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Two patients sit in two different offices, holding identical lab reports. Patient A sees a conventional doctor. Ferritin: 18 ng/mL. "Normal," he says. "Reference range is 12-150. You're fine." Patient B sees a functional medicine doctor. Same ferritin: 18 ng/mL. "That explains your fatigue, hair loss, and restless legs," she says. "We need to get this above 50." Same lab value. Different interpretations. Radically different outcomes. Five years later, Patient A has been diagnosed with iron deficiency anemia (ferritin now 8), thyroid dysfunction, and depression. Patient B optimized her ferritin to 80, resolved her symptoms in three months, and never developed any of those conditions. The difference wasn't in the blood draw. It was in how the numbers were interpreted. Conventional reference ranges are too broad, include sick people in their calculations, and catch disease too late. Functional ranges identify dysfunction years earlier, when it's still reversible.
Most people assume lab reference ranges represent "healthy." They don't.
Reference ranges are derived statistically. A lab takes samples from a "reference population," measures the variable, and defines "normal" as the central 95th percentile. If 95% of people fall between 12 and 150 for ferritin, that becomes the range.
The problems with this approach are significant.
The reference population includes people with undiagnosed disease. If 30% of women in the sample have subclinical iron deficiency (common), their low values pull the lower end of the range down. "Normal" now includes pathology.
Ranges are too wide. A ferritin of 12 and a ferritin of 150 represent vastly different metabolic states. Lumping them into the same "normal" category is clinically meaningless.
Ranges catch disease, not dysfunction. A TSH of 4.5 is "normal" but a 2005 study by Wartofsky and Dickey in the Journal of Clinical Endocrinology & Metabolism found that TSH above 2.5 correlates with thyroid symptoms and antibodies. Waiting until TSH hits 10 (overtly abnormal) means years of suffering.
Ranges are population-specific but not age or sex-optimized. A fasting glucose of 99 is "normal" for the American population, but it would be alarming in a traditional hunter-gatherer society.
Laboure and colleagues published a critique in Clinical Chemistry (2004) showing that reference ranges vary by 10-20% between labs, further undermining the idea of a universal "normal."
The bottom line: "normal" means "you're within the statistical middle of a potentially sick population." It does not mean "optimal" or "healthy."
TSH 3.8 is "normal" on every lab report in America. The reference range extends to 4.5 or even 5.0.
But a person with TSH 3.8 often has fatigue, weight gain, brain fog, cold intolerance, depression, and hair thinning. They feel hypothyroid because they are functionally hypothyroid.
A 2002 study published in the Journal of Clinical Endocrinology & Metabolism by the National Academy of Clinical Biochemistry recommended narrowing the TSH reference range to 0.4-2.5 after excluding subjects with thyroid antibodies. NHANES III data showed that 95% of disease-free individuals had TSH below 2.5.
Functional optimal TSH: 1.0-2.0. Not 0.5-5.0.
Fasting glucose 99 is "normal." The cutoff for prediabetes is 100. So a patient at 99 is told "you're fine" while a patient at 100 is told "you're prediabetic." One milligram of glucose per deciliter separates "healthy" from "diseased."
But dysfunction starts much earlier. Optimal fasting glucose is 70-85 mg/dL. Between 86-99, insulin resistance is already developing. Fasting insulin (which most doctors never order) is the earlier marker, but even glucose in the high 80s and 90s reflects years of metabolic stress.
Waiting until glucose hits 100 means you've missed the prevention window. The horse left the barn five years ago.
Ferritin is the most dramatic example of reference range failure.
Conventional range: 12-150 ng/mL (women), 12-300 ng/mL (men).
A woman with ferritin 15 is told she's normal. But she has crushing fatigue that worsens with exercise. Hair falling out in clumps. Restless legs at night. Inability to sleep. Brain fog. Shortness of breath climbing stairs. Heart palpitations.
Functional optimal ferritin for women: 50-100 ng/mL. Below 50 causes symptoms. Below 30 is frankly deficient, regardless of whether hemoglobin is normal.
Knovich and colleagues published in Blood Reviews (2009) that ferritin below 50 ng/mL is associated with hair loss (telogen effluvium) in premenopausal women. Iron supplementation reversed hair loss in multiple studies when ferritin was brought above 70.
Restless leg syndrome is strongly associated with ferritin below 50. Allen and Earley published in Sleep Medicine Reviews (2007) that iron supplementation improved or resolved RLS when ferritin was raised above 75.
Thyroid function is impaired by low ferritin. Iron is required for thyroid peroxidase (TPO) enzyme activity. You can't make thyroid hormone efficiently with ferritin below 50.
For men: functional optimal is 100-200 ng/mL. Below 100 can cause fatigue and suboptimal performance. Above 300 warrants investigation for hemochromatosis or chronic inflammation (ferritin is also an acute-phase reactant).
Ferritin 15 is not normal. It's barely above the threshold for frank iron deficiency anemia. It causes real, measurable, treatable symptoms. Calling it "normal" is a disservice.
Conventional lipid interpretation focuses on total cholesterol and LDL. But these markers are poor predictors of cardiovascular risk in isolation.
HDL 45 mg/dL (men) is "normal" by most lab standards. Functionally, it's low. Optimal HDL for men is above 55, for women above 65. Low HDL strongly predicts cardiovascular disease and correlates with insulin resistance.
Triglycerides 140 mg/dL is "normal" (reference range goes to 150). Functionally, it signals insulin resistance. Optimal triglycerides are below 80. Between 80-150 reflects early metabolic dysfunction. Above 150 is overt.
The triglyceride/HDL ratio is the most useful marker from a standard lipid panel, and your doctor probably isn't calculating it. McLaughlin and colleagues in Annals of Internal Medicine (2003) showed this ratio correlates strongly with insulin resistance:
Optimal: below 1.0 Early IR: 1.0-2.0 Established IR: above 2.0 Severe IR: above 3.0
LDL cholesterol alone tells you almost nothing about cardiovascular risk. Particle size and number matter more than LDL-C. A person with high LDL-C but large, buoyant particles (Pattern A) has lower risk than someone with lower LDL-C but small, dense particles (Pattern B). Advanced lipid testing (NMR LipoProfile, Cardio IQ) measures particle size and number.
hs-CRP (high-sensitivity C-reactive protein) below 0.5 mg/L is optimal. Between 1.0-3.0 is "average risk" by conventional standards but represents meaningful inflammation. Ridker's JUPITER trial in NEJM (2008) showed that elevated hs-CRP predicted cardiovascular events independent of cholesterol.
Your cholesterol panel isn't telling you what you think it's telling you.
Here's your quick reference. These are the ranges associated with optimal health, not just absence of disease.
Metabolic markers: - Fasting glucose: 70-85 mg/dL (not 65-99) - Fasting insulin: 2-6 uIU/mL (not 2-25) - HbA1c: below 5.3% (not below 5.7%) - HOMA-IR: below 1.0 (not below 2.5) - Triglycerides: below 80 mg/dL (not below 150) - HDL: above 55 men / above 65 women (not above 40/50) - TG/HDL ratio: below 1.0 (not below 3.5) - Uric acid: below 5.5 men / below 4.5 women (not below 7.0)
Thyroid markers: - TSH: 1.0-2.0 mIU/L (not 0.5-5.0) - Free T4: 1.0-1.5 ng/dL (upper-mid range) - Free T3: 3.0-4.0 pg/mL (upper third) - Reverse T3: below 15 ng/dL - TPO Antibodies: below 9 IU/mL (not below 35)
Inflammatory markers: - hs-CRP: below 0.5 mg/L (not below 3.0) - ESR: below 10 mm/hr (not below 20) - Fibrinogen: 200-300 mg/dL (not 200-400)
Nutrient markers: - Ferritin: 50-100 women / 100-200 men (not 12-150/12-300) - Vitamin D (25-OH): 60-80 ng/mL (not above 30) - RBC Magnesium: 5.0-6.4 mg/dL (not 4.2-6.8) - Vitamin B12: above 600 pg/mL (not above 200) - Folate: above 15 ng/mL (not above 3) - Omega-3 Index: above 8% (not above 4%) - Zinc: 90-120 mcg/dL (not 60-120) - Homocysteine: below 8 umol/L (not below 15)
Print this. Bring it to your next lab review. Compare your results to both conventional and functional ranges. The gap between "normal" and "optimal" is where chronic disease develops.
Talking to your doctor about functional ranges can be awkward. You're challenging their training. Here's how to do it effectively.
Be collaborative, not confrontational. "I've been reading about functional lab ranges and I'm curious about optimizing some of my markers. Can we look at these together?"
Bring research. Print the Wartofsky/Dickey paper on TSH ranges. Bring the McLaughlin paper on TG/HDL ratio. Doctors respond to peer-reviewed evidence more than blog posts.
Explain your symptoms. Connect the dots between your ferritin of 18 and your fatigue, hair loss, and restless legs. Doctors are trained to treat symptoms. If you can show that your "normal" lab value explains your symptoms, they're more likely to act.
Use direct-to-consumer labs for anything your doctor won't order. You don't need permission to understand your own biology.
Find a functional medicine practitioner if your doctor isn't receptive. The Institute for Functional Medicine (IFM) has a practitioner directory. These doctors are trained to interpret labs through a functional lens and will order the comprehensive panels you need.
Your lab work is not your doctor's property. It's your health data. Interpret it wisely.
"Normal" doesn't mean healthy. It means you fall within the statistical middle of a population that includes people with undiagnosed disease. Functional ranges represent where your body functions best. Where symptoms resolve. Where disease risk is lowest. Where you actually feel good. The gap between "normal" and "optimal" is where millions of people live in quiet suffering. Tired. Gaining weight. Losing hair. Anxious. Foggy. Told by their doctors that everything is fine. Everything is not fine. The wrong ranges are being used. Test comprehensively. Interpret functionally. Optimize aggressively. Your body deserves better than "normal."
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