Labwork 202 Flashcards
What is your assessment and response to a patient with a Mean Corpuscular volume (MCV) of 89.5 (typical reference range (TRR) is 80-100 fL) and a Methylmalonic Acid (MMA) of 0.48 (TRR 0.1-0.6 mmol/L)?*
Comment on both the markers and the levels. Be thorough.
(1) Value is in the optimal zone of MCV (functional range).
(2) This MCV value indicates agile red blood cells or ones that can circulate freely.
(3) Bio-individuality may still make this MCV value suboptimal for some (we teach the threshold for optimal is less than 90 fL (midpoint RR).
(4) MCV at this level indicates sufficient vitamin B12 and Folate in this regard.
(5) MCV and MMA are both functional markers and are better indicators of nutrient sufficiency than plasma/serum levels alone.
(6) An MMA in the upper half of the reference range, however, indicates suboptimal Vitamin B12 in this regard.
(7) The form of B12 used by the body in reference to the two markers is different, and the body may be struggling to convert.
(8) Inborn errors of metabolism (genetics) can cause high MMA.
(9) Having ample or excessive folate (esp. via supplement) can mask B12 deficiency.
(10) It is fair to assume in this case that Vitamin B12 is insufficient.
(11) Serum B12 would help to confirm whether the root cause of the lack is at the GI absorption point (e.g. low stomach acid or insufficient intake)
(12) Homocysteine would be an ideal additional marker to run to confirm folate sufficiency.
(13) MTHFR SNP testing will help to distinguish any issues with intake vs. utilization of folate.
(14) There may be a lab error that would explain the conflicting meanings of the two lab makers.
(15) Iron deficiency may be driving the MCV down lower than it would naturally be, making the two markers inconsistent in ability to reflect status of other nutrients.
(16) RDW is a helpful measure to determine if the MCV is an average of large and small sized red blood cells.
In men, a strong cortisol “stress steal” due to sustained, debilitating stress may have dramatic negative effects on two key androgens which are ____________ and _____________. Symptoms of these low androgens might include symptoms such as (name at least three):
DHEA and Low Testosterone ● Low libido or sex-drive ● Erectile dysfunction ● Weight gain, especially around the stomach area (central adiposity or obesity) ● Loss of muscle mass ● Increase in overall body fat ● Low energy, lethargy, low motivation ● Depression or mood swings ● Facial or body hair loss ● Gynecomastia or man boobs or other estrogen dominance symptom
Describe the difference in labwork measuring “total” vs. “free” levels of a hormone?
Labwork assessing total levels of a hormone (usually measured in blood) gives feedback on overall synthesis of the hormone (noting health of a gland). Assessing free levels of a hormone indicates the amount of hormone the body is choosing to have available for cellular effects (often noting the body’s response to the external environment e.g. stress and how our overall interconnected HPATG axis is responding). We know that hormones in the body are in a “soup”, and various hormones affect each other (e.g. stress hormones affect sex hormones which affect metabolic hormones). For example, at any given time, the vast majority of sex hormones (90%+) are “locked up” by being bound to binding globulins e.g. SHBG, sex hormone binding globulin. Both sets of numbers can be valuable for various cases.
When Phase 1 and Phase 2 liver detoxification in the body are imbalanced, there can be significant damage caused by elevated ___________________. There is also an important “Phase 3” of detoxification which refers to _______________
When Phase 1 and Phase 2 liver detoxification in the body are imbalanced, there can be significant damage caused by elevated oxidative stress (or oxidative damage or free radicals). There is also an important “Phase 3” of detoxification which refers to excretion, the ability to freely release toxins - both from the cell and then from the body via the primary excretion routes (stool, urine, and skin – and to a lesser degree respiration). Open, healthy Phase 3 requires healthy cell membranes, good gut motility and regular bowel movements as well as healthy kidneys and also ample intake of fiber (to help bind toxins in the gut) and clean, plain water (to help flush toxins via the kidneys). Healthy skin also requires hydration (not just water but electrolytes as well) and ample intake of Vitamin A, Zinc, and essential fatty acids in particular.
The three B vitamins which are most important for all components of methylation are _______________, _______________, and _______________. The organic acid which measures cellular sufficiency of folate is called _______________. Methylation is required as a precursor in the formation of the body’s most important intracellular antioxidant which is _______________.
Folate, Vitamin B12, and Vitamin B6
Formiminoglutamic acid or (formiminoglutamate or FIGIu)
Glutathione
What specific skewing in the types (or differential) of white blood cells can indicate a persistent, perhaps “simmering” infection?
The WBC “differential” indicates the actual number and percentage type of the major categories of white blood cells. There are a few particular patterns that might meet this criterion: (1) Low neutrophil percentage (2) High lymphocyte percentage (3) High monocyte percentage (4) Overall low level of WBCs or white blood cells, or (5) High eosinophil and/ basophil percentage (e.g. potential parasitic infection). In contrast, a very high-within-range (or
even clinically high) neutrophil percentage might indicate a brand new infection, especially if the total WBC count is a bit elevated (for this unique person – perhaps you can compare to a prior lab set from a year ago to confirm this person’s typical baseline WBC count). A WBC differential that is older than about 4-6 weeks is likely not helpful for assessing either of these dynamics.
The two most common “liver enzymes” (or liver function tests, that is LFTs) measured in conventional labwork are ________________and ________________. These are markers of ________________. What might elevated liver enzyme levels indicate? What about depressed liver enzyme levels?
These are markers of tissue turnover or damage, a certain low-level of which is expected and healthy to renew tissue. Despite the alternative name of "LFTs", these are not markers of liver function. Elevated levels indicate excessive stress or damage to the tissue. ALT is more specific (though still not fully) to liver tissue. AST is also generated in other tissues (e.g. heart, brains, skeletal muscles, and kidneys) and is less specific in origin. Clinically low ALT and AST may indicate a need for more activated Vitamin B6, required for enzyme formation. An elevated AST:ALT ratio (>2) is often indicative of a fatty liver, which might be as a result of dynamics such as excessive alcohol or metabolic syndrome (especially when combined with elevated triglycerides). Less commonly, this ratio will be high in those with hepatitis. However, a fatty liver may still exist with these enzymes showing optimal levels. Less commonly, GGT (gamma glutamyl transferase) is also measured which is an indication of the body's effort to generate increased glutathione (primarily in the liver, but in other tissues too). High-within-range GGT may indicate the body responding to elevated oxidative stress or the need to detoxify heavy metals or other toxins whose Phase 2 process is glutathione conjugation. Alkaline phosphatase (ALP) is also sometimes measured and referred to as a "liver enzyme" or part of an "LFT" panel. It is, however, made in the liver, bone tissue, the intestines, and a few other tissues to a much lesser degree. ALP is elevated (and healthy) in children who are still growing, reflecting their higher activity in bone tissue. Elevated ALP in adults can indicate sluggishness or blockage in the hepatic-biliary system (which remember, starts in the liver, transverses the bile ducts, and is then stored in the gallbladder; gallbladder"issues" very commonly originate in the liver with i mbalanced amounts of component ingredients which makes it likely that the bile will crystalize out of solution). Clinically low or very low-within-range ALP may indicate a need for more zinc, magnesium, or Vitamin B12 (among other nutrients).
List three relatively common reasons as to why someone might have low levels of key trace minerals such as zinc and selenium.
● Insufficient dietary intake e.g. a diet high in refined foods vs. whole, unprocessed foods.
● Maldigestion. Sufficient stomach acid is required to isolate minerals chelates from their mother
proteins. Digestive enzymes are also important in this function. Hypochlorhydria may be a significant cause of low minerals (e.g. H Pylori infection, ongoing use of PPI or similar medications to purposefully reduce stomach acid, chronic stress, low thyroid and/or adrenal function).
● Malabsorption. Damage to the intestinal lining (e.g. parasite infection, yeast overgrowth, SIBO – especially due to the biofilms created by these microbes) can impair nutrient absorption (even if there is adequate digestion).
● Competitive inhibition. Some minerals may be poorly absorbed in some individuals when consumed with substantial amounts of other minerals (especially via supplements). Many minerals compete for absorption e.g. zinc and copper.
● Binding/excretion in the gut. Dietary oxalates and phytates and tannins (e.g. black tea intake) can also bind with minerals and impair absorption (by increasing stool excretion).
● Diarrhea leading to loss of nutrition before gut absorption can take place e.g. poor eating hygiene, anxiety, lactose intolerance, fructose intolerance, gut microbial imbalances.
● High levels of stress which can impair availability and utilization of various minerals systemically.
● Genetic impairments in absorption or transport or utilization.
