It’s the most ordered blood test in medicine and one of the most misread. Here’s what gets missed, the one ratio almost no one calculates, and the optimal ranges to read your own against.
A few additions from someone who has practiced both primary care of varying flavors as well as Hematology.
A low hemoglobin means either blood loss or impaired production. While we usually attribute menstrual blood loss in premenopausal women, both urine and gastrointestinal occult bleeding can lead to this as well. Certainly in men, these are the two main causes. Unless of course you donate blood regularly. Intravascular hemolysis is another cause of blood loss. This could be metabolic (inherited disorders), autoimmune or physical (bad heart valve). Impaired production can run the gamut of mineral and vitamin deficiencies, hormone deficiencies, chronic infections or inflammatory diseases, toxins (including alcohol) and malignancies. Your reticulocyte count usually answers whether its blood loss or impaired production.
A high MCV may simply be part of increased RBC production/reticulocytosis which should be included when considering a cause.
I see the absolute neutrophil and lymphocyte counts ignored when they are borderline. Not a good idea. The ratio between the two is good to calculate, but the ANC and ALC are even more important.
It’s important to repeat the CBC when secondary labs are drawn if there is an initial abnormality. One needs to know whether the abnormal values are trending or correcting, or new ones have developed.
Unfortunately the good old peripheral smear, which can detect many problems or point to a cause when there are abnormalities, has pretty much gone to the wayside with automated lab devices. If you’ve got problems that are not easily diagnosed, that should also be part of the workup.
It so funnny that most MD’s dont even look at a lab value unless its FLAGGED IN RED. Also, the typical “normal values” are being calibrated off a VERY sick population - The USA!!!
Don;t even get me started on the standard lipid panel…. jeeez Louise!!
Dagmara, I am also a PA. I have 36 years of experience and have my own lifestyle medicine practice in Fayetteville, NC. I am able to take most insurances and order nearly the same labs that you recommend, sometimes using a cheaper lab so that patients can pay out of pocket when insurance declines. Bravo for an excellent article! Let me know if you would like to exchange numbers and chat by messaging me on my website which is sleep and diet dot com (no links allowed apparently here).
Thank you, I wish lab results are captured in the same format in different countries! Canadian lab results show differently for quite a few of the values, but this was very handy even if conversion was necessary for me to see what my results were like. Very much appreciated.
I got back my cbc and even though it's abnormal, all three of these are good. My ferritin is living it's best life yet. Yay. 😆 It only took 6 rounds of infusions and I may need my hematologist to rerun the blood after my period is over depending on how I feel. 😅 Thanks for the article. Especially the little division one as that was off back when I was at my worst.
I just discovered your thoughtful Substack. I noticed that in the last issue you avoided discussing LDL as a critical measurement, using ratios instead. I would refer you to two trials:
1-Effect of Very High-Intensity Statin Therapy on Regression of Coronary Atherosclerosis
The ASTEROID Trial
2-Effect of Statins on Endothelial Function in Patients With Acute Coronary Syndrome: A Prospective Study Using Adhesion Molecules and Flow-Mediated Dilatation
Obviously, not all patients can tolerate statins, but the ASTEROID trial provides a target for the level and the endothelial function trial suggests the use of statins in the dose that can be tolerate with the addition of other drugs to address the LDL level.
that is a very good question. Optimal ranges do not change BUT individualized care and patterns depending on the patient is key that is how I work with patients 1:1 but when teaching thousands individual care can't be applied.
Thanks for all this information. I’m looking at my husband’s, my daughter’s, and my lymphocytes and neutrophils on our portals, and they are all in percentages. How do I use those to get the ratio you are talking about?
I would start with a few very simple things. Look back at your last couple CBC’s and first see if its a pattern. Run your CBC’s through my paid post this week I just published. This will give you next best steps.
As far as oral iron goes, once you have determined the diagnosis of iron deficiency and the workup has identified the source, iron replacement is indicated and will need to continue for as long as the blood loss continues and then maybe 6 months to get your iron stores normal. Oral iron is the most physiologic. Tablets are the most common type prescribed. They can be hard on the stomach, may not dissolve well, and cause constipation. Liquid oral iron has the benefit of allowing you to titrate the dose to what one can tolerate. It generally is absorbed better as well. Some preps can cause staining of the teeth. I’ve had folks recover well and replete their iron stores on as little as ¼ the usual dose, avoiding IV iron. IV is nice when you need it, but it is not as physiologic as oral, and besides being much more expensive has some small but defined risks. Most of the time oral works faster if taken correctly. Monitoring the ferritin, iron, iron binding capacity are important in determining how effective treatment is, not just the red cell count or hemoglobin. Those will often correct in 2 weeks, but iron stores usually take about 6 months to fully replete.
I have had a lot of success with beef liver capsules and nutrition vs oral iron, not in every case but in many. Like you said I don’t like how hard on the GI system they are.
The main advantage of beef liver is that its iron is heme based rather than inorganic, so it is absorbed better, but I’m more a purist and don’t like having to worry about the possible contaminants, or varying dosage between lots.
Like I said, you can titrate the oral ferrous sulfate solution to tolerance. A typical 1 tsp dose is about 44 mg elemental iron or 220 mg ferrous sulfate. You can start with ⅛ or ¼ tsp perhaps dissolved in water, drink with straw to avoid any tooth stains, and go from there if folks are having trouble tolerating oral iron. Especially since you are supposed to take it on empty stomach. Remember a number of things inhibit iron absorption. Especially tea. And if I remember right, rhubarb. It’s generally cheaper than any other source other than generic ferrous sulfate tablets.
What is the name of this test? All I am seeing in my annual bloodwork is my Lipid Panel, My Basic Metabolic Panel, My Glyco hb and my TSH thyroid panel. Perhaps they did not do a CBC?
Thank you Dagmara, I am not seeing that test on my results page in my-chart. I will be seeing the doctor again in 2 months so will ask for another blood draw to get more of these tests you have recommended completed. Appreciate your answering my question.
A few additions from someone who has practiced both primary care of varying flavors as well as Hematology.
A low hemoglobin means either blood loss or impaired production. While we usually attribute menstrual blood loss in premenopausal women, both urine and gastrointestinal occult bleeding can lead to this as well. Certainly in men, these are the two main causes. Unless of course you donate blood regularly. Intravascular hemolysis is another cause of blood loss. This could be metabolic (inherited disorders), autoimmune or physical (bad heart valve). Impaired production can run the gamut of mineral and vitamin deficiencies, hormone deficiencies, chronic infections or inflammatory diseases, toxins (including alcohol) and malignancies. Your reticulocyte count usually answers whether its blood loss or impaired production.
A high MCV may simply be part of increased RBC production/reticulocytosis which should be included when considering a cause.
I see the absolute neutrophil and lymphocyte counts ignored when they are borderline. Not a good idea. The ratio between the two is good to calculate, but the ANC and ALC are even more important.
It’s important to repeat the CBC when secondary labs are drawn if there is an initial abnormality. One needs to know whether the abnormal values are trending or correcting, or new ones have developed.
Unfortunately the good old peripheral smear, which can detect many problems or point to a cause when there are abnormalities, has pretty much gone to the wayside with automated lab devices. If you’ve got problems that are not easily diagnosed, that should also be part of the workup.
It so funnny that most MD’s dont even look at a lab value unless its FLAGGED IN RED. Also, the typical “normal values” are being calibrated off a VERY sick population - The USA!!!
Don;t even get me started on the standard lipid panel…. jeeez Louise!!
A fellow CBC sister! Yes, such invaluable markers! SO happy to find you here on Substack.
Dagmara, I am also a PA. I have 36 years of experience and have my own lifestyle medicine practice in Fayetteville, NC. I am able to take most insurances and order nearly the same labs that you recommend, sometimes using a cheaper lab so that patients can pay out of pocket when insurance declines. Bravo for an excellent article! Let me know if you would like to exchange numbers and chat by messaging me on my website which is sleep and diet dot com (no links allowed apparently here).
Laurie Powers PA-C with Sleep & Diet Restoration
Thank you, I wish lab results are captured in the same format in different countries! Canadian lab results show differently for quite a few of the values, but this was very handy even if conversion was necessary for me to see what my results were like. Very much appreciated.
I got back my cbc and even though it's abnormal, all three of these are good. My ferritin is living it's best life yet. Yay. 😆 It only took 6 rounds of infusions and I may need my hematologist to rerun the blood after my period is over depending on how I feel. 😅 Thanks for the article. Especially the little division one as that was off back when I was at my worst.
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I just discovered your thoughtful Substack. I noticed that in the last issue you avoided discussing LDL as a critical measurement, using ratios instead. I would refer you to two trials:
1-Effect of Very High-Intensity Statin Therapy on Regression of Coronary Atherosclerosis
The ASTEROID Trial
2-Effect of Statins on Endothelial Function in Patients With Acute Coronary Syndrome: A Prospective Study Using Adhesion Molecules and Flow-Mediated Dilatation
Obviously, not all patients can tolerate statins, but the ASTEROID trial provides a target for the level and the endothelial function trial suggests the use of statins in the dose that can be tolerate with the addition of other drugs to address the LDL level.
I wonder what a blood draw that removes blood from a closed system and looks at it outside its normal environment shows at all?
Is there a different set of Optimal ranges depending on the medications a person takes; for instance, a biologic like Rinvoq or Humira?
that is a very good question. Optimal ranges do not change BUT individualized care and patterns depending on the patient is key that is how I work with patients 1:1 but when teaching thousands individual care can't be applied.
Thanks for answering!
Thanks for all this information. I’m looking at my husband’s, my daughter’s, and my lymphocytes and neutrophils on our portals, and they are all in percentages. How do I use those to get the ratio you are talking about?
you want to divide the absolute neutrophils by the absolute lymphocytes OR just put your CBC into the tool I gave today on my post.
NLR: 2.9
I went to two doctors in the last year and neither of them mentioned this. What exactly do I go back and ask? What’s my best plan of action here?
I would start with a few very simple things. Look back at your last couple CBC’s and first see if its a pattern. Run your CBC’s through my paid post this week I just published. This will give you next best steps.
My Esoniphils are at 5.5% (optimal 1-3%) and my Basophils are at 1.9% (optimal 0-1%) HELP! 😩
Guduchi is a strong white blood cell builder. That is why it is the primary ingredient of CelWel.
As far as oral iron goes, once you have determined the diagnosis of iron deficiency and the workup has identified the source, iron replacement is indicated and will need to continue for as long as the blood loss continues and then maybe 6 months to get your iron stores normal. Oral iron is the most physiologic. Tablets are the most common type prescribed. They can be hard on the stomach, may not dissolve well, and cause constipation. Liquid oral iron has the benefit of allowing you to titrate the dose to what one can tolerate. It generally is absorbed better as well. Some preps can cause staining of the teeth. I’ve had folks recover well and replete their iron stores on as little as ¼ the usual dose, avoiding IV iron. IV is nice when you need it, but it is not as physiologic as oral, and besides being much more expensive has some small but defined risks. Most of the time oral works faster if taken correctly. Monitoring the ferritin, iron, iron binding capacity are important in determining how effective treatment is, not just the red cell count or hemoglobin. Those will often correct in 2 weeks, but iron stores usually take about 6 months to fully replete.
I have had a lot of success with beef liver capsules and nutrition vs oral iron, not in every case but in many. Like you said I don’t like how hard on the GI system they are.
The main advantage of beef liver is that its iron is heme based rather than inorganic, so it is absorbed better, but I’m more a purist and don’t like having to worry about the possible contaminants, or varying dosage between lots.
Like I said, you can titrate the oral ferrous sulfate solution to tolerance. A typical 1 tsp dose is about 44 mg elemental iron or 220 mg ferrous sulfate. You can start with ⅛ or ¼ tsp perhaps dissolved in water, drink with straw to avoid any tooth stains, and go from there if folks are having trouble tolerating oral iron. Especially since you are supposed to take it on empty stomach. Remember a number of things inhibit iron absorption. Especially tea. And if I remember right, rhubarb. It’s generally cheaper than any other source other than generic ferrous sulfate tablets.
What is the name of this test? All I am seeing in my annual bloodwork is my Lipid Panel, My Basic Metabolic Panel, My Glyco hb and my TSH thyroid panel. Perhaps they did not do a CBC?
A complete blood count
Thank you Dagmara, I am not seeing that test on my results page in my-chart. I will be seeing the doctor again in 2 months so will ask for another blood draw to get more of these tests you have recommended completed. Appreciate your answering my question.