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1 Megan: Hey everyone, I'm Megan Ramos, and I'm here today to answer your questions. Today's question involves lab tests, and what blood tests you should ask your doctor for. You can find a list of recommended blood work on our website at All of these tests are listed there, I know it's a lot of information [00:00:30] up on our website, so it's a little tricky to navigate through, but we'll break down the blood tests here for you today. In terms of assessing your blood sugar levels, fasting glucose and hemoglobin A1C are always great tests to have. In terms of assessing your insulin levels and your pancreatic function, you want to be testing your fasting serum insulin and your C-peptides. Your fasting serum insulin, [00:01:00] there's a lot of controversy out there right now over what time of day is most important to check your insulin levels. Just to get a baseline and an overall idea of how you're doing, it's always good just to get your fasting 12 to 14 hour insulin levels done and see what those levels are. C-peptides tell us how many cells in your pancreas are actively producing insulin. For most type II diabetics, this number is very high, [00:01:30] unless the type II diabetic has a lot of fat in their liver, and the fat is preventing the liver from producing adequate insulin. Then we see very low C-peptide levels. Those are the tests that we use to test your insulin and pancreatic function. Now if you really wanted to get a good insulin test, it's expensive and difficult to find a doctor who will do this. We can't even do it at our clinic, but the idea would be to replicate oral glucose tolerance tests, but instead of us [00:02:00] checking your glucose levels periodically over that two hour period, you would check your insulin levels instead. That's the best way to get an overall indication of your insulin resistance. There's a lot of people talking now that your two hours postprandial insulin level is more important than your fasting insulin level, so that means you would eat, and then two hours later you would check your insulin level and see what your insulin is. That can be a little [00:02:30] bit skewed too, if you eat out maybe, there's a little bit of sugar in your salad dressing. Maybe the chicken you're having was brined in sugar, or the pork you have is brined sugar. There's all kinds of hidden sugars when we eat out in restaurants, so that's tough. Also, if you don't eat an ideal meal either, you eat too many carbs, or too much protein, that's going to be high. It's pretty controversial, I do think the replicating the oral glucose [00:03:00] tolerance tests by checking your fasting insulin levels is really the gold standard. That's what we call the Kraft test, but I do think the second best thing that we have for right now, is just checking your fasting insulin levels. That gives us a little bit more information that we know of, but maybe in six months from now we'll have more data to understand why checking your insulin levels two hours after eating, or two hours postprandial, would be more beneficial for fasting insulin. There's a lot of research that needs [00:03:30] to be done, I'm sure a lot of this is going to change and change dramatically within the next five years, so we'll do our best to keep you updated. Page 1 of 5

2 For right now, a simple fasting insulin test is easy to order, it's affordable to order if your health care insurance won't provide it as well. Other recommended tests would be to check your electrolytes, sodium, potassium chloride, magnesium, calcium, phosphorus, just to make sure there's no issues with malnourishment, to make sure [00:04:00] that you're not entering a fasting state, too dehydrated, so we know the effects of your other medications might be having on some of these levels too. We like to keep a close eye on your electrolytes just to make sure we don't run into any issues during the fast or re-feeding. Medications that we take can have a huge impact too on our electrolytes. Our diet can have a big impact on our electrolytes, so if we're eating lots of carbs, we're going to be having [00:04:30] lower magnesium levels, and we need to supplement with lower magnesium for example. It's always a good idea to keep a good eye on these electrolytes, and adjust any supplementation that you might have to take as a result based on the blood work. We also test kidney... Quite a lot of kidney tests, or kidney markers rather. We take your urea, your creatinine, your bicarbonate, and your uric acid levels. The reason why we check most of these, is just to make sure [00:05:00] that you're properly hydrated, and that you're keeping your kidneys watered. Kidneys are like a plant, you don't want to over water them, because that's damaging, but you don't want to underwater them either. People ask us all the time how much water they should consume, and the answer is there's no magical number, not per pound of body fat, or lean mass, or total mass. My husbands a foot taller than I am, and he drinks half as much as I do throughout the day. You need to drink when [00:05:30] you're thirsty, everyone has different hydration requirements, and there's no magical formula that can give you the perfect amount. Drink when you're thirsty, keep it really simple. Also, if you feel hungry, maybe have a little bit of water, see if that helps take away your hunger. Try to just drink when you're thirsty. We keep a close eye on these numbers to make sure that people aren't overdoing it, or under doing it with the water. A lot of people who have these numbers skewed in the direction [00:06:00] where it looks like they're dehydrated, we talk to them to say, "Are you drinking when you're thirsty? Are you eating? Maybe you're actually thirsty when you go for food." If someone who has these dehydrated kidney numbers comes in and they say, "Oh, I'm always hungry all of the time," well there's someone I'd say, "Hey, why don't you try drinking a glass of water when you experience this urge to eat, and see if that goes away, because it looks like you might be a little bit thirsty on this blood work." Also, sometimes people just get obsessed [00:06:30] and think they need to drink X numbers of liters or ounces or gallons of water a day. They might be over hydrating their system. Everything that's good for you is bad for you in excess, just like not enough of it is... If you don't have enough of something that's good for you, it is bad for you also. It's about finding a balance, and this is why we check the kidney numbers. Page 2 of 5

3 The uric acid is a little bit different, the uric acid kidney marker doesn't really tell us a whole lot about [00:07:00] your hydration for example, but it can give us an indicator of your risk of gout. We all know that gout's one of the more significant side effects of intermittent fasting. People who don't have a history of gout rarely, rarely, rarely experience gout when they start fasting. People who don't have a history don't experience it, and even though their levels go crazy high, as your body adapts to being more in a fat fueling [00:07:30] state from a sugar burning state, your uric acid levels will come down. If someone has no history of gout, we're not too concerned about it, but we keep an eye on it. If someone has a history of gout, there are certain interventions that we've talked about in other Q&A's that we utilize to prevent the gout. We like to keep an eye on the uric acid levels just to know in either case. Other blood tests that we check, is we check your complete blood count, or a CBC panel, [00:08:00] that's just to make sure that everything else in the body is completely okay, and that you're not fighting off of any infections that might be the reason why your blood glucose levels are up, or you're not losing weight. Sometimes our body's fighting off infections even though we feel perfectly okay, and this causes our body to produce a lot of cortisol to help fight off the infections, which can temporarily raise our blood glucose levels and inhibit weight loss, since cortisol is a fat trapping hormone. [00:08:30] Sometimes people aren't too sure why they're not making progress, and it could just be because they're fighting off an infection. We also check TSH levels quite regularly as well in our clinic. TSH is a thyroid stimulating hormone, and we often notice with our patients that their TSH levels start to improve if they have hypothyroidism or Hashimoto's disease once their body has adapted to fasting. We [00:09:00] initially find that they get a little bit worse, and then they get a lot better. TSH also appears to be highly affected by stress too, so it's another indicator that you might be going through something personal or physical that's creating a lot of stress in the body, and that might be why you're not seeing as a great of improvement as you'd like in your blood sugar levels or in your weight loss. In terms of assessing cholesterol, we would prefer that our patients check their NMR Lipoprofile, [00:09:30] but that's not super easy to do here in Canada. If you do have access to checking your NMR Lipoprofile, I would take advantage of it. In Canada, we have to ship it to the US, and it costs $140, and even still the patient's paying for it out of pocket. The government gets a little bit cranky about why we're ordering these tasks and shipping down to the States. It's a little bit controversial in a lot of places, and there are very few countries in the world that actually can [00:10:00] do NMR Lipoprofile testing, so it's challenging. Right now it's most commonly done in the United States, so if you can get it, get it done. It does give you an indicator of your insulin resistance. It gives you an insulin resistance score based on various components of your Lipoprofile. Page 3 of 5

4 We've often found that even though patient's fall into the normal range, they still have quite a lot of diabetes. They have very high fasting insulin levels, and very high C- peptide levels, [00:10:30] which means their pancreas is producing a lot of insulin. We're not quite sure how much of an indicator that actually is, but it does give us some really great other markers to check in your Lipoprofile. If you can't get access to that, then just ordering your traditional lipid panel is important. Again, we talked about this in the previous Q&A, but you don't want to be fasting for an extended period of time before you do any sort of lipid profile, [00:11:00] whether it's just your plain lipid panel, or it's an NMR Lipoprofile. You want to be eating ketogenically and not fasting for more than 14 hours for three to five days before you have your lipids assessed. Another marker that we check, is high-sensitivity C-reactive protein. Now high-sensitivity C-reactive protein is thought to be a cardiac inflammation marker. A lot of people, if they have not the best lipid [00:11:30] panels, that they appear to be hyper responders, and all of their lipid numbers go up, but their triglycerides go down. If their triglycerides go down and their high-sensitivity C-reactive protein is quite low, people assume that they're not at high risk for heart disease. C-reactive protein can also be a measure of other inflammation going on in the body, whether it's from your arthritis or from an autoimmune addition or from an injury at the gym. [00:12:00] C-reactive protein can fluctuate depending on other inflammations that are not related to your cardiovascular system. We do notice with most of our patients that C-reactive protein does come down with time. People with great lipid panels or bad the panels can have good or bad C-reactive protein. Usually with a patient who has a really good lipid panel and has high [00:12:30] C- reactive protein, their patients with fibromyalgia, with severe arthritis, and other kinds of chronic pain issues where there's lots of inflammation involved. The last test that we check regularly is vitamin B12, that's not the best test, but it's easy to get access too. It gives us a good ballpark of your vitamin B12 levels. We find at baseline, most of our patients are actually deficient in vitamin B12, [00:13:00] and fasting doesn't make it worse. We'll usually recommend some sort of vitamin B12 supplementation at their baseline blood work, and half of the people will take it and half of them won't. For that percentage of the population that won't take it, their numbers don't get worse, but they don't get better with time. We find that people who have normal B12 levels at baseline, continues to have normal B12 levels when we're fasting. We don't see the fasting or the change in diet really affect [00:13:30] the B12 levels at all. Some people just really don't absorb B12 very well, and some people absorb it great. Guys, those are the blood tests that we typically order. In our clinic, we do most of these tests actually on a monthly basis. The test that we don't do on a monthly basis is the high-sensitivity C-reactive protein, the vitamin B12, Page 4 of 5

5 the lipid assessment, and the C-peptides and fasting insulin. We check those [00:14:00] every three months in our clinic. We recommend that you get your blood work done probably about every three months, and test fasting insulin, C-peptides, lipid panels, NMR Lipoprofiles, C-reactive protein, vitamin B12, they can be done every 6 to 12 months depending on your insurance. Of course this is all up to your healthcare provider. Anyways guys, thank you for your questions today, keep them coming. [00:14:30] You can send them in to Questions@IDMprogram.com. I'm Megan Ramos, I'm signing off, happy fasting guys. Page 5 of 5

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