Tag: functional medicine

Optimal Not Normal
Is Your Body Digital or Analog?

Is Your Body Digital or Analog?

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We live in a digital age.  Do you think of your body as digital or analog?  Answer this simple question.  Do you wear a modern digital watch or a traditional analog watch?

classic analog watchcontemporary digital watch with dateWhy do I ask these questions?  Because it shows how you can look at the time and space in different ways.  An analog watch does not need to be exact or precise.  A quick glance and you know exactly where you are in a diurnal 24 hour cycle.  You immediately see a relational picture.  A digital watch simply gives you a notion.  It does not show you a picture of the day.  Your brain takes a few extra steps converting that to a perceived notion.

Similarly, the problem I see constantly, day by day, is labwork with arbitrary lower and upper boundary values.  All my patients asked me, “well, is that value normal?”  To which I frequently say, “there really is no such thing as normal.”  There is only optimal and acceptable.  And normal changes decade by decade.   Normal for an 80-year-old would not be normal for 35-year-old.

Another easy to understand analogy is your car.  When do you decide to pull into your favorite gas station?  When is your panic time to fill up your tank?  Do you wait until it’s ¼ full?  Until it’s 1/8 full?  Or wait until the dire warning light tells you only have 20 more miles left before you run out of gas?   Just how proactive are you with your car?

You can look at your body in the same way as your automobile.  If laboratory values are “low normal” they are low.  As you will see in the graphic illustrations below.  But first, let me expand upon the title of this blog.  Are you digital or analog?

Because of time constraints and poor learning habits, all lab work is conventionally seen as digital or binary.  You are either in the box or out of the box.  It’s a very simple calculation.  It removes all guesswork, estimates, finesse and discretionary thinking from medical lab analysis.  There are capricious cutoff values that are usually set at 1 to 2 standard deviations (σ) above or below the mean value.  The mistake made by virtually every conventional physician is diagnosing health or disease using in range values.

But lab values represent our personal human physiology.  We are all individuals.  And all these optimal values are better represented by skewed binomial distribution curves.  Seen as part of a continuum — all the way from low to optimal to high.  It is far more physiologic and rational to look at all your lab values as a continuum that fall on a distribution curve. And most often the curve is skewed to the left or right.

This is the basis of Functional and Anti-Aging medicine.

So let’s look at these illustrations taken from my own real clinical data spanning 12 years.  Data from 5000 samples of hematocrit as example.  That is the percentage of red blood cells in the serum. It is essential for oxygen carrying capacity.  A low hematocrit is a measure of anemia.  And that is not a healthy state.  Re-read my blogs on iron deficiency anemia.

Hematocrit viewed as a binary solutionHematocrit seen as a continuum of values

Now let’s say your value is just slightly above the lower cut off with the green stars.  But then you rerun the lab today or tomorrow which will always be slightly different and suddenly the value might be just slightly below the lower level cut off with the red stars.  In the first instance you are “in the normal range.”  In the second instance you are now out of range.  What is the difference between these 2 values?  Essentially nothing.  So the entire practice of looking at lab values in range is neither functional nor rational.  You want to be looking at all lab values as an optimized value on a continuum.  Optimal is the “happy face” zone.

So this then is the difference between digital / binary medicine and optimized functional medicine.

Let’s finish with one more example.  Vitamin D is one of the few lab tests where values are denoted in more rational ranges.

  • 15-25 ng/ml is deficient.
  • 25-33 ng/mL is insufficient.
  • 33-100 ng/ml is sufficient.
  • 100-150 ng/mL is considered excess.
  • And >150 is considered toxic.

Although, in reality, vitamin D is never toxic.  Another wild misconception that dates back decades.

You can see how much more rational these multiple discrete quintile ranges are.

So when I speak with my patients, we are always looking for optimal values not lab data points that are necessarily in range or out of range.  And furthermore, I take a Grandmaster view of laboratory.  I look at balances, relationships and longitudinal trends.  I see a picture of overall health or dysfunction.  Not a list of disparate lab values.

So that is your challenge.  Do you see yourself as digital or analog?  Maybe in the next 20-30 years after The Singularity, when we all have various bionic components, the answer to this question might change.  My answer for today is  — your body is analog.

Food for today’s thought.   Now that you have read through today’s blog, go back and read my thoughts on the Tyranny of the TSH.

Write me with any questions, thoughts or comments.

Philip Lee Miller, MD

Carmel, CA 93923

Treat and Prevent Iron Deficiency Anemia

Treat and Prevent Iron Deficiency Anemia

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Iron deficiency anemia

This is the last in our series on Iron Deficiency and Iron Deficiency Anemia. In parts I, II, III, and IV, I talked about all aspects of the essentiality of iron. How to diagnose iron deficiency anemia. Various controversies surrounding iron supplementation. And the relationship of iron to various inflammatory states including cancer.  Let’s recap this series with specific treatment routines.  I encourage you to read this final wrap-up containing new and revolutionary medical paradigms.

[If you want the nitty gritty, scroll down to “treatment.”]

Enter Functional Medicine

I want to introduce one more refining and overriding concept. A new paradigm shift in medicine. Functional Medicine.  We need to rethink the entire subject of iron deficiency and anemia.  How and when do we recognize the condition of iron deficiency and progressive anemia? And then what triggers our decision to treat – or prevent?

Functional Medicine is a systems biology–based approach that focuses on identifying and addressing the root cause of disease. Each symptom or differential diagnosis may be one of many contributing to an individual’s illness.   — from the Institute for Functional Medicine

Binary vs. Optimal Choices

In America I see two competing medical paradigms. Structural pathologic medicine based on illness and disease. And functional medicine which is based on dysfunction, suboptimal values with the goal of restoring health and wellness. The goal is not identical.  It leads to totally different approaches for you, the patient.

The functional approach to iron therapy realizes various degrees of iron deficiency rather than a binary choice.  “In the box” or “out-of-the-box.” You’re either low or you are high. In reality virtually all medical paradigms follow a normalized distribution. A continuum from very low to very high. The goal is always optimal — in the middle — values. This is a concept stressing to all my audiences 20 years.

Fortunately, a new model is proposed and advocated in a major publication in the Austrian literature. This paper lays out guidelines for treating iron deficiency anemia in cancer patients using absolute (AID) and functional (FID) iron deficiency.  Seemingly two sets of criteria.

Anemia is common in cancer patients [2]. From a practical viewpoint, two forms of iron deficiency need to be differentiated: absolute iron deficiency (AID) and functional iron deficiency (FID). AID is defined by a TSAT < 20 % and a serum ferritin level < 30 ng/ml in otherwise normal individuals, while in cancer patients a higher cut off level of ferritin levels should be applied (< 100 ng/ml). FID is defined by a TSAT < 20 % and serum ferritin levels of > 30 ng/ml in normal individuals and of > 100 ng/ml in cancer patients.

Great.  Here is a clear path.  The Austrian literature articulates a major shift in modern medical thought. That is my purpose in writing series for you.  Iron therapy is anti-angiogenesis preventing neo-vascularization.

Challenging Standard Definitions

I see so many patients who are relatively anemic and are symptomatic. But they still fall within the “normal range.” And are therefore dismissed.  Not falling within the treatment guidelines.  Ready for the paradigm shift?

Now remember from the previous blogs that iron deficiency will proceed anemia. So here is the continuum of iron from fully sufficient to deficient that precedes anemia .  This is a functional view.   We want optimal values.

continuum from iron deficiency to iron deficiency anemia

Anemia appears only after more severe iron deficiency progresses.  Once iron falls to more severe levels.

Conventionally, your diagnosis of anemia must meet these standard criteria.  Hematocrit values < 35% (women) or <40% (men).  Or Hemoglobin values <13 in men or <12 in women.  Remembering that hemoglobin is oxygen carrying capacity.

But in reality, you won’t be diagnosed or treated until values fall even much lower.  At that point you are really sick.

See figure 2 for “normal values.”  You want optimal values.

Men Women
RBC Count (million/ug) 4.2 – 5.9 3.6 – 5.5
Hemoglobin gm/dl 13 – 17 11 – 15
Hematocrit % 40-52% 34-46%

Treatment Options

This is a re-cap and wrap-up of the previous blogs. All preceding blogs give you a more in depth look at all the issues of iron therapy.

How do we treat knowing that earlier intervention is essential?   The total daily dose for severe cases is 180 mg of elemental iron.  I usually use lower doses.   You will need increased doses of magnesium to prevent constipation.

Heme vs non-heme iron sources in food.  

  • Heme based sources of iron is the most efficient. Best source is red meat or chicken livers or sardines.   Non-heme sources, plant based is a less efficient source of daily iron.

Iron Salts

  • Ferrous sulfate 325 mg (65 mg elemental iron) three times daily. The preferred form.  This may raise hepcidin levels thereby decreasing efficient absorption.³
  • Ferrous gluconate 325 mg (12 mg elemental iron) three time daily
  • Ferrous fumarate 325 mg (107 mg of elemental iron) three times daily

Iron chelates

  • AminoIron – 18 mg elemental iron as bis-glycinate
  • Reacted Iron – 29 mg elemental iron as ferrous bis-glycinate

Iron Infusions

  • Ferric carboxymaltose (injectafer) — the most potent and effective for severe cases and those not responsive to oral consumption.
  • You will need to find a sympathetic and creative hematologist to administer and infuse parenteral (im or iv) iron.  A hematologist who is willing to treat early and not late in the process.

Philip Lee Miller, MD
Carmel, CA
May 24, 2018

  1. Iron metabolism and iron supplementation in cancer patients: Wien Klin Wochenschr (2015) 127:907–919 DOI 10.1007/s00508-015-0842-3
  2. Ludwig H, Müldür E, Endler G, et al. Prevalence of iron deficiency across different tumors and its association with poor performance status, disease status and anemia. Ann Oncol. 2013;24:1886–92.
  3. Iron Dosing for Optimal Absorption:  NEJM Journal Watch Oct 30 2015.
  4. Iron deficiency Anemia  NEJM May 8, 2015 
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