Facilitated

The Four Horsemen: Understanding the Silent Killers of Chronic Disease

• The Facility Denver • Episode 2

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Dr. Mitchell Rasmussen and Kate Daugherty explore the importance of comprehensive lab testing for preventing chronic disease and detecting health issues before they manifest as symptoms. We'll double down on why an annual metabolic check-up matters and how to interpret results beyond standard "normal" ranges that might be misleading patients about their true health status.

• Core lab tests should include comprehensive lipid panels with lipoprotein markers
• Enzyme testing reveals more than just liver health—it can indicate nutrient deficiencies or tissue breakdown
• The "four horsemen" of chronic disease: cancer, neurodegenerative disease, cardiovascular disease, and metabolic dysfunction
• Your body breaks down internally long before external symptoms appear
• Stress dramatically impacts blood sugar regulation, described as "the syrup on the pancake of life"
• Finding patterns between seemingly unrelated markers gives deeper health insights
• Standard "normal" ranges are based on increasingly unhealthy populations rather than optimal health
• Patient advocacy is crucial—don't accept being told everything is normal when you still feel unwell

Find a healthcare provider who doesn't gatekeep your health information and knows how to interpret labs comprehensively, connecting all the pieces with your history, complaints, and lifestyle to craft thoughtful answers.


Thanks for tuning in to Facilitated! If you enjoyed this episode, hit subscribe because, let's be honest, you'll forget otherwise. And if you really loved it, please leave us a review. Not only does it make Mitchell feel warm and fuzzy inside, but it also helps more people find functional medicine without falling into a Google rabbit hole.

Want to take the next step with functional medicine? Learn more about our new patient process and lab testing at www.thefacilitydenver.com

For more insights, tips, and behind-the-scenes content, follow us on Instagram @thefacilitydenver

Stay curious, stay proactive, and we’ll catch you next time!

Mitchell:

Welcome to Facilitated, where we bring you real stories, strategies and science from the world of functional medicine. I'm Dr Mitchell Rasmussen, a functional medicine practitioner.

Kate:

And I'm Kate Daugherty, a certified nutritionist. We are the owners of the Facility, a functional medicine clinic here in Denver, Colorado.

Mitchell:

We help people improve their biology and get out of their own way. We help people improve their biology and get out of their own way. In my view, our work is about getting to know the person with the condition much more than it's about understanding which condition the person has. As I always say, diagnose the biology, not the disease.

Kate:

On this podcast we break down complex health topics, share real patient cases anonymized, of course and explore cutting-edge wellness strategies so you can make informed decisions about your health. Quick heads up before we dive in this podcast is for education and general information only. We're here to share insights, not to diagnose or treat. So if you're dealing with a health issue, chat with a qualified healthcare provider before making any changes. All right, let's get into it.

Mitchell:

We've got a fresh, steaming cup of mold-free coffee.

Kate:

I got a booch.

Mitchell:

And we're ready to get a little more into some specific lab tests.

Kate:

Let's jump in.

Mitchell:

Any updates Kate.

Kate:

Life updates. Well, I'm currently at the stage where I have a bed in the floor of Lucy's room. My bed consists of three blankets stacked on top of each other, so I'm firing on all cylinders today.

Mitchell:

I currently have a dog with a diaper. So for dog, yeah, that's. That's where I'm at, trying to figure out how to get a 10 year old dog to not have incontinence. That's what I'm up to this week on a personal note.

Kate:

Do they make pelvic floor for dogs? I don't know, Sorry. Pelvic floor PT for dogs?

Mitchell:

I don't think so. We might try a little hormone replacement therapy for that little girl. Try to get that bladder to have a little more control so she doesn't have to wear diapers the rest of her life. So last week I'd say a little bit bumpy, but we got it in the can. Now we're sailing confidently on episode two.

Kate:

Confidence is a loose term.

Mitchell:

Yeah, we're feeling good about that. Hey sound quality is everything. At least we have that down.

Kate:

We really hope.

Mitchell:

We're not listening to this, we're just going to post. At least we have that down. We really hope we're not listening to this, we're just going to post it.

Kate:

We have no idea. I wish we could all have your level of Blind confidence.

Mitchell:

Is that what you were going to say Exactly? What are we trying to talk about today?

Kate:

I think we should get into some specifics on lab markers what to ask for, what to look at, what makes sense, what maybe is a little bit more on the periphery.

Mitchell:

Yeah, that sounds good head around when it comes to not only why annual lab testing matters, but how to interpret them.

Mitchell:

What to look for, what to track, is the most primitive concept of what is most likely to cause disease and death in the Western world, and that's a big concept related to metabolic health.

Mitchell:

Big concept related to metabolic health cancer, heart disease and neuro neurodegenerative disease is those are the top killers that we see and we always explain how, if you have metabolic dysfunction or insulin resistance, non-alcoholic fatty liver disease, things like that, you are more likely to die. Of those top three killers of chronic disease, we live longer and we develop more conditions. The average american is on at least, if not more than, half a dozen medications to manage these conditions, these diseases, and in my opinion, that's not a way to live, that's not health span. That's a lifespan, not a health span. So to me, that's why annual checking in on certain labs is important because, as we talked about last time, establishing trends is everything when it comes to your health, and don't wait until you are sick to understand your basic biology. You will break down on the inside well before you will break down on the outside when it comes to chronic issues.

Kate:

So I think I've heard you call them the four horsemen of chronic disease. So just to recap, number one Cancer.

Mitchell:

Number two Neurodegenerative disease number three cardiovascular disease and we always say for you know, diabetes or metabolic resistance. I think it currently is the seventh highest killer in the united states. So it's not technically one of those. But why we include that is again, because that's more likely. When you have that, you're more likely to get the big killers. So that's, I think, what we should look at for annual lab testing is how do I dive into those concepts of managing those conditions as well as possible?

Kate:

and especially from a preventative approach too exactly yeah, um, okay, really basics. Let's start with the basics. What are the core labs that we think we want to look at?

Mitchell:

From a core lab perspective, we want to look at a lipid panel, basic lipids like you could get from an insurance-based system, things like a total cholesterol, triglycerides, ldl, ldl, hdl. That's all well and good, but we, on top of that, as a core lab, we believe lipoproteins and apolipoproteins are also important. So that is, in my opinion, a core lab, because it is actually quite cheap when you pay cash. Lp little a and apo b now in, in my opinion, are considered a core cardiovascular heart disease biomarker. We also look at a lot of different enzymes in the body.

Mitchell:

Enzymes are proteins that catalyze or speed up chemical reactions. Enzymes make things happen in the body. Enzymes require nutrient cofactors and when enzymes are off, this can speak not just to oh, my liver enzymes are high, I need to stop drinking. They can actually speak to certain autoimmune conditions, certain cancers. Essentially, when an enzyme is high, you have excessive tissue death, excessive breakdown of your tissues, have excessive tissue death, excessive breakdown of your tissues, and because of that, that tissue is releasing specific enzymes into the periphery which can then be found on a blood test. We go very deep into enzyme testing with patients, much more than just your liver test. Alt AST, alt AST. We always add something called GGT, something called ALP, ldh, and those give a much more comprehensive view of not only certain nutrient status but also what types of tissues might be disturbed or potentially even having a tumor in them.

Kate:

Yeah, so I'm kind of. My interpretation of it is more like your enzymes are your check engine light. They're your little blinker warning sign on your car that you got to take it in and get something checked on it. Is that good, is that a good analogy? I?

Mitchell:

don't know. Maybe we could put it to the tens of people listening right now and see if they like that. I look at enzymes, not only as is it high, but actually oftentimes certain low enzyme levels can speak to things like organic pollutant exposure, pops we call them. We can look at, you know. A common one we see is the enzyme alkaline phosphatase. We learn in school bone or liver. When it's elevated there's a bone condition or a liver condition, very non-specific, but it gives you a place to dig in deeper. But other way it.

Kate:

Take your car to the mechanic.

Mitchell:

Just keep going with that and. But ALP, when it's actually functionally low, oftentimes speaks to a zinc deficiency. As I said earlier, enzymes require nutrient cofactors, so when we see something low, that often is a hint of an unmet need for a specific nutrient. Another one we talk a lot about is lactate dehydrogenase as a potential cancer marker. I love this marker because when it's normal it rules out a whole host of potential conditions all over the body, and when it's high we run another marker that's about $30, where we actually look into each specific type of LDH to try to zone in, zoom in on which tissue might be diseased potentially. So I'm a big fan of the enzyme testing, not just from a metabolic perspective but also from a potential cancer look as well.

Mitchell:

On top of the cancer. Look. We also look a lot at things like calcium albumin. These are all part of a comprehensive metabolic panel, which is about a $20 blood test where we look into your electrolytes, your kidney function, your blood gases, as well as your minerals, and when we see a calcium that's off, that does not mean take more calcium. That often points to something like a parathyroid condition or a potential cancer or a stomach acid problem. So again, it's not black and white. This means that, but it gives us a place to dig in with people. So I'm a big fan of a cheap, readily accessible, comprehensive metabolic panel as well.

Kate:

Yeah, I like that idea. Let's get a general look when things flag, that's where when things flag outside, even our functional range, that's where we can get more specific as needed, but start with a pretty big basic look and we always tell patients what we practice is middle medicine, this idea that I work well with others.

Mitchell:

We refer to medical specialists quite frequently when something is outside of our scope. We recently had a young guy really high liver enzymes despite not being a drinker, much to speak of and negative on all of the viral hepatitis titers that were run, and I just did not feel comfortable. So we referred him to a gastroenterologist, who's a liver specialist, for further workup and diagnostics and that's one of the most valuable things I think I've done in the last few months for a patient, and it had nothing to do with the care we actually provided. We simply helped this young man who was scared, find a path into the medical system where he was educated. He had a broad understanding of the other things going on in his biology and then he entered that visit much more ready to have a conversation that he understood with a specialist.

Kate:

And there was plenty that we're still working on in the background while he's getting those further diagnostics to the liver, just thinking about how can we minimize impacts of inflammation from a dietary and lifestyle perspective while he is doing further diagnostics.

Mitchell:

And back to getting testing while you feel. Well, this guy feels great.

Mitchell:

He's not traditional, you know hepatitis picture of jaundice or fatigue or abdominal swelling. He's actually on the outside, he appears quite healthy and that's again to the point of you break down on the inside before it becomes obvious on the outside. How rewarding to get this man answers now, while he's still a young, strapping lad, where he can prevent potential problems in the future. From a neurodegeneration perspective, we now refer to diabetes as one of the first hallmarks of neurodegeneration. In fact, dementia in a lot of places is now referred to as type 3 diabetes. The brain is one of the first impacted organs of insulin resistance. So when we think about that big killer, neurodegenerative disease, this is where, looking at things like blood glucose management, insulin sensitivity, uric acid, even valuable as it relates to our brain health. A brain that cannot get nutrition to it is a brain that's inflamed and unwell and you might simply have insomnia or chronic pain or anxiety and that could be a result of having metabolic dysfunction or insulin resistance.

Mitchell:

From a brain perspective, we are also big on testing hormones. Our baseline blood panel includes sex and stress hormones in the blood as well as the brain hormones that signal to the body how to make hormones. So that might not be considered baseline core tests. But to us it is looking at things like a free testosterone, a sex hormone, binding globulin, estradiol, even a thyroid panel. You know, oftentimes your doctor will just run a TSH, which is a brain hormone that does get wonky when you have hypothyroidism. But we see, oftentimes when we run a comprehensive thyroid panel your TSH will be fine. But you have, say, antibody production.

Mitchell:

So we know there's some sort of autoimmune interest in the thyroid. Or maybe even your TSH is fine, as is your output of thyroid hormone, which is called T4, but your T3, which is your most active form of thyroid hormone, that might be off. And then, because we're looking comprehensively, we'll see oh, your inactive storage form of thyroid hormone, called reverse T3, is through the roof and we know that there's so many lifestyle things that can drive that but that will never show up as you need levothyroxine. So they'll send you home. They'll tell you you're just getting older, you're a mom now. This is normal when you're 29 years old. I've heard all of it and we just know that you're right. You don't need a medication because you fall within these wide ranges of air quote, normal for a sick population. But because of this body dysfunction and metabolic issue. Your body's essentially acting like a body that is hypothyroid, and for those people we can make massive improvements just by working on metabolism, nutrient levels and stress yeah, those are my, those are my oyster people.

Kate:

Those are the people I'm telling you need more zinc, you need more selenium. Please eat some oysters, it's the best source of zinc. Please eat some Brazil nuts it's the best source of selenium. And as much as we can, we can use real food to correct nutrients, to impact your physiology, physiology.

Mitchell:

I see this mainstream idea right now that food is not medicine. I could not agree more. Doing this for the last six years with you as a nutritionist, seeing the impact that diet has on outcomes, I now fully believe that your eating strategy might not solve all of your problems, but if you are not eating congruently with what your body needs, you will never get well yeah, it has.

Kate:

It has to be the foundation. Yeah, you, you put that just right. If it is not a piece of it, every supplement you take, every cold shower and face plunge and sauna and Red light. All of those things. They are just not going to touch it. The diet has to be in place.

Mitchell:

Yeah, you wear your blue blockers at night but you eat gluten at the same time and your body's having an immune reaction to it. I say throw the glasses away, Focus on the big things, right? We don't want to major in the minors, we want to focus on those key things. And because neurodegeneration is rising, it is serious. It is a horrific way to decline and die. Trust me, as someone who's watched his grandfather die of Lewy body dementia, I will do anything I can for you to make sure that you are well aware of the risk factors and you are learning to track those, like we said, at least once a year to make sure you're staying on that path. So, hormones, blood sugar, massive piece of that neurodegeneration.

Kate:

Yeah, and I think before you move on, I want to just focus on that hormone piece for a second. I think it's majorly changed how we practice now that we include that in our baseline panel. Just having the sex and stress hormones it's allowed us to be so much more specific with patients right away without needing to make so many assumptions, especially in these peripheral markers. So, looking at the A1C and the insulin, with a full hormone panel we can really make better directives, seeing what an estrogen level or seeing what a testosterone level is alongside that A1C or insulin, mostly in women, I'm thinking.

Mitchell:

And just thinking about how stress affects blood sugars, right. We have another panel that we sometimes run. It's a specialty urine and saliva test where we look at all sorts of metabolites of estrogen, how your body gets rid of it. We look at cortisol within the saliva multiple times throughout the day. That's expensive, that's hard for the patient to take and now what we've seen time and again the last six months is a serum cortisol almost always relates when we run a person's salivary cortisol. So we're now seeing it's much easier just get a quick blood draw and at least gives us an idea of where we're at with that.

Mitchell:

And one bout of stress can increase your blood sugar by 50. How many times have you heard me tell a patient stress is the syrup on the pancake of life? Right, pancakes on Pancakes on their own are fine, Syrup is fine. When you combine those two it's an exaggerated response. It's unbelievable. A pancake with syrup on it. If you have X, Y or Z condition and you're not mitigating your stress, which will show up in blood chemistries as potentially an elevated or, if it's been going on a long time, a completely depressed cortisol, we will see an elevated fasting insulin. We will correlate that to maybe increase in abdominal adiposity. Poor sleep we know that no amount of blood sugar regulation will solve that until we get on top of the stress and the sleep piece.

Kate:

I don't know how many times I've written in our follow-up report. Controlling your A1C or controlling your insulin is so much more about how you're eating than what you're eating.

Mitchell:

And what do you mean by that?

Kate:

So it goes into how are you eating from an environmental perspective or just from a mindset? Are you actually connecting with a mindset? Are you actually connecting with your food? Are you sitting down, not distracted, and eating so that piece of it? But also, just how are you pairing your foods? Are you having a balanced meal that has carbohydrates with fat and protein versus simple carbohydrates on its own?

Mitchell:

We could do an entire podcast on what naked carbohydrates are?

Mitchell:

We absolutely will. Kate likes to get a little saucy with her recommendations, but that's what we always say is no naked carbs and really connect with your food. Again, this circles back to the start, is a conversation about baseline blood tests and I guess we couldn't help ourselves. But if you are seeing elevation, say, your A1C is rising, still within air quote, normal, but it's a 5.6 or 5.7, and you are stressed, that's where I want you to start. Go for a walk, chew your food, connect with a friend, share some gratitude and joy. Don't take berberine I mean berberine's great, I love it, but really start with that stress piece, 100 percent. We also look a lot at, I guess, specialty labs.

Kate:

I'd say this is like tier two right yeah and they, they absolutely have a place and are very, very helpful, especially when we're thinking about this specificity in can we get more information to make more specific recommendations to get you closer to feeling your best sooner, and I think that's where those specialty labs make sense. So you think in stool testing hormone.

Mitchell:

Even things like a red blood cell magnesium and omega index, where we can actually for a very maybe $50, we can have a lab, rip apart your red blood cells and analyze the membranes themselves. You are only as healthy as your cell membranes. And the content of fats within that membrane either improves fluidity to allow diffusion of nutrients in and out of the cell, as well as things like hormones to dock on and cause changes within that cell. But they also have a lot to do with your inflammatory burden. So we look a lot at your omega index as more of a specialty lab lab, especially with someone who's stressed or chronically inflamed. You know and we don't by the time people see us oftentimes we don't get the chance to. I just want to take a peek and look at things. We work with a lot of people who are chronically infected and chronically inflamed. So I think maybe in some ways our idea of what's a basic blood test is actually quite advanced. I mean, I think right now our new patient panel is 102 markers. It's a lot of information there, you know. And then, from a nutrient perspective, what I would consider back to the basic idea, things like a vitamin d, but we like to correlate your vitamin d to your calcium, to your parathyroid hormone. We want to. That's all related and I think we talked a little bit about that last time, looking at how everything is connected.

Mitchell:

Oftentimes people have a low vitamin D because of in a blood test, because of a chronic viral infection. So this is where, if you're taking it and it's not happening, I'm going to work you up for things like gallbladder issues, stomach acid problems. Is there H pylori, which is a bacterial infection in the stomach? Do you have sludge in your gallbladder? We can get an ultrasound to see that and even do you have something like Epstein-Barr virus or cytomegalovirus. So this is where we can really branch out simply by looking at a vitamin D level, where it's not often just like top it off, keep taking more. It's about why is your body not raising these blood levels? Is it a liver issue? Is it a kidney problem? So that goes a little bit more into the weeds, I think, but it's quite valuable how just seeing a vitamin D can actually give you a broad idea about other potential issues.

Kate:

Yeah, I think there's a lot of markers like that that we they mean more than the face value and, uh, callback I I've made a whole instagram post about this. You can go and search it. I think it's called five common lab markers that tell you much more than you think they do catchy Catchy title Kate. Yeah you know me.

Mitchell:

And even you know uric acid. I think that's a basic blood test, but we're not looking at it. Do you have gout or not? What is one of the first things that we see in?

Mitchell:

our patient population that causes elevated uric acid Fructose. We recently had a young guy with gout taking allopurinol. He had an accident, broke his arm, and it stimulated this massive inflammatory response which drove his body to create more uric acid and it just didn't quite add up to us. And then we dove in a little deeper to his morning routine and figured out he was mixing copious amounts of honey into his coffee or into like a protein shake.

Kate:

He was sweetening his protein.

Mitchell:

Yeah his sweet protein with more sweetener and on its, on its face, honey is probably a decent option, but it all depends on your biochemistry that goes into this idea of biochemical individuality. For him, honey was quite literally part of his routine. That was sabotaging his ability to get over his gout flare-up. And we never would have known that if we didn't have multiple rounds of uric acid testing, with medication on board, with nutrients on board, having him read all about uricase enzyme function, and there was this one missing piece for him that we were able to figure out, I think, simply because we kept running the tests, we kept making a small change and kept pulling, pulling more things back and finally we were left with hey, man, man, this honey is, it's got to go.

Kate:

And it I can't help but say it's very different for every individual. Honey is not a bad food for everybody, but in the case of elevated uric acid, it's definitely going to be something I take out of your diet. I recommend taking out of your diet.

Mitchell:

Unless you're of your diet, unless you're drinking soda, drinking beer. You know that's where we start, right like let's, let's pull out the big things. And it just became more and more obvious for that guy okay, what do you think are some good takeaways for today?

Mitchell:

big, big idea here don't wait until you're sick to get information about yourself. If you're not getting answers, ask somebody else for help. The worst thing you can do is have an issue going on. Go ask a doctor for help. Something's going on. They run the basic insurance labs, email you back two weeks later and say good news, everything looks good.

Mitchell:

To me, that is negligence, that is gaslighting and that is essentially creating this idea of suffering as being normal.

Mitchell:

Some degree of suffering is absolutely part of life, but there is probably some sort of metabolic disturbance going on if you're having a chronic issue and just because it's not picked up in a basic insurance-based test does not mean you are incapable of healing. So I want you to advocate for yourself and to find a new doctor. Find someone who is not gatekeeping your health information. Find somebody who knows how to interpret labs on a comprehensive and, I would say, congruent level, where they can put those pieces together with your history, with your presenting complaints, with your lifestyle and all of that to be able to craft some thoughtful answers. It happens over and over again. I am so tired of hearing wow, you guys looked so much deeper. It's like maybe that's supposed to make me feel good, but more than anything, it bums me out that you had to suffer for so long until you got answers, simply because of the reliance on an insurance-based investigation which is way too narrow and not deep at all.

Kate:

Yeah.

Mitchell:

So patient advocacy, that's everything.

Kate:

Let's do it different. And that's a wrap for this episode of Facilitated. If you enjoyed it, hit subscribe because, let's be honest, you'll forget otherwise. And if you really loved it, please leave us a review. Not only does it make Mitchell feel warm and fuzzy inside, but it also helps more people find functional medicine without falling into a Google rabbit hole. For more about what we do at the facility, check out our website, wwwthefacilitydenvercom. You can also follow us on Instagram at the facility Denver for extra tips behind the scenes, fun and updates on new episodes. Thanks for listening. Now go facilitate your own health and we'll see you next time you.