My Labs Are “Normal,” So Why Do I Still Feel Terrible?

Her blood work comes back normal twice a year, but her body tells a very different story. New symptoms and neuropathy specifically have recently troubled her, scared her, her words, into asking this question of us: If my blood work keeps coming back as normal, but I keep getting worse, where do I start testing? What am I missing? And how do I actually know if I'm making progress and what we're doing is working versus we're just guessing and treading water or maybe even going backwards? Good morning, everyone. Dr. Stillman here, back for another fun and exciting public Q&A. These are based on your questions. You can ask me any question. You like below. I may or may not have time to answer it. The way this works is that you submit a question and then I will come up with a number of questions that we have to answer in order to actually answer that question because there's always a lot of context that I like to share with people. So today's question comes from someone we're gonna call Pam. She's retired. She lives in Georgia. She's tried different functional medicine doctors, supplements, strict autoimmune dieting, and yet, quote, nothing has helped, quote. She's worried it will, quote, just keep getting worse. Her blood work comes back normal twice a year, but her body tells a very different story. New symptoms and neuropathy specifically have recently troubled her, scared her, her words, into asking this question of us. So let's get into the core question today at the heart of what she's asking, which is, if my blood work keeps coming back as normal, but I keep getting worse, where do I start testing? What am I missing? And how do I actually know if I'm making progress and what we're doing is working versus we're just guessing and Treading water, or maybe even going backwards. All right. Again, you can ask me any question you want. The link should be below wherever you're watching this video. If you'd like our help with your case, there's also a link to book an evaluation with a member of my team, which is how you become a member of our practice. All right. So first question, why can blood work look normal twice a year while symptoms like fatigue, joint pain, nerve issues actually keep getting worse? What a great question. So when people say my labs, I usually think of about 3 lab panels that most doctors will run. There's the CMP, which includes your liver function tests, your electrolytes, your kidney function, and your blood glucose. There's your lipid panel, cholesterol, triglycerides, and that's broken down into HDL and LDL. And then there's your CBC, which is your white cells, your red cells, your platelets. And then there's different species or types of white blood cells, and there's little indices like the size of your red blood cells, et cetera. The problem with these labs is that the way I look at them is if your physiology is like a football field, these labs are like the 10-yard line. When you have abnormalities in these labs, it means that all these other systems and all these other factors in your diet and your lifestyle and your environment are actually awry. So way before we get abnormalities in that blood work, we'll see abnormalities in other lab tests. What sorts of other lab tests? If you want to know exactly what panel I count on to really prognosticate, In other words, how sick is this person and what are the main problems they're struggling with? I look at what I call our repair deficit panel. That's freely available, the analytes, how I look at them, how I think about them at drstillmanuncensored.com. If you want more background on that, I encourage you to look it up and I encourage you to subscribe there for the kind of content like that that I put out there. Okay. There's 14 markers on that test. And most of the markers you're gonna get in your routine lab work are not there. Without going in detail on each of those lab markers in that panel, and by the way, there's more that I run. Our comprehensive wellness panel is that repair deficit panel plus then probably twice as many markers or twice as many markers again as that panel. So it's a lot of markers. And when I say 14 biomarkers on the repair deficit panel, you know, there's just, I don't know, gosh, it's gotta be hundreds maybe in the full comprehensive wellness panel, but I digress. You really need more expansive labs than just routine labs. And that's really where the value's gonna be. I wrote a lot about this, by the way, in chapter 5, which is where I break down, at least in a little bit more detail, the repair deficit panel, how to think about blood labs. And that's chapter 5 of my book, The End of Autoimmunity, available for preorder now at Amazon. We've also got, I think last I checked, we were outta stock in our store at store.stillmanwellness.com, But check back there in the future. We should have copies available for purchase there. For now, I know you can get it on Amazon. Okay. What other labs do I count on? Because, you know, regardless of what the blood labs say, there are other things that I really like to run. We run in our practice, the hair tissue mineral analysis. Why do I run that lab? It's so much more sensitive than the other blood lab tests that people tend to get. And it's 20 different minerals and metals on our panel. There's HTMAs, hair tissue mineral analyses, that test more than that. Regardless of which one you get, 20 different analytes in an HTMA is amazing. The test costs $100. It's hard to get anything that gives you more insight for such a great price. And why do I actually emphasize the price? Because I work with a lot of people who want to optimize. And for many of them spending $400 or $500, let alone $2,000 a quarter on testing is a huge financial drag. And I get it. So I like the HTMA. For that reason, it's also, and I covered it more in my book if you want to read it in chapter 5. The other reason I really like the HTMA is that I can infer all kinds of things from the HTMA that I can't infer from anything else. Or maybe I'll state that a little bit differently. In order to get the same amount of data might take me 2 or 3 panels put together that are, you know, hundreds of dollars each. So the HTMA gives me a really exceptional amount of insight into what's going on in your body. Your metabolism, all kinds of other things. All right. So question number 2, what is standard blood work actually built to catch and what does it typically miss? So again, it catches these very significant abnormalities that are really the end result of your physiology being so run down that now you have life-threatening issues. So if your CMP, your CBC, and your lipid panel are abnormal, it means that things like your kidneys, your liver, your gallbladder are not functioning properly. And when these organs are actually starting to break down and malfunction, That's when you're gonna see really significant disease emerge. And so standard blood work is really, I think if you're counting on it to keep you well, I wouldn't count on it. If you're looking at it from the perspective of an urgent care, an ER visit, you're just looking for significant organ dysfunction. You're not looking to optimize your health, your wellness, your physiology. You're not looking to prevent major diseases. It can be helpful for triaging patients. This patient needs this, this patient needs that. Maybe they need to go to the hospital. Maybe they need to be seen by a subspecialist, like a cardiologist or a GI doc or whatever, but otherwise that standard blood work just doesn't have enough information to be relevant or useful. Okay. Why do people often see, despite seeing a functional medicine doctor, taking supplements and following a strict diet, why do they often see these, these measures fall short in terms of relieving their symptoms? This is a great question. And I feel like this is basically the crux of what I do day to day in my practice. So first of all, there's a huge variability between different functional docs. They have very different training. They have different ways of interpreting labs. And, you know, average patient at our practice has seen 4 to 5 practitioners before seeing us. So we have a pretty good idea of what people are doing. We also have a pretty good idea of where it actually falls down or falls apart and why people are not getting the results often with functional medicine that they thought they would get. Let's get into the supplements next. So why do the supplements often not work? So in my book, I write 3 chapters, one on principles, one on essentials, and one on hazards, part of our 5-part framework. Why do those 3 chapters not include any supplements at all? Because what I found practicing with patients, particularly people who'd already failed other clinics and weren't better after spending a lot of money and spending a lot of time, was that there was always, always a problem with one of those 3 things. What are principles? Principles are, do you have the right mindset, the right beliefs about getting well, your body health, wellness, et cetera? Do you have a positive attitude? Do you do what you say you're going to do? Do you keep your word? Do you show up on time? Are you polite? Do you treat other people well? Believe it or not, these things are, I consider them to be very important elements of actually getting well. I went and I shared the book. I don't even know how many it is. It's a lot of case studies. And as I considered the case studies that were most profound, most impressive, these were very altruistic, kind, thoughtful, considerate people. who did what they said they were going to do and needed frankly very little accountability. And also who found a way to get things done. That's principles, essentials. Why are essentials essential? They're the things we need to do. We all need to do to be healthy. If you look at cases of patients who don't do well, and we do this regularly, we look at the patients who are not getting results, who are saying I'm not any better. And we say, what could we be doing differently? Always find that there's major problems with their diet and And their lifestyle and their environment. Many of those things I consider to be the essentials, the things you have to do to be well. They're not getting good sleep. They're not getting time outside. They're not eating a healthy diet. I mean, you know, sometimes I'm shocked by what I find patients are eating, you know, and I can talk about it on social media till I'm blue in the face. And I can talk about it on coaching calls and I can talk about it in one-on-one consultations. And yet, no matter how much I seem to talk about what people should eat in order to be healthy, when I get into one-on-one consults, I'll find That people still don't know, which clearly means that I need to do more information or more content like this, which is why we're here anyway. Last, hazards. There's often a hidden hazard in the environment or the lifestyle that is making them unwell. And it's our job as a team to figure out what that is. Give you a case in point. We recently did a dietary history with a longtime patient of ours. We looked in their data and it turned out that they were eating a lot of processed food. Processed food is just plain old flat out hazardous to your health. For more reasons than I care to mention here. If you want more on that, read the book. I go over it in, I think, pretty good detail. So that's why the supplements often fail because people don't have those things in place first. And that's why I didn't even write about supplements until chapter 6. And the supplements come after diagnostics. What I found is that you need to have a rational basis for your approach to therapeutics. Yes, there's supplements we use in every case, you know, across the board, With great results, but truly exceptional results. All 3 of those things I mentioned earlier, principles, essentials, and hazards are in play. And then when you get to supplements, you're actually targeted. And, you know, I talked to another patient just yesterday. He said, yeah, I went to functional docs with my wife for years. We were taking fistfuls of supplements and yet we were just thinking, we're not getting the results that we want for this to be worth it. So they fell off. Right. And you'll see that a lot. There's a very high, we call it churn at a lot of these practices. Ours is very low. It's 2% per month, which by industry standards is extremely small. My point is people will just get put on tons of supplements. The body has a limited capacity to respond to supplements. If you're good at what you do, you can generally put people on 5 to 10 different products at any given time and get better results than if you were just throwing dozens of products at them. But that takes a skillful practitioner who knows how to take a history and talk to a patient, understand their context, and then I think be in relationship with them to determine which of these things are going to fit your current situation best. Because there's all kinds of caveats for why we might not use one or another thing. Some of it frankly depends on the patient's goals, which I think are very important to take into account. Okay. Last piece of this question. Why sometimes do these elimination or strict diets not work? Well, I'll tell you all the things I just said apply to this as well. It's not just about your diet. You know, diet, there was certainly a period of time in integrative natural health space where diet was just everything. Everyone was talking about diet. If I'm being totally honest with you, that's because there was a lot of money and still is to be made in supplements. But the reality is that, you know, that then paid for a lot of free content to be made about food and nutrition and supplements and a lot of other really important things like sunlight and circadian rhythms and healthy mindset really just got kind of marginalized. People didn't talk about it for a long time, even though it is so important. And that's why I wrote my book. And why I packed a lot of good information about that in there. Other reason the strict diets sometimes fall apart is this. You'll routinely find that people react to the things that they eat the most and they can react to anything. I've had patients who reacted to coconut and vanilla and chocolate and coffee and tea and mustard and turmeric and you name it. And this frustrates patients because they're like, well, what on earth can I eat and how do I know? That's why we run testing to see what your immune system is actually reacting to in terms of your diet. And then we tailor it from there. And we'll get some pretty amazing results. I'm going to be sharing a case study in our community this month of a patient who had a really profound improvement in their health with cessation of a food that they were allergic to, which was something they were putting in their morning coffee every single day. Just changing an ingredient changed their life. If you want access to that, book an evaluation with a member of my team. They'll tell you how to get access this month. Okay. What's the difference between chasing individual symptoms one at a time versus treating the whole person? This is such a deep and profound question. So I feel like a lot of patients and a lot of practitioners, they sort of wind up playing what I call therapeutic whack-a-mole. I got hemorrhoids. Well, we got a thing for that. Boom. I got headaches. Oh, we got a thing for that. Boom. Everything's got a protocol. Everything's got a remedy. You end up the next thing you know, on 20 different supplements. You're not sure what's working, if anything's working. And you wonder what is happening? Why am I spending $1,000 a month on supplements and why am I not feeling better? Well, that's why I always start with principles, essentials, hazards, because, you know, what I've found overwhelmingly is that when you're chasing individual symptoms, usually what ends up getting lost is what do I need to do every day to be healthy on a fundamental level? What do I need to do or avoid every day on a fundamental level to not get sick? When you don't have time with a coach or a practitioner who understands these things, what ends up happening is your supplement list just explodes or your medication list explodes and you're not feeling any better. So that's the difference in my view between chasing individual symptoms one at a time and treating the whole person. When you treat the whole person, you're looking at their whole diet, their lifestyle, their environment, their medication list, their supplement list. And it takes time to do this right. Hours, which is why when we work with people, we really commit to spending hours with them in one-on-one calls in a structured way. So we know that we're not going to miss anything because I can't stand missing things. It bothers me deeply. It's also why, you know, I have some colleagues who do like a 3-hour intake. I don't do a 3-hour intake. Why? 3 hours. No one's attention span is that long. I will overwhelm people with recommendations in 1 hour. I try not to, but it happens. We need more follow-up. We need more calls. We need day-to-day interaction through a chat portal so that you can get your questions answered as they come up. Not next week, not next month, not next quarter, like a lot of practices do it. And so setting things up that way, creating them that way is, I think, strongly the way to go because it allows us to treat the whole person and really get to know you. Next question is more testing than if routine labs are not revealing. The answer, I will go back to what I said earlier, which is I really feel strongly about this approach of principles, essentials, and then hazards. Why? Because I've seen people order more and more and more testing when the reality was, you know, things that they were doing, we knew were leading to the lab abnormalities. I'll give you a really clear example. I just came out, I think it was last week with my omega-3 guide at Dr. Stillman Uncensored. And I share my own omega-3 labs. And I, I'm of two minds about this because on the one hand, if I have a patient come in and I see their omega-3s in their dietary history, and I know that they're not taking a supplement and they're not getting enough omega-3s, why do I check an omega-3 level? I check it because it gives them a baseline that they can then work off of. How bad is their omega-3 balance? How much change do we need to make in their diet and their supplement regimen? And then we can track and see 120 or 90 days later, where have they moved with the interventions that we made? But my point is you don't always need a test in order to know that something in your diet and your lifestyle and your environment is wrong. You know, is the right place to go next if your initial tests are unrevealing more testing, clean up your diet, clean up your lifestyle, focus on your mindset every day. That's as important as getting another test to give you some more insight because routinely people come in, they've had tons of testing. It wasn't useful. It wasn't helpful. They didn't get answers largely because these other things got ignored. Okay. Why does a trend in labs over time matter more than a single test result? This is so important. I see all kinds of people on social media talking about what labs mean. And I gotta tell you, I think a lot of it is nonsense. Here's why. I think that because most practitioners don't run a membership-based practice with a strong retention, like patients stick around for years, I think that they end up seeing patients once and then having a huge drop-off. And when you have this drop-off, you don't get feedback. And you don't actually understand what drives the lab abnormalities. Let me give you an example. Many people out there are saying, well, you can take niacinamide to reduce your triglyceride levels. I gotta tell you, I haven't seen that work well. I haven't seen it work nearly as well as giving people real niacin. Now, if you go out there, you'll also hear, well, if you're gonna use niacin to drop a triglyceride level, you gotta use like 500 milligrams 3 times a day. These huge doses that frankly, for some people can be Very unpleasant in terms of side effects. I haven't found that to be necessary at all. I'll use a 50 milligram tablet twice a day. How did I figure that out? Well, a mentor long ago told me that that was the dose I should use for an elevated triglycerides level. So long as it was mildly elevated, we're not talking about something crazy here. We're talking about something in the high hundreds, 200s, maybe low 300s, which is usually where I find people. He told me that. I then tried niacinamide when I heard that maybe it was a lighter option. I had patients complain about the flushing with niacin, and guess what I found? Even though I was using doses of niacinamide that should have worked, I didn't see the same therapeutic result. When I switched back to the 50 milligram tablets of niacin, I saw them work. Could I be wrong? Is my sample size small? Yes. But in the absence of any better data and more clear indication, that's what I do. I also saw testing labs in healthy people year to year or quarter to quarter, if they were just curious, which many of my patients are, they just want to get more labs because they want to know, they want to see. There's an enormous amount of noise in data. So like, I'll use the example of TSH. My TSH will be 1.5 one day and 4.5 the next. And I don't have any thyroid issues. I'm not tired, I'm not sluggish, I'm not gaining weight. I don't have a loss of outer third of my eyebrows. I don't have any of the signs of hypothyroidism. So if I feel and function well, and I, yet I've got a TSH that some people would replace at a 4.5 one day versus a 1.5 the next week, when people say a TSH over 2 is suboptimal, just check it next week. It might be 1.5. I almost don't even check TSH. This is not the only lab like that. Ferritin varies a great deal as well. That's a really important marker that we rely on a lot. Testosterone levels can vary 200, 300 points in the average guy, and that's total testosterone, by the way. Hormone levels in women, estradiol, other forms of estrogen, progesterone, they can vary tremendously. Even in menopausal women where there's not supposed to be any variability, if they're on hormone replacement, they can still vary. And in women who are premenopausal who are menstruating, And cycling, they can be wildly different from day to day. And they can also be different. Part of this is because of the hour-to-hour difference. Like you get a testosterone drawn at 7 o'clock one week versus 8 o'clock the next. And oftentimes the lab doesn't tell you what time the lab was drawn. The patient has to remember, they might misremember. And you know, how much does it matter to them that their 7:00 AM testosterone last year is being compared to their 8:00 AM testosterone this year? I don't know. Here's what I know. The only way to sort this stuff out is in relationship with a doctor or another practitioner who understands these labs and can actually give you useful feedback that is based not only on the lab value, but your story. I see it over and over and over again. And so the trends over time are really what matter because you can get outliers. I'll see this all the time. You know, some lab that was getting better pops up. And it gets worse. Wait 3, wait 3 months, wait a quarter and get it back to normal or see it come down again. If you don't trend labs over time, you have no idea where you're going. This bothers me deeply, seeing patients come in, get labs, and then not follow up. Even though we try, we call, we email, we text, we really work hard to get our patients to do the repeat lab testing. And I'm not just doing it for fun. Usually when I'm really serious about this, It's because we're monitoring a therapy that's potentially got some dangers to it, like say high-dose vitamin D, or these are markers that have genuine implications for someone's longevity and vitality. You know, if you look, for example, at homocysteine, it correlates very strongly with heart attack and stroke risk. I don't want to wait 6 months, a year to see if your heart attack or stroke risk has gone from extremely high to normal. I wanna make sure we're making progress at least every 3 months. Don't you? Anyway, I go deeper into this in chapter 5. I show you real trends from a real case that we managed for over a year, and we got tons of lab data and you'll see it fluctuates. It varies a lot, which is also why I don't freak out when labs look bad. And I have a very low threshold to retest because, oh my gosh, sometimes if the labs don't fit the story, we just retest. Boom. They look exactly like what they should. And then I just move on. All right. What does it usually mean when a new symptom like neuropathy shows up on top of ones you already have? So I think about this in terms of what the homeopaths called Hering's Law. Hering's Law states that illnesses go from the outside to the inside of the body. So if you talk to patients, what you'll find is that if you really take a careful, close history, when they were well, no symptoms, right? Usually the first thing to emerge is something in a tissue that's very exposed to the environment. It was mouth ulcers or canker sores or, you know, say like cold sores. It was reflux in their esophagus. It was GI issues, IBS, then the IBS turns into IBD maybe. Then, you know, you get skin issues. You got eczema, psoriasis, other forms of dermatitis, allergies, asthma, right? These are all in tissues that are what we call epithelial, which means that they're exposed to the outside world. You might not think about your gut as being exposed to the outside world, but truly it is, right? Because it's a giant hollow tube within your body. Okay. When you leave illnesses unaddressed in those tissues, or even when you just suppress them with things like steroids or immunosuppressants, what you'll tend to find is that yes, the symptoms go away, but 5, 10, 20, 30, 40 years later, other illnesses appear. And guess what? The risk factors for those illnesses are the same as the illnesses you just suppressed or ignored. Here's an example. This is the kind of story I hear in my practice all the time. Billy starts life, gets eczema, allergies, asthma as he grows up. Steroids are used. They cover his symptoms. They resolve them. They reduce them. He feels better. Then what happens? He grows out of them. They become minimal in terms of their symptom burden. Maybe he needs a puff of his inhaler once or twice a week or a couple of times a month. Okay. Then he starts to get these abdominal issues. He starts to have abdominal pain, bloating, diarrhea, nervous stomach, can't eat things, not sure what he's reacting to. That's IBS. Wait long enough and this turns, not always, but potentially into something like Inflammatory bowel disease, let's call it Crohn's. So Crohn's, it's not just some mild issues and irritation in the gut. You may have fistulas, you may have ulcerations between different parts of the intestine. You may have, you know, anemia, you may have gross malabsorption, inability to absorb your nutrients. Terrible malnutrition can be a consequence of that. So then maybe you take some prednisone, some other immunosuppressants, the symptoms go away. Okay, great. But all the things that created these diseases, the heavy metals in the environment, the endocrine disrupting compounds, the free radicals, the stress, the artificial light at night, the circadian disruption, all stuff I talk about in my book, right? In chapters 3 and 4, all of these things are still present. They're still causing and creating disease. We're just suppressing the symptoms with things that modulate the immune system. I'm not passing judgment on that approach, by the way. I think it's totally reasonable, but I do not think it is reasonable to do all that and then completely ignore the root causes of the disease that are driving it. Okay. Now Billy is in his 30s or his 40s. Now he starts to get overweight. His metabolism starts to go. He starts to feel fatigued. He starts to have maybe anxiety or depression. Then he gets diagnosed with hypothyroidism. Maybe he's got Hashimoto's. You know, that's a typical diagnosis I'll see in these men. Then later on, 50s, 60s, he's got fatty liver. Maybe he has a heart attack. Maybe he has a stroke, you name it, right? Then later on, 60s, 70s, 80s, if he gets there, he ends up with dementia. Look at all the same root factors or all the risk factors for these diseases. It's kind of the same cast characters. It's the usual suspects. It's all the stuff I write about in chapters 3 and 4 of my book. Now, how do the supplements and diagnostics help get us out of that? Well, it helps us to basically dig him out of the hole of what we call repair deficit that his body hasn't had time to heal from because it didn't have the right environment, the right diet, and the right lifestyle. And so, the supplements kind of help us solve these problems faster, right? Because they're supplemental. You know, and they can also be very powerful in terms of modulating the immune system so that the inflammation that's going on, you know, just is basically treated sufficiently. High-dose vitamin D is one of the things that we'll use in the practice in order to do that, among others. So when I see neuropathy arise on top of a bunch of other symptoms, I think, okay, there's more going on here that hasn't been diagnosed. There's deeper lab testing we need to do. There may be high doses of supplements that are needed in order to solve this problem. Case in point, I just took a history of a guy coming to us for neuropathy that emerged 6 to 12 months ago. His labs tell a very, very different story, particularly one of his repair deficit panel markers, the homocysteine, that he may have a folate or a B12 deficiency that was missed on prior workup. And this is why I'm not a fan of testing B12 or folate in the serum the way most docs do. I don't even like the methyl or the RBC folate test, which a lot of functional docs do. I don't think they're reliable. I look at a homocysteine, I take a history, I look at a hair test, I'll go from there. In a guy like him, sometimes frequently I like to get a methylmalonic acid or a formylaminoglutamic acid level, and I like to adjust it or calculate it based on the creatinine level in the urine, which is a whole nother story. On the other hand, if I've got a good story for B12 or folate deficiency, I also sometimes don't even test for it. I just treat empirically. Do they feel better? Do they respond well? Yeah. With an elevated homocysteine, I'm doing that anyway. We're gonna track it, we're gonna see what happens, and we're gonna follow up in 3 months with repeat labs to make sure that this guy just doesn't continue to get worse, but that his labs and his symptoms get better to the best of our ability. All right, that's all I got for you today. Again, the book's available on Amazon. I strongly recommend it to everyone. And you can ask me anything you like and maybe I'll answer it in my next livestream. Link is below. Book a conversation or an evaluation with a member of my team if you're tired, foggy, and inflamed. And you'd like our help reclaiming your health. Thanks for watching everyone. Take care. Have a great day.