Popular Blood Tests—the Facts, Ranges, and Alternatives You Should Know

Inline_Blood_Test_PrimerI’m of two minds when it comes to blood testing. For myself, I’m not a huge fan of obsessive, frequent testing and optimization. I have a good idea about how to optimize my health through the actions I take and the foods I eat, and by monitoring how I’m feeling, looking, and performing in response. It’s worked well for me. Whenever I do get a checkup or have blood drawn, my numbers are great.

But many people are the opposite. They like to quantify what’s happening under the hood. That’s great, and often necessary. The problem is that there are big problems with many of the most common blood tests.

A glaring problem for almost every blood test are the reference ranges used. What’s wrong with those?

Reference ranges reflect what’s common, not normal. A reference range for a blood test refers to the values possessed by 95% of the normal population.

Reference ranges for blood tests are based on the people who get lab tests. Who gets lab tests? People who go to the doctor, often because there’s something wrong with them. They may not reflect normal ranges for truly healthy people.

Reference ranges are extremely broad, which may give a false sense of security. Having blood sugar on the high end of “normal” isn’t healthy. It actually presages type 2 diabetes.

Another problem inherent to almost every blood test you’ll take is that the result represents a snapshot in time, a brief glimpse at a situation in constant flux. Your cholesterol was elevated today at 12 noon. What does that say about your levels tomorrow at six in the evening? Next week? Nothing. To account for natural fluctuations, get tested at regular intervals and observe the trends.

Let’s get more specific.


“Oh, gee, Tom, steak and eggs for lunch again? You ever get your cholesterol checked?” We hear this all the time, the chorus of pleas that we please go get a “cholesterol test” before we keel over. Say you decide to humor the skeptics. You go get a cholesterol test. What should you watch for?

Most of the time, LDL is calculated, not directly measured. If you have low triglycerides, as is common on low-carb diets, your calculated LDL will be higher than the reality.

LDL-C refers to the passengers in the cars, not the number of cars on the highway. Most basic tests don’t measure LDL particle number. All evidence points to the number of LDL particles being far more predictive of heart disease risk than the more common LDL-C. More LDL particles means LDL is hanging around in the blood, increasing the chance they’ll become oxidized and atherogenic.

The guidelines aren’t supported in the literature. Many studies have shown a disconnect between supposedly dangerous cholesterol levels and actual heart attacks. In a 2009 study, 75% of people hospitalized for a heart attack had “healthy” cholesterol numbers. A 2016 review found the lowest levels of LDL were actually associated with higher mortality in the elderly—you know, some of most vulnerable among us.

What can you do?

Request an advanced lipid test. Tests like VAP, NMR, ApoB, and LDL particle number testing all provide deeper insights into the state of your blood lipids.

If you’re stuck with the basic test, take a look at ratios. Total cholesterol/HDL ratio is a good indicator of how long LDL is hanging around in the blood and remains the best standard assessment of heart disease risk. Another good one is triglyceride/HDL ratio, which is a strong surrogate marker for insulin resistance. In both cases, lower is better. An ideal T/HDL ratio is 1:1; 2:1 is about as high as you want to go. An ideal TC/HDL ratio is 3.5:1 or lower.

Blood Sugar

There are three primary types of blood sugar tests: fasting, postprandial, and hemoglobin A1c (HbA1c). Postprandial blood sugar measures your blood sugar response to eating at various intervals after meal. Fasting blood sugar measures your blood sugar levels at rest, when no food is coming in. HbA1c measures your average blood glucose across the previous three months. They’re all important, but the tests all have issues.

“Normal” might not be normal. According to the American Diabetes Association, a fasting blood sugar (FBG) under 100 is completely normal. It’s safe. It’s fine. Don’t worry, just keep eating your regular diet, and did you get a chance to try the donuts in the waiting room? They only start to worry at 110-125 (pre-diabetic) and above 125 (diabetic).

This may be unwise. Healthy people subjected to continuous glucose monitoring have much lower average blood glucose—89 mg/dl. A 2008 study found that people with a FBG of 95-99 were 2.33 times more likely to develop diabetes in the future than people on the low-normal end of the scale.

How about HbA1c? A “normal” HbA1c is anything under 5.7. And 6.0 is diabetic. That’s what the reference ranges, which mostly focuses on diabetes. What does the research say? In this study, under 5 was best for heart disease. In this study, anything over 4.6 was associated with an increased risk of heart disease.

That 5.7 HbA1c isn’t looking so great.

Healthy FBG depends on your BMI. At higher FBG levels, higher BMIs are protective. You read that right. A recent study showed that optimal fasting blood glucose for mortality gradually increased with bodyweight. Low-normal BMIs had the lowest mortality at normal FBG (under 100), moderately overweight BMIs had the lowest mortality at somewhat impaired FBG (100-125), and the highest BMIs had the lowest mortality at diabetic FBG levels (over 125).

The oral glucose tolerance test is unrealistic. The standard way to test postprandial blood sugar is the oral glucose tolerance test: 75 grams of pure glucose in liquid form. Unless you’re downing jumbo Slurpees, you’re not consuming that much pure glucose in a single sitting, so the results may not be relevant.

HbA1c depends on a static red blood cell lifespan. A1c seeks to establish the average level of blood sugar circulating through your body over the red blood cell’s life cycle, rather than track blood sugar numbers that rapidly fluctuate through the day, week, and month. If we know how long a red blood cell lives, we have an accurate measurement of chronic blood sugar levels. The clinical consensus assumes the lifespan is three months. Is it?

Not always. The life cycle of an actual red blood cell differs between and even within individuals, and it’s enough to throw off the results by as much as 15 mg/dl.

Ironically, people with healthy blood sugar levels might have inflated HbA1c levels. One study found that folks with normal blood sugar had red blood cells that lived up to 146 days, and RBCs in folks with high blood sugar had life cycles as low as 81 days. For every 1% rise in blood sugar, red blood cell lifespan fell by 6.9 days. In those with better blood sugar control, RBCs lived longer and thus had more time to accumulate sugar and give a bad HbA1c reading. In people with poorer blood sugar control, red blood cells live shorter lives and have less time to accumulate sugar, potentially giving them “better” HbA1c numbers.

Anemia can inflate HbA1c. Anemia depresses the production of red blood cells. If you have fewer red blood cells in circulation, the ones you do have accumulate more sugar since there are fewer cells “competing” for it.

If you’re very low-carb, postprandial blood glucose will be elevated. This is because very low-carb, high-fat diets produce physiological insulin resistance to preserve what little glucose you have for the tissues that depend on it, like certain parts of the brain. The more resistant you are to insulin, the higher your blood glucose.

What can you do?

If you need to pass a test, 150 grams of carbs a day will do it. Eat that way for three days to a week before your OGGT.

Try meals, not sugar solutionsMixed meals of fat, protein, and carbs are better candidates for testing one’s real-world glucose response.

Take all three measurements into account. If your HbA1c is higher than you’d like but you ace all the postprandial tests, you’re probably fine.

Follow trends. Even if your red blood cells are centenarians, you can track the trend of HbA1c with multiple readings.

Liver Enzymes

The most common liver enzymes you’ll test are alanine transaminase (ALT) and aspartate transaminase (AST). Another one is gamma-glutamyl transpeptidase, or GGT.  When the liver is damaged or inflamed, liver enzymes generally go up. They’re usually pretty straightforward—more straightforward than the cholesterol and blood sugar tests—but not completely.

Weight loss can change them. Weight loss transiently increases ALT and AST in women and decreases them in men. If you’re in the process of losing weight, you can safely ignore small improvements or increases in liver enzymes.

Normal isn’t healthy. The normal range for GGT is 8 to 65 U/L, yet men under 70 years of age with GGT levels over 38—right smack in the middle of “normal”—have an increased risk of heart failure. Another study found that even low-normal levels of GGT were associated with an increased incidence of atrial fibrillation, a harbinger of more serious cardiovascular conditions.

What can you do?

Just be aware. Don’t fear weight loss for transient changes to your ALT/AST, and don’t rest on your laurels if your GGT looks “normal.”

Testing your cholesterol, blood sugar, and liver enzymes is helpful, informative, and often necessary—but only if you’re aware of the limitations and you know how to account for context.

Thanks for reading, everyone. Take care!


TAGS:  prevention

About the Author

Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending three decades researching and educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates Primal/paleo, keto, and Whole30-friendly kitchen staples.

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68 thoughts on “Popular Blood Tests—the Facts, Ranges, and Alternatives You Should Know”

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  1. I learned the hard way years ago to have as little truck with the medical profession, lab tests, and drugs as possible. When I have an issue arise, I prefer to treat it in the least toxic, least invasive manner possible. For me, this invariably means alternative rather than allopathic modalities.

    There’s no such thing as “normal” other than how each one of us, as individuals, feels and functions. We are our own yardstick. Living a Primal/Paleo lifestyle and keeping stress to a minimum will serve most of us better than constantly having someone in a white coat checking internal processes. Tracking every bodily fluid and function and then stewing over it because the numbers are less or more than someone else’s can be highly counterproductive.

    1. Fully agree with you Shary. The main function of all these tests is to come up with some excuse to get you on drugs. The doctors work for big pharma with very few exceptions and have very little idea of what real health is or how good it can feel.Why anyone should go to another person who is usually less healthy and over weight is beyond me. Listen to your body and use websites such as this and Mercola.com for any information required.

  2. Regarding LDL-C, didn’t you mean to say that higher LDL is associated with lower mortality in the elderly?? I hope so, because I looked at the link, and otherwise I’m confused.

    1. I noted the same thing. I think he meant to say that *higher* LDL-C is associated with lower mortality in the elderly.

    2. Hey, thanks for catching that one, folks! It’s corrected now, but it should’ve said (and does now): “A 2016 review found that the lowest levels of LDL were associated with higher mortality in the elderly—you know, some of most vulnerable among us.” Grok on, everyone!

  3. Thank you for this one, Mark!

    While lab results can offer useful information, the way they’re typically used in conventional medicine does NOT support health and wellness. Rather, it feeds fear, health and diet myths, and the pharmaceutical industry.

    When someone is put on dangerous drugs (statins, for instance) as a result of an inaccurate or incomplete understanding of lab results, the tests can do more harm than good.

    1. Dr Lyons

      This is your description from your website

      I’m a licensed Doctor of Oriental Medicine – Acupuncture Physician in Colorado, Florida and Maryland. I’m also a certified Primal Health Coach trained in ancestral health and nutrition. I hold a Master’s degree from Georgetown University and completed my 5-year Doctor of Chinese Medicine training at the Academy of Classical Oriental Sciences, in British Columbia.

      So – you can’t prescribe any drugs of any kind can you?
      Can you request lab tests via a patient’s insurance?

      What are your qualifications to label statins as “dangerous drugs?

      How many people die yearly from taking these dangerous drugs?

        1. https://www.medscape.com/viewarticle/879613
          Muscle Pain Reported Mostly by Those Aware They’re on Statins: ASCOT-LLC Analysis

          The controversy over statins has revealed something: the nocebo effect is real

          “I saw a woman in her early 60s today who had a stroke last year and, after a shaky start, made a fantastic recovery. She’s stopped smoking, which is the most important factor in preventing a recurrence. But she remains at high risk. She’s slim with an impeccable diet and walks every day. But her total cholesterol is 7 and most of that is the bad type. She’s adamant that she doesn’t want to take statins. I ask why not. “Because I tried and they made me ache all over. I read in the paper that they cause muscle pains,” she says. And so she stopped them a few months ago. I ask how she is now. “Oh I still ache all over,” she says.

          And this is nocebo at work. Nocebo is the opposite of placebo, something we’re all familiar with. A placebo is an inert pill or treatment that can work wonders if it’s prescribed with enough persuasiveness. It’s a very well-recognised phenomenon and contributes to the healing power of many treatments. A sham injection into a painful, arthritic knee gives nearly as much relief as a steroid injection.”

          The Nocebo Effect in the Context of Statin Intolerance

          1. noone denies the mind over matter side of things in any field.
            The issue here is that it’s been proven ages ago that the ONLY reason cholesterol was associated with vascular disease is that the “quick aid bandage” the body uses to cover lesions from inflamation in the arteries is made up mostly of colesterol. However, examples such as the French population wich has skyrocket levels of cholesterol yet very little heart disease, led to new reseach that showed blood levels have no correlation with the formation of plates. As a review, HDL and NORMAL LDL are simply indicators of how much fat is being mobilized back and forth in the blood. If you are on keto diet, intermitent fasting, or any other variation that addapts your body to work mainly with fat, you WILL have plenty of fat traffic. It’s free radicals, the lil demons of inflamation, that oxydize LDL and cause problems, not the LDL by itself. and even small amounts will be a problem, so there’s no way high cholesterol is any indication of heart disease.
            BTW, fat itself does not cause free radicals, quite the oposite. It is the glucose metabolism for energy that releases free radicals. The use of ketones or free fatty acids as fuel is quite clean power source instead.
            Trans fats on the other hand are a totally different subject, but everyone already knows THAT part…

    2. https://www.euyansang.com.sg/cholesterol-and-tcm/eyscardio1.html

      Managing Cholesterol Levels with TCM
      Red yeast rice contains natural statins to invigorate the body, aids digestion and revitalises the Blood, lowering LDL cholesterol

      Do more of these
      • Eat fruits, vegetables, whole grains, good quality fats

      • Sleep and exercise

      Do less of these
      • Consume alcohol, meat and dairy products that contain high amounts of saturated fats

      • Late nights

      • Smoking

      OMG – take a natural statin and eat less saturated fat!!

      1. Mr. Grashow,

        While you are entitled to your opinion, it is interesting that you seemingly attempt to insult Dr. Lyons and question/belittle her credentials while in your next immediate post you offer none of your own, and provide only a link to a web site where the reader is, presumably, to be compelled to believe your post over hers, which, incidentally, are not your ‘insights’ at all but are taken directly from the web site you reference. This is a forum of highly educated and informed individuals who believe in captaining the ship of their own well-being. No one, LEAST OF ALL mainstream medicine and its usurpation of the label of “M.D.” or “Doctor”, has a corner on the market of health, wellness, testing, cures, diagnosis, education, knowledge, learning, expertise, information or research. Having checked out your link I will take it for what it is: yet more information to add to my personal arsenal of research and do with as I please and see fit.

        In the meantime, I gladly welcome the professional opinion and input of Dr. Lyons, as well as the many others on this thread, yours included.

        ** On a side note, I certainly wouldn’t go to an allopathic doctor to receive acupuncture. One does need to be FORMALLY TRAINED AND LICENSED, after all, to perform such a procedure! ;0)

        Enjoy the day and be well, Sir.

        1. I’m merely pointing out the fact that just because one has Dr in front of their name one cannot assume that person is a medical doctor. I also point out the fact that while she rails against dangerous stain drugs there are TCM web sites that promote the use of “natural” statins like red rice yeast.

          “This is a forum of highly educated and informed individuals” This is a website with a specific point of view and the vast majority of the people here are not interested in anything that goes against their paradigm.

          For example

  4. I’ve heard Rhonda Patrick mention that cholesterol levels will look worse if you’re stressed, so that if you’ve just experienced some big stressful event in your life, your cholesterol test will be misleading.

  5. A lot of fine information in one post. After reading Kresser/Masterjohn and others on this subject, this is by far the clearest and most helpful. Thanks!

  6. I’m one of those people obsessed with the data… I love to see my glucose, ketones, weight and HRV numbers every morning… I love to see how things change based on diet and lifestyle (ie sleep, crossfit training, cumulative allostatic load, sun exposure, earthing, etc).

    I love giving my list of requested labs to the doctor’s office and telling them how to prepare the specimens… I make sure that the vitamin A specimen is wrapped in gauze so that the light doesn’t ruin the sample. I make sure that may DHT specimen goes straight into the freezer. It’s better than Christmas when my labs are ready! I love reading, and re-ready my labs. It’s like forming and cultivating a bond between my biology and me.

    1. Wow, that is very cool! Do you pay much for that service? I live in Canada and not sure if our health system includes all those tests?
      What I would really like to know….is how are my gut/brain doing? Of course, who would decide what is ‘normal’….?????

      1. Glucose, ketones, weight and HRV numbers… fixed cost (HRV monitor) and cost of strips. All the other labs/ data is pretty much covered by my insurance though I’d be willing to pay… because, after all, I see value in all the data.

        One of my favorite things to do is to change one variable (lifestyle or diet) and see how it impacts the data.

        1. Brian, check out Dave Feldman and the tons of tests he does tracking his cholesterol lipids. I think his site is CholesterolCode.com. He gave a presentation recently showing an inverse relationship between his test results and his dietary saturated fat intake 3 days prior to his cholesterol test. I was amazed how easily cholesterol test results could be ‘gamed’

  7. Funny timing. I just got my annual physical and test results back. Everything was normal as usual except for my Alkaline Phosphatase which is consistently low (34 U/L vs standard range 37-113 U/L). I’ve tried looking into it to determine the cause or effect but there’s not much information out there.

    Mark or anyone have any ideas?

    1. Low Alk Phos may indicate low zinc. I believe it is s zinc dependent enzyme. Just about everyone could use extra zinc anyway. Go for it. Try 30 to 50 mg . Use capsules. Take before a meal unless you get nausea, then take with food. I’m s licensed nutritionist.

      1. Zinc status is easy and cheap to test at home – get a bottle of Liquid Zinc Assay on Amazon, put about 3/4 tsp in your mouth – if it is tasteless, you are low; if it’s a bitter metallic taste, you’re fine. A good multi like Life Extension Two Per Day has 30 mg of a bioavailable form (not zinc oxide).

  8. As a huge fan of this website and also the “Stop The Thyroid Madness” website , the term that makes most sense is ” optimal”, not ” in range”…
    Then you are working with what is best for you personally, not some arbitrary ” range”.

  9. Mark, please always include Lipoprotein(a) testing as part of your recommended lipid panel. Particle counts from VAP, NMR are great. But regardless of the type of lipid panel Lp(a) just gets lumped into the LDL number. Unless you specifially request an Lp(a) test you won’t get the number. Its a number you should know, because Lp(a) is nast.

    High levels of Lp(a) are inherited. If a relative had early heart disease, you should definitely have this checked. (I didn’t learn about this until years after my heart “event”). While there is little you can do about high Lp(a), you can focus on inflammation reduction through diet (e.g. paleo) and supplements like fish oil.

    For more info https://www.lipoproteinafoundation.org/

  10. I’m a newbie to this site and I think it is factual, educational and well worth reading. I’ve been eating a primal diet (ala Nora Gedgaudas) for a few years, and I feel so much better than when I was eating vegan. Lately though, I had some blood work done through the Mayo clinic, and the results returned showed that have Apolipoprotein E Genotyping, B Result Genotype e3/e4. The e4 allele leads to down regulation of the LDL receptor in the liver and is associated with increased total cholesterol (mine is 362) triglycerides (mine are 59) and LDL (mine is 260) The naturopath has suggested I stop eating all dairy products…I’m confused as to what to do. I love my primal diet and believe it is healthful…but how many folks have this kind of blood work results and what is best to do for it?

  11. I just had blood work done and my glucose was 103 and I’ve been Paleo for over a year. Hopefully as he states it’s because of low carbs. Also just got diagnosed with auto immune hypothyroidism. I was quiet shock giving how healthy I eat. 🙁

    1. Omg Helen, my blood glucose is consistently around 90 no matter what, but after being Paleo for 2 years, and feeling absolutely fabulous, I crashed. I too got diagnosed with hypothyroidism, hashimoto’s, goiter and and multiple nodules on my thyroid two years ago, and I’m still trying to get “right”, and so far, the only thing making me feel even a little better is seriously cleaning up my diet, and trying to get more sleep.

      In general, the medical community does not know how to treat the autoimmunity, and sure doesn’t have any notions about root causes.

      1. Hey Teri and Helen- consider looking at Dr Alan Christianson’s thyroid program. He has an incredible understanding of all thyroid issues and you can take an online course from him to help with all aspects!

      2. How frustrating Teri. I have had Hashimoto’s over 30 years with little change in dosage of meds. After I went Paleo I was able to reduce the levothyroxine twice in the last year and a half. I could not find an endocrinologist that was up on any current info and would spend more than 10 minutes with me so I switched to a naturopath. Much better fit.

    2. So I was also recently diagnosed with hypothyroidism (NOT autoimmune) and my fasting glucose surprisingly high at 98 even on low carb, primal diet. I’ve been told hypothyroidism can mess with blood sugars, but now I am wondering if it could be to do with low carb? Doctor was very supportive and told me to just keep cutting out all starches and sugars – but I can’t envision going lower carb than I am ready am (NOT willing to give up vegetables and occasional fruit). Would be interested to hear from others who eat primal while hypothyroid.

      1. Being too low-carb harms the thyroid and can cause paradoxical high blood sugar. Many source for these ideas exist, here are just a few:

        The book “The Perfect Health Diet” by Paul Jaminet, especially around page 94. The entire book studies science behind problems with being too low carb, and presents evidence for better health by raising carbs, and doing so with certain safe carbs.

        Also this site, although not nearly as thorough as that book is:

      2. There’s lots of info online about hypothyroidism not being compatible with a very low-carb diet. Moderate carb may be better for you. It is for me (like 120 g per day).

  12. “If you’re very low-carb, postprandial blood glucose will be elevated. This is because very low-carb, high-fat diets produce physiological insulin resistance to preserve what little glucose you have for the tissues that depend on it, like certain parts of the brain. The more resistant you are to insulin, the higher your blood glucose.”

    Would this also apply to AM fasting glucose testing? I’m low carb/keto and finding I test well with most carbs post meal but AM fasting is mid 90’s to low 100’s. BMI is good. All other things Excellent. Hope Mark can chime in on this topic!

    1. I would like to know a little more about this too as I prepare to do Robb Wolf’s “7-day Carb Test” to see how few of my favorite foods I can safely eat.

    2. I’m in this boat too. I discovered it two years after having a blood tests. I almost always have fasting blood glucose between 90-100. After getting my own glucose monitor I discovered though that this only in the morning. The rest of the day by blood glucose is a more reasonable 75-85.

      After over a year of trying to “fix it” I am convinced that this is fine and just how my body is.

      I don’ think this is due to some sort of low carb insulin resistance. Quite the contrary, I think it is due to being very insulin sensitive (in my case). I got my insulin checked and it was extremely low in the morning and I gave myself glucose tolerance test and never got above 110. So I think that my insulin levels are extremely low during fasting to prevent my blood sugar levels from falling. What happens is in the morning there is a cortisol release, which will increase blood sugar levels, but my pancreas doesn’t bother releasing more insulin because the blood sugar won’t get too high. Very unscientific sounding, but I am convinced it’s true.

      The only other explanation is that I have some pancreatic beta cell dysfunction, but I think the previous explanation is more likely.

      Your case may be insulin resistance if you are on a true keto diet (close to zero carbs, and little protein) however if you are on a more traditional low carb diet, I bet it’s my situation. Especially if you exercise.

      If you ever talk to a physician or somebody that works with patients, they will tell you this is somewhat common. That is why fasting blood sugar between 90 and 100 is considered normal. Yes the epidemiology does show a risk of developing diabetes, but it does not mean it still isn’t normal.

  13. This is perfect timing for me! I’ve been a long time lurker on the site and understand the primal lifestyle is exactly what I need to feel, look & be my best. I’ve managed elements at times but fall off the wagon – too much beer and the all too frequent Nashville fried chicken sandwich are the big hurdles for me along with binge eating chips once in a while… At 32 and overweight but not obese I just kept making excuses and never commited to making a full lifestyle change.

    My insurance company just started offering health checks and I had my first blood work done:
    Total 286mg/dL (ideal < 200)
    Tryglicerides 104 (ideal 40)
    Ldl 226 (ideal < 130)
    Total/HDL rario: 7.15 (ideal < 4.5)
    uric acid: 547 umol/L (ref range: 202-417) 9.2 mg/dl (ref range: 3.4-7.0)
    Glucose (fasting): 5.3 mmol/L (ref range 3.9 – 6.1) 96 mg/dL 70-110

    As you can imagine, with a 66 year old father on statins and due to my young age my doctor is a little worried! (As was I) He wants to re test in 3 months and gave the usual dietry recomendations around whole grains And cutting out eggs…

    My plan is to finally do the primal blueprint challenge and be strict about it and see how the results are. I'll also ask for an LDL-P test.

    My question is, based on my blood work is there anything I need to be conscious of or tweak when going primal? Perhaps less of the full fat dairy and limit the bacon?!?

    1. Do you think my LDL numbers will go down naturally if I do the 21 day primal challenge?

      1. Yes! Do it! And don’t worry about full fat dairy and bacon, but also DONT ever mix high carb and high fat.

        1. Be careful offering this “advice”. I had been on Paleo for a year then Keto for a year and my numbers never went down. I’m a hyper-responder and needed to cut way down on sat fat and more mono fats (mediterranean diet).

  14. I love this post. I literally just got my blood test results in the mail today. All looks good, except maybe my A1c at 5.3. Thanks for all the great info and hard work you do to get it our to us!

  15. Question: what is the effect of giving blood on the HcA1c?

    Is it a bit like the effects of anemia?

  16. I think we should take lab results more as an indication of where we might be going wrong as every person is different and it’s impossible to make a standard because of this. I had no idea that the standards where that low I think they should rise them a bit up being borderline with a condition is not normal and will place false security on people and eventually shock because think they are ”normal” and then suddenly you are over. Cheers for this great post Mark 😀

  17. Reference ranges for blood tests are based on the people who get lab tests. Who gets lab tests? People who go to the doctor, often because there’s something wrong with them. They may not reflect normal ranges for truly healthy people.”

    Not so! Establishing reference ranges involves testing healthy people, not patients. There are criteria to meet before being allowed to donate for a reference range study and they are different depending on the analyte being measured. Every lab either establishes it’s own reference range or validates one that is in common use and this is done on a regular basis since you want YOUR reference ranges to reflect YOUR patient population; not someone else’s. There will (and should) be slight differences from one location to another due to genetics and local eating habits as well as the instrumentation and methodology being used.

  18. Thanks for the subject and your info Mark. Just had my yearly blood drawl and all is good but blood preassure is high as it has my whole active life.

  19. Those ratios are suspect. At 1:1, that would mean your total cholesterol was all HDL.

    Years ago there was a really smart, well informed poster here named Griff. I don’t know if he was ahead of his time, but now I’m started to see some ratios show up on some lab reports. The original link apparently is no longer live, but here is the text:

    From: https://www.marksdailyapple.com/forum/topic/cholesterol-a-primer?replies=3#post-63791

    By Griff

    I’ve been working on this for a while, and I think it’s finally ready to post here. A lot of people post to MDA’s forums freaking out about their cholesterol tests after going Primal – their numbers are higher, their doctor wants them on statins, etc. and so forth. I’m usually called on to answer them, because I’ve done quite a bit of research on the great cholesterol con, and I know how to interpret the results. But I think this is a tool that everyone should have, so without further ado, here’s an article for you about cholesterol, what it does, and what those numbers mean.


    Total cholesterol: This is the total of all three kinds of cholesterol: HDL + LDL + Triglycerides. Each of them has a different function inside the body.

    The recommended level of total cholesterol these days is 200 or less.

    Cholesterol: A waxy substance that is actually an alcohol (hence the -ol suffix). It’s carried by lipoproteins (fats and proteins) through the water-based environment of the bloodstream (remember that water and oil don’t mix). It’s necessary to sustain cell wall integrity and to repair damaged cell walls within (among other places) the arterial system of the body. Many things can damage the cell walls in the arteries and veins, including (but not limited to) stress, high blood sugar, high insulin levels, and lack of physical activity. When damage happens to these cell walls, the body has to do something about it. Normally, it will repair them with saturated fat and protein, which is what cell walls are made of, but if we’re not eating those things, the body can’t produce them out of thin air, so it sends cholesterol in as a stopgap measure. Your body uses cholesterol to make a “patch” over cell walls that need to be repaired, but if we don’t give it the proper amount of raw materials (saturated fat and protein) to repair them with, the patch will stay there, and like any old bandage, eventually start to peel off. In the absence of the proper raw materials, the body slaps another layer of cholesterol over them to make sure that the patch doesn’t break. This is where cholesterol buildup, or plaque, in the arteries comes from. The longer the body has to go without the right raw materials, the worse the problem gets, and these plaques can eventually break off, just like a scab on the outside of your body does, and block up the arteries, causing a heart attack or a stroke. The technical term used for “increases risk of heart disease” is “atherosclerotic,” which, translated out of its non-English roots, means “athero” (artery) “sclerotic” (hardening).

    One of the problems with the way that current medical science treats cholesterol is that it doesn’t recognize the function of cholesterol. It just sees higher cholesterol readings and naively assumes that since high cholesterol and heart disease “seem” to go together, that cholesterol must be the cause of heart disease. The real cause of heart disease is what causes both the damage to the cell walls and the (ideally) temporary patches of cholesterol: not enough of the right raw materials being given to the body, and too much of the stuff that damages the cell walls being given to the body – to wit, too many carbs and not enough saturated fat or protein. It’s like blaming firemen for a fire, or blaming a bandage for the wound, and saying “if we take away some firemen, the fire will die out,” or “if we take the bandage off the wound, the wound will heal without help” (even though it’s usually a wound that needs stitches in order to close up and heal). It’s overly simplistic, it’s a junior-high-school-level mistake, and it makes no sense.

    LDL (Low-Density Lipoprotein): This has been blamed as the “bad” cholesterol because its job is to go around inside your body, bringing cholesterol from the liver to spots that need repair, and placing cholesterol “patches” on them. There are two types: Pattern A and Pattern B. Sometimes you’ll have a mixed bag: Pattern A/B, some of each. When you have a VAP test, this is part of what gets reported. Pattern A is “large and fluffy” and non-atherosclerotic, like a cotton ball. Pattern B is “small and dense” and atherosclerotic, like a BB pellet. You want to have Pattern A. Pattern B is sometimes called “oxidized” cholesterol, and because it’s so small and dense, it can penetrate the endothelium (the thin layer of cells that line the inside of the blood vessels), just like a BB pellet penetrates skin. So Pattern B LDL is worrisome, because it can also cause damage to the cell walls inside the arteries. LDL becomes Pattern B due to a number of reasons, but one of the main ones is insulin resistance. If you lower your insulin resistance (which low-carbers almost always manage to do), then your LDL Pattern B goes down, which is good.

    The recommended level of LDL these days is no more than 150, and most doctors now want it below 100.

    HDL (High-Density Lipoprotein): This is considered the “good” cholesterol because its job is to go around inside your body and clean up used cholesterol. HDL goes around after the patched area has been repaired, and cleans up the old cholesterol patches, taking them back to the liver for processing and breakdown. You can see why HDL is high-density: it carries old cholesterols with it to the liver, so it’s got lots of tightly-packed stuff on it, hence high-density. Low-density LDL is just the opposite – it’s dropping cholesterol here and there, so it’s no longer as dense.

    The recommended level of HDL these days is at least 40 for women and 50 for men. Some recommendations are “get it above 60.”

    Triglycerides: The “cholesterols” made in the liver from the carbs you eat. They are technically not cholesterol at all, but fat. They’re used by cells for energy. A third kind of cholesterol called VLDL (very low-density lipoprotein) carries triglycerides around in the body, delivering them to cells for energy. When VLDLs lose most of their triglycerides, they become smaller and denser, and now they’re LDLs instead of VLDLs. Triglycerides can shoot the level of VLDL way, way up – the more triglycerides you have, the more VLDL is needed to move it around the body. So if you’re eating lots of carbs, your triglycerides are going to be higher, and since VLDL becomes LDL when it deposits its triglycerides into the cells, your LDL will also be higher.

    The recommended level of triglycerides these days is under 150.


    There are two equations used today for cholesterol measurement. The first one, and the one most commonly used, is called the Friedewald equation. It works fine as long as your triglycerides are at least 100 and below 400, but outside of that range things get wonky. And the main problem is, when your triglycerides are below 100, it overestimates LDL levels. A quick rundown:

    The Friedewald formula used to calculate total cholesterol is:

    LDL + HDL + [Trigs/5] = total.

    But because LDL are so small in comparison to the other particles, what they usually do is calculate your LDL. They measure your HDL, your Trigs and your Total – so the equation becomes:

    Total – (HDL + [Trigs/5]) = LDL.

    (I don’t know why the triglycerides are divided by 5. I haven’t yet found that out.)

    Because this equation miscalculates LDL if you drop below 100 trigs, I’d recommend that you always, always demand a VAP test, which is a direct measurement of the LDL. People who restrict carbs usually have very low triglycerides, which means that we’re going to have problems if the lab uses the Friedewald equation to calculate our LDL levels. According to Dr. Mary Vernon, “These labs in which the LDL is calculated are not accurate if your triglycerides are below 100… The equation used to calculate these numbers makes assumptions which are not accurate when triglycerides are low.” (from https://www.livinlavidalowcarb.blogspot.com/2006/04/traditional-cholesterol-test-results.html).

    To give an example of how it doesn’t calculate LDL correctly, let’s look at a hypothetical cholesterol result. Let’s say that Joe the Primal Dude goes in for a lipid profile after six months on the Primal diet. Here’s his results (before they do the LDL calculation):

    Total: 250 (ideal 60)
    LDL: ? (must be calculated) (ideal <100)
    Trig: 40 (ideal <150)

    This is a common profile for someone who's been low-carbing/eating Primally for a while. Now, when we put that into the Friedewald equation, here's what we get:

    250 – (70 + (40/5)) = LDL
    250 – (70 + 8) = LDL
    250 – 78 = LDL
    250 – 78 = 172

    This may give Joe's doctor a heart attack if he doesn't know what he's looking at, as many doctors don't. To him, Joe's LDL and total cholesterol levels are way above the "ideal" numbers, and that must mean that Joe is headed for a heart attack or a stroke if he doesn't take a statin drug immediately and get those numbers down.

    For many doctors, this level of analysis is as far as they go. The nuanced information about the two types of LDL is something they either don't have or aren't aware of. And recognizing that if Joe's HDL were lower, his total cholesterol would be lower too – they don't often see that, either.

    However, there is a newer equation, called the Iranian Equation, that does a better job of calculating LDL when trigs are below 100. That equation is:

    (Total/1.19) + (Trig/1.9) – (HDL/1.1) -38 = LDL

    Let's plug Joe's numbers into this equation and see what we get.

    (250/1.19) + (40/1.9) – (70/1.1) – 38 = LDL
    210 + 21 – 64 – 38 = LDL
    231 – 102 = 129

    Look at that. It's a difference of almost 50 points in Joe's favor. With the Iranian equation, his numbers come out to:

    Total: 250
    HDL: 70
    LDL: 129
    Trig: 40

    Part of the reason the Friedewald equation doesn't work so well is that Trig/5 issue. The Friedewald equation assumes that anything that isn't HDL or triglycerides is LDL. LDL is the "leftover" number. Well, when your trigs are 200/5, the number it will subtract from the overall total is 40, but when your trigs are 40/5, the number it will subtract from the overall total is 8. That's a big difference, because the smaller your trigs are, the more of the "leftover" number in the equation gets attributed to LDL, and that's really misleading.


    There are three ratios that scientists have found which measure the impact of cholesterol in the body. These are the ratios between the total amount of cholesterol measured and the HDL (Total/HDL), between triglycerides and HDL (Trig/HDL), and between LDL and HDL (LDL/HDL). Each one is an indicator of something different. Many doctors don't pay attention to these ratios, and that's a shame, because they're a far better indicator of cardiovascular health than the total cholesterol number. You'll see why in a minute.

    The ideal ratio of Total/HDL is 4.4 for women and 5 for men. Also, according to https://wwww.yourmedicaldetective.com/public/532.cfm and several other sites, the ratio of your trigs to your HDL will indicate whether your LDL is small and dense (bad – Pattern B) or large and fluffy (neutral – Pattern A). A larger number indicates smaller LDL particles and a smaller number indicates larger LDL particles. It's an inverse relationship.

    The ideal ratio of Trig/HDL is 2 or below. 4 is high. 6 is "danger!!" This ratio indicates the level of risk for heart disease. Additionally, a low ratio of Trig/HDL is great because it's a semi-reliable indicator of lower free insulin levels. Lower free insulin is good. (However, this doesn't appear to work for those of African descent, so take that with a grain of salt.)

    The ideal ratio of LDL to HDL is 4.3 or lower. 4.4 to 7.1 is average. 7.1 to 11 is moderate. 11 or more means you're at high risk for developing heart disease. The ratio of LDL to HDL is considered to be a marker of carotid plaque, or how much plaque you have built up in your arteries.


    So if we look at Joe's results (using the Iranian equation), his ratios are:

    Total/HDL: 250/70 or 3.57 (ideal = 5 or below)
    Trig/HDL: 40/70 or 0.57 (ideal = 2 or below)
    LDL/HDL: 129/70 or 1.84 (ideal = 4.3 or below)

    Even if we use the Friedewald equation (with its misleading, overestimated LDL), Joe still does pretty well:

    Total/HDL: 250/70 or 3.57 (ideal = 5 or below)
    Trig/HDL: 40/70 or 0.57 (ideal = 2 or below)
    LDL/HDL: 172/70 or 2.45 (ideal = 4.3 or below)

    In all cases, Joe's ratios are well below the "ideal" – and being below the ideal is awesome. And look at that ratio of trigs to HDL! It's a great indicator of lower free insulin levels for Joe, and the ratio of Total/HDL also says that his LDL is probably (mostly) Pattern A.

    Let's compare that to Pat, who's been on a low-fat, high-carb diet and exercising with chronic cardio, and whose doctor thinks he's doing really well because his cholesterol tests came back with these numbers:

    Total: 180
    HDL: 25
    LDL (calculated with the basic Friedewald equation): 131, or (calculated with the Iranian equation): 153
    Triglycerides: 120

    Pat's ratios are:

    Total/HDL: 180/25 or 7.2 (ideal = 5 or below)
    Trig/HDL: 120/25 or 4.8 (ideal = 2 or below)
    LDL/HDL: 131/25 or 5.24 (Friedewald LDL); 153/25 or 6.12 (Iranian LDL) (ideal = 4.3 or below)

    Compared to Joe, Pat's got one foot in a heart disease grave! His Total/HDL is way above the ideal, his trig/HDL is in the "nearly danger" zone, and his LDL/HDL says "Look, you're at average risk for heart disease and heading higher." But if the doctor only focuses on total cholesterol, Joe's the one who'll be put on a statin, while Pat might be advised to find ways to bring up that HDL number a little bit, if his doctor does anything other than congratulate him on his "good" cholesterol numbers. And way too many doctors focus only on total cholesterol.

    https://www.mayoclinic.com/health/cholesterol-levels/CL00001 for information on recommended cholesterol levels
    https://www.proteinpower.com/drmike/weight-loss/low-carbohydrate-diets-increase-ldl-debunking-the-myth/ for more information about cholesterol generally
    https://www.atherotech.com/images/vapliterature/pdfs/CholesterolTest.pdf for more information about the specific results of a VAP test
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664115/ for information about the ratio of triglycerides to HDL
    https://www.lipidsonline.org/news/article.cfm?aid=8583 has an article about the LDL/HDL ratio
    https://www.healthtipscity.com/cholesterol/LDL-HDL.php has the numbers I cited for LDL/HDL ratio level meanings
    https://www.atherotech.com/images/vapliterature/pdfs/20090119_UnderstandingVAPResults.pdf has information about insulin resistance raising Pattern B cholesterol.
    Other information about cholesterol was found in Anthony Colpo's book "The Great Cholesterol Con" (which is entirely based on peer-reviewed research), the Protein Power books by Drs. Michael and Mary Dan Eades, Gary Taubes' "Good Calories, Bad Calories" (again, with a ton of peer-reviewed research), and Mark Sisson's "Primal Blueprint."
    Posted 3 hours ago #


    Great work! I'm cutting this out and pasting to a word document for saving. BTW, my blood stats done last fall certainly show the ravages of a high fat diet! (Snark)

    Trig/HDL: 1.8 slightly better than ideal
    Total/HDL: 3.2 about 60% of ideal
    LDL/HDL: 1.9 less than half of typical

    As I've said to others, it's too bad I don't believe in the lipid hypothesis of HD since my total is 174, about 40 points lower than when checked some years ago.

    Darned artery clogging saturated fats! My ratios indicate that I should eat more carbs. Right?
    Posted ago # Edit

    1. If your Trig are low, use the Iranian equation
      (LDL = TC / 1.19 + Trig / 1.9 – HDL / 1.1 – 38).
      Saves the cost of an additional lab test.

      1. Thanks for this ! My TG levels are always low (46) and I knew this made the usual calculation for LDL pretty meaningless. Didn’t know there was another, more accurate one. Will have to educate my doctor………….

    2. Thanks for that brilliant summary OnThe Bayou (interesting name). This confirms what I have known instinctively for the last ten years. I was put on a low fat diet by a witch doctor before this and was very ill from all the bread and sugar. Probably pre diabetic with some candida thrown in. Felt horrible with very bad digestion, bloating and elimination.
      Ten years ago went low carb high fat and the rest has been great. Back in great shape , rarely ill and love exercise. The cholesterol con is taking away people’s lives and making them sick. This is all about selling statins for big pharma and has nothing to do with health.

  20. Anyone have any info on iron levels? I was recently told by my company doctor I had high iron levels from one year to the next in my company physical. He advised to get checked by my personal physician who did a second set of labs and said he had no concern. Level was around 290. I cut out eggs ( was having two every morning). Any thoughts?

    1. Did he check you for hereditary hemachromatosis? If your iron levels are chronically elevated it can be damaging to your organs (it builds up in liver and heart among others). I would double check that due diligence was done in working up the cause. As is mentioned, regular phlebotomy (therapeutic or through blood donation) is effective treatment, but knowing the cause and excluding end-organ damaging if you’ve had high iron over a long period of time are essential!

  21. Any evidence on the anemia ‘competing’ effect on A1C?
    Doesn’t sound very logical…

      1. Thank you for the link. I am trying to not freak out with an elevated a1c of 6.5. My hemoglobin is 10.7 however ferritin is 8 optimal range 90, iron saturation is 5% optimal range 20%-50%. I have an appointment scheduled with a naturopath to help figure this out.

  22. There was a documentary in UK where twins tested different diets. One cut out all carbs and his blood tests after a couple of weeks were so bad according to the doctors regarding insulin resistance that he had to start eating carbs again because the inference was that it was life threateningly bad for the body to eat this way. They suggested that your pancreas stops producing insulin if it doesn’t get the call for a while. So is the insulin resistance from a low carb diet something to be concerned about or not? I eat very few carbs, nowhere near 150g and feel pretty good but this study is always in the back of my mind……would be good to put my mind at rest.

    1. I lost 29 lbs eating low carb and couldn’t lose anymore for about 10 months. I Was very frstrated and had no energy. Then I ate a pint of Ben and Jerry’s ice cream and thought I’d really blown it. Checked the scale and I actually lost 2 more lbs. All this stuff about nutrition makes no sense.

  23. I really enjoyed this read. It brings Normal and Normal pages into light and that is a great thing, however, if we look at the reference ranges there is always that place where practitioners believe most people should be, however, there are always the outliers (those who function better at elevated or reduced rates). As a rule, and I believe this blog is all about, is that we need to establish norms of living in our daily lives. Such as, don’t go off the rails two or three times a week and eat a greasy hoagie and expect cholesterol to stay the same (low). However, if you combine it with exercise proper dieting a healthy level of caloric intake and avoid most things that ail us on a regular basis, it should not really matter. I eat healthy, more veggies, then meats (most meats are fish), I exercise regularly on my TotalWave Fitness and I over count my caloric intake. I avoid anything in a box like the plague (that’s what it is once it becomes a habit). At that point, it really should not matter if I go in for a blood test, because if they find something abnormal then its probably a concern. Having your blood checked once in a while could be a good thing as a preventative measure, but, if your life is in balance you shouldn’t be finding much that would be out of balance.

  24. My triglycerides has been above 400 since I was 20 ( I am now 44) Of course I have been in statins for almost as long. Total cholesterol is normal. Any thoughts on whether this is really a concern??

  25. May 03 2017
    Popular Blood Tests—the Facts, Ranges, and Alternatives You Should Know

    As a retired laboratory technician, I found this is a well informed article backed by good references. The most important takeaway is that context is everything.

    I have found that different labs use different reference ranges for the same test. If you must chase numbers, find the best price on sirloin.

  26. Thanks, Mark! All my ratios are great but my fasting blood sugar is in the high 90’s to low 100’s even though I eat low carb. A1c is 6. I’m considering Metformin. I do 3 day fasts each quarter and do occasional 24 hr fasts. Your thoughts. Thanks, Dave