The Rise of DTC Lab Testing: A Clinical Perspective

On Wednesday, April 22nd, FMCA hosted a special Ask the Expert webinar with Dr. Aaron Hartman, a functional medicine physician, clinical researcher, and author of UnCurable: From Hopeless Diagnosis to Defying All Odds. After years in family medicine and more than 70 clinical studies, Dr. Hartman is known for helping patients with complex, chronic conditions uncover root causes and improve their health.

Hosted by FMCA Founder and CEO Dr. Sandra Scheinbaum, Dr. Hartman shares what he is seeing as more patients come in with their own DTC Lab testing results. We will explore how this shift is affecting patient engagement, the practitioner relationship, and outcomes, along with what it means for health coaches.

In this webinar replay, you will learn:

• What types of DTC testing patients are using today
• How access to personal data is shaping motivation and engagement
• The challenges and opportunities when patients bring their own results
• How DTC testing can support or complicate outcomes
• How practitioners are adapting to more informed patients
• Where health coaches can support clients using test results
• Key trends in functional medicine and chronic care

Watch the Replay

The Rise of DTC Lab Testing: A Clinical Perspective, With Dr. Aaron Hartman:

Listen to Dr. Aaron Hartman’s Episode of Health Coach Talk here: Revealing the Blind Spots in Healthcare, With Dr. Aaron Hartman

Transcript

Dr. Sandi: So, I want to welcome you, Dr. Aaron. When I think of who is really serving at the highest level of integrity in our functional medicine space, you are top of mind. I have known you for a while and so respect everything that you do and contribute to this field of functional medicine. So, welcome.

Dr. Aaron: Thanks for those really kind words, Sandra. I’m excited to be here and just contribute to your community. And hopefully, my expertise in clinical experience through building companies and organizations and seeing patients can be super helpful to the people who are in your community.

Dr. Sandi: Thank you. And you are a big supporter of health coaches. I want to point that out as well. So, for those who might not know you, can you share your background and how you got into functional medicine and what you’re doing now?

Dr. Aaron: So, I’m a triple board certified medical doctor. I’ve been an associate clinical professor of medicine at the Medical College of Virginia since 2011. I had a clinical research company for 15 years, was involved with 70 different clinical trials, even published in Lancet. So, I’ve got a very academic kind of practice. But what kind of got me into functional medicine wasn’t all those things. It was my daughter, Anna.

My wife and I…my wife is a pediatric occupational therapist and our daughter was one of her patients. And so, we brought her into our home. Actually, her foster home was closing and we adopted her and brought her home. Her prognosis was pretty poor. Her birth mother had done crystal meth throughout the entire pregnancy, and she was never supposed to walk or talk or crawl. The system was like, she’s going to be a vegetable and that’s it. And basically, through adopting her, through fighting the system, which is that’s a whole other story I won’t go into, it forced me to dig deep because I bore the weight of my daughter’s future.

And that kind of got me down these little pathways of lipid medicine, nutrigenomics, peptides, stem cells, exosomes, functional medicine, integrative medicine, translational medicine, which a lot of what I do these days is translational medicine, which we can potentially talk about. It’s changed my entire practice of medicine.

And so, now, our clinic in Central Virginia, we see people from all around the country who’ve been to multiple doctors, multiple specialists, been told nothing’s wrong with them, it’s all in their head, they can’t be helped. And they usually come to us and then we’ve diagnosed their mast cell, their Lyme, their mold, their undiagnosed immune issues, their POTS, their dysautonomia, whatever it may be, and put together an individualized plan for them.

So, it’s really cool to see really difficult patients have enjoyed this, but it’s become kind of an epicenter or a destination point for people who’ve been around. And where we’re at on the East Coast, we get a lot of people from Mayo, Hopkins, UVA, and the Medical College of Virginia are the major places people come to us after going to those places.

Dr. Sandi: Well, you are doing such important work. And I know we shared this powerful story about your daughter on our podcast, “Health Coach Talk,” and it’s just such an inspiring story. So, let’s get into the main subject of today’s “Ask the Expert,” which is this rise, precipitous rise of direct-to-consumer testing. So, as a physician, from your perspective, how are you seeing this type of testing that is being used? Has it changed your strategies at all, how you work with patients?

Dr. Aaron: It depends on which hat I put on for this, because I put on my primary care hat, which I did for almost 15, 20 years. I’m going to look at it differently than my functional medicine hat versus my business owner. So, I’m going to try to give you a couple of different angles. I look at individually for my practice as a medical doctor, I don’t see it as a “business threat” per se, just because of where I’m at in my practice. But for people coming in, I can see this as being a competition because a lot of individuals don’t necessarily value your coaching. They don’t value how much it costs, how much education goes in.

And so, a lot of the direct-to-consumer testing becomes all of a sudden a way to get functional or get access to stuff. Some of my patients actually are doing…I don’t want to name names or platforms out there, but I think everybody knows the big platform out there that’s pretty popular. And people get that product, and they come to me and we interpret for them. And I’m like, well, you just paid $300, $400 for these labs. Okay, and I’d help them. So, it’s interesting to see how my patients who’ve paid significant amount of money to work with me are still doing this because they feel like they’re getting something that they’re missing. But when they bring it to me, it’s literally not even an eighth of what I order on them for a basic follow-up, let alone an intake.

To put things in perspective, one of my intake patients, I’ll do 800 to 1,000 biomarkers on them. This one lab I’m thinking about is maybe 120 biomarkers. And so, I think it depends on where you’re at out there, but it’s interesting because there’s a need. People want a deeper dive. They know that the typical thyroid panel is not adequate. They know they need a nutritional evaluation. They know they need to have predictive autoimmunity. They need to see if they have autoantibodies. So, they know these higher level things that people in the community already know about. And they’re trying to meet that need with of subpar products.

And so, I think where this community, where we can come into play is to educate people, like really you need more than just a vitamin D level and a B12 level. You probably need organic acid testing. Need more than just TSH, T4, T3. You need a full antibody panel. And so, I feel like it is an opportunity for us to educate more specifically to people looking for those products, but to realize that, really, these things are really popular. People are looking for answers, and because they don’t know where to go, they’re spending $400 for this hormone test or whatnot. And when they get the results back, they still don’t know what to do with them.

Now, they’re throwing stuff into AI, thinking they’re getting answers. So, in many ways, this might be muddying the waters a little bit, but I think it just speaks to there is a need, and it’s such a need that these different platforms are blowing up right now.

Dr. Sandi: Would you say that these platforms could be a start, like starter test for somebody to get into the world of functional medicine and it might then empower them to go seek a consultation with someone like yourself? And health coaches can lead the way. They can help people to understand that there might be something missing or that they still really need the care of a physician trained in functional medicine.

Dr. Aaron: I think that’s a good perspective because, for me, usually, I’m the 7th or 8th person, or 10th sometimes that someone’s seen before they get the answers. So, it can be like a stepping stone to get people in the world of…I won’t say alternative, but more advanced testing. They say, oh, I got a free T4 and a free T3 and reverse T3. My endocrinologist never ordered that. Or you did a vitamin D level on me, or you did a homocysteine on me. It is an entry point, but my…again, as a medical doctor and the way I’m looking at things is more like…for my patients, it’s more like they feel like they’re missing something. So, they get it, but they’re really not missing that much.

I do feel like, for probably the population at large, it can be an entryway into functional medicine, seeing that there’s something else out there, but it’s just getting their toes wet. Even I’ve set up my own platform online program that uses…I actually use Fullscript. You can order a big panel on them, and patients get through a lower price point. I’ve seen people… So, my patients actually sign up for that and getting it done and seeing the results and just realizing that people really need to work with somebody. You get the stuff back and you’re like…and I’m seeing this on a message, and I’m using my AI tools to dictate to them. And I’m like, you really need to see someone because you have a positive antibody or your cholesterol is 290. Do you have a chronic infection somewhere or a toxin exposure?

And so, I feel like, for me, when people would get just the labs, it’s like… Maybe the way to think about… I’m thinking out loud here. Maybe it’s an Alice in Wonderland thing where they’re like, oh, my gosh, there’s another world out there. Who’s going to help me? Maybe that’s the way to think about it more so than anything else.

Dr. Sandi: Yeah. And sometimes going down the rabbit hole and what we’ve seen is people who are freaking out because they will look at a marker on a consumer lab test, and they will then just get so anxious because they’ll now start digging into what it could possibly mean. And now, they’ve convinced themselves that they have some life threatening condition, and they’re anxious about it.

Dr. Aaron: Maybe I think…I’m just thinking out loud here. Maybe the way to look at it is this is going to be a…it’s almost like my first learned functional medicine. It’s like, once you learn, you can’t go back. You’re like, oh, my gosh, there’s another world out there. Maybe this is that gateway drug, so to speak, for people going like, whoa, there’s a whole new world out there. I really need someone to work with me because I have no idea. And now, the AI is literally starting to consume its own data it’s created, which is an interesting phenomenon that’s started in the last month. People even more so now need reliable, dependable people they can work with, especially when some of these things are easy to get a hold of and then you get misinformation, wrong interpreted information. So, maybe that’s the way to think about.

Dr. Sandi: Yeah. I know my own experience. Recently, I had family members who went through one of the common platforms, and it had to do with LP. Well, I love it. And they discovered that they were at risk, and it led to doing a lot of research then, going online, they were seeing…they were completely unaware because they had been just seeing conventional doctors, getting the most standard lipid panel. And now, they feel like they…this has opened up a whole new world that they didn’t know existed. And so, they went to a cardiologist and said this is a risk factor. And it’s led to, in one case, starting to take the… So, a step to transform lifestyle and looking at what they’re eating and moving and for example, so identifying stress as risk factor. So, it was eye-opening, but it was very specific in terms of one particular biomarker.

Dr. Aaron: That’s where coaching or educating individuals can be super helpful because the NIH published some information November a year ago, so, maybe a year and a half ago that for females, the three biggest…the three markers that can predict someone’s risk for heart disease out 30 years. One’s the LDL particle number, hs-CRP and LP(a). So, all of a sudden, those three data points become huge. And they kind of represent inflammation, oxidative stress, and immune dysregulation, which are Mark Houston’s big three. And so, it’s literally like giving you a view of kind of those things a little bit.

Then you can educate people and like, can you get your LP(a)…you hear that you can’t get it down. I’ve gotten people to have those lower 50% using doses of vitamin C, NAC, aged garlic, LP, fish oil is great. One of the many things you can use to get the LDL particle number down, hs-CRP, it can be infection or whatnot. So, I definitely think that, from a coaching perspective, the education…it’s going to be a huge educational and a huge opportunity, but it’s going to cause angst, and people are going to get their information…if they’re not working with someone, they’re going to probably be largely confused.

Dr. Sandi: Yes, absolutely. So much confusion out there. And speaking of confusion, what would you say in terms of the traditional medical doctor amongst your colleagues? What are you hearing about their…how they think about it or the misconceptions that they may have about this type of testing?

Dr. Aaron: You know what, I’m going to take a different angle than probably what you’re looking at because of my perspective and when you’re asking me this question, it depends on what I’ve just done. But I literally just finished re-upping my malpractice insurance and how to get training. And in order to keep my rates down, I got…every year, I go to this two-hour course. In the regular world right now, what’s happening is people are taking these extra labs and AI tools, like I have these diagnoses to the primary doctors, and the doctors are blowing them off or ignoring it. And they’re complaining to the boards of medicine on these.

And so, part of my malpractice mitigation was training on…because I have an hour of patients. So, it’s not an issue with me. But the average person who has a 10-minute visit, all of a sudden, patients are researching, getting labs, going to their primary, and the doctor is like…does not have time. And they’re now being reported, complained about, get bad ratings online. And so, that’s probably more important…I won’t say more important, but probably more on their mind than how to address these labs. Like, how does this become a liability when you can have a bad review now?

In Virginia, as of a couple of years ago, every reported complaint has to be investigated, which it didn’t have to be. Which is depending on which state you’re in can change things a lot. So, it’s really interesting how, depending on where you’re at in the medical world, you’re concerned about these things will be a little different.

But for licensed practitioners, probably one of the biggest issues is how not to get sued. And so, now that people are upset, why won’t you talk to me, a lot of times what they’re going to do is just mitigate like, I didn’t order those, I can’t do anything about those, or I’m not trained in that, or see someone else. And so, that’s where I feel like, again, people to walk alongside these people is going to be more necessary. People who have time to spend, which is not the case in our current healthcare system, that’s the biggest claim I’ve been also hearing from some of my colleagues. They’re just like, why do people do AI? Why do people get these crazy labs? There’s no data. There’s no evidence behind that, yada, yada, yada. And we know that’s not true, but that’s… My journals, which I get once a month from the American Academy of Family Medicine, to date, they haven’t written a article about advanced lipid markers. So, it’s like, if I wasn’t reading all those things, I probably still wouldn’t know about those.

Dr. Sandi: Absolutely. I was speaking to a friend and she was concerned about… She’s my age, 76, and possible risk of heart disease, wanted to be proactive. So, she made an appointment with the cardiologist a year. It took her a year to get an appointment. That was the first available opening. That’s what it’s like out there. And so, she said, yeah, I had my visit, did an EKG. Going to do a stress test. And so, I asked her, did he talk about LP(a), ApoB? What are…what? No. Didn’t do that. And so, it’s pretty common that we’re sharing that.

Dr. Aaron: Well, Sandra, I was at a mastermind that we were both at not too long ago, talking about coronary artery calcium scores. And one of our colleagues at this one mastermind, who had paid a lot of money to see a concierge doctor, when I said a CAC score, he had no idea what I was talking about. So, I feel like that’s been around for long enough. That should be a common…oh, a calcium score. What’s your calcium score? So, even in people that are seeing concierge physicians aren’t getting some of this information.

Dr. Sandi: Yes. So, what about the potential of overtesting or just, you know, people see something on social media, perhaps it is one of these home kits, you know, that you get and it’s a finger prick, and they have all these biomarkers. And people are…and we have an issue where, you know, health coaches are thinking that they can use those and interpret and make recommendations, which of course we are 100% against. But, you know, what are some of the things out there that people should be really cautious about when they look at this world, which is rapidly exploding?

Dr. Aaron: It really depends on which lab test you’re looking at. So, if you’re talking to urinary or hormone testing or cortisol testing, for example, a lot of those tests — I’m thinking of one in particular — are looking at metabolites. And so, they’re qualitative, not quantitative. So, the way I tell it to patients, it’s like you go outside and it’s hot, and then you go outside, it’s cold. Okay, your hormones are high or low versus you go outside, it’s 87.5. That’s the difference between a salivary test that looks at an LCMS versus EIA versus a urinary mass spectroscopy. They’re giving you the difference between an exact point versus high or low. And so, people don’t realize, when they see a number, it doesn’t necessarily mean it’s an exact number.

Also, some of the other tests, like the finger prick versus serum testing, are not quite as accurate. So, you’ll get a little…there’s a variation or like…every lab has a variation range. So, if you do like a glucose you can take the same sample and run it, and you might get a 97 and you might get 105 and you might get an 83. And based on where the sample’s from, that variation is considered within normal range. But someone might say, oh, 87 and 103, that’s the difference between being okay versus in the prediabetic zone. That could just be a normal variation based on the lab test and was it a finger prick capillary test versus a serum test.

And so, a lot of people don’t realize there’s nuances, which also can lead to more confusion. So, that’s where, okay, you did a capillary test, a spot test for some of the nutrients and sugar. This is more in the glucose world, where the capillary testing for the blood spot is not going to be as accurate as a serum level. And then how do you delineate the serum level, the fasting, non-fasting, that’s where having A1C, having maybe in a fructosamine and a fasting insulin or C-peptide based on the person can help you get really, really narrow or a CGM. That’s where I feel like the coaching…coaches are perfect for explaining these differences to people because they don’t understand the difference. And that depends on which podcast they just listened to most recently and it tells them that whatever test they had means they’re going to die soon.

So, I feel like the more I just think about it and process it, it just seems like all this cool stuff means people just really need to be working with skilled people even more so to help guide them through the angst and the uncertainty of something as basic as a fingerprint glucose versus a serum glucose and how that relates with an A1C or fasting insulin.

Dr. Sandi: Yeah, exactly. So, on that topic, I’d love to hear your thoughts about CGM’s continuous glucose…I’ve been…you know, I wear one on and off. And I just started with the Lingo, which I am just so pleasantly surprised to see. In fact, I had a conversation. I was at an event this past weekend. It was a fundraiser for our big hospital system here. And so, the…Abbott is in this area. And so, there were a lot of Abbott representatives there. And I had a conversation and he was asking my feedback on Lingo. And I love that Abbott has this direct-to-consumer now that you can just order this and it’s connected to it. They’re refining the app. And to know that, you know, for example, in my case, my fasting glucose is always high when I get a blood draw because it’s just the cortisol. And I know when I measure it with the monitor, it is stable, you know. And it’s within a really ideal range of morning glucose. So, getting those insights, knowing that stress will raise it more than anything else, for example.

Dr. Aaron: Just out of curiosity, Sandra, did you actually look at your Lingo glucose and then compare it to the…how close was it when they did your blood draw?

Dr. Sandi: Yeah. So, with that particular time of day, it was like a good 20 points lower, really, with the…because I’m just in a different state at home, and I’m not tense about getting a blood draw.

Dr. Aaron: No. My question is, when you had the blood draw done, when they drew that blood, did you then compare to see what the difference was?

Dr. Sandi: Yeah.

Dr. Aaron: And you saw a 20-point difference.

Dr. Sandi: It was 20 points. Sometimes it’ll be a little less than that, but yes.

Dr. Aaron: Yeah. It’s one of those things where, you know, when you start…because, you know, I do a lot of deep diabetes stuff. I have patients on insulin pumps. And it’s interesting. There are certain CGMs that are FDA approved for dosing insulin pumps and certain ones that aren’t. And it depends on the manufacturer. You know, you might have a…they might not be as tuned in, which is difficult. You’re looking at Dexcom versus, you know, whatever else is out there. But not all of these have been…they might have been FDA cleared for testing, but not all of them are FDA approved for actually treating type 1 diabetes. And that’s a different nuance. Again, how closely is it tied in? And then with all these glucose monitors that are capillary versus serum tests. And so, I’d be kind of curious, you know, because a lot of patients…because on their daps, it actually tells them what the A1C would be relative to the glucose.

And a general rule of thumb is someone who has an A1C of 6, their average glucose is about 135. And every point it goes up, it’s about 35 points. So, 7 is about 170 and 8 is about 205. And so, the question is, looking at A1C…and you might have to calibrate your things on your own because they’re all calibrated differently. And so, that’s where people don’t know these nuances with even among the same device from their manufacturers. It’s almost like getting a thyroid medication. I think everybody knows that if you get a thyroid from a different brand, different compound, your body is gonna absorb them differently. You have to test again. It’s similar to that with these monitors. And that’s where I feel like, knowing that and…like yourself, you see this 20-point disparity. Is that just the difference between serum and capillary? Well, then what was your A1C? What was your fasting insulin? I’m not familiar with the Lingo, but with the…it is a nuance that not all the devices out there are FDA approved for use in type 1 diabetics. It might be an FDA approved device, but that’s not the same thing.

Dr. Sandi: Sure. No, that is such a good point and something that coaches can inform their clients about to check those things out. So, a question came in from one of our audience members that I want to get to. When clients come in with a stool test result, something like a Viome, they have no functional medicine doctor, what would be the best way to support them as a health coach?

Dr. Aaron: And they’re not working with someone?

Dr. Sandi: They’re not working… And many of our coaches have clients who, for a variety of reasons, often cost or availability, there is no functional medicine. They can’t afford it because they’re not insurance based. So, how would you respond to that?

Dr. Aaron: I mean, I would probably… If it’s the first test, I would use it as an educational tool to… The reality is we all have dysbiosis. You know, I’ve had multiple patients that have tested stool tests over years on the same patient. I’ve done some myself as well. And the reality is there’s always going to be something off, you know. And so, someone’s always going to…they’re always going to have overgrowth of this or a paucity of that or an elevated secretory IgA or low short-chain fat, whatever. There’s always gonna be something else. I always say, looking at it as an educational tool, they’ll go, look, this is…and that’s the reason I like the scores sometimes that have, you know, inflammation, metabolic issues. They show their scores. Everyone’s a little different.

I’ve not personally ordered the Viome test. So, I don’t know what it’s…but they all have their own little markers. Honey Health was the most recent one I tried out to see what their stuff was like. But to use an educational tool like, look, you have overgrowth of this bacteria versus that, you can change this with diet. You know, look, you have low short-chain fatty acids, pre, pro, and postbiotics. The prebiotics are the colors that feed the bacteria, the probiotics are the bacteria, and the postbiotics are the butyrate, right? So, you can start having these educational things.

You know, it all comes down also to the person’s experience. How experienced are you with taking these labs and making a specific recommendation? If someone’s beta glucuronidase is elevated doing calcium D-glucarate can help abate that, or if they have an elevate secretory IgA, using Saccharomyces boulardii can help bring that down. If you’re not comfortable with making those kind of recommendations, you can just use it as a way to focus on food as a way to modulate the microbiome. If you’re not making up short-chain fatty acids, focusing on pre and postbiotics. If you have inflammation, that might be a place to put more spices, herbs in the diet, and even fasting.

You know, it’s interesting how much these irregularities can be addressed with either doing a 12 to 16, 18-hour fast a day or even throwing in 24-hour fast from time to time. You can almost use it just as an educational tool to move people in a certain direction because there’s always going to be something off. But that’s also part…I found that’s part of my education is explained to people. You’re always going to find something like…I feel like I do pretty good with my diet. I’m getting eight, eight and a half hours of sleep at night. I check my stuff every three months. I’ve been doing that for years. And there’s always something off.

So, part of the education, I think, with people, especially with almost an excessive amount in your VOMIT syndrome, we’re victims of modern imaging techniques, there’s too much stuff out there. Realizing you’re always going to find something. This does not mean you’re going to die. We can change it. And these tests will change seasonally as well based on our dietary changes.

So, there’s so many ways to take that and use that as an educational tool and as a motivational tool. I’ll just be careful not to keep on ordering it over and over again, unless you have the ability to do antibiotics, placebo and other kinds of things, or you feel comfortable recommending herbals, etc., based on the testing because you always will have something off.

Dr. Sandi: Yeah. Well, speaking to that, so, now in a lot of these platforms, it’s possible to click the box and get your own full-body MRI scan. You can get cancer scan. And, you know, my perspective at my age is that, you know, I want to wake up every day thinking today’s going to be a good day, and focusing on health and vitality. And I know my personality that I would be obsessed in the probability of finding something. But how would you address that in terms of just over-testing, getting too sophisticated in our imaging?

Dr. Aaron: Well, I mentioned VOMIT syndrome, which is victims of modern imaging techniques, which also includes tests now. But that was actually something I was exposed to at trauma. When I was back in the military, I did a lot of trauma medicine. And I was actually at a conference in Las Vegas among trauma surgeons. Okay. This was 2005. So, this was a long time ago. It was 21 years ago that we were worried about too much information. I mean, think about now. It’s almost like we were in the dark ages 21 years ago.

And so, that’s where… A lot of these things have error…like the whole-body MRI. If you’re a female in your 40s, for example, I’ll give about a 40% chance of having a liver cyst or a kidney cyst or cyst somewhere in your body. All of a sudden, you do this test. You’re going to find something and then you get a biopsy. It’s normal. Mammograms, another great example, which is super basic. A mammogram has about 10% false positive rate. So, if a female is about in her 40s, you do 4,000 mammograms and save a life. So, 4,000 are done, one life is saved, but 400 women get a biopsy, get repeats. So, they’re traumatized literally by… This happened to my sister-in-law where she was like, oh, my gosh, I’m going to leave my kids and I haven’t written my will for my husband. And three months later, they’re like, bye-bye, see you later. And she was like, every time I go to the doctor’s office now, my heart races.

And so, there are harms with some of this stuff. And that’s where knowing enough about the testing people are doing… With AI now, you can…if you prompt it the appropriate way, you can figure the data out and accuracy pretty quickly and easily. As a medical doctor, I have access to OpenEvidence, which is a great AI-driven tool that only pulls stuff from PubMed. It’s great for finding this kind of data. And if someone has a cyst, that’s really great for a one-centimeter adrenal app…cyst. It’s really great for getting data on is this something that needs to be followed up or not? That might be outside the scope of your audience, but people realize there are…even just the stress finding something that then you spend months going through, that can cause medical trauma. And I’m used to seeing patients with medical trauma because they’ve had mold or Lyme, and been ignored. Now, I’m seeing people come with medical trauma because they’ve ordered these tests that told them they’re going to die and they’re fine. So, there’s a dark side to everything, I guess.

Dr. Sandi: Yeah. And I guess this is my bias having spent years as a health psychologist with mind body medicine and the power of belief and the power of having imagery and thoughts and picturing wellness versus imagining the worst and what that can do at a level of creating your own inflammatory response based on your reactions.

Dr. Aaron: Well, Sandra, let’s go back to the LP(a) real quick. Okay. So, if you look at the literature and listen to certain people, you think if your LP(a) was 200, you’re going to die of heart disease when you’re like 40, right? I have multiple patients whose family members have a history of high cholesterol and their grandmother is still alive in their 90s, their mom’s in their 70s, and they’re in their 40s. And their cholesterol is 240, 280, and their LP(a) is high. But they know they have longevity in their family.

And so, for them, they’re like LP(a) is up, they’re not super worried about. They do their…the calcium score, it’s zero. You do CMT, it’s three years younger than the age. You do plethysmography, your arteries are three years younger than your age. You draw the inflammatory markers and they’re fine. And the LP(a) is just…it’s gasoline on the fire, but there’s no fire. Guess what? The gasoline doesn’t do anything.

And so, that’s where, you know, something like that, but that…the mantra out there currently is if you have it, you’re going to die. And my patients who have the mindset that, you know what, my grandma’s lived forever, my mom’s still doing great… And it’s funny because these patients, their parents, their grandparents actually live out of the country, actually from the Caribbean, which is interesting. But that’s the point. They don’t get that worried about…they were like, I just want to minimize my risk.

But I’m thinking of one patient in particular who had an APOE4 and elevated LP(a) and her mom had dementia. And I can never get her over the hump of she’s a lawyer, she works out, she eats good. I can never get her over the hump that you’ve never smoked, your mom smoked, right? Your mom was diabetic, you’re not diabetic. I could never get her over those humps because she’d been programmed, I have LP(a) and APOE4, I’m going to get dementia like my mom. There’s actually a book called “The Biology of Belief,” right? People’s belief systems can have a profound impact on their physiology’s response to whatever risks are going on.

Dr. Sandi: Yeah. I’ve been studying that since the ’70s, and looking at those beliefs and how it can change behaviors, but also physiology based on those beliefs. I know personally because I used to get panic attacks thinking I was having a heart attack because I had a whole long history of heart disease in the family. I used to think I was… And really learning how to change that with power of different beliefs and imagery.

So, I want to turn to our audience. And we have one question that’s already come in. And I encourage everyone here, if you have a question, now is a good opportunity to submit that. So, Hillary wants to know, let’s say coaches want to get education around understanding conventional versus optimal labs. Well, Hillary, we have in our core curriculum, labs for health coaches. And so, that would be a possibility because I think you want to be careful that you can get education, but how you use that education as a coach would be quite different than if you are a practitioner. So, I think that there’s a lot that…and this is a good question that I want to turn to you, Aaron, to address, and that is, a lot of these platforms, you get the interpretation and they’re telling you, okay, based on your test, this is what you should eat. This is how you should work out. And I wonder if you could comment on that.

Dr. Aaron: Some of the labs, what I’ve noticed with the platforms that I’ve looked at, I’ve looked at two different platforms that patients have brought in, they have their “functional ranges,” but they’re very broad functional ranges. So, they don’t specify like in a cancer patient, you want your vitamin D level closer to 100. They might recommend… Actually, the one lab, the one I’m thinking at, you can have a vitamin D level 38 and they’ll flag it as normal. And I’ve never… For just general longevity, you want it over 50 optimally between 60 and 80. It’s like A1C. So, your A1C is 5.7. Well, that’s depending on Quest versus Labcorp, that’s a difference between pre-diabetic and diabetic. But if you read UpToDate, which is the most…it’s like the big evidence-based platform that physicians use, it says anything over 5.0 has an increased risk for microvascular disease.

And so, a lot of these functional “platforms” aren’t picking up those nuances. And that’s where if you’re a coach and really want to take a dive into this and get really educated with it, you can actually get people like, well, this is…and that’s where…I would probably maybe look at the coaches. I remember when drug reps used to come to my office, right? They bring me an article like, here, our drug is best. Look at this published article. I don’t know why a coach can’t do that, but here’s this research that shows your A1C should be less than 5.5.

I’ve got a textbook right here. Dr. Paul Merrick gets some cancer therapies and he has 1,400 references in it. It’s 50 pages. The index of references is like this big as some books, right? He goes through like, melatonin in cancer patients. And with AI, all of a sudden, you can actually get the articles. And all of a sudden, as a coach, I would say almost like a drug rep, here’s the article, here’s the data behind what I’m saying, because there is that scope of care thing, but also not to…and you might…I’d be kind of curious to get pushback on this, Sandra. But you know, as non-licensed practitioners, drug reps do this all the time. They’re doing that for, like, buy my drug that has the study as a non-inferiority study, which is not the same thing as a equivalent study.

And a lot of doctors don’t know the difference statistically, right? That’s where I feel like having that data and that ability to give that to your patients… I’m not sure if your reference range stuff, if you have research articles or things like that to share, because I feel like that makes what you say more powerful when you actually have an article to go along with it. Yeah. So, I’m not sure if you have any…

Dr. Sandi: Oh, yeah. That’s a great point. And perhaps, Hillary, what you may have been asking was understanding that difference between an optimal versus a conventional range. And a lot of times, most times, you know, doctors are just…conventional doctors are just going to show you the conventional range. And functional medicine doctors may have an optimal range. And so, there’s a lot that is written in the literature about that. And we will continue to have…we already had a direct-to-consumer labs symposium. We will have other events. That’s why we brought on Dr. Aaron today to talk about this, because it is something that we think it is really important for coaches to know. And you will be that person providing the education about what might be optimal versus what is the standard reference range.

Dr. Aaron: Yeah. I don’t know, Sandra, what resources you all have. Because for me now, it’s with DocsGPT and with OpenEvidence, I could literally go in, what is the optimal A1C? It’ll give me a number, it’ll give me…still give me a bunch of articles. I say, well, now, look at macro versus micro. I can prompt it differently. And it’ll literally give me…I can now find articles that would have taken me 30 to 40 minutes. Now, I’m getting stuff in literally three to five minutes. I don’t know what kind of resources that you all have that are equivalent to that, or if there is anything equivalent on you all’s side to…that enable people to get actual published literature within 30 to 40 seconds.

Dr. Sandi: Yeah. No. I think that’s a great idea. And we will look into those resources. So, we have a question that came in about…mentioned Fullscript lab order process. Health coaches can now order labs. They do a feature in which a practitioner review the labs, but it still seems problematic. How might coaches use this feature and remain in scope of practice?

Dr. Aaron: That’s a great thing. Because I use that with my online program, and I use their…because they basically have the lab ranges that are semi-functional, I’ll say. And you can click the option where they have one of their providers look at. They’re looking at mainly for, you know, is the kidney function off? If someone’s A1C is 7.5, they’re diabetic, that’s different than a 5.9. So, it just flags that to…it basically tells the patient to see their primary care. The way to stay…I think to stay within the scope of practice is just always say, if you have an abnormal range, you need to follow up with your primary care provider. You need to follow up with your licensed practitioner that can guide you on if things are needed.

But let me tell you about what could make your glucose go up or your…could make your hs-CRP go up. Let me talk about what could actually make your ferritin low. Your ferritin is 30, that’s normal. And your hemoglobin as a female is 11.9, that’s normal, but these are all low, right? So, you can all of a sudden talk about that diet and do you have any GI issues, etc. But I think that the trick is not being a licensed practitioner, not diagnosing things, not treating things, but you can support nutrition and support physiology. And that’s where, I think, the verbiage becomes important because a lot of these issues…you know, if someone’s hs-CRP is up, sometimes you can get that down just by changing someone’s diet, taking accurate vitamin C, getting their D up. If your homocysteine is elevated, getting on the appropriate B vitamin support and you can watch the hs-CRP come down just from those few interventions.

So, I think, stay within your scope, acknowledging you’re not a practitioner, you’re not diagnosing or treating things, but you can support people’s natural physiology. You can actually help lower… And that’s where…inflammation is not a diagnosis. Dysbiosis is not a diagnosis. IBS is. And so, you can use different language to describe the phenomenon. You know, myalgia, arthralgia are not diagnoses. You know, you ache and you’re hurt, you have joint pain, that’s not a diagnosis. Arthritis is, right? So, that’s where doing collagen peptides for things to support the joints, to support physiology. I think it’s…the devil’s in the details, but just using the right verbiage and clarifying beginning and ending with I’m not licensed to diagnose or treat and ending with I’m not, but these are all things that support your natural physiology and help with these processes, I think, is within the scope.

Dr. Sandi: Yeah. And you can also, in terms of Fullscript, if you’re a coach, you may not be the one ordering. It’s actually your client is ordering it. And so, you make sure that they are the one that clicks. You are not ordering it and charging the client as a service. So, you’re not. The labs aren’t being run through you. And also the results, the results are not going to you and then you are interpreting it with your client. The results are emailed to your client and then they choose to share them with you and you educate them about next steps and what all this may mean in terms of you’re just reading, you’re just saying, okay, it says here that this is…your vitamin D is this. Would you like to hear about what the optimal range might be?

Dr. Aaron: I think what I see, you know… And, Sandra, this is not an issue with the coaches that you train and I’ve worked with, but there are organizations where people use the word practitioners and they have their own personal story, like I had fibro, my kid had autism, and they figured out one of the 50 ways to treat it. And all of a sudden, they push themselves as the expert. And you don’t ever want to miss colon cancer. You don’t ever want to miss an appendicitis or inflammatory bowel disease because you just said it was IBS or whatever. And that’s where just that to think stick within your scope of care, supporting people’s physiology and always referring back to the licensed practitioner will keep those lines safe.

I spent seven years in medical school learning tens of thousands of diagnoses you never ever want to miss. And it’s really hard to replicate that. Most doctors stay in that world and they only…once I rule out death, I’m done. Right? And that’s where the functional medicine is different. It’s like, good, death is ruled out, but you still feel like crap. You still don’t feel good. So, that’s where I feel like the coach can be super helpful. But realizing the scope of practice and that a lot of people out there are not doing things appropriately and people are getting hurt because of it.

Dr. Sandi: Such an important point. And I’m glad you brought that up because it is a real danger out there because when you are coaches, prospective coaches are marketed, too, that you can interpret labs, you can order labs, you will learn a protocol that you can give to your clients. And coaches might be insecure about how to coach. And so, they’re attracted to this way of operating. But it is practicing medicine without a license. And in my experience, and I know you and I are in many networking groups, and the power is in your network. It’s in your relationships. And so, as a coach, when you cultivate relationships with doctors like yourself, others that you that will then respect you because you are staying in your lane, you are referring to them, and then they will refer to you as well. And you will grow that way as opposed to thinking, I can do it all. I can call myself a practitioner, and I can order and interpret labs, and have protocols for treatment.

Dr. Aaron: Yeah. Those are all good points.

Dr. Sandi: So, Denise says, peptides, where can we get more information on peptides? And what are…are these things that coaches can suggest to clients? I think the issue there would be the same thing, that providing education, but not making direct suggestions. But I’d love for you to comment on that, Dr. Aaron.

Dr. Aaron: I mean, I don’t know what peptide-trained things that are available to coaches per se. I got my certification through A4M as well as the Seeds Institute, which is Dr. Seeds was one of the first guys that set stuff up with this. And so, there’s training definitely out there. Now, even some pharmacies are providing training. Peptides are really interesting. They nudge your physiology forward. Some of them are gentle, some of them not so much. But they do have significant effects, particularly some of the growth hormone mimicking peptides. Some of those actually, there is some data on growth hormone levels over 50, increasing the risk of cancer. So, when you do a growth hormone peptide, you want to use something that is saturatable, that it won’t give you a super physiologic range. So, that’s the reason why I like CJC and ipamorelin versus using straight up growth hormone or HCG or whatever.

I don’t know what education is available to non-practitioners. So, I just know the education that’s available to me as a physician. But there’s some basic things like BPC-157, TB4. There are some basic peptides, TB-500, that have general immune support. Low-dose naltrexone. There are things that are really benign. I mean, naltrexone is funny because, literally, one of the things that, Sandra, you and I…I’m not sure if you were at that meeting. But, literally, they’re handing out nasal sprays for people to use for opioid overdose, handing out thousands of these things. I mean, it’s that’s safe, right?

So, it’s one of those things where, can that be in your armamentarium of things to discuss? Sure. But ultimately, those things, probably a practitioner should be some part of that because if they have an idiosyncratic reaction or whatnot, you probably don’t have the experience to say, oh, yeah, that’s from your mixture of your cough syrup and your low-dose naltrexone, for example. You might not know those things, but they can be super helpful. And they’re safe enough that BPC-157, Thymosin alpha-1, TB4, and even…it’s the KPV are now available as supplements through Quicksilver or Integrative Peptides. So, they are fairly safe, but some of the other peptides, the higher level ones, particularly GLP-1s mean that you need to be…again, that’s from a practitioner who knows how to use the drug.

Dr. Sandi: Absolutely. It’s such a good point. And I want to get back to a point you made earlier, and that is, you went to medical school and you did such deep dives into these rare conditions. And as a coach, you got a certificate and are the expert in behavior change and lifestyle changes. And so, therefore, when you defer to the expert, the practitioner, then everybody is safe in terms of not…perhaps not recognizing one of those rare medical conditions.

So, Carol has something that I’m going to…she says, knowing the tests and helping investigate the paths of action after getting results, looking to see if the tests would be effective. Is there anything that would be confounding the importance of getting a result at the present time, or how much it would influence their actions with or without the test? So, she says, I’m finding that the interface to coaches is marketing the labs they’re interested in, not educating to coach appropriate other products. So, she says it’s good marketing that coaches need. Which test companies have the best programs for coaching specifically?

Dr. Aaron: Can you say the question? I’m a little confused about it.

Dr. Sandi: Yeah. So, she says, I think, as coaches, we need to do the prepping for testing, ask questions to figure out the reasons the client wants to do the testing. I think that’s accurate. That’s the model that we teach. So, tell me more about what you’re hoping to find, discover. How did you learn about this test? What would you hope to…what would be an ideal outcome? And then ultimately directing the conversation to using those if they choose. It’s a client’s decision to do the testing. And then how can we use these results to track your lifestyle changes, for example?

Dr. Aaron: There are definitely certain labs you can do with that, like an A1C, like cholesterol, like a… I’ve been using sed rates for patients to track inflammation, blood related inflammation since 2007. And you can see people’s weight and watch their sed rate come down. So, there are definitely things you can look to see. Are you decreasing inflammation? Cool. Your liver enzymes, looking at a functional level for a GGT, AST, ALT. I mean, 30% of the population has fatty liver. That’s ridiculous. So, all of a sudden…

I remember when I was doing my training back in ’96 to 2000, we ignored fatty liver because it was not a thing. Yeah, it’s fine. It doesn’t hurt people. Well, now we know it’s a big deal. It’s soon to be the biggest cause of liver transplants. Well, check in AST, ALT and look at the functional ranges. If it’s 39, it’s actually a little too high. If your GGT is 50, that’s too high. You want that lower.

And so, you can track those coming down. Talk about, yes, you’re decreasing liver inflammation. Your body detox, fine, better. There’s less of a need for your body to make more glutathione, which is how you can interpret the GGT. So, there are certain labs that can help you with the coaching to show people are making progress. But I think the verbiage is important like you’re not, you know… Even if someone has…there’s a thing called Gaucher’s…it’s not Gaucher’s. It’s Gilbert, sorry.

Dr. Sandi: Yes.

Dr. Aaron: Gaucher. Get right G here. Gilbert’s, which is genetic. It’s people who have an issue actually conjugating bile. So, your bilirubin will be slightly elevated. And someone can take DIM, take, and other sulfur-based liver detoxifying things. You can actually see it come down. So, that could be a thing like, are you getting enough cruciferous vegetables if that’s slightly elevated? Again, it could be a educational nuance, but I’m not sure if you’re always training, if you talk about labs in that way. If you do, yeah. Because certain ones you 100% can do that with and other ones that you can’t. So, I think it depends on which lab and what you’re trying to communicate to the patient. In terms of inflammation in the weight and liver and gut stuff, there are definitely labs that you can talk about and watch them come down and you’re staying within your scope.

Dr. Sandi: Yeah, absolutely. So, speaking of labs that you can talk about, if you had somebody and they were going to their annual checkup and you know…it would be very incomplete. I know I see what my husband gets back from his checkup. But what are some of the ones that you think are just so important that are really missed in the conventional medical world? We already talked about the lipid.

Dr. Aaron: I’m surprised how many people don’t get A1Cs done, who don’t get vitamin D levels done. When I was still doing just my regular practice, I would use a B12 and a folate level as a surrogate marker for all your B vitamins. The average American is deficient…about 40% of Americans are deficient in any one B vitamin. So, a lot of patients now I do a complete panel of all the Bs, but you could do a B12 and folate. And if they’re low range, your B12 is less than 500, then all of a sudden, they probably have other B vitamin deficiencies. Ferritin is a standard test for iron deficiency, but also if it’s elevated, it can be a marker of inflammation. Platelets, if someone has platelets are high, that’s actually an acute phase reactant that can be a marker for inflammation. If that’s up and they have a little bit of anemia, you can also now know they’ve got some bone marrow inflammation issues.

So, you can actually look at regular labs as well and use them, the glucose, knowing that if your glucose is over 87, every point it goes up, you have a 7% increased risk for developing diabetes, for example. A lot of the regular labs you can look at functionally and say, hey, look, your fasting glucose is 97, it should be lower.

Homocysteine levels is another one. There’s a marker for methylation issues. If it’s high, it’s a marker for endothelial dysfunction and increased risk for heart attacks and strokes, for example. OmegaCheck is a great one that’s available at Labcorp and Quest. OmegaCheck is interesting because if that level is low, which is it’s a marker for…it’s measuring your Omega-3 and 6 levels. You have this equivalent risk for heart disease as a smoker with a normal Omega-3 level. So, the question is, are your Omega-3 levels as predictive for heart disease as quitting smoking? And then Omega-3s also can lower your risk for sudden cardiac death 50%. So, all of a sudden, that’s a test you can order.

I’m not going to list a whole bunch of other ones, but I feel like those are some basic ones that fit the hybrid. Then the hs-CRP of course and the sed rate between markers, one looks at red blood cell inflammation and the hs-CRP is actually antimicrobial peptide. So, if you have the elevated hs-CRP, it can be suggestive of a cold infection, whether it’s reactivation, Lyme, whatever, or simply endothelial inflammation. So, again, those are markers that are not expensive that you can do that can help guide conceptually big things that people can work on.

Dr. Sandi: Wow. That is really insightful and really important that coaches…this is something you can definitely…this is in scope 1,000%, you can share this with clients and help them to feel empowered to have agency to go to their doctor and request these tests. Or if that’s not an option, look at the direct-to-consumer route. So, we have no more questions. I want to thank you, Dr. Aaron. This has been so, so educational, informative. Thank you for being with us. You are such a wonderful supporter of the health coach movement. So, thank you for everything that you do.

Dr. Aaron: Thanks a lot. And thanks for inviting me.

Dr. Sandi: Thank you. And thank you to everybody who tuned in today. Stay tuned for more “Ask the Experts.” Thank you for being here. Bye, everybody.