Beyond "normal": What CBC, urinalysis, and electrolytes reveal about your health | Dr. Rich Joseph
In this episode of A Whole New Level, Levels editorial director Mike Haney talks with Dr. Rich Joseph, an internist who practices what he calls "health management medicine"---treating health as an asset to strategically invest in over decades. With a background in strength and conditioning and training at Boston Medical Center, Rich brings a systems-level approach to interpreting lab work, looking for drift and dysfunction rather than just disease.
This conversation is part of Levels' ongoing series exploring different organ systems and biomarkers. Unlike other episodes focused on specific systems like kidneys or liver, this one covers the foundational lab tests most people get regularly: the complete blood count (CBC), urinalysis, and electrolytes. These are inexpensive, common tests that often get glossed over with an "everything's normal," but they contain valuable information about your overall health.
They discuss how to interpret red blood cells, white blood cells, and platelets; what your urine reveals about kidney function, hydration, and metabolic health; and why electrolyte balance matters. Throughout, Rich emphasizes that context is everything---understanding these markers requires knowing the person's lifestyle, symptoms, stress levels, and trends over time, not just whether a single value falls within a reference range.
Rich's approach to health management medicine
Mike Haney: For folks who maybe haven't heard some of the other shows we've done in this series or aren't familiar with what we're doing, we're doing a series of shows on different organ systems or different parts of the body, how we measure them, what we can do to improve them. And this is inspired by Levels getting into expanded blood testing.
We're going to have members or just folks who consume this podcast go get these expanded blood tests. They're going to start getting markers they haven't gotten before. And what we're really trying to do here is just talk to experts to help people figure out what to do when they get those back.
And the series we're going to talk about today, we're going to spend some time talking about your practice and just how you approach medicine, but then when we get into the markers, we're going to talk about ones we haven't really discussed in the other ones because they don't fit into this systems approach that we've been taking---kidney, liver, main hormones. But we're going to talk about the CBC, complete blood count. It's just all these basic blood markers we get. Urine. We all have to go pee in a cup when we do this. We're going to find out why we have to do that. And we're going to touch on electrolytes as well.
And I'll be honest, we tossed it in because we just didn't have a natural place to put that. We touched on a little bit in the kidney episode we did.
Dr. Rich Joseph: Yeah. They impact everything, right? You can't put them in one system.
Mike Haney: Yeah. And I think that's similar with the rest of these. That's where we're going to ultimately go with this conversation, but let's just start with a little background. Maybe just tell me how you came to focus on what you focus on now.
Dr. Rich Joseph: Yeah. Well, it's great to be here. It's long overdue that we actually hang out in person. It's cool to be here. And again, we got connected a long time back. Casey who started Levels is a close friend of mine. And my background is first actually, I think the place to start: I was a strength and conditioning coach for a long time. Movement was my first love and passion, fitness, and still is in many ways. And even before going to med school, I had it in mind that I wanted to do something that brought that world together with a more preventive and proactive approach to health.
It's actually been fun to see the zeitgeist changing now, people caring about proactive health, longevity, people putting more and more of their energy and resources into this. And it's a fun time to be in this space and practicing.
I trained in Boston. I went to med school with Casey. Obviously trained in Boston. And then after med school, started my practice, which I currently run as somewhat of a side hustle for a lot of guys my age, your age who weren't going to primary care, but had real risk if you looked under the hood. They had work that they needed to do to be much more strategic around how they thought about their exercise planning, their nutrition, etc.
And it started off as very much an experimental side hustle and now it's become my full-time.
Mike Haney: What kinds of stuff are you treating there? What are folks coming to you for? What's a typical day look like for you in the practice?
Dr. Rich Joseph: Yeah, it's a good question. I describe what I do and I think one of the things actually you asked me before I came is how would you describe how you practice? And I try not to subscribe to one banner, right? There's conventional medicine, which is how I was trained. I'm an internist by training. There's functional medicine, there's now longevity medicine. There's all these thiefs that are popping up and I try to take I think what is best from all of them and apply them to the person who's sitting in front of me.
I describe what I do as health management medicine with the idea that your health is an asset, right? Like your wealth. I actually learned a lot more about my practice by hanging out with wealth managers than I have with concierge doctors and thinking about how do we both protect and strategically invest this asset for the future? How do we think about it across decades, not just right now? And how do we look at all your data points in context, across the lifespan?
And I work with, I describe what I do as very performance focused. And I say, performance has a sports connotation to it. I describe performance as your capacity to bring attention and energy to what matters to you most. And for most people, that's what they care about is to be present and to show up in their life.
And even if you're not sick or dysfunctional by traditional standards, people want to continue to perform optimally or better. And I think how you do that, you actually have to strategically stimulate and stress the system. You have to recover appropriately. And there's a lot of strategy that takes place there.
I work with a lot of executives, CEOs, entrepreneurs, but also people who just are trying to get the best out of their life. And I think it's more of a common ethos that people bring to the practice and not a typical patient, if that makes sense.
Mike Haney: Yeah. We end up talking a lot to functional med folks. And I think it's largely because the thesis Levels is based on, which is essentially, I always describe our thesis as you should probably pay more attention to your blood sugar than you are. But that alone is not a statement that tends to fit into mainstream medicine.
I had the sense talking to mainstream doctors, my own GPs and stuff over the years, that I don't get a lot of argument about that as a concept, but just structurally the way mainstream medicine is set up, billed for, etc., something like you should pay attention to blood sugar or you should pay attention to preventative or that approach that you just talked about investing in, it's just not structurally how mainstream is set up.
And then I find with functional med practitioners, they take that approach. It's a root cause, whole body approach. But I find a lot of people go to functional med practitioners when they have a problem, right? It's still the same reason you'd go to your GP. It's just they're dissatisfied with what the GP has done. Or they believe based on their own education that some alternative therapy might be better and that's why they go there.
What you're talking about feels to me almost like a third bucket of preventative---is too broad a term, but the idea of a clinician as a partner in understanding your health and then staying healthy. Is that fair?
Dr. Rich Joseph: Yeah, that is fair. And obviously, I deal with disease and dysfunction for people because that stuff comes up. My goal is to stay with people across the lifespan. And I think what you care about when you're 30 or early 40s is different than what you think about when you're in your 50s or 60s, right?
I still refer to specialists at the MGB and the Brigham, which I'm in Boston. Having, conventional medicine does amazing things for people and people are going to need some of that at some points in their life. But I'm much more invested in how do we get people who are younger to make a more proactive investment in their health at an earlier phase.
And I agree with you. I've taken I really appreciate a lot of the functional medicine approach because it does go deeper. It thinks much more like a systems biology approach, which I think is important because I think we miss a lot in a very reductionist approach in conventional medicine.
But trained as a traditional internist, my job was to look at what qualifies as disease and what's not disease. And there's some clear cutoffs for some of those things. Functional medicine I think looks more for dysfunction when people already have symptoms of something. My job I would say is to look more for what I call drift. We've checked enough, we have enough data on you over time, I have the context of what life you live, what stress you're under, how you train, how you eat, etc.
And I'm looking for drift which may be in normal bounds, but it may be different for you over time. And how do we use that as feedback loops to continually conduct n-of-1 experiments with your health?
I'm looking for drift which may be in normal bounds but it may be different for you over time. How do we use that as feedback loops to continually conduct n-of-1 experiments with your health?
— Rich Joseph, MD
How Rich incorporates comprehensive lab testing
Mike Haney: Interesting. Well, I think that's a good lead-in to talking about blood testing in general and where blood testing---and we'll say blood testing mean blood and urine, but lab testing in general---fits into how you assess people. How do you, maybe just I'll start broadly with that, how do you incorporate lab tests into a typical interaction you'd have with a client?
Dr. Rich Joseph: Yeah. Can I start sharing a bit about how I do it in the context of my practice? Is that okay? As part of my practice, I do a pretty comprehensive assessment from the get-go for people and the assessment becomes a separate product in of itself within the practice.
Again, I think for people who are in their late 30s, early 40s, they may be doing quite well and they just want to start monitoring this stuff over time. They may want to have data from year-over-year that they can trend so they can see this drift over time if it happens.
And the assessment that I conduct, I think the value of it is that it takes a lot of the---again, all this data is out there now, to your point. People can go get a bunch of data on themselves without even an MD being involved in that or a doctor's order. And obviously, part of what I do in the data is comprehensive blood work because I do think it's extremely valuable to look under the hood. You can see a lot of pieces. You can look at real risk for people---cardiovascular risk, metabolic risk, obviously you guys think a ton about.
But then you can see a lot on people's blood work, which I know we're going to talk about today. I do a whole functional fitness assessment with people, DEXA, VO2 max testing, cognitive evaluation, germline genetic testing, all that. And I think the value is that then you bring it together in a whole comprehensive report for people so that it's structured, it's synthesized, and it's contextualized for them.
Because I think to your point, you go out and get all this data on your own, you have no idea heads or tails what to make of it. And some things are in the red and does that really matter? Do you have to pay attention to that?
Mike Haney: Yeah. I think that's a really good---the idea of the broad set of doing that assessment in the broadest way possible, right? We think about this. We've done things like, okay, we're going to help you figure out your blood sugar. That's step one. Now we're like, okay, we're going to look at a bunch of different markers, but, we've looked at adding things like DEXA, VO2 max. A bunch of us in the company have done that as well. Grip strength, even some of these cognitive assessments.
How important is that understanding of your own full body health in understanding something like blood lab results? In other words, if I don't have a practice like yours that I'm a part of or a functional med doc and I just go to Function or Levels and I get a hundred blood tests and I get some markers back, how much sense can I make of these without also understanding some of the things that some of those other tests like particularly a DEXA or VO2 max might tell me?
Dr. Rich Joseph: Yeah, I think that's where it gets a little bit tricky for people because I think you have to---the context is everything. And I'll keep hammering that home. I think that it's hard to look at one lab value or even a series of lab values and make some diagnosis about it.
I think certain things matter. Like an A1C. I know you talk a ton about hemoglobin A1C with the folks at Levels and you can make clear diagnosis---pre-diabetes, diabetes, etc.---with that. You can look at cardiovascular risk markers and understand those in the context of family history, things like that.
But I think some of the labs we're going to talk about today like a CBC, urinalysis, electrolytes, I think you really have to---a lot of that has to be grounded in physiology. And I think there's a lot of value to looking at patterns over time. I think a lot about rather than just explicit data points, think about patterns and think about context.
And because a lot of, I think some of the values that we'll talk about today, it's really hard. You're not making diagnosis based off of these things. And that's where it gets like understanding physiology I think is critical.
Complete blood count (CBC): The three big buckets
Mike Haney: Yeah. Let's talk about the CBC, which is people have probably seen that acronym, complete blood count. It's a test I think everybody basically gets if you're going to get---it seems like one of the most common tests just in your, as part of your annual physical, not even if you're going out and paying for additional labs. It's very cheap test, I know having seen pricing out at Quest or whatever.
It's super common but as you said, it's not diagnostic. It's not the test you take to find out do I have X condition. Why do we do a CBC? What's the information I'm getting from that?
Dr. Rich Joseph: Yeah, great question. I think just high level, CBC, electrolyte panel, and urinalysis are all really cheap, which you said. They're very basic. I got to make this podcast exciting for people. I always say basic is still foundational.
I know everyone's like, "What's the newest test out there? What's the coolest thing to get?" But these are still very foundational labs and you can actually learn a lot by looking at them. And going back to the CBC, to your point, there are certain things that can be diagnosed off of a CBC---anemia, things like that you can look at.
But how it breaks down: you look at red blood cell count, white blood cell count, and platelets. Those are the three big buckets that come out of a CBC. And I think the first thing I'll look at usually is red blood cell count. And when you think about red blood cells, why are they important? They carry oxygen to all parts of your body, which is essential for energy production.
And hemoglobin, which is the protein that's in red blood cells, does that. And you'll see first you'll see the readout of a hemoglobin or hematocrit which is similar, interchangeable, basically talking about the amount of hemoglobin that you have in red blood cells. And that's critical because you want to see how much capacity does someone have to transport oxygen.
And I think that people have heard of anemia and that gets diagnosed based off of the hemoglobin hematocrit concentration. And you can have all different types of anemia, we can get into all that type of stuff.
But that's one thing that's very clear and there's in traditional medicine, there's a very clear cutoff. Versus and I hope to bring a little bit of this to this podcast of how might a more functional medicine or even the way I practice think about this. If someone has their hemoglobin is 14 and then the next time they check it's 13, that's a decrement for sure. And why is that? Even though that might still be normal within bounds, they might not qualify as having anemia, it's not normal for them.
Mike Haney: Yeah. How transient are those readings? Let's just stay on hemoglobin for a minute of the red blood cell ones. You mentioned that a move from a 14 to a 13. Is that the test---because I run into this a lot in these conversations about tests---that there are some of these tests where you get an abnormal reading and it's, I don't know, something just happened that day. Your body was off whatever. Next time you test it, it's normal. Other tests, even that movement might mean something. Where does movement fall within the red blood cell and how durable or transient are those readings?
Dr. Rich Joseph: It could be very different based on hydration status. It's just one easy thing that can affect it. And that's where the context matters a ton where it's like, are we talking about a female that's menstruating and has had heavy periods recently and that could be cause of blood loss? Are we talking about someone who is in their 70s and has never had a colonoscopy before and they have downtrending hemoglobin and never looked to see do they have a bleed or something going on? Those are obviously extreme or dangerous examples.
But even in someone who is maybe vegan or overtraining or something like that and they're not taking in enough folate, B12, which are essential for production of the DNA in red blood cells, you can see that downtrending over time.
And then we'll get into other markers but looking at something like the MCV which is basically looking at how big a red blood cell is. If you have iron deficiency, usually you'll see that MCV will be lower. If you have B12 or folate deficiency, that MCV will be higher. And you can still have anemia---both of them are types of anemia. And that's where that context matters. It's so different person to person based off of who they are and what their risk factors are and how they live their life.
Reading red blood cell markers: conventional vs. functional approach
Mike Haney: When you start to see in a patient that comes to you and you do that initial CBC, is it typically the hematocrit that would be off first and then you would look at something like an MCV or an MCHC? There's a bunch of these acronyms. To dig a little bit further? Or could the MCV be off while even the hematocrit's fine?
Dr. Rich Joseph: Yeah, the way conventional medicine would look at it is: do they have anemia? Look at hemoglobin hematocrit. Is it below normal? Do they qualify as having anemia? If yes, then let's look at the MCV, let's look at the RDW, let's look at the red tick count and see why.
Versus a more proactive or even functional lens is like do they have an uptrending MCV with still a normal hemoglobin? Could that indicate some subtle sign of micronutrient deficiency, B12, folate, iron, etc.? What's their RDW doing?
RDW is the red cell distribution width. Basically how variable in size are these red blood cells? Is the marrow basically saying it's just trying to spit out a bunch of red blood cells as fast as possible or is it making them with integrity because it has enough of the building blocks?
And again, it's all about the perspective a little bit. And my job is to bring both lenses or multiple lenses as much as possible. The type of clients that I'm working with, I'm not usually concerned that they're having GI bleeds or---and I'll get their menstrual history and learn about things like that.
But it's more of these subtle drifts and changes over time that matter, which is why even in my first assessment that I do with clients, it's not---I don't see usually that much on a CBC that will tip me off to something because it's more about the trend or pattern over time.
Mike Haney: Are there other---we talk a lot about anemia. Are there any other, and some of those extreme things like an internal bleed that you're not paying attention to, are there other conditions that something being off in the red blood cell markers would point you to?
Dr. Rich Joseph: Good question. I think that's the main one that comes to mind for me. I think that there are different, again, different types of anemia, different causes of anemia. It could be through blood loss. It can be underproduction of red blood cells because they don't have the right building blocks like iron, B12, folate, etc., which we talked about.
Less likely in most healthy people is they can have hemolysis which is basically the destruction of red blood cells intravascularly for a variety of reasons. Certain viruses and things like that can cause that. Those are the main ones. And then there are inborn genetic related reasons. There are, obviously people have heard of sickle cell which causes dysfunction the way that red blood cells are formed. There's what's called thalassemia and the different types of thalassemia which is again genetic. And yeah, those are the things that come to mind for me with red blood cells.
Mike Haney: Is there interaction? We'll move on to the other buckets. And I appreciate the way you bucketed these red blood cell, white blood cell, and platelets. Is there interaction between those? In other words, if something's off in the red blood cell, do you look at the white or the platelets? Or are they all doing such distinct functions that they're not really related?
Dr. Rich Joseph: They're doing pretty distinct functions honestly. I think that, a few larger ways to think about integrating these is someone is under chronic stress for a long period of time. Do they therefore have any type of gut related dysfunction issues where they're not absorbing B12, folate, iron enough? If they're highly inflamed for too long, again, that can reduce iron, the capacity to use iron because it gets attached to hepcidin.
And then at the same time, high level of chronic stress for too long, you can see low white blood cell count due to that versus more acute stress you'd see a higher white blood cell count. And I think there's ways to bucket or put big umbrellas under these things but again, it depends so much on the context and what you learn from the person that you're talking to or the person who's going to get these blood tests. It's important for them to understand what is my life like? What are my symptoms like? What am I dealing with? So I can think about what might be going on here.
Mike Haney: Yeah, that feels like the umbrella there is almost some of those conditions like you mentioned like chronic stress. If you were somebody who's got chronic stress or terrible sleep, some of these things which might have a similar effect to chronic stress, you could see that manifest in all sorts of sets of markers. This comes up in all of these conversations I have, right? When you go like, well, what could cause X value to be off? And people are always like, well, chronic stress.
Dr. Rich Joseph: It's a big bucket. Chronic stress. Because again, it's systems level. It affects everything. And again, stress manifests, whether that's stress due to burnout at work, whether that's relationship stress, whether that's overtraining and exercise. Again, all the stress manifests in the same way. Same thing with chronic inflammatory responses whether that's because you have some GI permeability, leaky gut type of deal and you have that or you have some virus that has not been adequately treated, that's triggering this low-grade inflammatory response. Metabolic dysfunction also tracks closely with inflammatory response as well. And this systems level. And this is again where I think functional medicine has just done a great job of helping people better understand those systems biology because again, you can't take a reductionist approach to these types of conditions or symptoms.
White blood cells: The differential and what it reveals
Mike Haney: Yeah. Well, I think talking about inflammation is a good move into the white blood cell bucket. Tell us about what are you testing and what are you learning within that white blood cell bucket of the CBC?
Dr. Rich Joseph: There are different types of white blood cells. There's neutrophils which you can think of as your first line of defense. Your skin's your first barrier of defense for pathogens or bacteria, but then your neutrophils are the next line of defense. They're the immediate inflammatory response cells, especially to bacterial pathogens.
And then you have lymphocytes and that's more of your adaptive immune system---B cells and T-cells. And there they more respond to viral illnesses usually.
You have what are called monocytes which are basically the garbage trucks which pick up a bunch of the debris after you have an inflammatory response.
You have eosinophils which are related---people think about this often in terms of autoimmune conditions, gut related permeability issues, hypersensitivity, histamine related---that's the allergy often.
And basophils which actually are the ones that are full up with histamine and release histamine into the system.
And that's where what's called a diff---you get a CBC with a diff and segments out those different types of white blood cells. And then you can see a little bit, you can get clues to what might be going on with someone. Did they have---again, I just did a workout before I came in here which was pretty taxing. My neutrophil level might be high after that. That was acute stress on my body. I created inflammation in my body and then activated the neutrophils. Hopefully they'll come pretty quickly.
But if someone then has like a high lymphocyte count, low neutrophil count, that might indicate much more of a lingering viral type of infection for them.
If you have chronic stress, again, you can have what we'll call leukopenia or neutropenia where your white blood cells, your neutrophils actually become suppressed over time because you're basically continuing to hammer that HPA axis over and over again. And cortisol basically can suppress or lower that neutrophil count.
And then I think the eosinophils are really interesting because that's a nice tipoff if those are elevated. Tipoff is this allergy related, hypersensitivity related, mast cell related condition, which I think is something I know a lot of functional medicine doctors look at very closely.
And I do think that you can actually see, again, conventional medicine standards, it's like do they have a high white count? Do they have what's called a left shift, meaning that their neutrophils are really activated and the marrow is pumping out a bunch of neutrophils. Likely they have some bacterial infection. In the context of being in a hospital or something like that, you're always looking at the white count and you're looking at the diff. But that's not the only setting in which people have inflammation or some infection.
And that's where I think the white blood cell count can be really useful. That was a lot, but I hopefully that will provide some context.
Mike Haney: Yeah. What's interesting about that set of white blood cell markers as you just went through is, we I think we bucket that under immune inflammation, and that's, my context just talking to doctors over the years when they talk about white blood cells, it's usually is your immune system healthy, is your white blood cell count healthy. What's interesting about those is the specialized job that each one of those has. It sounds like, all of these markers we're talking about, they're not really diagnostic, they're a part of an investigation. And it sounds like what's interesting about the white blood cells is because they all have these specialized jobs, they do point you in a more focused direction like oh, you've probably got a sensitivity or with the basophils like we've got some allergy going on here. I feel like, yeah, that's why I hear about this more from the functional med folks because they're more likely to investigate that as a potential cause of some set of symptoms that maybe your GP went I don't know.
Dr. Rich Joseph: Right, again, because conventional medicine, you're trained to just look what's the normal value, is this in the normal value or not? You don't even rarely look at a diff usually if you're just going for a basic physical or something like that. And again, my sense is that most of the people who then go to use functional medicine, maybe their conventional doctor said, "Hey, I don't know what's going on" or "Sorry you have these symptoms but we can't figure it out." They just go a level deeper probably for most folks. And, I think that's extremely valuable.
Usually those people do have symptoms already though is my sense.
In conventional medicine, you're trained to just look: what's the normal value, is this in the normal value or not? You don't even rarely look at a diff usually if you're just going for a basic physical.
— Rich Joseph, MD
Patterns in chronically stressed, high-performing clients
Mike Haney: How do you make sense of that initial assessment you get from somebody and then what patterns are you looking for over time? Or maybe another one is what patterns do you typically see over time in the kinds of folks you work with?
Dr. Rich Joseph: It's a great question. A lot of the folks that I work with are, say call them high performing but also chronically stressed, don't take great care of themselves, may work out a lot but also don't recover enough. Like a lot of my job is actually like don't work out, recover a bit more, and help them be more strategic about how they think about applying stimulus and recovery in their life. Because a lot of the folks I work with are always flirting with that line of adaptation or burnout or overdoing it, which is a very fine line.
And often I would say what I see the most is I'll see a chronically suppressed neutrophil count or just even lymphocyte count as well. Cortisol being the actor that's doing that, suppressing this. And I think looking in the context then you'd go get a high sensitivity CRP, look at an ESR, look at other markers of inflammation like total body inflammation to corroborate a little bit is that what's going on. And then understand what's your HRV trend looking like? How are you sleeping? Those types of things. Because they may be crushing their workouts but they're chronically underrecovered.
Mike Haney: Yeah, that's an interesting example where that context feels important because, as you were describing those things, it's like okay, a low count of those or a neutrophil being off could be indicative of some viral infection or bacterial infection maybe. And lymphocyte could be maybe more viral that we just don't quite know about. But if you're talking to the person and you know them and you know that this is somebody who, like you said, flirts with that line, works out really hard, but maybe is very stressed, then you're going to interpret that chronic abnormal result in those as something else.
Dr. Rich Joseph: Yeah, that's exactly right. And I think that's why it's helpful for me to really have the full context of the person I'm working with and then see these patterns over time. And again, if someone has an acute infection or you're worried about something like that, then, you might see something totally different on the CBC and you check it for more of a diagnostic corroboration purposes. Versus a let's trend this over time and look for subtle differences or drift and understand that in the context of other things that you're tracking and the things that I know about you in your life.
When to retest and understanding reference ranges
Mike Haney: Is this one of the CBC in general, is this one of these markers---because this has come up a lot in these conversations---where if you go to get this on your own as part of some blood panel or you get it even through your physical but don't, I think so many of us have the experience of getting the physical and then no follow-up from the doctor if nothing is crazy. They just go it's fine. But if you see any of these markers off, are these the kinds of markers where you should just go get another test in a week or two weeks or a month and then look to see that it wasn't some transient blip? Or is this the marker where if something's off, you should follow up with your GP or somebody else and say, "Hey, my neutrophils looked weird in this thing. What's going on?"
Dr. Rich Joseph: Hard to answer that. I think tough questions. Because it depends. If someone, again, extreme example, someone has leukemia, you go get a, they feel like crap for a few days. They go get their, or for like a while been feeling pretty terrible. They go get their blood work done. Again, hopefully this is with the supervision of a physician, but sky-high white count. And other cell lines also raised and indicative of more of a blood cancer. That's extreme. Obviously, that's something you want to follow up on and have good care around.
The challenge is that, that red or green on the panel that you get back of what's in range versus not in range is just one little fine cutoff. You can have a white count that is just right to the right of that or right to the left of that and it will flag as red but it may mean absolutely nothing in terms of clinical decision-making or the clinical context.
And that's where I think the risk is with---but I think it's an interesting time where people can go out and do a lot of this testing. And I think it's important for more people to have more autonomy and agency around their health. Because we're never going to have enough primary care doctors to do this for everyone and go this in depth. And it's just not possible. It's not a knock on primary care. It's just they don't have the time or the training to do this.
But that's where I think it's about understanding, what's way off versus what's within acceptable clinical context and how else am I feeling and what else has my body been dealing with these days? And sure, then go get it checked again. And there's no harm to getting it checked again. I believe in getting these markers checked with some regular frequency so that you can actually again see that drift and use it as a feedback tool. Not a diagnostic tool all the time, but a feedback tool like I'm changing this thing that I'm doing in my life. I have certain lifestyle or performance type interventions that I'm working on. How does this impact this?
Mike Haney: That, the word of the day is context. We keep coming back to that.
Dr. Rich Joseph: We keep coming back to it. Yeah.
Mike Haney: This is one of the things I've taken out of these conversations as well is and I've been telling friends is if you go get a blood test, even just your normal physical, take a minute and write down somewhere what's going on in your life. Are there any symptoms, weird stuff you've been having? Look, I'm middle-aged. There's always some weird thing going on and some ache, some something. But write that stuff down. Write down what else is going on. Oh, that's right. I did have a cold last week. Oh, I just ran a marathon. I've been sleeping crappy lately. Even if you don't have this conversation with a practitioner, just you being able to look at any result in the context of what else is going on might at least give you some notion of oh, I should follow up on this or oh, this might be related. Or worst case scenario, if you're going to go talk to ChatGPT about it, which is what a lot of folks are doing now, you could say here's my CBC panel and here's my list of what else was going on and you'll probably get closer to an answer than just going here's my CBC, be seen for results.
Dr. Rich Joseph: Totally 100%. The context is everything. Have people, your practitioner or your ChatGPT practitioner understand your age, the context of your life, stress levels, how you train, how you eat, how you sleep, etc. All those things matter a ton. And again, when something's really way off, then it's when, really I think prudent to then work with a practitioner to really understand it. But I think until then or at least, catching drift is the more important thing to do.
Platelets: The clotting component
Mike Haney: Well, let's talk about platelets before we leave the CBC part of this. What are the platelet markers and what's that telling us?
Dr. Rich Joseph: Platelets are important for clotting, help with blood clotting. And, I think that the way I think about platelets is they can be elevated in particular in an inflammatory response. You can see a high platelet count and a high MPV.
And, truth be told, I don't think about them too much most of the time unless they're really low, called thrombocytopenia, which can be, what's called idiopathic for different reasons. People take a certain medicine, they have a certain virus, something like that, they can actually totally knock out their platelets, which is a real risk because then you can have internal bleeding and things like that. If they're really low, that's a problem.
But I think more, for the audience we're talking to now, it's do I have something that's causing acute inflammation in my body? And then you can see what's called a reactive thrombocytosis, increase in platelet count.
Mike Haney: That's not something you're typically going to see off and if it is, it probably is worth following up in some way because it's just not a thing that's typically---
Dr. Rich Joseph: Yeah, not usually. Candidly, at least in the context of my practice and who I'm working with, I trend the CBC, I'll look at CBC at least annually for people, but it's not something that you can see subtle changes but it's not usually huge like oh diagnostic, this is a big deal type of thing.
Urinalysis: Windows into kidney and metabolic health
Mike Haney: Well maybe keeping in that vein then, we should move to the urinalysis because it feels like that's similar. There's, within I think any of the urinalysis you get, I know within the lab tests we're doing, I've got it written down here and I think there's 15-20 different things that come out of urinalysis. Maybe just start broadly: why do I have to pee in a cup when I go to get my physical?
Dr. Rich Joseph: The urine as well as other parts of the body---the skin in particular, the mouth---they're windows into some of what's happening internally in the body. And, you can learn a lot by looking at someone's pee and understanding what's in it.
And some of the things that I think a lot about are: specific gravity talks about how diluted or concentrated the urine is. And particularly a lot of the folks that I work with, are they underhydrated? Are they sweating too much? Are they spending too much time in a sauna? Things like that can cause concentration of the urine.
You can look at the acidity of the pH. Our body, talk about one of the main acts of homeostasis in the body is to maintain a really tight pH. All of our enzymes have to function with a very narrow band of pH.
And, see if the urine is slightly acidic. Does that therefore indicate or maybe suggest just a low-grade level of acidosis in the body? That can be due to a lot of different reasons, again, inflammation, metabolic dysfunction. All these things can create low-grade acidosis.
And then looking at specific metabolites or, chemical things that are in the urine. Glucose being one of them, obviously. And you shouldn't have glucose in your urine generally. And, that could be indication of metabolic dysfunction progressing to things like pre-diabetes or diabetes.
You want to look at some of the other things are protein in the urine. You shouldn't have protein in your urine either. Your kidney should filter that out. They should maintain a very tight barrier in the kidney so that protein is not spilling into the urine. Is that indicative of some type of renal damage that's going on?
Ketones, another one. And again, ketones---conventional medicine doctor thinks ketones in the urine, risk of, diabetes, particularly type 1 diabetes with diabetic ketoacidosis. Do they have, are they spilling ketones into the urine? But if someone is doing a, low carb or keto, or trying a ketogenic type of diet, not uncommon that they might have some ketones in their urine. Again, that could be adaptive in certain circumstances, very maladaptive in other circumstances.
Those are some of the big ones that I think about. And then again, you can do---I don't know if you guys are doing that---you could then look at someone's urinalysis under a microscope and look to see do I see different types of---do I see casts in the urine? Do I see crystals in the urine? And again those can all indicate different types of things going on.
Mike Haney: It feels like the buckets---kidney function is one of the things you're going to learn about because the kidney basically filters things into the urine so it tells you something about basically how well the kidneys are filtering or if there are things like glucose or protein that are overwhelming the kidneys' ability to get them out. Kidney function, hydration is another thing you're going to learn about, color or that stuff. That's the old thing you hear when you're a kid is if your pee is really light colored, it means you're drinking enough; if it's dark---is that true? Are there other color things you're looking at?
Dr. Rich Joseph: That is generally true. However, I think if you take a lot of vitamins, your pee is usually going to be bright yellow a lot of times. You're spilling a lot of excess vitamins into your urine. Your kidney is extremely good at retaining exactly what it needs to retain to keep it in your blood and titrating your electrolyte levels very finely. And it's very good in getting rid of the stuff that it doesn't need in your urine. But that's generally true, yes. Yeah, those are the big ones.
Mike Haney: And then things like UTI would be the other?
Dr. Rich Joseph: Urine to see you have bacteria in the urine, you have what's called leukocyte esterase or positive nitrates---those are indicative of infection. But you can also see those things in menopausal status too. Again, the vaginal colonization is changing, the milieu of the vaginal canal is changing. And it's not all the time that you see those things as positive that someone has a UTI. There's a clinical diagnosis that has to be made.
Mike Haney: With the urine markers, it feels like these are also just pieces of information. Seems like some things like maybe the UTI markers might be a little bit more diagnostic. Other things are going to be, yeah, this is a little off, we should look further at maybe some of the kidney markers or, just lifestyle stuff like are you drinking enough?
Dr. Rich Joseph: That's right. I think it's a broader clinical context for sure. I think, again, back to the big buckets of, say chronic stress, chronic inflammation, overtraining, micronutrient insufficiency. And I think again, all three of these big buckets of tests that we're talking about right now, I think can all provide diagnostic clues or clues to see is this going on with someone. But alone, just one value alone or one test alone isn't usually going to tell you that much.
Electrolytes: Essential for every cell function
Mike Haney: Well maybe we'll move on then to electrolytes which, like I said, is related but slightly different than these other ones that we're talking about. Maybe first, let's just go through what are electrolytes? What are some of the substances? Because these are things people have probably heard of but may not think about as a bucket of electrolytes.
Dr. Rich Joseph: Electrolytes are, at least the way they exist in the body, as chemically charged particles that are essential for pretty much the function of every single cell in your whole body. Which is again why electrolyte imbalances or disturbances are systemic in their effects. It's not like affecting one organ or something like that.
And the main electrolytes in the body are sodium, potassium, chloride are the big ones. Magnesium is another big one. And those are the ones that I think are most usually checked on the panel. You can have CO2, which is also checked, which is a proxy for bicarbonate, which looks at acid-base balance in the body.
Mike Haney: My sense of electrolytes is because they are so critical to---I don't know if signaling is the right word, but they are mechanistic in the way that cells do the things they do. Like the production of ATP, which is our energy currency within cells, mitochondria---everybody's heard of this---relies on electrolytes to complete that chemical reaction. There's these key players in these systems that are happening in all of our cells. My sense is because of that, the body is very careful about keeping really precise levels of these. And I guess one of my questions is how often do you see these things being off? And is this a thing where if this is off, whoa, something seriously wrong? Or do you see fluctuations even just in normal health, sickness?
Dr. Rich Joseph: I think it's a great question and again, back to all my answers, it depends. I'm sure you hear this a lot. Some of our electrolytes are so tightly regulated and it depends---some of them exist more extracellularly, some of them exist more inside the cell. Sodium exists more outside the cell, important for maintaining blood pressure, intravascular volume, important for conducting action potentials with nerves, triggering muscles to fire, things like that. Sodium and chloride tend to hang out together.
In the cell, potassium is the big ion in the cell. And magnesium and potassium track pretty closely together. Magnesium, I think of more as a coactor for a lot of enzymatic reactions. Actually, ATP can't work if it is not attached to magnesium. It's that critical.
And if you're leaking out potassium for some reason or if you're leaking out magnesium, usually you're also taking the other one with it. Deficiencies tend to go together. And yes, the body's tightly attuned to regulating these things, particularly the kidney, reabsorbing what it needs and letting go of what it doesn't in the urine.
I think back to residency when you spend time in the hospital and you think about, what are the things you get paged about? High potassium---critical. That can trigger arrhythmias, really bad stuff. And, potassium is greater than 5, 5.5, that's seriously problematic. Most of that, your body's very---you shouldn't have much potassium in your blood relative to inside your cells.
That's one that flags as a conventional medicine problem. And why is that? How do we deal with that? And, again, and I think one of the reasons that people can have a high potassium is because they have kidney dysfunction. Their kidneys aren't working well, again, back in conventional disease setting, it's do they need to be dialyzed? Is their kidneys failing essentially?
Your body is very good. You shouldn't have much potassium in your blood relative to inside your cells. So if potassium is greater than 5 or 5.5, that's seriously a problem. That can trigger arrhythmias.
— Rich Joseph, MD
Subtle electrolyte changes and chronic stress
Dr. Rich Joseph: More in the context of my practice now, you don't usually see that. You don't see worries in potassium values. You see more subtle changes in sodium. Maybe people have a low normal type of sodium for some reason or another. Again, it can be due to chronic stress is another thing. If you have chronic stress, it activates the HPA axis, hypothalamic pituitary axis, which releases cortisol, tends to also activate the renin-angiotensin-aldosterone axis, which is important. Aldosterone helps reabsorb sodium and keep your blood pressure up. You think about it in a stress response, you want both of those things working.
And, if someone is just, if they've been overtaxing that system for too long and their aldosterone levels are dragging, you can see a lower sodium for that person. That's one thing.
Again, I think, what I'm looking at most of the time is the drift and subtle dysfunction. It's not overt disease like we need to do something about this right now.
And then I think a lot about, I think a lot about magnesium. I think that magnesium is, people are starting to think more about understanding how critical magnesium is just for pretty much every function of the body.
And how, another big theme of mine is that normal is not optimal. And, just a blood test of magnesium, usually people aren't going to be low generally. But if they have a low potassium, it might suggest that they might have a low total body store of magnesium, which is, again, you'd see that more in an RBC magnesium test, looking at how much, magnesium is inside a red blood cell, which tells more about the total body store than just what's in the blood.
Mike Haney: Right. Because in this, yeah, you're testing just blood levels of it, but that's not reflective of---because these electrolytes are all over the body. The blood concentration is a proxy.
Dr. Rich Joseph: Yeah, and I think that's important for anyone going to get a blood test, right? The blood can tell you a lot. There's a lot of stuff that's happening in the blood for sure. But the blood doesn't tell you everything that's going on in the body. A lot of these things exist within cells, intracellularly, which you don't get when you're just getting a blood test.
Electrolytes and the Gatorade question
Mike Haney: I think the context a lot of people---you say electrolytes and people think Gatorade. Just, square that circle for us. What's the connection between what we were just talking about, electrolytes helping you produce ATP, and Gatorade? Why are we equating these things?
Dr. Rich Joseph: Well, you can sweat out a lot of electrolytes. That's, the context in which Gatorade was developed was in the context of a football team down in Florida that was sweating profusely. And, when we sweat, we're not just losing water, we're also losing electrolytes. And the importance of replacing those is for sure true.
And I think the pendulum has swung a bit far the other side of that where people think they need to be drinking a bunch of salt and things like that all day. Not necessarily. I think if you're training in a lot of heat as one, if you're doing a lot of sauna, things like that, I do think it's important to replace electrolytes.
Again, if you have good kidney function, it's not usually a risk. It's not like it's harmful. Do I replace electrolytes in my body? Yeah, I do. But I don't think that it's still a little bit of majoring in the minors in my opinion.
Mike Haney: One of the electrolytes you're going to sweat out is sodium. Is that primarily what you're losing?
Dr. Rich Joseph: You're primarily losing sodium, but you're also losing magnesium too. And a sports drink, an LMNT or something like that is going to replace those. Or the tabs that I think a lot of runners and stuff now take.
But I still think a lot of it you can get just through good dietary sources, salt your food, things like that. And again, I think you don't do that for someone who has high blood pressure and is really sodium sensitive or if they have heart failure or things like that. Again, the clinical context matters.
You're not telling people with those conditions to go do that. But if you have good kidney function, you're not retaining a bunch of fluid, things like that, no risk to topping off your electrolyte levels.
Mike Haney: Yeah, I was going to---it's a good answer because I was going to ask where, particularly because you work with performance related people, where you fall on this salt question or the, the LMNT question. Not to pick on them because I like LMNT, I do too. But I do think it's, their case is, look, we don't get enough salt. You all need more salt. And there are books out saying we've completely mischaracterized salt. In fact, you need a lot more of it. And we did an article on it trying to answer this question.
I think where you're landing, which is if the other systems of the body, particularly the kidney, are healthy, you don't have hypertension, you probably just don't need to worry about it. You don't actually need a lot more. But you also don't need to be super careful about cutting it down.
And the electrolyte replacement is pretty specific to: are you running a marathon in hot weather? If you're not or working out on a football team in Florida, if you're going to the gym doing the stairstepper for half an hour, you probably don't need to replace your electrolytes. Is that where you fall?
Dr. Rich Joseph: That is definitely where I fall for sure. And again, I think that's where checking some of these levels is useful. I just think the caveat being that you don't see everything with just the blood tests. You don't see the total intrabody, intracellular stores of these electrolytes. And, but again, I think it's important to know that our body is pretty finely attuned to regulating these things pretty closely.
I'm a big believer of not tampering too much with physiology.
Electrolyte imbalances and symptoms
Mike Haney: If somebody has for some reason one of these electrolyte markers off, is that often going to be accompanied by some symptom? They're going to have fatigue, they're going to have something?
Dr. Rich Joseph: They could, they could. Or it could be, always what we say in medicine, it could be true, true, and unrelated. They could have that for 10 million other reasons that they feel fatigued or brain fog or whatever it is. And, I think that's the hard part. It's that these tend to track with what we call non-specific type of symptoms. And they can help point in the direction of trying something. Let's try this. Does this improve one, how you feel? Two, levels that we're checking? And therefore, I think you design these experiments with people a little bit.
And I think that's a lot of where my focus is, is I think it takes a lot of energy to do that proactively with people, is to figure out what are these small micro experiments that we're going to conduct with you? Because we don't always know what's causing what. But let's try something as long as it's not harmful. Let's make sure we have the objective metrics that we're going to look at, both subjectively from you as well as objectively like either lab data or whatever it is, so that we can learn.
Real-world example: The vegan Ironman client
Mike Haney: Can you give me an example of what some of those micro experiments might be? What are some things you've done with clients?
Dr. Rich Joseph: Good question. I have a client right now who, typical, finance guy who also wants to be doing Ironmans and has two young kids. And I'm just like, what are you trying to do, man? This sounds tough.
It's just chronically crushing himself. And then he also told me that his wife is pretty much vegan and so he tries to eat mainly with her. It's not that he's averse to eating meat or anything like that, but he tends to eat most of his meals at home or follow that dietary pattern.
And looking at both subjective fatigue---again, that could be related to the fact that he's probably doing too much and not recovering enough. But then if you look at his blood panel, he did have a bit of an elevated MCV. He didn't have overt anemia. But, the elevated MCV as well as a higher retic count, or an RDW, suggested to me, hey, you're probably not getting enough B12 because you're not, you're following this dietary pattern. You're doing a lot of intense exercise. You may need additional protein too.
And let's at least make sure. It wasn't a thing where it's like I don't eat red meat or I'm not going to eat meat. And, have the discussion with your wife. I'm going to eat more of this because I need this for my training. And then see subjectively how I feel. Let's check these things back in three months and see if this has changed, which it did for him.
And I think that, again, you don't know what you don't know. For him, it was just like, I'm being supportive of my spouse by eating this way and for me, it's probably better for me anyway from a health perspective. But actually from the way he was training and what he's trying to accomplish from a performance perspective, this probably wasn't the best way for him to be eating.
Mike Haney: How do you think about people doing those n-of-1 experiments, those little micro tests on themselves, if they're not working with a doctor? Do you think that people---is there utility in doing things like a specific dietary intervention and carefully tracking it for some amount of time? Or do you find that when folks try to do it on their own, it just either they don't stick to it or it gets too confounded with other stuff and it may just lead to more confusion?
Like how do you, when you're working with that client, are you careful to say to him, look, this is the thing we're going to do. I need you to hold other things constant?
Dr. Rich Joseph: Correct. Yeah. I think you have to really change one lever or one factor at a time or else it does get confounded for sure.
And, these don't have to be long experiments. Give it, a month, two months, three months to see what happens. And let's learn from it.
There's textbook medicine and then there's everything else, which is everyone. Everyone is different in how their body responds to certain things. And I think that we have to honor that. And in medicine, at least in conventional medicine, you're trained to detect patterns, but really it's about knowing people in many ways, which takes time to do that.
And, I really push the clients I work with and I would push anyone to really spend the time understanding themselves, understanding, learning about, not just their data, but how they're living their life. And start conducting these experiments on a quarterly basis to see what works and what doesn't.
And then also just to advise people not to fall into habits---I think habits are very helpful for getting certain health behaviors going. But habits, the danger with them is they become mindless over time. And I'm a big believer that in order to keep advancing, to keep adapting, you have to continually change the stimulus for yourself and you have to try different things.
And for me, that's the fun of it though, candidly.
Training for life and balanced stimulus
Mike Haney: That might manifest in---I'm just guessing here, but would that manifest in things like, I'm a runner, I like to run, and your advice might be that's great, but also now let's incorporate some weight training, let's try doing HIIT for a while, let's do a different sport?
Dr. Rich Joseph: Well, totally because a lot of, the premise of how I work is you're training for life. Certain people I work with, they have sport specific performance goals that they're working on, which is totally fine. Sometimes, however, and I think you probably know, they can be orthogonal in some ways to performance for life. Training in a very specific way, you're just doing one thing. It sounds cliche, but balance is really the name of the game if you're thinking about training for life.
And, I think it's easy to live at the extremes for most people because again, it's mindless. It's a lot harder to create balance.
I think physical training is a nice metaphor for that because you have these different domains across which you have to train. But it's true both in, in other domains of life too. Cognitive, emotional, relational, like all those same concepts.
Major in the majors: Focus on fundamentals
Mike Haney: What are some other lifestyle interventions that you are either excited about prescribing more frequently now, seeing really good results from? Is there anything specific that comes to mind when I say that?
Dr. Rich Joseph: Yes. I'm a big "major in the majors" type of guy. I think there's a lot of commercial pressure out there to major in the minors these days.
Mike Haney: Unpack that phrase, "major in the majors."
Dr. Rich Joseph: It's how you sleep. How you train. How you eat. How you connect with other people. High sense of purpose in life. Those are big vital signs for me.
And I think the risk honestly, back to the discussion of some of these labs, is that you look at these labs in isolation and then you don't necessarily treat with medicines, but you're still treating with supplements or something like that, versus a more holistic prescription for people.
And, I have seen a number of people who have just become over-supplemented on a bunch of things without going back to some of the foundational principles of how am I living my life day-to-day.
And I really try to focus there. I'll say that, for me it's been a personal experience too. This is not just Rich the doctor prescribing things to people. It's Rich the guy who used to train in a certain way and realized that now that I'm almost 40, I can't do that anymore. Now that I have three little kids who, I have to adapt the way that I live my life and I can't just run on adrenaline all the time. Sleep has become way more critical for me to function at a high level during the day.
And my tendency used to be thinking more is better---more training, more whatever. Now it's actually, what is, I think the question of, what is the exact stimulus that I'm giving my body and what is the adaptation I'm hoping to get from this? And that's a lot of the question that I ask myself and try to encourage my clients to ask themselves too.
And I think that's hard because we become entrenched in our own behavior patterns over time. And you have to change the script for yourself sometimes and really force yourself to ask, is this serving me right now? What do I need?
Tailored dietary interventions and metabolic dysfunction
Mike Haney: Yeah, I like that model of stimulus and adaptation. How might that manifest in a dietary intervention? Or maybe another way to ask is what kinds of dietary interventions do you find yourself talking to folks about?
Dr. Rich Joseph: It depends. A lot of the folks that I work with, I, the typical client to my practice is someone who maybe has traded health for wealth for a number of years. Maybe they were an athlete back in the day in high school and college, still have that vision of themselves, still think that they are that person, but they're not. This is you 25 years later of sitting at a desk and being under chronic stress. And now maybe they have little kids and they're usually eating most of their kids' food most of the time. That's the life that they live now.
And, no stranger to you guys on this podcast, a lot of what I work on is metabolic dysfunction with people. And, metabolic dysfunction being one of the most important controllable things that we can actually do something about. Versus, people can have cardiovascular risk or cancer risk for other reasons that they can't totally control. But, if you can tackle metabolic dysfunction, you can really do a good job of helping to prevent those other things.
And, a lot of times if they have signs of early insulin resistance, they have a high fasting insulin, they have an elevated HOMA-IR or whatever it is, and they have visceral fat, etc., then I will, we'll talk a lot more about a lower carb approach to their diet. They need less insulin on board.
And, even the guy I was just talking to yesterday, it's not---I'm not strict around you need to do keto, you need to do this. I think it's very easy to fall into a camp or try to, subscribe to some dietary ethos. I don't have that. I think, what's feasible for you in your life?
This one guy I'm working with yesterday is like, have four days a week, have no carbs at dinner. We become more insulin resistant throughout the day. Let's at least target dinnertime. Have an earlier dinner, really low carb, ideally no carb for that time. And work on some more fasted zone 2 type of cardio in the morning to just get your mitochondria used to oxidizing fat.
And again, I think it has to be tailored to the person with what they're working on. That's not how I train now because I don't have to, and that's not how I eat. I eat plenty of carbs, but I also have a different physiology than he does.
How do you just apply it to the right person? And then also within the context of not just their physiology, but their psychology and their priorities. I would say the three Ps. The physiology one is actually probably less hard to understand for most people. It's the psychology and the priorities. That's really the nut to crack for most people.
Mike Haney: Well, I think that's a great place to end it. Rich, thanks so much.
Dr. Rich Joseph: Thanks for having me, Mike.