The Peter Attia Drive - #124 - AMA #15: Real-world case studies—metabolic dysregulation, low testosterone, menopause, and more

Episode Date: August 17, 2020

As a follow up to AMA #14 where Peter explained his framework for analyzing labs, this “Ask Me Anything” (AMA) episode focuses on a number of real-world case studies exploring metabolic dysregulation, low testosterone, menopause, hypothyroidism, elevated uric acid, and more. From the examples discussed, you can follow along how our clinical team goes about interpreting diagnostic measures and applying relevant research findings. Once again, Bob Kaplan, Peter’s head of research, will be asking the questions. 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 #15 show notes page. We discuss: Should you stop taking supplements before getting a lab test? [2:45]; Family history—Questions to ask and what to look for [5:30]; The purpose of an oral glucose tolerance test (OGTT) [12:15]; Case study—Insufficient muscle mass for proper glucose disposal [17:15]; Why hemoglobin A1c is a relatively unhelpful metric [24:00]; Case study—Exceeding carbohydrate tolerance [26:30]; Case study—Metabolic dysfunction and a framework for metabolic health [33:30]; Peter’s ideal tracking of metabolic health for all his patients [43:30]; Contrasting presentations of hypogonadism—Low free testosterone [45:00]; How sleep, exercise, and alcohol affect testosterone levels? [56:20]; Case study—Surprisingly fast onset of menopause [59:25]; Case study—Hypothyroidism and high cholesterol [1:07:00]; Case study—Elevated uric acid and hypertension [1:10:55]; and More. Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/ama15 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 Atiyah. 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 peterottiamd.com forward slash subscribe. So without further delay, here's today's sneak peek of the Ask Me Anything episode. Everyone, welcome to Ask Me Anything or AMA episode number 15. Now in May, we released the first part of our AMA focusing on my framework for analyzing labs. But in that episode, it took me a little longer to get to some of the actual labs and we weren't able to cover as much as I wanted. So this is a

follow-up to that greatly appreciated episode. People had a lot of really kind things to say about it. They really wanted more. And so it was a pretty easy decision to follow up and go a lot deeper because in that episode, we really only got to cardiovascular labs. In this episode, we kick it off with some of the stuff around insulin sensitivity, getting into some oral glucose tolerance tests. We get into testosterone replacement. We talk about menopause and female sex hormones, thyroid hormone, other metabolic stuff that can be gleaned from labs. Overall, I found this to be a really fun episode and I'm really glad we did it. And also there were a couple other pretty cool nuggets that Kaplan threw in here based on some questions from the previous one. So before we start,

of course, I need to remind everyone through the obligatory legal disclaimer 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 the podcast is 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. And with all of that said, and without further delay, I hope you enjoy AMA number 15.

Welcome back to another AMA. We may consider this one a part two. I think it was back in May we had, let's call it part one, where a lot of questions came in about what lab test should I be getting? And I think that turned into, well, it depends. And actually it's more of, how does Peter think about labs? And we got into some really interesting case studies or patient cases on cardiovascular. And I think that we wanted to get into more cases and didn't have enough time. So we're going to come back and discuss a few more patient cases. But first, we had some feedback from the first part one AMA, where we got a couple of really interesting questions that I think we should address up top. And so the first question that I have for you, Peter, is this one. When a patient is going in for their labs, how long before the lab should they cease taking any supplements if they're

taking any? And should they stop taking supplements for labs at all? So, I mean, I think it really depends on what the supplement is and what's the purpose of the test, but almost without exception in our practice, it's the opposite. We'll check in with patients a month before a scheduled test to be sure that they are on their supplements. And if they are not, we'll postpone the lab test until they resume them. For most supplements, there's some biomarker that we would track. For example, if we care about a person's homocysteine level as the metric we're

tracking, then that's why we might be giving them methylated B vitamins. So if we find out, hey, I ran out a month ago and I forgot to refill it, it wouldn't make a lot of sense to repeat the information we already know, which is, hey, when you're not taking a methylated B vitamin, lo and behold, your homocysteine is high. I'm trying to think of an example of when I want someone to stop a supplement or a medication outside of when I want to actually know how they look without it. But I think the more important point here is you need to know how long it takes to see the effect of the intervention. And so for example, one of the longer tail things is looking at, for example, the omega quant test that we use to measure EPA and DHA index. So this is a test that looks at the

red blood cell membranes and measures the amount of EPA and DHA, which are omega-3 fatty acids. We spoke about this on a podcast with Bill Harris some time ago. That's a test that you use to assess either how much fish a person is getting through their diet, like how much fish oil is coming in naturally, or in the case of most people, through supplementation. But you have to know that it could take up to three months to fully assimilate the change you make to see that. So if you gave somebody that supplement and then tested them a month later, you could be misled into thinking you're not giving them enough. Whereas other things work very quickly. For example, a drug like Repatha,

probably within two doses, which is given over the course of two weeks, would be sufficient to know if the drug is working or not. So whether we're talking about drugs or supplements, the real question is knowing what the period of time is it takes to see an effect and making sure that you're being thoughtful about that. And again, I think the bigger issue is making sure that the patient didn't run out or didn't forget to take it so that you're not scratching your head. And this happens to us still, despite all our checks and balances, this still happens to us where we get labs back and we think, oh, this can't make any sense. And then we talk to the patient and they're like, oh yeah, I ran out of that thing. Sorry, I forgot to tell you guys. So that's our take on that.

Okay. The next question is, you mentioned asking your patients about their family history and how important that is. I know we got into that about how important it is, how much you can learn from getting a family history. And this person asked, what questions or information do you ask new patients on family history? Oh, I'm glad somebody asked that question because it's something I feel so strongly about. A lot of times patients will come in and they'll say, I have my 23andMe data. Is that all you need? And I was like, actually, that pretty much tells me nothing. We'll take it. Thank you very much. And we will scour the hell out of it. And we'll find out if you have a Tom40 SNP, and that'll increase your risk of Alzheimer's disease. And maybe you got a certain FOXO3 SNP, and there's some interesting

stuff here and there. Obviously, the genes that we think really matter, we're measuring on our own, such as the MTHFR genes and, of course, the APOE. But what I say to them is, look, this stuff doesn't mean jack compared to your family history. Once in a while, you'll see a patient who's been adopted or has been estranged from some part of their family for which that's simply impossible to know, and that is what it is. But for somebody who's not in that situation, we actually give our patients a template to be filled out in advance of our first meeting. And the template goes through the following. So for mother, father, both sets of grandparents, and all aunts and uncles and siblings, we actually want to know everything that is knowable. So our template is really painful for the patients.

I will acknowledge that upfront. So starting with cardiovascular disease, does anybody have a history of cardiovascular disease? Did they take any medication for blood pressure, cholesterol? Did they ever have a stroke, chest pain, heart attack, all of these kinds of things? We go through the same type of questions around dementia and then cancer and then metabolic disease. Did they have diabetes? And then when we're talking about this, because the reality of it is virtually nobody can

show up with that level of granularity. So then these become the questions we prod. And I think it's important to give patients that information long before you see them. Nobody can show up to a first meeting with their doc and know that. You'd have to be a freak of nature to have that information at hand. And it usually requires lots of phone calls. And sometimes you're asking about relatives that have been long dead and or for whom you've never met. So the more you know these things, the better. And it's also important to understand context. You'll get some family histories that are full of cancer, but then you ask that second order question and find out,

oh, well, that person also smoked three packs a day. If you didn't know that detail, you might be inclined to think, well, this person's family history of cancer is crazy. But in reality, every one of the people who died of cancer was also a three pack aday smoker. So you have to take that with a grain of salt. Similarly, the person who has a family member that died of a heart attack at 50, well, it's really important to know a lot about that person. Is this a case of LP little a, which can easily present in myocardial death at 50? Or was this somebody who was an alcoholic and or a very heavy smoker and or had some other risk factor?

So I don't have a simple formula or template from this other than the more time you spend on it, the richer it is and the more you can potentially glean about what's really at the root of the genetic template that your patients inherited. It may sound silly, but it's almost like doing a book report when you're young and you're doing it on your dad or somebody like that, and then just extending it out. And then you may learn some things that are really surprising. Like you're talking about your dad's brother died of a heart attack at age 50. And then you found out they have more siblings and they had cardiovascular disease and it seems a little bit younger and realize like, if you haven't

looked at it before, that can start to connect some dots there, just looking at family history rather than looking at labs. I think it's a really important thing. I didn't even do my own until somewhat recently in the level of detail that I would expect of a patient. And that was kind of humbling first to realize, Hey, I hadn't done it, but two, to actually learn the information about the true mortality of all the aunts and uncles. And even now, by the way, I can't really provide a single shred of insight about how my paternal grandparents died because they died before my dad was even married. My dad is potentially the world's single worst historian. So asking him anything about how his mom and dad died, I might as well use a Ouija board. He just keeps rambling off things that

make absolutely no sense. So I can absolutely relate to my patients who come in and complain of the same thing, which is I asked my dad how his parents died or asked my mom how her parents died. And they just said they make up something that sounds completely nonsensical. So I truly have no clue how his parents died. And frankly, I probably have no clue about a bunch of things in my family history. So it's tough, but you do the best you can. And that information usually pays off quite a bit. And you're looking for patterns.

This is where a lot of the times you'll see that signature of cancer. You'll see that signature of dementia, cardiovascular disease. And it also really helps with understanding what to make of the findings you have in front of you. One in 10 people roughly show up with an elevated LP little a, but the number by itself doesn't tell you how bad of a problem it is. I mean, we know LP little a is bad, but is this a big problem or just a medium problem? But the family history can often elucidate that. And the people who have a lot of sub 60 year old cardiovascular events and elevated LP little a boy, like you need to be acting on that in the most aggressive manner. And then in the families where the LP little a is, like you need to be acting on that in the most aggressive manner. And then

in the families where the LP little a is very elevated, but nobody's having any events into their eighties, maybe you don't need to be as aggressive. I think that's a nice segue. When you talk about your dad, not being the best historian that you may have talked about this in the previous podcast about a lot of this stuff when you're talking about labs, but really you're trying to put a puzzle together where you have some pieces talking about labs, but really you're trying to put a puzzle together where you have some pieces and it's like an investigation or you're a detective trying to figure out what are the things that we should be looking for. And I think these patient cases are great examples of, you get this question so often, Peter, what are the top five lab tests

that I should be looking at? And maybe you have your five, put a gun to your head, you've got your five, but based off what those labs tell you, you have 10 more questions that you want answered and they're not going to be answered within those five labs that you just got. It might take you down a path. And so I think what we want to get to here is we've got a couple, I think at least, yeah, we've got a few cases of OGTT or oral glucose tolerance tests that I think that you do with most, if not every one of your patients. And what information can that yield beyond a lot of people just use fasting blood glucose or even an oral glucose tolerance test with looking specifically at glucose and not

looking at other things like insulin. So are there any cases in particular that you would want to get into that can help elucidate some of this stuff with OGTT? Yeah, Bob, as you said, the OGTT is a really cumbersome test. And there's a reason that it's not a test that is done commonly, certainly not with frequent sampling and looking at glucose and insulin. In fact, when we began working with our current lab, which is called Boston Heart Labs, they didn't even have a protocol for it and they refused to do it initially. And it took us six months of arm twisting to even get them to agree to do the test such that we could do it all under one rec form and have the information reported. That's how cumbersome it was. So obviously I believe in this test or I wouldn't

jump through the hoops to do it. So what is the test? Thank you for listening to today's sneak peek 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. Ridiculously comprehensive podcast show notes that detail every topic, paper, person, and thing we discuss on each episode of The Drive. Access to our private podcast feed. The Qualies, which are a super short podcast, typically less than five minutes, released every Tuesday through Friday, which highlight the best questions, topics, and tactics discussed on previous episodes of The Drive. This is particularly important for those of you who haven't heard all of the back episodes.

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