Labs & Imaging
Health Assessment Roadmap
Most people have never had a Fasting Insulin, ApoB, or CAC Scan. These are the tests that reveal what standard panels miss — often years before symptoms develop.
Foundation
These are the tests included in a standard annual physical. They establish a baseline and are necessary — but they miss most of the markers that reveal early metabolic and cardiovascular risk.
CBC (Complete Blood Count)
Screens for anemia, infection, immune function
CMP (Comprehensive Metabolic Panel)
Kidney, liver, electrolytes, glucose
Lipid Panel
Total cholesterol, LDL, HDL, triglycerides — a starting point, not the full picture
Average blood glucose over ~3 months — screens for pre-diabetes and diabetes
Snapshot of blood sugar — often normal even when insulin resistance is present
TSH (Thyroid)
Screens for thyroid dysfunction
Deficiency is extremely common and affects immune, metabolic, and cardiovascular function
Note: If your doctor only orders these, you have a baseline — not a complete picture. The most important markers for metabolic and cardiovascular risk are at Level 2.
Optimization
These are the markers that reveal what standard panels miss. Most are not included in routine physicals. You will likely need to request them specifically — or order them independently.
The earliest marker of insulin resistance. Normal fasting glucose with high fasting insulin = early metabolic dysfunction
Counts the actual number of atherogenic particles. Far more predictive of cardiovascular risk than LDL-C alone
Genetically determined cardiovascular risk factor. Should be tested once in every adult — it does not change with lifestyle
High-sensitivity C-reactive protein — a marker of systemic inflammation and cardiovascular risk
Sensitive marker of liver stress, oxidative burden, and metabolic dysfunction — often elevated before ALT/AST
Measures EPA+DHA as a percentage of red blood cell fatty acids. Below 8% is associated with increased cardiovascular and cognitive risk
Elevated levels are associated with cardiovascular disease, cognitive decline, and B-vitamin deficiency
Elevated uric acid is associated with insulin resistance, gout, kidney disease, and cardiovascular risk
Calculated from fasting glucose and fasting insulin — quantifies insulin resistance
Note: These tests are widely available. Many can be ordered through your physician or through direct-to-consumer lab services. The cost is often modest relative to the insight they provide.
Advanced
These are imaging and advanced panels that reveal structural changes and body composition data. They identify risk factors that blood tests alone cannot detect — often years before symptoms develop.
Measures calcified plaque in coronary arteries. A CAC score of 0 is highly reassuring. A score above 100 significantly changes risk stratification and treatment decisions
Measures intima-media thickness of carotid arteries — a non-invasive marker of atherosclerosis progression. No radiation
Gold standard for body composition — measures lean mass, fat mass, and visceral fat separately. Visceral fat is a key metabolic risk marker
Non-invasive assessment of liver stiffness and fat content. Detects early NAFLD/MASLD before it progresses
Measures LDL particle number and size — more predictive than standard LDL-C. Small dense LDL particles carry higher cardiovascular risk
Reveals glucose variability, post-meal spikes, and overnight patterns that fasting glucose and HbA1c miss entirely
Note: CAC Scan involves a small amount of radiation and requires a physician order in most states. Discuss with your doctor whether it is appropriate for your risk profile. CIMT and DEXA involve no radiation.
Clinical Decision Framework
Decision Tree
A simplified framework for thinking through key results. This is not a clinical protocol — it's a starting point for understanding what your numbers might mean and what questions to ask.
Step 1
Elevated ApoB?
ApoB > 90 mg/dL
Yes → Get CAC Scan
No → Check Fasting Insulin
Step 2a
CAC Score = 0
No calcified plaque detected
Reassuring result
Monitor ApoB, retest in 3–5 years
Step 2b
CAC Score > 100
Significant plaque burden
Discuss with cardiologist
Aggressive lifestyle + possible pharmacotherapy
Step 3
Fasting Insulin > 10
Early insulin resistance signal
Prioritize metabolic health
Nutrition, movement, sleep, stress reduction
Simplified ApoB → CAC Pathway
Get ApoB tested
Request from doctor or direct-to-consumer lab
ApoB elevated (>90 mg/dL)?
Yes → Consider CAC Scan
Quantifies actual plaque burden in coronary arteries
CAC = 0
Highly reassuring. Monitor and retest in 3–5 years.
CAC > 100
Significant risk. Discuss with cardiologist. Aggressive lifestyle + possible pharmacotherapy.
No → Check Fasting Insulin
Fasting Insulin > 10 µIU/mL = early insulin resistance
Important Context
CAC Scan involves a small amount of radiation and requires a physician order in most states. It is not appropriate for everyone — discuss with your doctor whether it fits your risk profile.
Lp(a) is genetically determined and does not change meaningfully with lifestyle. It should be tested once in every adult. If elevated, it changes risk stratification significantly.
Fasting Insulin is not included in standard metabolic panels. You will almost certainly need to request it specifically. Many physicians are unfamiliar with its significance.
Reference ranges on lab reports are population averages — not optimal targets. A result flagged as "normal" may still represent suboptimal function.
For those using a ketogenic or low-carbohydrate approach, pairing blood glucose and blood ketone measurements provides a more complete picture of metabolic state. Annette Bosworth, MD (Dr. Boz) and Benjamin Bikman, PhD both emphasize this combined monitoring approach.
This roadmap is for educational purposes only. All testing and treatment decisions should be made in consultation with a qualified healthcare professional.
Ready to go deeper?
Explore metabolic and cardiovascular health topics in detail, or meet the experts behind this framework.
Disclaimer: This website is intended for educational and informational purposes only. The information on this page does not constitute medical advice and should not be used to diagnose, treat, cure, or prevent any disease. Always consult a qualified healthcare professional before ordering tests, interpreting results, or making changes to your healthcare plan.