The Peter Attia Drive - #111 - AMA #14: What lab tests can (and cannot) inform us about our overall objective of longevity

Episode Date: May 18, 2020

In this “Ask Me Anything” (AMA) episode, Peter explains his framework for understanding what lab tests can (and cannot) inform us as it pertains to overall longevity, with a specific focus on atherosclerosis, cancer, Alzheimer’s disease, and the physical body. Additionally, Peter shares details into two patient case studies around cardiovascular disease, including how the lab results influenced his diagnosis and treatment plan for the patients. Once again, Bob Kaplan, Peter’s head of research, will be asking the questions. If you’re not a subscriber and listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or on our website at the AMA #14 show notes page. We discuss: Important lab tests and reference ranges [2:35]; How lab testing fits into the overall objective of longevity [4:25]; A healthcare system set up to react to a disease rather than prevent it [8:00]; The four pillars of chronic disease, and the three components of healthspan [14:30]; Atherosclerosis—How much can labs tell us about risk? [18:00]; Coronary calcium score (CAC)—Interpreting results based on your age [24:15]; Cancer—What lab work can tell you, and the future of liquid biopsies [28:00]; Alzheimer’s disease—What’s driving Alzheimer’s disease, and what labs can tell you about your risk [33:15]; Healthspan and the physical body—Where lab testing fits, the endocrine system, and zone 2 testing [39:00]; Summarizing the usefulness of lab testing—Where it gives great, reasonable, or lousy insight [43:15]; Patient case study—Elevated Lp(a): Understanding ApoB, and how cholesterol levels get reduced [45:30]; Patient case study—Familial hypercholesterolemia [59:30]; Coming up on a future AMA [1:10:30]; and More. Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/ama14 Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

Hey everyone, welcome to a sneak peek, ask me anything, or AMA episode of the Drive Podcast. I'm your host, Peter Atia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to PeterittiaMD.com forward slash subscribe. So without further delay, here's today's sneak peek of the Ask Me Anything episode. Hey everyone, welcome to another Ask Me Anything or AMA episode. This is number 14. One of our previous AMAs I mentioned

how I like to think about lab ranges, and I might look at them in a way that's not necessarily congruent with the way the labs themselves talk about them. And I talked about doing potentially an episode about looking at labs and such. So this is that episode. So this is a pretty big topic,

and we actually didn't cover as much as I thought we would before we ran out of time on this episode. So in this episode, I talk very broadly, but I think comprehensively in a manner that's helpful to think about labs, about my framework for what labs can inform and what they can't inform. And again, even though that took longer than I thought it would take, I don't think it makes sense to get into this discussion without starting with a foundation. And so I think you'll find that interesting and hopefully it's the type of thing you don't have to go back and revisit over and over again,

but sitting through it once is a really good way to say, okay, if I'm gonna go to the trouble of doing advanced testing, what am I learning? And just as importantly, what am I not learning? We then go into a couple of cases around cardiovascular disease, and that's pretty much where we run out of time on this episode. It goes by really quick, and what we're going to do is come back and just pick it up on the same thread going into other sorts of cases. So at the end of this episode, I talk about what we're going to come back

and visit. And of course, if based on this episode, you have specific types of lab questions or scenarios, maybe as a more important way, think about it that you want to dive into. Please let us know and we can obviously add that to subsequent episodes. So before I start, I have to obviously give the obligatory disclaimer, which is that this podcast is for general informational purposes only. it does not constitute the practice of medicine including the giving of medical advice, the use of this information and the materials linked to it in the podcast are at the user's own risk. The content of this podcast is not intended to be a substitute for professional medical advice diagnosis or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they have.

should not disregard or delay in obtaining medical advice for any medical condition they have. So with that said, and without further delay, I hope you enjoy AMA number 14. Hello podcasters. Welcome to another Ask Me Anything with Peter Atia. This is your host, Bob Kaplan, asking your burning questions. This time around, we've compiled the many questions you have on the topic of lab tests. I know Peter has answered a few questions here and there and actually on our first AMA, he discussed some of the best lab tests for assessing overall longevity. We can possibly revisit some of those, but either way we'll be sure to include that information in the show notes. Peter has also left a lot of breadcrumbs in podcasts and interviews where he'll discuss

ranges and cutoffs he likes to see on a given test. And those values might not always reflect the ones you might see on the report that you get back from a lab. So I've actually gathered a bunch of those ranges, so one thing we can do is throw those into the show notes of the episodes that are all in one place. If you put those two topics together, many people essentially want to know, what are the tests that I should be getting?

And what do the specific results of those tests tell me? A number of the questions we've received really feed into the broader question of, how does Peter think about labs? Both as a patient himself and as a doctor who treats patients. What does a lab test actually tell you? What does it not tell you? Where can you be fooled? How often should I get a particular test? How can one lab test inform another lab test? What's the difference between normal

and optimal? What tests are most useful? What tests are useless? Why are we doing these tests in the first place? So those are all listener questions. And so instead of just taking these questions in isolation, one by one, we thought it would make for a much more useful podcast for Peter to actually walk us through his stick on labs that he gives to patients. And secondly, for Peter to share some really interesting cases he's experienced with patients that can give us real-world examples of how Peter thinks about labs and how it might inform his decision-making. So I guess Peter, the first question goes to you, which is, if I'm a patient of yours and you want to take a bunch of my bodily fluids, I guess my question is, A, why do you want

to do that and B, what information are you trying to extract from that? So I think every time I sit down to review labs of the patient for the first time, I usually take a step back and try to put the labs in the context of how they fit into our overall objectives with respect to longevity. And I do this through the lens of the way I've spoken about this before, which is longevity as these two components, lifespan and health span, by identifying the components of each of those and then looking at where labs have information or can shed light on those things versus where they can't. You start to get a sense of where the labs are adding value and of equal importance where

you have blind spots. So I do think it is important to have this discussion before we jump into the examples that we've pulled aside. So what is longevity? Again, longevity is a function of two things. It's how long you live, and that's the part that's called lifespan, and how well you live. That's the part that's called health span. The lifespan part is easier to explain, because it's binary. A person is either alive or they are dead. The health span part, which will save for second, is a little harder to understand. Maybe harder to quantify as a better way to say it, I think it's relatively straightforward to understand. Okay, so living longer is effectively going to boil down to how long can you delay the

onset of chronic disease? Many people have probably heard me say that before, but I want to unpack that a little bit more. If we look at the centenarian literature, and as you know, we have devoured that literature in the process of writing the book. In fact, one chapter of the book is entirely dedicated to centenarians. I think it's chapter four. They've taught us a lot. So even though they turn out to be sort of genetic lottery winners, people who almost through no action that they've taken are going to live to be 100 or beyond, and instead through some amazing luck that they've inherited a set of genes, are still a very illustrative population to study.

And we learned a lot from them, but I think this single most important thing we learned from them is they don't live longer once they get a disease, they just take longer to get a disease, and that's really important. That's not obvious. If you haven't sort of dug into it, it could easily be the case that centenarians acquire disease at the same rate and at the same time as non-centenarians, but their superpower is living longer with the disease, being more resilient to a disease once it sets in. But as you know about that turned out to not be the case. So when we ask that question directly, the answer was overwhelmingly in the opposite direction. And indeed, their superpower is how long they can go before they get the first chink in their armor. But once that disease sets in, they've basically been exposed to

kryptonite, and they are now just mere mortals like the rest of us. So the way I describe this in the book is they have a phase shift. So they have a phase shift in time that delays the onset of disease. So if you want to live longer, the mathematical equivalent function is delay the onset of chronic disease, not figure out ways to live longer once you have chronic disease. It's worth noting that unfortunately, the entire healthcare system is mostly geared towards the opposite. Prevention is not really the mainstay of medicine. Medicine has had its greatest impact, or its greatest efforts, basically on what to do once you have a disease, how do you live longer? So once you have Alzheimer's disease, what drug might reverse the dementia or slow its progression? Of course, the sad reality of that

is none. We've spent billions of dollars trying to answer that question and come up empty-handed. Similarly, when we look at cancer treatment, once you have cancer, what can you do? when we look at cancer treatment, once you have cancer, what can you do? Well, unfortunately, we haven't made a lot of progress in 50 years. So if you go back to 1970, and you look at what the long-term survival was of a patient with metastatic cancer, and you compare that to today, the answer is almost the same. It's roughly about a 5% improvement we've made in 50 years. Again, not great, and it probably speaks to the challenge of treating a disease like cancer, or Alzheimer's disease, where once you have it, modern medicine doesn't seem to be able to do that much more today than it could 50 years ago to erase it.

So I think one place where we've seen the most progress on managing a disease once it sets in is cardiovascular disease. And I could do spend an entire AMA just discussing the differences between cardiovascular disease and cancer and dementia. But part of it I think has to do with the fact that atherosclerosis is much more of a continuum than dementia and cancer. And therefore, that coupled with the fact that we have a far better understanding of atherosclerosis, I think, is complicated as a disease as this is.

And I don't mean to undermine people who study it for a living. It is far and away a simpler disease process to understand than the other two major pillars of mortality. So that's a long-winded way of saying, I hope I can convince a person that if you want to live longer, you've got to figure out how to delay the onset of these chronic diseases. Not live longer once you have them. I think it's a study by the group Thomas Pearls, which is, I think he's got a BU,

the New England Centenarian study. We are looking a lot at near-barcelized longevity genes project, but Pearls is an interesting article where he talks about exactly what you're, you just framed there, where there are three groups, there's delayers, escapers and survivors and so you have the people so how many of these

centenarians are delaying disease, how many are completely escaping some of these chronic disease and then how many are just living with it and have superpowers and the majority of the cases were probably no surprise they were the delayers and so they're delaying disease, which fits exactly with what you're talking about. Yeah. And again, it's important for me to explain to patients that phenomenon. And you actually just stated in about 31 seconds

what it took me probably five minutes to explain. So I might have to start bringing you in on these meetings. And then secondly, it's important to explain to them that this approach while conceptually logical, and I think once most people hear it, they're like, yeah, that totally makes sense, is not congruent with how most people go to the doctor. And again, it's been stated a million times before. We don't really function in a system of healthcare. We function in a system of sick care, meaning we interact with our healthcare system in a

manner that is once there is a problem, we seek help. And again, you know, I'm not one of these guys who likes to rail against healthcare. And it's just not true. Look, that's just the nature of the way the system works. The system works by identifying a disease and then label, you know, basically the more clearly you can identify and label a condition, the more accurately you can provide a treatment for it. And so that's the way we were educated.

So medical education is predicated on this idea that you put a label on a disease. And by the way, the entire financial system around it is predicated the same way you have to come up with a billing code that explains what a person has, this person has hypertension, this person has dyslipidemia, this person has fill in the blank. So we have a code, the code allows us to bill an insurance company for it. We peg treatments to these things

and that's the way we go. So everything that we learned in our medical training was based on this and it's not surprising then that when patients go to their doctors and say, hey, I'm perfectly healthy, but whatever, 40 years old, but I really want to do everything I can to live to be a hundred. Most doctors would look at you like you had three heads. They can offer you sort of glib insight, like don't smoke and quote unquote eat well and exercise in those things, but how would we go

further? We have to sort of change the way we think about risk, which will come to in a second. Can I ask one question? This is maybe a silly question or an uninformed question. On those codes, are there codes for say pre-diabetes or pre-hypertension or on the road to metabolic syndrome or even metabolic syndrome where you're essentially saying, like we need to do something so that this person

doesn't develop one of those diseases or chronic conditions. There's not a silly question and definitely things are changing. Thank you for listening to today's sneak peak AMA episode of the drive. If you're interested in hearing the complete version of this AMA, you'll want to become a member. We created the membership program to bring you more in-depth, exclusive content without relying on paid ads. Membership benefits are many, and beyond the complete episodes of the AMA each month, they include the following. Redeculously comprehensive podcast show notes that detail every topic, paper, person, and

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