Labs Your Doctor May Not Be Ordering but Should Be

Meet the Docs: Two leading physicians in the field of anti-aging and integrative medicine will join us for a new series over the next few months covering a range of topics. These articles will review new research and provide tips on advocating for your health from a holistic perspective.

Dr. Robert Brookman is board-certified in Internal Medicine, Pulmonary Medicine, Critical Care Medicine, and Anti-aging/Regenerative and Functional Medicine.
Dr. Alan Redash is a board-certified OB/GYN, Diplomate with The American Board of Obstetrics, and a former Fellow of The American College of Obstetrics and Gynecology.

by Rachael Ling

The health screening blood work that accompanies the average annual check-up allows your doctor to monitor how specific organ systems are functioning with the goal of catching any disease processes early. The blood tests your physician orders will depend on your age and gender along with your medical history and family risk factors. Getting tested at routine intervals provides data about the way your body changes over time. This information can empower you to make informed decisions about your health with the guidance of your physician.

However, is the basic routine blood work ordered sufficient to paint an accurate picture of one’s health? Are we really in perfect health when basic labs come back normal, but we are still plagued by nagging fatigue, forgetfulness, skin or gut issues, aches and pains, weight gain, etc.? In this installment, the Docs offer specific suggestions of tests that may help to fill in some gaps.

How is the “normal range” established?

Laboratory test results reported as numbers are not meaningful by themselves. Instead, their meaning is determined by comparison to reference values, which are deemed “normal ranges or limits.” A reference range is defined as the set of values that 95 percent of the average population falls within. To determine ranges, labs may conduct their own studies for the tests they perform, adopt reference ranges from test manufacturers or other labs, or obtain reference ranges from existing patient data.¹

What is “normal”?

Dr. Brookman tells his patients, “There is no ‘normal’, only ‘optimal.'” Indeed, reference ranges provide guidance for comparison’s sake; however, every individual is just that, an individual. Dr. Redash sees it as analogous to the images collected by a traffic camera at an intersection. “They are mere snapshots in time. If we were to compare images taken over a period, they would look different. Our job as doctors is to evaluate a person’s well-being by taking a step back to assess trends in the data.” The Docs both agree it’s all about the bigger picture specific to the person in front of them. Only with data accumulated over time do the doctors feel they can start to make educated assessments.

Take Note: while the accuracy of laboratory testing continues to evolve and improve over the past few decades, some lab-to-lab variability still occurs due to variations in testing equipment, chemical reagents used, and analysis techniques. 1 Consequently, there is no universally applicable reference value for most lab tests. Therefore, values must be compared to that lab’s set ranges and not from lab to lab (i.e., Quest vs. LabCorp).

CLIA Certified

Consumer beware! Not all labs are created equal! There are many smaller, private labs cropping up that allow the consumer to skip the middleman (physician) and order bloodwork directly. Although this direct-to-consumer option may seem appealing, it may not be in your best interest. Dr. Redash insists you only work with labs that are CLIA certified. “CLIA” is the acronym for the Clinical Laboratory Improvement Amendments of 1988. This law requires any facility performing examinations of human specimens (e.g., tissue, blood, urine, etc.) for diagnosis, prevention, or treatment purposes to be certified by the Secretary of the Department of Health and Human Services.²

Vitamin D3

Vitamin D influences and regulates calcium absorption. It also boosts the immune system and eases inflammation. Current guidelines for “adequate” vitamin D levels are greater than or equal to 30 ng/ml. However, the Docs argue that the lower-end range is “too” low. Therefore, they prefer the minimum cut-off to be closer to 60 ng/ml.

High Sensitivity CRP (C-Reactive Protein)

Studies show that inflammation plays a significant role as a leading cause of degenerative disease. The hs-CRP test accurately measures levels of inflammation not typically picked up on the standard CRP test.

Are the routine* tests typically ordered sufficient?

According to the Docs, no. However, they understand that not everyone has the resources to obtain the slew of labs they would want to run in a perfect world. Therefore, when asked to compile a list of labs to add to routine blood work, below is what they both agree to be the bare minimum. Their professional opinion is that the addition of these labs provides a more global picture of basic metabolic functioning.

*Routine lab work typically includes a complete blood count with or without differential, metabolic and lipids panel, and fasting blood glucose.

Homocysteine

Homocysteine is a very valuable inflammatory marker. Chronically elevated homocysteine increases one’s dementia, diabetes, and cardiovascular disease risks.

Ferritin

This test aims to provide clues about your stored iron levels. Having too much ferritin is detrimental to overall health and well-being. The Docs believe this value should be far lower than what the standard lab reference range deems “healthy.”

B-12 & Methylmalonic Acid

B-12 is crucial for nerve tissue health, cognitive function, red blood cells, and energy production. Even if your blood test shows “normal” B12 levels, an individual may still experience symptoms and complications related to a deficiency. This phenomenon is known as functional vitamin B12 deficiency. Although circulating B12 may be normal, it doesn’t mean the body can process and use it. High levels of methylmalonic acid (MMA) and homocysteine (HC) have been identified as better indicators of B-12 deficiency than the actual serum B-12 level itself.³

Comprehensive Thyroid Panel

The comprehensive thyroid assessment is a hormonal test that reveals imbalances that often go undetected with more limited assessments. This test analyzes serum levels of TSH, free T4, free T3, reverse T3, and anti-TPO antibodies to assess central and peripheral thyroid function and thyroid autoimmunity. In short, it provides the most accurate overview of thyroid function.⁴

Once considered quite rare, the Docs have seen an explosion of Hashimoto’s (autoimmune disease of the thyroid) over the past several years in their practices and among colleagues alike.

Expanded Cholesterol Panel

Standard cholesterol tests may not wholly represent cholesterol-related risk for heart attacks and strokes. Some people continue to have progression of cardiovascular disease (CVD) even when their low-density lipoprotein (LDL, aka bad) cholesterol is at goal. This is because LDL particles are not all created equal. An expanded cholesterol panel provides information on the size and type of particle and the presence of particular proteins such as apoB, Lp(a), apo A-I, etc. This information provides a better gauge of actual CVD risk.

Elevated Lp(a) is among the most important, though underrecognized, cardiovascular disease risk factors. Lp(a) levels are genetically driven and are not influenced by statin therapy. Some studies show that statins may actually increase Lp(a) in some cases. Therefore, additional or alternative interventions may be required in some individuals to lower CVD risk in those with high Lp(a).⁵

Disclaimer: Unfortunately, many insurance carriers may refuse to pay for said additional lab work unless deemed by the ordering physician to have cause.

What variables can affect values?

In addition to the values themselves, multiple variables must also be considered when interpreting results. The specimen used (i.e., urine, blood, or saliva), time of day, time of month, age, gender, fasting state, recent food/drink binges, stress, herbs, medications, etc. all play a role. For this reason, it is crucial the provider reviewing your lab work has extensive knowledge of all these factors and consider that they may influence the acquired results.

How about when all your labs come back normal time and time again, but you still feel “off”?

This is where the Docs’ expertise kicks in. Ultimately their goal is to figure out why you feel “bad.” Just because your initial bloodwork came back “normal” does not mean you are without reasons for feeling unwell. The Docs both state, “We let the symptoms guide the investigation process. If the symptoms don’t match the numbers, we dive deeper. Patients are their own best advocates and should not be dismissed merely because their preliminary lab work comes back ‘normal.’ If they feel ‘off,’ something IS off.” In their own patients, the Docs will search for clues of subclinical inflammation, infection, hormonal imbalances, gut health, and dysregulation of how the body processes metabolites and environmental toxins. The Docs use stricter reference ranges for some tests and use alternative labs that are more sensitive and specific. For example, they may prefer to use different specimens to test hormone levels to acquire a value, such as saliva vs. blood. Unfortunately, on many occasions, traditional lab work tends to only present red flags once the body is quite dysregulated or more chronic disease has manifested. At this point, conventional medicine seeks to treat symptoms rather than discover root causes. Stress and aging are not acceptable diagnoses for the Docs. They are certainly contributing factors and will need to be accounted for; however, these are only pieces of a larger puzzle. In order to return someone to an optimal state, all aspects of dysregulation must be discovered and remedied. The Docs are firm believers that the body can heal itself when allowed to help itself. But first, you need a “why.”

References