber and gain access to this and over 65+ episodes plus new monthly releases for 12 months here.
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Are You Thinking What I’m Thinking?

🍌 ‘Are you thinking what I’m thinking, B1?’

🍌‘I think I am, B2! It’s time to separate the B12 from the B*S#!’

Ok, if you’re reading this and you’re not from around here you have reasonable grounds to conclude I’m the one who’s gone 🍌 but if you grew up with a show all about 2 adults dressed up as bananas and creatively known as B1 and B2, then we’re all good!  Ok now for the next bit, you might need to sit down.  Nothing not everything in the wildly popular, and dare I say it populist, doco The Game Changers was scientifically rigorous.  I know, I’m loving the strike through a little too much today.

Goodness, when otherwise intelligent friends of mine forced me to watch this, they found the need for both restraints and duct tape over my mouth, to hear or see anything other than me jumping up and down, arms flapping, mouth yapping. People only tend to make this mistake with me once.

Among the many many dubious XXX was a terrible mis-truth about our ‘new modern reliance on animal food or supplements for B12’. Woah…back up there Game Changers Gang, say what?!  Does anyone on their research team read any research?  So that got me all motivated to go back to the books on our beloved B12, which is simply like no other micronutrient in human physiology or in nature, for many reasons…starting with 1) it contains a metal in the middle 2) it has dietary dopplegangers (plant forms that look just like it but actually are decoys that need to be actively removed from the body so as not to block its actions) and 3) has the most complex and sophisticated pathway for digestion and absorption, which surprising equates to brilliant average bioavailability (much better than most micronutrients)…until it doesn’t!  And that’s when the trouble starts.  Once you don’t have an intact IF absorption pathway, you’re down to picking up < 1% via simple diffusion, and suddenly we see why patients can be vulnerable to not meeting even the piddly required amount. Not to mention the vegans, of course. I’m on my best behaviour.

But the B*S#! about B12 is far from limited to the documentary.  It’s in the words of the Methylation Mystics, making methylation sound like rocket science and in the supplements we’re being sold.

But don’t get me wrong…effective B12 treatment in the right patient is a total wow moment. I’ve literally seen all the lights go on⚡ in some .  So what do we need to do to find our way out of the dark?  Go back to the solid science.   Come on. There’s nothing else you need to do and nowhere else you need to be… we all know it…so start by reading this and this.  There’s plenty more of course but these are excellent appetisers. And if you want to cut to the chase and get the lowdown on what’s B*S#! versus what’s the real magic of B12, you can always settle in and listen to my latest Update in Under 30 – complete with a very cool clinical tool to help you choose the best B12 for each individual, but spoiler alert, it ain’t rocket science.🤫

B12 is a routinely under-rated and recognised micronutrient, which is in fact in high demand by many of our patients.  As nutritional research pushes back against defining adequacy as simply the prevention of the deficiency-associated disease (macrocyctic anaemia, irreversible neurological damage) we enter a new landscape of more individualised approaches where we’re better able to recognise and treat those at risk of falling below ‘optimal’.  But how do we accurately identify this and then choose the ‘best’ B12 (methyl- cyano- adenosyl- hyroxo-) supplement? Does it need to be this complex?  Time to sort the B12 from the B*S#!!  This recording comes with a bunch of great resources including a very handy clinical tool
The latest Update in Under 30 has landed!!!
You can purchase April’s episode, Separating the B12 from the B*S#! is here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.

 

Helping Patients Achieve Their PB

Listen to me, I’m sounding all sporty 😂. I’m not though, just in case you suffer misguided visions of my virtues!  But it’s not just the self-declared serious athletes that we need to have on our radar in relation to optimising their oxygen carrying capacity (aka window to winning). Our clinics are full of people, regularly running, doing triathlons for fun (!), riding vast distances clad in Lycra to drink coffee in other town’s cafes etc. etc. whose FBE might be feeling the pinch! That’s right!  All these individuals, depending on the frequency and intensity of their exercise, could have the so-called, anaemia of an athlete.

Long gone is the idea that exercise-induced changes to your haemoglobin and red blood cells and perhaps even your iron, would only affect the ultra-marathon runners among us.  It’s the swimmers, the cyclists, the Roller Derbyists, the CrossFitters, the basketballers, the Gym Junkies, the lawn bowlers..ok I may have gone too far now…they all are at increased risk.

Why? Isn’t exercise good for you?  You know I so want to say, ‘Surprise! It’s not!’ but alas.  Of course it is good for us BUT there are some fascinating challenges regular exercise can throw at your dear old blood and its bestie, iron. These challenges are incredibly dynamic – having one effect during exercise, a different one immediately following, and yet another in the days of rest in between. And sometimes, in fact, often, our patients can end up on the wrong side of these seismic shifts.  Here’s how the story usually goes

“Oh yeah..I’ve had anaemia for ages!  You know and it doesn’t matter how much Iron I take or how I take it – it never budges. But I’ve been told to stay on the Ferrograd anyway”

Typically, being told it’s ‘Athlete’s Anaemia’ is the first, in a series, of many many errors to follow. Because in fact, there is no such thing.  That’s right. Anaemia is a symptom not a disease and exercise induced anaemia comes in 4 common flavours: Dilutional, Heamolytic, Iron Deficient & Acute Anaemia of Exercise, and knowing the difference is critical to correct management.  Only 1 of them will reliably improve with iron and it needs to be prescribed in a totally novel way. Others will get worse with more iron. Yep. And one is a complete illusion. So when we don’t make the right diagnosis, which of the 4 types your patient actually has, we fail to find the fix. And while all of our patients may not be overly obsessed with improving their performance or even winning, let’s face it, they all want to achieve their PB, that’s why they came to see you.  So can you tell the difference? 

WARNING: I got so enthused about this topic that I went over.  The current ‘Update in Under 30’ is a ‘serving suggestion’ only!  And you may need to speed up your playback to squeeze in another bonus 10 min, if you can only afford your usual 30 min car trip to listen!

Outrunning ‘Athlete’s’ Anaemia

Persistent ‘hard-to-resolve’ anaemia is a common presentation for anyone participating routinely in sport and that can be at any level, not just among the professionals. From our lovely ladies who take up running or CrossFit in their middle-age, to our MIL (men in Lycra) and ‘weekend warriors’, they may love it but their haemoglobin and their iron doesn’t! Anaemia equals reduced oxygen carrying capacity, a concern for anyone interested in optimising their performance but equally relevant to patients just trying to manage their energy throughout the day. In this important episode we identify 4 different types of anaemia seen in patients as a result of exercise, incorrectly lumped together as ‘Athlete’s Anaemia’.  Each type is easy to recognise once you know how and effective treatment of each is remarkably different. This summary and the super handy clinical resource that accompanies it will help you and your patients absolutely outrun it, at last. 

The latest Update in Under 30 has landed.
You can purchase March’s episode, Outrunning ‘Athlete’s’ Anaemia here.
For all Update in Under 30 Subscribers, you will find it waiting for you in your online account and don’t forget the **EXTRA BONUS LIVE CALL WITH RACHEL.
**This live Zoom call with Rachel is for current Update in Under 30 Subscribers ONLY. A Q&A session for subscribers on the UU30 episodes released in 2020. Contact the RAN Team to reserve your spot!

 

 

Putting Young Heads on Old Shoulders

Do you know this saying but the other way round? My dad said it often enough and always with such an exasperated tone that it’s got its own dedicated lobe in my brain. Almost. Lately, however, I’ve been reflecting on how much I learn from people younger than me, both patients and practitioners and think we need to flip it!  I love the way that young people (oh lordy I just used the term, ‘young people’!!) can be incredibly solution-oriented, seemingly undaunted by the perceived barriers that tend to affect us older folk. A perfect example of this really is a young naturopath who previously worked for me, an absolute gun who seemed fearless in the face of any challenge who used to say, “my real super-power is forming the perfect Google search term” 😂 Of course this was totally under-selling her cleverness but I take the point that this is skill-set that us older peeps may be a little short on!

I really enjoy my consults with my Gen Y patients too for similar reasons.  Check out this recent exchange with a 20 something female when I asked about her supplement compliance:

“Yeah, I use an app to remind me to take all the supplements and that gives me a weekly report so I know I’m usually about 80% compliant. I’ve dropped off a lot over the holidays but I’m getting back into it now. So I’ll wait til I’m back up to 80% to do these next bloods, right, because that would be pretty representative and show us the effect of what I am actually taking”

Are you hearing this?!  How incredibly clever!  One: she found an app (Medsafe) because she knows herself and she knows apps work for her! (and by the way, she said…yeah so the government probably now has this data as well but really, they had it anyway!) Two: she knows that it’s not human nature to be consistently consistent with compliance with anything, so more importantly she aims for doable, sustainable and therefore representative!! I myself even find myself delaying the pathology sometimes, erroneously thinking, oh I wasn’t at my absolute best this week!! 🤦‍♀️Dang, I wish I was that smart in my 20s. I may have saved a lot of sun-damaged skin, some serious $ and my dad many many headaches!

And my New Grad mentees, not all of them young by the way (!), but all new to the profession, when you check out their social sites, their business models and hear the life experience/past work they’re bringing together for exciting new hybrid offerings, it’s a quick reminder that wisdom isn’t a one-way street!

Want to know how else we can get smarter regarding your patient’s pathology?

As my patient points out, we should never put off getting labs done, waiting for 100% compliance.  It may never come and if it does…it’s likely only fleeting and therefore any results in this context will be too! What are you and your patients missing in relation to their blood tests – like when to have the blood tests done in relation to food, exercise, alcohol etc  Beware of Bad Bloods! Occasionally, the fault of the pathology company but much more often the fault of the patient and the referring practitioner, who has not educated the patient correctly about what to do and not do prior to blood collection for certain tests. This recording clearly describes the 7 classic give-away patterns of ‘Bad Bloods’ which will enable you to spot them fast in the future.  In addition to this.  while we are unlikely to know the idiosyncrasies of very lab our patients will ever have done, knowing the ideal collection times and conditions for the most common ones assists you and your patients to avoid any in the future – handy clinic resource included.

You can hear all about it and download the resource when you purchase Beware of Bloods here.

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

 

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

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

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

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

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

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

You can purchase Gilbert’s: New Goals & Good News here.
If you are an Update in Under 30 Subscriber, you will find it waiting for you in your online account.
**But if you’re just joining us & this important conversation now,
ideally get the basics and backstory first and purchase all 3 key episodes in
‘A Guide to Gilbert’s Package’
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Next time your log in, you will experience a more user friendly way to search, view, listen and download your resources. Find out what’s new here.

 

I Was Wrong

I take my job to heart.  When someone asked me recently to choose the single value that spoke most to me personally I couldn’t seem to go past, ‘Purpose’.  I feel very honoured to have contributed to the learning of so many health professionals in their undergraduate and so many more in their professional careers following graduation and I know that with this comes huge responsibility. Second on my values list  (again, possibly unsurprising) is Empowerment & coming in with a photo finish at 3rd: Integrity.  Discernment and critical thinking (about information, about research, about reflective practice) are perhaps the eggs in this souffle, helping us all to rise up. 

As part of our critical thinking we need to accept a few truisms:

Research changes     Experience changes    Knowledge changes

Information is not static. So we need to ask ourselves, how long ago did I learn this? How long since I’ve checked it is still correct? And just because perhaps this information came out of the mouth of our mentors or teachers, makes it no less up for regular review.  I’m trying to undertake these internal audits on a regular basis. Typically they’re prompted by bloody good questions my mentees have asked me. A question I can’t answer or, more to the point, I can’t answer with full confidence I’ve double-checked my old beliefs and understandings against new evidence recently…these almost always provoke a lost night of sleep for me.  Not from sleeplessness per se but due to immersing myself in the latest research and performing a mini informal lit review, bringing out all my old beliefs/evidence etc. Marie Kondo style and asking do they still spark joy✨  (in light of the latest evidence)?!   And yes sometimes there’s a little bit of heartache when you have to let your old tightly held beliefs and understandings go 😢

The 1st  update is about N-acetyl cysteine.  Some of you may have heard me previously question the efficacy of the vegan form. Now that all but 1 Australian product is vegan, produced from bacterial fermentation or purely synthetic, I was wayyyyyyyy overdue to check the validity of my old ideas.  Let the record show, I was wrong.  Unlike some other nutraceuticals like chondroitin sulphate, wherein the source radically changes the overall structure of the molecule and therefore its uptake and actions – the same is simply not true for NAC.

So those ducks, & their NAC rich feathers, can all sleep a little easier at last…phew!  Now the 2nd internal audit well that did cause some tears for me…

Setting the record straight: The ABC of CDG

We often identify patients who could do with a little glucuronidation first aid: marked dysbiosis, Gilbert’s syndrome, oestrogen excess, cancer risk (especially bowel, breast & prostate) and one of our nutritional go-to’s has typically been Calcium D Glucurate. While there is ample evidence that one of CDG’s metabolites: 1,4 GL – inhibits beta-glucuronidase, is an antioxidant, platelet activation inhibitor and generally all-round good guy to have onboard, new research strongly challenges that oral CDG will convert to this at levels sufficient to support this detoxification pathway.  Sounds like we’re overdue for an update on this supplement and when and where it might be useful in addition to how to find the real deal in real food!

 

Iron – Another Important Discovery

Yet another super-helpful part of Iron-Land has been mapped!!  Ever struggled to correct chronic iron deficiency in athletes or even just weekend warriors?  Yep, me too. One of the key barriers being the 2-3 fold rise in hepcidin in response to exercise. Hepcidin whose day job is an inflammatory signal that two-times as an iron uptake blocking agent at the small intestine.  In addition to other exercise-induced factors that either reduce Fe uptake or increase losses, it really is no surprise that these cases can be hard to treat. However, a recently published small Australian study has brought to light some constructive new information. Similar to the often talked about ‘anabolic window of opportunity’ whereby we encourage people to consume protein +/- CHOs within a short time-frame post-exercise to optimise exercise outcomes and negate negatives, these new findings imply the same might be true for optimal Iron uptake. But only in relation to exercise done in the morning! 

The key finding was when individuals consumed iron after 90mins of exercise in the morning they exhibited higher uptake than both when they took the iron at the same time but didn’t exercise beforehand or took it after exercising at night.

This is a game-changer for potentially ALL our patients who struggle with iron absorption.  With the key take-home being…not just take your iron preferably in the morning which we already know (when hepcidin is naturally lower as part of its diurnal rhythm) but before you pop that pill, pop on your sneakers and get busy sweating! How on earth might this be working?  Well this study demonstrated that while hepcidin rises after exercise typically for up to 6hrs…it is not yet ‘up’ and blocking within the first hour – gotcha! But why would this mean an even greater uptake compared with the same iron at the same time in the same individual…but a resting version of themselves?  Because exercise may in fact cause a transient leaky gut post exercise & enhanced nutrient uptake may be its silver lining!  A small study that actually punches above its weight, this one is worth the read – via a great comprehensive summary on Medscape if you have it or you can check out the abstract.

Our ever-expanding Iron knowledge gives us great hope for the improved understanding we are likely to reach with all nutrients in the future.  Let’s not forget Iron has about a 70 year head-start on other microminerals such as Zinc and almost a century on Selenium, which was identified to be essential in just 1979! 

And the contrast is apparent anywhere you care to compare and contrast the ‘older’ with the ‘younger’ nutrients. Just look at iron studies. A personalised detailed account of each individual’s iron story: how much you’re consuming, how effective you are at absorbing what you’ve been offered, how hungry that makes you for more and what good stores mean to you (not some fictitious average male or female)!  All told through 4 distinct but inter-related markers: serum iron, transferrin, transferrin saturation and ferritin.  What can we glean from our current routine assessment of Selenium in contrast?  Their short-term Se intake…yep. Looking forward to the multi-parameter markers of each individual nutrient we just might have at our fingertips in the future, thanks to iron nutrition which continues to teach us how sophisticated nutritional physiology really is 🙂

We know the most about iron and yet we know there is always more to learn.  And who better to teach us this than our clients with iron deficiency or iron excess?  Need some help getting across the most important aspects of recognising and correcting each iron issue in clinic?  We released an Iron Package earlier this year for this very reason. It covers how to really read iron studies (with a great cheat sheet), how not to fall for a fake (deficiency) and what the best supplements and dosing regimes look like and how that differs in pregnancy, athletes, those with marked gut issues and other key groups. It’s your 1 stop iron shop.

Nutritional Medicine: A Place For Science Not Wishful Thinking

Show me a nutrient that doesn’t demonstrate a U shaped curve with our health (too little produces negative effects – too much produces negative effects)  and I’ll go ‘HE!’ Go on…try it now… But the way many have been taught nutrition has lead to some erroneous thinking, it would seem, about the inherent ‘safety’ of all micronutrient prescriptions.  To know these vitamins and minerals well is to respect their potency in every sense – from their incredibly positive application at both physiological doses, correcting deficiencies,  and in a small number of scenarios almost pharmacological benefits, when used at doses that are intended to exceed the natural physiological state (think IV vitamin C, or high dose B3 for lipid-lowering as two famous examples), to their potential for fallout when healthy levels are unwittingly exceeded, especially long-term.

Our risks of over-supplying individual micronutrients have arguably been amplified by the industry’s increasing promotion of nutritional formulas or complexes over the use of single nutrients.  How often do you go through and studiously add up all your cumulative totals for individual nutrients for each prescription? 

Especially those that tend to find their way into such a large number of formulas and have clear upper limits, such as Vitamin B6, Folate, Selenium and Manganese…to name a few of my (not so) favourites.

Many of you will know I am a fan of staying single 😉  I mean using single nutrients rather than all the ‘bells-&-whistles-formulas’ we’ve come to rely on so heavily.  This is one key reason.  But the other is that many of these formulas are someone else’s, perhaps a whole tech team’s, idea of what a ‘generic’ low thyroid patient, or an ‘average’  immune challenged patient needs. Not sure about you, but I don’t subscribe to ‘average’ and ‘generic’ when it comes to nutrition…that’s one of naturopathic nutrition’s key criticisms of conventional dietetics, right?  So where does this reliance on generic nutritional complexes comes from? Is it purely convenience -yours and the patients?

Or are we insecure in our confidence in creating our own crafted formulas? Is it a need to know our tools of trade better..because if we did, might we better realise the power and potency (positive or negative) of our own prescriptions? Especially in the realm of accurate assessment and individualised requirements.

The latter is my call to action on this, predictably! 😉

I am often asked about where my ‘nutritional nous’ comes from. Which magic journals do I subscribe to that fill my head so full? What non-existent-far-superior-course did I undertake?  The answer I give is the same every time. I had one solid nutrition teacher in my under-graduate across my 4 years of naturopathic nutrition at SSNT.  What made her so good and why has so much she taught stayed with me?  She simply taught me every single nutrient literally from the ground (soil) all the way up (human nutritional physiology) and everything in between.  Once you know each nutrient that well and the big concepts that are a truism in nutritional science…you can never go back and you will practice nutritional medicine at its best. My wishful thinking? I wish that for us all 😉

Mastering Micronutrients – 4 hours & clinical tools that will seriously change the way you work in Nutrition

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!