Quoth chiropractor William Cole: “Have your doctor run a bunch of useless functional medicine tests”

“Well, I’m back.” It’s a new year, but I’m still dragging from the old one; so I’m going to start out slow. I’ve written about so-called “functional medicine” on many occasions before here on Respectful Insolence. The reason, of course, is that, of all the forms of “integrative medicine” pseudoscience practiced, functional medicine “feels” the most like real medicine, so much so that it often even fools physicians into thinking there must be something to it. Indeed, the guru of functional medicine, Dr. Mark Hyman, who originally made a name for himself advising moneyed urbanites who retreat to Canyon Ranch in Lenox, Massachusetts, now counts Bill and Hillary Clinton as admirers. He’s also the founder of the Cleveland Clinic Center for Functional Medicine, which, unfortunately, has apparently been highly successful (financially, that is) thus far, complete with stealth advertising disguised as news reports in Ohio. That’s because one of the hallmarks of “functional medicine” is the ordering of lab tests—lots and lots and lots and lots of laboratory tests. There’s a reason that I’ve described functional medicine as the “worst of both worlds”. It combines the massive overtesting and overtreatment that can happen in conventional medicine with pure quackery, like “detoxification,” naturopathy, homeopathy, and chiropractic. It’s basically “making it up as you go along” with respect to interpreting the dozens (sometimes hundreds) of laboratory tests ordered by functional medicine practitioners, plus treating fake diseases, like “adrenal fatigue” or “leaky gut.” Speaking of chiropractic, what spurred me to discuss functional medicine again is an article by a chiropractor named William Cole, “Feeling Off? These Are The Tests To Have Your Doctor Run.” It’s basically an article that encompasses all that is wrong with the very construct that is “functional medicine” in a single article.

Functional medicine

Before I get to the article itself, let’s briefly discuss functional medicine itself. There’s a reason the construct attracts not just physicians, but alternative medicine practitioners as well. The lab testing and false claims of being able to understand what the results of all those lab tests mean can be attractive to doctors, but its claims of “getting to the true cause” and how each person has “biochemical individuality” are particularly attractive to quacks, such that we now often see naturopaths and chiropractors claiming to practice “functional medicine.”

It’s actually a very old paradigm—old as in “ancient”—tarted up and combined with science-y sounding jargon. What do I mean by ancient? Well, let’s just reconsider the seven “precepts” or “principles” of FM yet again:

• Acknowledging the biochemical individuality of each human being, based on concepts of genetic and environmental uniqueness
• Incorporating a patient-centered rather than a disease-centered approach to treatment
• Seeking a dynamic balance among the internal and external factors in a patient’s body, mind, and spirit
• Addressing the web-like interconnections of internal physiological factors
• Identifying health as a positive vitality—not merely the absence of disease—and emphasizing those factors that encourage a vigorous physiology
• Promoting organ reserve as a means of enhancing the health span, not just the life span, of each patient
• Functional Medicine is a science-using profession

In any post about functional medicine, I feel compelled to remind our readers that the very first principle is, in essence, functional medicine’s “get out of jail free” card for basically anything its practitioners want to do. They can always find ways to justify any form of treatment, be it science-based or quackery, simply by invoking the “biochemical individuality” of the human being whom they are treating. I also like to remind my readers of my retort to this: Yes, human beings are individuals, and each human being is unique. However, we’re not so unique that our bodies don’t all work pretty much the same way. In other words, in terms of biology, physiology, and yes, systems biology, human beings are far more alike than they are different. If that weren’t the case, modern medicine, developed before we had the tools to probe our genetic individuality, wouldn’t work as well as it does. Functional medicine fetishizes “biochemical individuality”, not so much because humans are so incredibly different that each one absolutely has to have a markedly different treatment. We’re not. Functional medicine fetishizes “individuality” because it distinguishes functional medicine as a brand distinct from science-based medicine and, I suspect, because it makes functional medicine practitioners feel good, like “total” doctors never at a loss for an explanation for a patient’s symptoms or clinical condition, and makes patients feel like special snowflakes whose every bit of “individuality” is being catered to.

As for being a “science-using” profession”, functional uses science the same way a drunk uses a lamp post – not for illumination, but for support. Just look at the way functional medicine guru Mark Hyman has mangled autism science and systems biology, and you’ll soon realize that this is true. Also, any specialty that is willing to consider homeopathy as anything other than rank quackery cannot claim to be science-based.

But what’s ancient? Well, let’s look at its focus on “imbalances”:

1. Hormonal and Neurotransmitter Imbalance
2. Oxidation Reduction Imbalances and Mitochondropathy
3. Detoxification and Biotransformational Imbalances
4. Immune and Inflammatory Imbalances
5. Digestive, Absorptive, and Gut Microbiological Imbalances
6. Structural Imbalances from Cellular Membrane Function to the Musculoskeletal System
7. Mind-Body/Body-Mind Imbalances

Does this remind you of anything? How about “imbalances” in the four humors? Or “imbalances” in the Five Elements in traditional Chinese medicine. Basically, functional medicine also fetishizes “balance” in a way that sounds very much like both ancient Asian and European medicine. It’s a philosophy more than a scientific principle. Mark Hyman, of course, is guilty of all these things, as are other prominent functional medicine advocates.

There’s also a variant of the “principles” of FM that I’ve come across. It’s similar, but with some differences:

FM has five basic principles. 1. We are all genetically and biochemically unique so it treats the individual, not the disease. 2. It’s science-based. 3. The body is intelligent and has the capacity for self-regulation. 4. The body has the ability to heal and prevent nearly all the diseases of ageing. 5. Health is not just the absence of disease, but a state of immense vitality.

Notice that part about the body being “intelligent”? Doesn’t that sound rather vitalistic to you? Of course, one other part is rather ridiculous, namely #4. If the body truly has the capacity to heal and prevent nearly all the diseases of aging, then why does every single human being eventually die? Why is it still quite uncommon for a human being to live beyond 100 years? Functional medicine mavens would claim it’s because of the “toxins” and our lifestyle choices, and it’s true that our lifestyle choices can contribute to and exacerbate chronic disease (one of the few things they get right), but it does not follow from that that if we did all the happy magical things functional medicine practitioners suggest that almost none of us would suffer from diseases of aging. We all would, although perhaps at a more advanced age. It would also still be true that none of us would live forever.

Now, back to the chiropractor.

Lab tests galore!

You can see the elements of functional medicine that I discussed above coming into play immediately right from the very beginning of Cole’s article:

When we’re not feeling our best—maybe we’re suffering from chronic bloat, migraines, fatigue, or insomnia—it’s tempting to search for that one hidden illness, dysfunction, or deficiency. The truth, however, is that every system of our body is inextricably connected to others, and health problems are almost always multifactorial—due to a number of different dysfunctions and imbalances that, over time, finally show up as various symptoms.

As a functional medicine practitioner, I run a lot of labs. They are great for pinpointing specific problem areas and help guide my treatment recommendations in a major way. And while it is important to remember that every person’s health case and biochemistry is unique—and health issues are often caused by a lot of small problems rather than one big one—talking to your doctor about testing is a great place to start.

Of course, Cole is not a doctor so he might not be able to order blood tests, depending on the state. Instead, he might have to have real doctors order blood tests. In any event, he’s basically telling people to do one thing that is rarely helpful when you have a health issue: Ask your doctor to order a bunch of lab studies. Cole even implicitly admits that these labs are not indicated in the next paragraph:

Unfortunately, many of these test won’t be covered by insurance (although you should always call and check to be sure!), and unless you have a particularly open-minded conventional medical doctor who is willing and has the time to explore these tests with you, the typical general practitioner probably won’t be ordering these tests on the reg or be comfortable making them part of your treatment plan. Because of this, I’d recommend working with an integrative or functional medicine doctor who is well-versed in these labs and how to read them from a holistic perspective.

The reason, of course, that insurance doesn’t cover most of these tests and that “conventional” physicians won’t order them is because they are unhelpful, useless, and/or not based in science and evidence. I once discussed a functional oncology case report published by naturopaths. They ordered dozens upon dozens of laboratory tests and prescribed a boatload of supplements for this poor woman with breast cancer, and the only things they did that arguably helped her were to prescribe exercise, a personal care giver, counseling, and perhaps her sleep log. Everything else was not evidence-based and almost certainly at best useless and at worst potentially harmful. All of it cost a lot of money.

But, hey, if you can’t get a real doctor to order you all the useless functional medicine tests Cole recommends, then Cole’s more than happy to recommend at-home tests:

If that’s not in the cards for financial or other reasons, another option would be to order the labs yourself. Companies like Thorne, EverlyWell, and Found My Fitness all have at-home tests you can purchase, administer yourself, and send in to be processed. These can also be pricey and time-intensive, but if you’re feeling less-than-optimal and you’ve explored the standard options offered by conventional medicine without any success, they can be great options. Many of them come with a detailed description of your results or a health plan based on your results.

I perused the lab tests offered by these companies. They include (of course) tests to measure heavy metals (e.g., cadmium, lead, mercury, zinc, copper, etc.) from a blood spot on filter paper; hormones using saliva and a blood spot; an “adrenal fatigue” factors using saliva; testosterone levels; vitamin D; thyroid hormones; and the like. There are “metabolism panels”, “methylation profiles”, micronutrient reports, and other tests favored by quacks. Not surprisingly, given that these tests are not evidence-based and certainly not optimal (saliva and blood spots are not the best source to measure many of these factors), there’s a quack Miranda warning on the websites of the companies selling the tests. (A quack Miranda warning goes something like this: “the tests we offer are not intended to diagnose or treat disease, or to substitute for a physician’s consultation” and the more common variant, “These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.”)

So what sort of labs does chiropractor Cole think you should have if you’re feeling a bit run down?

1. A 24-hour adrenal stress index
2. A full thyroid panel
3. Gut permeability labs
4. Sex hormone labs
5. Inflammation labs
6. Genetic testing

I’m surprised he didn’t include tests for chronic Lyme disease, candida, “heavy metal toxicity,” or “gluten sensitivity” (hint: there appears to be no such thing as non-celiac gluten sensitivity), other favorites as The One True Cause of All Diseases among quacks.

Adrenal fatigue, of course, is a fake disease. It’s a wastebasket diagnosis for people with symptoms like this:

1. You feel tired for no reason.
2. You have trouble getting up in the morning, even when you go to bed at a reasonable hour.
3. You are feeling rundown or overwhelmed.
4. You have difficulty bouncing back from stress or illness.
5. You crave salty and sweet snacks.
6. You feel more awake, alert and energetic after 6PM than you do all day.

It becomes clear if you look at a typical diagnostic questionnaire for adrenal fatigue that it’s a dubious diagnosis. I took the questionnaire myself, and guess what? According to the questionnaire I have “moderate” adrenal fatigue myself! Get me to a naturopath, STAT, for some diet changes and supplements! Well, not so fast. The Hormone Foundation and The Endocrine Society both point out that adrenal fatigue is a bogus diagnosis. Adrenal insufficiency is a real diagnosis, and, yes, sometimes it’s not obvious to diagnose, leading to confusion, but there are definite diagnostic criteria to guide physicians in making it. But “adrenal fatigue” is a nonexistent diagnosis.

As I mentioned before, the symptoms of “adrenal fatigue” are nonspecific and could be indicative of many different conditions—or nothing at all. Using the criteria I’ve seen on various naturopath, “integrative medicine,” and chiropractic websites, I conclude that nearly everybody suffers from some degree of “adrenal fatigue”; that is, unless one doesn’t ever have stress, is always happy, and eats a raw vegan diet, and even then one might still have “mild” adrenal fatigue.

Next up, thyroid:

Every cell of your body needs thyroid hormones to function, and unfortunately for us, many underlying thyroid problems don’t show up on standard labs because conventional medical doctors typically only run TSH and T4. A full thyroid panel is a blood test that looks at TSH and T4 but also at T3 uptake, total T3, free T4, free T3, reverse T3, and thyroid antibodies to give you the most accurate picture of your thyroid health and rule out possible autoimmune thyroid problems. Functional medicine also has a narrower reference range for what constitutes a “healthy” thyroid, which can explain why you may still be experiencing symptoms but haven’t yet been diagnosed with a thyroid problem.

As for thyroid disease, yes, sometimes nonspecific symptoms of feeling “run down” or “out of it” can be an indication of hypothyroidism, but there are usually other clinical indications of thyroid disease. As Harriet Hall has pointed out, most thyroid tests marketed by people like Cole for screening for thyroid disease are not helpful (and messing around with T3 is dubious). Notice, however, the very last part about how functional medicine has a “narrower reference range” for normal thyroid labs? That’s so that functional medicine doctors can treat more people for “thyroid problems”. I mean, do you really think that a chiropractor or an association of “functional medicine” advocates dedicated to overtesting and overtreating is more likely to have the most useful normal range of thyroid tests nailed than, say, actual endocrine physicians and scientists? If you look at his article on thyroid labs, you’ll also see this tidbit:

If you still have low thyroid symptoms and your TSH is “normal,” something is not being addressed. How do we get the “normal” lab range anyway? The reference range is based on a statistical average of the population of that lab. This is why, other than vitamin D and cholesterol levels, lab reference ranges will vary depending on the lab.

The people who typically have work done on labs — in other words, the population of that lab — are statistically not the healthiest segment of the population. So if the lab results are “normal” despite your having symptoms, what your doctor is essentially saying is you’re just like a lot of other sick people.

In functional medicine, we look at a much narrower range where your body functions optimally and you feel great, in perfect health.

There isn’t a facepalm big enough for this except perhaps this one:

I can sense our resident clinical pathologists getting concussions from all the facepalming. Does Cole really think that the population isn’t taken into account, that the reference ranges for thyroid function tests aren’t determined from healthy people without known thyroid disease? Here’s how reference ranges are really determined. I also can’t help but point out that in surgery, we sometimes say that the enemy of good is “perfect”. It’s in trying to make good results “better” or “perfect” during an operation that bad things happen, like accidentally cutting the aorta. I’ve described functional medicine as basically ordering every lab under the sun and then chasing the results and then using supplements, micronutrients, and other measures to try to make them perfect. Apparently Cole agrees with me that functional medicine is the chasing of the elusive “perfect” lab values.

As for the rest, measuring hormone levels outside of a specific indication is fraught with problems. Contrary to what Suzanne Somers or those promoting testosterone supplementation say, hormone supplementation is not an anti-aging panacea. “Leaky gut” is another fake diagnosis. “Inflammation panels” are rarely informative, and genetic testing should really only be done in concert with a genetic counsellor and/or physician skilled in the interpretation of the results. Basically, Cole is advocating tests that are expensive, whose results often can’t be interpreted and are not useful for guiding treatment, and that often lead to taking expensive and useless supplements.

Mitchell and Webb summed it up best

As I read Cole’s article, I couldn’t help but be reminded of a famous Mitchell and Webb comedy sketch about homeopathy. It’s pretty close to as applicable to functional medicine as to homeopathy if a few changes are made. For example, in my functional medicine version of the sketch, the doctors portrayed by Mitchell and Webb would be measuring hormone and metabolite levels of the trauma patient and maybe testing him for adrenal fatigue while giving him large doses of intravenous vitamin C while his condition deteriorated:

Of course, the part that is most applicable to functional medicine is this line near the end:

…when someone comes in with a vague sense of unease, or a touch of the nerves, or just more money than sense, you’ll be there for them, a bottle of basically just water in one hand, a huge invoice in the other.

In my functional medicine version of this sketch, all I’d change would be the part about a “bottle of basically just water in one hand, a huge invoice in the other,” for which I’d substitute something like “reams of useless and impossible-to-interpret lab results with a plan to correct each and every one of them in one hand, a huge invoice in the other.”

Now that’s functional medicine in a nutshell.