Bloodwork 101: Blood Test Results Explained | Dr. Anjali Dsouza & Mike Haney
In a recent episode of A Whole New Level, Levels editorial director Mike Haney sits down with Dr. Anjali Dsouza, founder and medical director of the District Center for Integrative Medicine in Washington, DC. A physician trained in nutrition, holistic care, and functional medicine, Dsouza works in the space between conventional medicine and root-cause care — spending 90 minutes with patients rather than 12, looking for trends before symptoms emerge, and helping people, particularly women, feel empowered rather than dismissed.
The conversation covers what a standard blood panel actually includes and what it leaves out, which expanded markers Dsouza considers most valuable, how to read results in context rather than in isolation, what test prep factors most people overlook, the difference between normal and optimal ranges, and how to think about retesting and trend-tracking over time. It's a practical, clinician's-eye guide to understanding what your lab work is actually telling you — and what it isn't.
"I'm kind of outside of the business of, 'Do you have a disease or not?' I'm in the business of, 'How do I ensure that you feel your best and how do I protect you against potential diseases?'" — Dr. Anjali Dsouza
From conventional medicine to functional care: the 12-minute problem
Mike Haney: So the context of today's conversation is that Levels has recently expanded into blood testing, or I should say expanded blood testing. We've had a panel for a few years now where we tested five key markers, but we want to explore the space of testing a lot of markers, over 100 markers. And so we're doing a series of podcasts around the idea of blood testing. And for most of the episodes we're doing, we're looking at chunks of markers — kidney markers, women's health markers, which we're going to talk about later. For this podcast, this is sort of what we're calling Labs 101, and what we wanted to get at in this show is with a clinician like yourself who works with actual patients day to day, just the concept of blood testing and particularly expanded blood testing, how you use it, what's valuable about it, et cetera. So I want to start just with some background for folks who don't know you. So you run a clinic in DC. Tell me a little bit about your background and what you work on now.
Anjali Dsouza: Well, my background basically originally was in nutrition and then I went to medical school and slowly over time collected a lot of additional training around holistic care, integrative medicine and functional medicine. And if we think about the District Center for Integrative Medicine, which I founded and am the medical director there, I want to step back and maybe start by saying and reminding our audience that the average amount of time a patient spends with their doctor is about 12 minutes. And this is certainly not enough time to really understand a problem or go in depth or definitely not understand root causes. So the most common thing I hear from people, women and men, is, "I went to the doctor, I have this complaint," maybe it was hair loss or weight gain, "and I told the doctor," and it was either like, "Sorry, this is part of aging," or, "Here's this medication, you can try it," or, "I've got nothing for you." And this was also my story.
I also was this patient at some point. And the combination of my previous interests and then my personal experience really lit an intensive passion inside of me to create a space where people could get better care. And especially when we're talking about women who are sensitive — like their bodies are more dynamic, they are sensitive to cues, to stressors in a very unique way, they often don't fit neatly into diagnostic categories. And so having a place where I spend 90 minutes with a patient to really do a full review of systems, understand connections, think about root causes, is very valuable. And I would say that in the end what's so satisfying is it helps women feel empowered and have agency and actually get better.
Mike Haney: So that's a good place to maybe dive a little bit deeper into the functional aspect of this. So is there a way to lay out a contrast of somebody who might come to you with a common concern somebody might come to you with and what they might experience in the quote, unquote, "traditional space" or with a sort of normal GP and what they might experience with you?
Anjali Dsouza: Yeah, I think maybe headache is a simple example that we can look at. So if you have a headache, let's say it's a migraine headache, you may go to a doctor or maybe even a neurologist and they certainly may do some level of workup. You might get an MRI, you might have certain tests done. But in the end there's pretty much a standard list of medications that you can try in succession. If they don't work, there's the next one. If that doesn't work, maybe you go to another thing. And while that's not wrong, it may be limited, both because those treatments may not be fully effective and/or you're dealing with side effects of those medications. But that's the offering, right?
If someone came to me with a migraine headache, it's not that I would say that those medications are not allowed or that they're bad, but I'm going to be thinking about what are the drivers for this headache? And those could be potentially food sensitivities, certain inflammatory compounds. I might think about the influence of hormones and/or toxic compounds like heavy metals, et cetera. And I want to think about all of those things, not to mention stress, which is kind of a mediator in all things, to really help someone have more of a comprehensive look of what's driving this headache and, potentially, if we're lucky, getting them to the place where either they need less medication or no medication at all.
Mike Haney: Where does blood testing fit into that initial investigation? Or is it part of the initial investigation or is it something that comes down the road? How do you think about blood testing in a kind of initial assessment of a patient?
Anjali Dsouza: In my experience and how I do this is everyone gets pretty comprehensive blood testing in the beginning. I throw a pretty wide net to look at a lot of areas of the body because I think, one, this is just a nice snapshot in time of what's going on with this person's health. It may help me make connections, but also because I'm deeply invested in prevention, I want to look at this more regularly so that I can look for trends that might be coming up that may give me information before someone actually has a diagnosis.
What a standard panel covers — and what it misses
Mike Haney: Most people's visit to their annual physical, there's a sort of standard panel that they get. What is the kind of standard panel and why is that the standard panel?
Anjali Dsouza: I think most commonly for your kind of physical or standard quick set of labs, you might get a complete blood count, you might get a comprehensive metabolic panel. So this is looking at some electrolytes, your liver and kidney function on a very high level. You probably will get a TSH, so thyroid stimulating hormone that looks at kind of a quick assessment of your overall thyroid health. And then you may get a hemoglobin A1c, and finally potentially a urinalysis if there might be a concern there. And those are reasonable tests to put together as kind of just a snapshot for someone's health because they would help you screen for, "Does this person have kidney disease? Is there a major liver problem here? Is there something going on with your immune system and is there an infection in their urine?" That's pretty useful. We do want to know those things. But it's quite surface level, right? And it kind of either puts you in, "You don't have a disease, go home," or, "You do have some disease process or condition, let's quickly come up with a treatment for this."
Mike Haney: And what are some additional areas then that you'd like to add onto that, again, as part of the initial before you know specifically what you're investigating or before you're sort of chasing a path, is there more you'd like to do initially?
Anjali Dsouza: Definitely. I mean certainly it's bound in some logic, right? There are some things that I may not test. For example, in women, if someone is on birth control, I may not do a full hormone panel. But just to answer the question, I certainly would do the things that we mentioned. But I would also add to that a fasted insulin, a lipid panel, looking at uric acid, I do some nutrients, so I look at vitamin D, I look at omega-3. Sometimes I will look at the zinc:copper ratio, and then there's sex hormone testing that can be added on as well. And as I said, it depends a little bit on if that's a goal or not and/or if someone's on birth control or not. But it's definitely one other thing that I might consider. And lastly, I would certainly always look at the hs-CRP, the highly-sensitive C-reactive protein, which is just a marker of inflammation.
Mike Haney: So in addition to that sort of how's your organs functioning, how's your metabolism functioning, how's your blood health, which is sort of part of that standard panel, you're looking at inflammation, you're looking at nutrients and you're looking at hormones.
Anjali Dsouza: And I should say, I guess, because I didn't and I'm realizing — on hormones besides the TSH, I'm definitely going to look at all the kind of related thyroid markers. So this would be your free T4, your free T3, your reverse T3, your total T3, and then the antibodies that are also involved in thyroid health.
Mike Haney: And as part of that initial assessment of somebody, what information are you getting from those additional tests? How is that completing the picture of what you're trying to understand about that patient?
Anjali Dsouza: Well, typically people are coming to see me because they have somehow either failed the conventional medical model or they're looking for a higher level of wellness. So I'm kind of outside of the business of, "Do you have a disease or not?" I'm in the business of, "How do I ensure that you feel your best and how do I protect you against potential diseases?" So here I'm often finding some insufficiencies or even straight deficiencies in nutrients. I might find, for example, in the thyroid it's quite common — maybe their thyroid function looks okay, but they've got skyrocketing levels of antibodies and this tells me, "This is a person that is stepping towards autoimmunity. Is there something that we can do about this now and/or is this already contributing to the fatigue that they are having trouble with?" It really helps me kind of have a bigger, larger sense of all the different variables that might be affecting someone's health.
Mike Haney: I think that's a really useful framing, the notion that by the time folks come to you or a functional med provider, they've probably already been through the step of traditional medicine.
Anjali Dsouza: Definitely.
Mike Haney: So how do you think people should think about the role of blood testing? Both whatever they would get at their annual physical, but then potentially something additional if they're not dealing with a specific problem, right? If you think you're relatively healthy, do you think it's useful to have some additional information as part of your annual just check-in on your health?
Anjali Dsouza: The way that I would answer that is probably kind of the way that I think about healthcare and the relationship between a patient and a doctor fundamentally. It depends a little bit on you, the patient. If you're overall feeling well and you're not someone who wants to go into the weeds of, "I want to know how to prevent every single thing, I want to maximize my nutrients and feel my absolute best," maybe that's not in your priority list. And so it's not for me to say, "Yes, everybody should do that." But my bias is I think that people can feel better than they potentially are feeling if they were able to look at these additional markers.
And if you're feeling quite well, it may be something that you don't have to engage in multiple times a year. Maybe you have — and if you're in the younger ages in your 20s and 30s, maybe every couple of years you might look at this more comprehensive panel. But as you age, I do think there's more utility to doing these more regularly, maybe once a year, so that you can start to, as I was saying earlier, look at trends.
Mike Haney: What other kinds of information are you looking at with a patient? Or if I'm somebody who's not seeing a doctor, I'm just getting a large panel, what are other aspects of my health — I'm thinking body composition and fitness — that I should look at in relationship to those markers to get the sort of full picture of my health?
Anjali Dsouza: I mean, certainly I'm going to ground it in whatever the clinical symptoms are that you're having and that helps me interpret — that's the lens by which I'm going to look at all those labs. But otherwise, in the end, and you don't need resources to think about this, those basic pillars of health are the most important things. How are you sleeping? What's your movement pattern like? Are you managing your stress and what does food look like? I mean that is typically the first section — those four things is the first section of every treatment plan that I make for a patient, in some ways to communicate how fundamentally important that is. So those are things that we are always hammering. And I think one thing I really want to say is it's also a process and a journey on how you think about those things. I think that in some ways, as easy as they sound, they're the hardest things to tackle and deal with.
So we have to have grace and kindness about how we think about it, both as a clinician on how I recommend things but also intra-personally how much pressure we put on ourselves to be perfect or if we're failing that, and especially on the east coast, I have a lot of high achieving perfectionistic people that can get really tight about like, "Well, I'm not doing it right," and in the end that's a stressor itself. So those four metrics I think are really important.
And then in my office I do have a BIA machine and pretty much everyone gets — so this is bioelectrical impedance that looks at the difference between tissues in your body, so I understand how much fat to muscle and then specifically how much visceral fat somebody might have in their bodies. And this is, I find, a very powerful tool to look at one more aspect of health that can help me, one, tell people, "Is your exercise working for you? Do we need to change up what this looks like? Do we think that the food piece is actually working and/or are we getting some additional information that maybe we need to change this? And/or is there some kind of underlying metabolic dysfunction brewing that actually didn't show up on blood work? But here I see your visceral fat is really higher than I'd like it to be."
How reliable are blood tests, really?
Mike Haney: That's a really great point that blood tests are not the end all be all or are not definitive. So maybe just a generic way to ask that is how reliable are blood tests? If I get a marker that's out of range — and tell me this will probably vary between markers — how much stock should I put in it? How often should I think about an immediate retest?
Anjali Dsouza: Yeah, it's a great question. I think it does depend on the specifics, but what I would say is, as an example, like the highly-sensitive C-reactive protein, the hs-CRP, this is a number that might be really high because you just got over COVID, for example. And I've seen this number up in the 20s for someone and they've been freaking out for two weeks before they come to see me because they have some really catastrophic notion about what this means about their health, and in the end it meant nothing because we retested it and it was totally normal.
So there are markers that change and there are some that kind of will acutely rise and come down. Hormone markers can change a lot, especially in women depending on where you are in your cycle. So I think in general, we have to think about markers with some grain of salt, understand context — this is where it's useful to work with a clinician and to have a sense from them about, "How seriously do I need to take this and/or do I need to repeat this marker just to confirm?" I do a lot of repeat markers when something seems out of whack for somebody's history and clinical presentation. But it is one metric, it's not the only metric.
Mike Haney: How common are just straight up errors, just abnormal readings, not because I just had COVID or some physiological reason, but lab screwed up — just wasn't right?
Anjali Dsouza: Yeah, in my experience I would say pretty uncommon. I've seen times where there might be a handling issue or an assay that might be wrong at the lab. I would say 5% or less of the time do I really have an absolute error where I'm calling the lab and talking about what might've happened, so infrequently.
Mike Haney: And how about if we take into account all the things that can throw off a lab — I mean when you do retesting of folks, how often does the marker change, whether for any reason, physiological reason or sort of lab error?
Anjali Dsouza: Yeah, so let me think about if I were to try to give you a percentage on that. I would say more than 50% of the time if something is really out of range that is kind of outside of the pattern that somebody has, oftentimes when we repeat it, more often than not it's normal the next time we check it or it's in range or it's optimal for them.
Mike Haney: So maybe expand on that idea of the pattern because I think that's really useful. One of the things that I'm learning as I learn more about these markers is that it's all about context, that any given marker — maybe with a couple exceptions — but it seems like most markers are most meaningful or maybe really only meaningful if you understand some other kind of related markers. So how important is a pattern or context in looking at a result that you might get back?
Anjali Dsouza: I think it's quite important. I mean a lot of things are timing sensitive or prep sensitive — when and how you do the test. Someone might come in for example with a fasted insulin of 19 and it turns out, as you talk to them about it, they're like, "Oh yeah, on the way to the lab I actually downed a latte with extra sugar in it." So the patient knowing, "When did I do this test? What was the context around which I did this test?" is really helpful for the clinician to unpack that. Hormone testing too — if I have the intention to have a luteal phase test done on a female and suddenly their cycle is a little bit different this time around and they end up starting their bleed five days before normal, maybe I now have to adjust my analysis of, "Oh, this wasn't truly a luteal phase test. This was a different time in the cycle that was really being tested here." So having that context I think is invaluable.
Mike Haney: Are there particular markers or maybe groups of markers that you most commonly see readings that change on a retest or that… I think what I'm getting at is the thing I'm thinking about is people look at a result and it's really easy to freak out. We all get the results back and you look at all the sort of greens of in range, in range, in range, and you're looking for those yellows or oranges that are saying, "Oh, this is abnormal," and it's hard not to feel stress when you see them. So are there particular markers or groups of markers that you would really say, "Take a deep breath if you see this," because it's likely to be off because of maybe some test prep or because of a transient condition of some kind?
Anjali Dsouza: Yeah, so a few that come to mind swiftly are people that are potentially on biotin, which is a B vitamin that often women will take to support hair growth. If they run their thyroid labs while they have recently taken biotin, their entire thyroid panel will be off. And this could be completely fixable by repeating the lab without the biotin on board. Similarly, we talk a lot about fatty liver and people are kind of educated about it and concerned about it, and I will see bumps in liver enzymes. So your AST and ALT that might be a little bit higher, that may cue someone to think, "Maybe this is a fatty liver situation," and in fact there was a little virus passing through, there was some unusual exposure that they had, and we repeat it and it's totally normal.
In that liver panel too, sometimes you might have one little marker that's off like an alk phos that might be a little bit off or a little bit lower and you repeat it and it's totally normal. But someone might look at that and say like, "Oh goodness, what's wrong with my liver? There's something really bad happening with my liver." Those are ones that come to mind pretty swiftly where repeats are typically very easily fixed.
"Hormone markers can change a lot, especially in women depending on where you are in your cycle. We have to think about markers with some grain of salt, understand context — it is one metric, it's not the only metric." — Dr. Anjali Dsouza
Test prep: timing, biotin, exercise, and hydration
Mike Haney: And what are some other test prep things that people should keep in mind besides fasting?
Anjali Dsouza: So I think the big one that I would remind people of is that hormones, when I'm thinking about women's hormones specifically, are really going to be most accurate and more robust in the morning. So before 9:00 AM is really when I want women to be collecting their hormone markers because that's when I get like, "Okay, what is the greatest potential of their hormone capacity if I get it at that time?" Now if it's after, I want to know that, it may help me reassess the situation. But before 9:00 AM I think is a really important time. If you're on thyroid medicine, I think just being consistent about taking the lab either before you take your thyroid hormone — which is what I like ideally — and/or at least be consistent with how you take your thyroid hormone and check those labs so that there is that through line that stays accurate when you're looking at those labs with your clinician. Those are two that I think of.
Mike Haney: How about things like exercise or hydration?
Anjali Dsouza: Yeah, so I mean those will definitely impact markers. I mean I have seen on that, going back to the hs-CRP marker, the inflammation marker, somebody who suddenly has a hs-CRP of eight who previously lived at 0.2, which is essentially negligible, it's negative, and kind of scratching my head and I'm looking for like, "Is there anything here that might be explaining this? Are you sick in any way?" And it turns out they did an intense Orangetheory exercise, they still went fasted to the lab and everything, but they did an intense Orangetheory exercise and that alone just bumped up their inflammation marker.
Mike Haney: So maybe back off real intense exercise?
Anjali Dsouza: Potentially, and/or at least — here's what I'd say most importantly — know what you're doing around the time that you take your blood tests. What did you take? What exercise did you do? Were you recently sick? Just so you can share that information with your clinician and that clinician can then unpack like, "Oh, how do I interpret this differently knowing that information?" And then on hydration, I mean first, being more hydrated just makes your blood draw more comfortable. But if you are dehydrated when you go, you might see elevated levels of, for example, BUN, which is a marker that we look at when we're thinking about kidney health, that might be inaccurately high because you were dehydrated. And you might see some changes in your urinalysis as well if you're overly dehydrated. Again, things that we can sort out if we know, but ideally you are hydrated before you go to your test.
Mike Haney: And how about supplements? If you're taking supplements, should you continue on what you normally do or should you back off of those prior to a test?
Anjali Dsouza: I mean besides biotin, I don't really mind people taking their supplements, especially if that's part of their routine. Because in some ways I'm assessing the efficacy of that. If you're taking a vitamin D, go ahead and take it and I'm going to run a level of vitamin D and then I'm going to know, "Oh, when you take 5,000 IUs of vitamin D, that actually gives you a good level of vitamin D in your blood."
Normal versus optimal ranges: when "in range" isn't enough
Mike Haney: Okay. How do you think about normal ranges versus optimal ranges? When we get our sort of annual physical back, I think the experience a lot of us have is you get back the handful of markers, you're told everything is normal and there's nothing to worry about and you sort of move on. If you've had the experience of working with a company like ours or functional medicine, they often are going to give you optimal ranges, or if you work with a functional med doc, you may see optimal ranges. How should I think about understanding the difference between normal and optimal? Do I need to always be striving for optimal? Is normal fine? Again, I'm sure this varies by marker, so feel free to break out that answer.
Anjali Dsouza: Sure, yeah. Well, varies by marker and maybe varies by how is the person in front of you doing? And there's a lot of individual variability — your B12 level might be 500 and you're like, "I feel great, I've got wonderful energy, my brain is constantly on," and mine might be that number and I'm like, "I'm brain foggy, I can't think straight. I'm a little bit vulnerable to depression." So you always need to ground truth it in the clinical information that's in front of you. But generally speaking — and it does vary a little bit by markers — as a reminder, when we have these reference ranges, they're made by looking at the population. And we come up with these ranges based on what's happening in the population and if you consider the fact that we also have sick people in the population, we're going to have a much larger range of what's considered acceptable. And that probably will get you by for some base level of wellness.
But if you are kind of normal by laboratory and yet you're like, "I don't feel well," or, "I don't feel well as I used to," or, "I know that I can feel better," that's when you should start to be curious about it. And I may contract the reference range by maybe 30% to think about what's more optimal overall. And then there are certain places where I really have — I'm a little bit of a stickler about what is optimal. B12 is one of them — like I was mentioning, I think that not just being sufficient for vitamin D but actually heading for a little bit higher in the 40s and 50s is definitely more optimal. For thyroid, I like TSH to be kind of in a tighter range between 0.9 and 2.5, and the reference range goes all the way up to 4.5.
But I find especially for women, as you creep towards 3 and 3.5, you can start to have trouble with fatigue and depression and weight gain. But again, you have to see the symptoms. I'm not going to chase my optimal range just because. It's more if I have someone struggling and I know that they are not in the optimal range, then my first instinct clinically is, "Can I get them there? And does that make a difference?"
How to handle results when you're not working with a functional doctor
Mike Haney: So if somebody does pursue blood testing outside of working with a functional health provider or even a GP who might be willing to order it, what do you recommend in terms of understanding the results? I can imagine a world in which… Well, I had this experience which I'll share. I got an expanded panel back, I had a PSA number, actually PSA free percent that was slightly out of range. I turned immediately to ChatGPT. I actually texted my GP who's great and he said, "Send me the rest of your results once you get them in." I told him I had done this very expanded panel, and we'll look at it in context, which was a perfectly reasonable thing to say. But in the moment I didn't want to wait two weeks to talk to him about it. So I went to GPT, I had a very long conversation about what this meant. And then I just went ahead and scheduled a follow up with the urologist.
What do you recommend when people get things back? Are tools like GPT or AI tools or other kind of health apps useful? I think the old advice was, God, the last thing you should do is Google anything, Google a result, Google a symptom. Should they reach out to their GP with an expanded result or should they pursue a specialist? Again, I'm sure this varies, but generically, how do you think about counseling folks?
Anjali Dsouza: Yeah, I mean I think if you have access to speak to someone who actually practices medicine, this is the best. Obviously AI is improving every single day, and I haven't run one of these searches myself, so I can't speak to that. But I imagine there's some information that you can find online that might help you. But more fundamentally, I would probably encourage people to really understand who they are. So you're science based, you love information, I imagine you looked at that and it was interesting to you, but it didn't necessarily — although I'm assuming, you can tell me — put you into a panic, right? For other people going down a rabbit hole of trying to do their own research might actually end them in a place that is much more catastrophic than they need to be.
So that same old adage of, "Stay away from the internet," in general, I still agree with because as we're talking about here — context, nuance, lab testing, your clinical symptoms — these are all things that a clinician is trained to think about when they're thinking about how to counsel you. And I don't know, maybe AI will get better, but I feel like that nuance is always going to be missed. Now if you're someone who can learn from the information and find it interesting and not stay up for two weeks while you're waiting to talk to the clinician, then great, go for it. But otherwise, if you can discipline yourself to say, "If I'm overall feeling okay, I'm not with the worst headache of my life, can't sleep, nausea, vomiting, need to go to the ER situation," — which by the way if that's happening, you would just go — then maybe you sit on it a little bit and wait for somebody to actually talk to you about it.
Now, it may be nuanced, especially with an expanded panel. If you're working more with a classic primary care physician, they may not have the time to unpack every single one of those labs with you. And so I would suggest, especially if you're working in that model, maybe you set up a couple of appointments and you decide, "What's the thing that is most concerning to me or that I most want to be educated about?" And you make an appointment just to talk about that, and then maybe come back later to talk about some other part of the lab panel that you want them to help you understand. But it probably is a lot to ask to show up with 50 markers and be like, "Can you unpack this?" if you're not working with a functional medicine doctor? And I want to be respectful because they're working on a different type of model as far as time goes.
Mike Haney: How common is it for a GP, a non-functional provider to order some of these more expanded panels? If I'm going for my annual physical, can I just say, "Hey, can you order me an additional 50 tests?"
Anjali Dsouza: I think it would be unlikely. And part of that is not because the doctor maybe doesn't want to or doesn't want to work with you, but they tend to have their hands tied about what they can order that's coming from higher up. But it depends on your clinician and the relationship that you have with them and the system that you're in. For example, if you're working with a Kaiser physician, I can pretty much guarantee that because they are really trying to manage costs and that's part of their model, asking for an expanded panel is just definitely not going to happen. But it could be, in some other private medical settings that are still more conventional primary care, that there may be a path or some of these that you could get. But most likely the easiest way for you to get them if you want them is to go out and seek them out and pay for them yourself.
Mike Haney: When I went for a panel a couple of years ago, my GP found out what I did and that I work for Levels and said, "All right, what do you want me to order for you?" And I got him to add on insulin.
Anjali Dsouza: Oh, that's great.
Mike Haney: And he said, "What am I going to learn from that and why am I ordering this?" And we had a long conversation.
Anjali Dsouza: And then you educated him. That's awesome.
Mike Haney: Yeah, exactly. Well, one of the things I'm taking from this is that beyond just sort of clicking the buy button on an expanded panel on some website, that some sort of preparation beforehand is helpful. Both in terms of practically getting the testing, really paying attention to the context of the testing — when were you exercising? How was your hydration? What was the last meal you ate? And what supplements, medications are you on? Having all that stuff written down somewhere so that if you need to follow up with a clinician, it's there. Because I also know that experience of once you are fixated on a marker, all that stuff goes out the window, you completely forget.
Anjali Dsouza: Oh, of course.
Mike Haney: "It was two weeks ago, I have no idea what was going on." But also maybe thinking a little bit about, "How am I going to follow up with this? Am I prepared to schedule a couple of appointments with somebody?" Knowing that this may not be the end of the journey, but that there may be some follow up that you're going to want to do.
Anjali Dsouza: That's right. And maybe what's your goal around it, right? Are you just infinitely curious and you just want to know this information because you're curious? Are you thinking about certain things that might be vulnerable in your family lines and you're wanting to have a keen eye on that specific thing? Do you know, for example, that everybody in your family has diabetes and so you want to look at those metabolic markers much more closely and trend those over time? Or are you feeling unwell in some way? And so that's the thing that kind of motivates the interest in looking deeper.
Mike Haney: How does insurance think about these expanded panels in your experience?
Anjali Dsouza: I mean it depends on… Luckily for me, people who come to see me are dealing with a lot of symptoms like fatigue. And honestly, fatigue is a diagnostic code under which there are lots of things that you can look at that qualify. But if you're kind of more thinking about the standard medical approach and you're coding for prevention of this or prevention of that or headache, then you might be limited on what you can order and probably a patient will end up with quite a large bill because the coding doesn't match what the orders are.
"If you are kind of normal by laboratory and yet you're like, 'I don't feel well,' or 'I know that I can feel better,' that's when you should start to be curious about it." — Dr. Anjali Dsouza
Trending over time: which markers to watch and how often
Mike Haney: We talked about repeat testing in the context of I get a marker that's a little off. How do you think about repeat testing in terms of just following trends? And maybe if there are particular markers or groups of markers where the delta over time is more important than the point in time, maybe let's talk about those.
Anjali Dsouza: Timing.
Mike Haney: And maybe if there are particular markers or groups of markers that where the delta over time is more important than the point in time, maybe let's talk about those.
Anjali Dsouza: So if we think about certain hormone dysfunction, maybe PCOS or even perimenopause, these are things that they may be kind of out of range or abnormal at a period of time that maybe gives me information about something I want to act on. But it also is going to change a lot over time, both in — "Is my intervention working?" So am I doing something with a woman with PCOS and I see, "Oh, she's starting to ovulate again and I'm starting to see her progesterone change." And so I might have some regular period at which I'm testing my interventions on some level to kind of ground truth what we're seeing clinically. Alternatively, like a woman in perimenopause — I mean pretty much every appointment is different as far as what symptoms they have and how the hormones are potentially changing and how that affects those symptoms. So I'm going to be looking at those things much more regularly because I want to know how they're moving and, again, how are some of the things that I'm offering having an impact or not.
Mike Haney: How do you think about confounding markers? This is something that I think we're going to see a lot more of as we get into these expanded panels. We hear all the time now the… There's a simple physiological story about the way, say, glucose and insulin interact within the body and what you should see if you are looking at those markers. And we hear often from folks who are seeing the inverse of that and going, "Why?" And often the answer is, "I don't know." And the more of these sort of markers you're going to get, the more likely you're going to get combinations that don't really make sense. So is that something you encounter and if so, how do you think about that and how should people make sense of it?
Anjali Dsouza: Yeah, I mean I'm pretty relaxed about it overall just because I believe that our bodies are more complex than we have understanding around. And maybe in time, and especially as we do more of these, it's more standard to do more comprehensive testing, that we'll start to understand these kind of variances a little bit more. But for the most part, especially if we're thinking about metabolic things, people are going to express those things slightly differently. And I see it all the time. And in the end, the clinical approach is pretty similar. "There's something going on here that I need to pay attention to."
But I also don't hang my hat on one laboratory value or two laboratory values that are out of range. If I trend over time, sometimes I'll actually see that thing that was kind of confusing to me went away on the third lab. So I mention it to a patient, I'll explain it and I'll even say, "I don't know exactly why this is happening. It's not kind of what my brain would tell me physiology-wise, but let's have surveillance over this. Let's look at it and maybe it will come into some kind of pattern that I can understand for you and maybe it'll totally go away."
Mike Haney: I think that's helpful context because the thing with any kind of data about our body — hard data, quantitative data about our bodies — it's so easy to read it as definitive because it is quantitative, it's a number, right? We look at our blood glucose —
Anjali Dsouza: And it has a red mark on it.
Mike Haney: Exactly. And it is so definitive that this is the state of my health. And understanding that a snapshot at any given time is just that, it is a snapshot and is not the sort of end all, be all.
Anjali Dsouza: No. Especially when we're thinking about the kind of medicine that we're talking about here. If you go to the ER and you've got acute pancreatitis, there are some markers that are going to be very specific and quite diagnostic and actionable in that moment. When we're thinking more about, "How do we prevent disease and how do we improve health?" and when we're in this more expansive, comprehensive, holistic care, absolutely what you're saying is really extra important. Everything has to be taken with a little bit of a grain of salt. You have to look at context, you have to repeat markers, you have to look for trends because it's not so simple. And that's part of what's amazing about it but also what's a little complex about it.
The most movable markers — and the three Dsouza wishes were standard
Mike Haney: What are the markers that are sort of most movable when you see them? For instance, we know that insulin can be moved pretty quickly with sort of lifestyle changes or can get bad pretty quickly if you're not following those sort of lifestyle practices. Are there particular markers that when they are out of range you know can be addressed pretty quickly or pretty easily with lifestyle changes?
Anjali Dsouza: Yeah, I mean, I don't know what your definition of quick is, but yes, the glucose, the insulin, I find markers in the lipid panel are movable too, especially triglycerides based on diet and exercise interventions. Although to be fair, some of the cholesterol markers are a little bit set because a lot of that can be genetic. But in a person who's going to be responsive to food and lifestyle interventions, I actually do see quite a swift change in lipid panel markers for people. And then nutrient markers, less so with food, but if you need to supplement, those change pretty quickly — like two months, even as quickly as two months, they will improve.
Mike Haney: Would it be possible to identify, say, three to five markers that are not part of a standard panel that you wish everybody had access to or that you wish could be part of a standard panel?
Anjali Dsouza: Mm-hmm. Definitely a fasted insulin. I think this is one of the most important markers that we can look at that has an impact on your hormones, has an impact on your brain, has an impact on preventing disease, and it's incredibly cheap. So a little bit of a head-scratcher about why this is not part of the standard panel. But I think this is a really important one, and I find dysfunction in this number pretty much every time I look at it. It's very rare, unless I'm working with someone in their early 20s, that I don't see some kind of rise in insulin, fasted insulin, that tells me that we're starting on that track towards metabolic dysfunction.
I also love the hs-CRP. So this is, again, partially because I work in functional medicine and I'm seeing people that are dealing with chronic fatigue or brain fog and they're like, "I don't understand this. I went to the doctor. They don't have a reason." And then that number when elevated — and especially if it's not, as we talked about, the acute rise and fall that might happen secondary to some acute kind of condition — it helps me understand there is something that I need to look for that is driving inflammation. And the most common things that I see is some kind of gut dysbiosis or kind of imbalance. So that could be someone's gut actually having elevated levels of inflammatory bugs that are sending signals to their brain that are causing fatigue. It could also be stress.
I mean, I will never forget the story of this high executive woman that I worked with who generally speaking was pretty healthy, but working excessively. She's partner at a law firm. And she felt badly and her inflammation marker was just through the roof. I mean the kind of level that we would worry that there was an acute event about to happen. And we tried everything. I looked at her gut, I looked at her hormones, I looked at nutrients, everything was pretty normal. And I essentially said to her, "I think you need to take an extended vacation. I'm not kidding. I'm writing it on a prescription pad so you take it seriously." And she asked for a leave of absence. She went to Greece for three months. She came back, we checked the number, it was zero.
Mike Haney: Wow.
Anjali Dsouza: So it just tells you how powerful stress is on some level. But also again, for me as a clinician, looking at that inflammation marker helps me know I need to look for a source of inflammation that is impacting this person's wellbeing. So I think that's number two. And then probably number three, interestingly, vitamin D is not a classic marker anymore. It used to be done a little bit more frequently, and now there are many insurance companies that don't even cover for you to get a vitamin D, not even once a year. But vitamin D is integral for your hormone health, for your brain health. So that's one that I wish was just part of the standard panel because I actually think there's so much you can help just by having a sufficient vitamin D level.
Mike Haney: Is there anything we didn't touch on here that you would advise thinking about, folks that are watching this that have either gone and gotten an expanded panel or are thinking about exploring deeper blood testing, that you want them to know before they go out and do that?
Anjali Dsouza: I think I would say just that if you want to be engaged in your health in this very proactive way, that having more information is actually quite useful.
"Fasted insulin is one of the most important markers that we can look at — it has an impact on your hormones, your brain, preventing disease, and it's incredibly cheap. A little bit of a head-scratcher about why this is not part of the standard panel." — Dr. Anjali Dsouza