The Peter Attia Drive - Qualy #26 - What is Peter looking to achieve and monitor with his blood glucose monitor?

Episode Date: September 18, 2019

Today's episode of The Qualys is from podcast #26 – AMA #3: supplements, women’s health, patient care, and more.   The Qualys is a subscriber-exclusive podcast, released Tuesday through Friday, and published exclusively on our private, subscriber-only podcast feed. Qualys is short-hand for “qualifying round,” which are typically the fastest laps driven in a race car—done before the race to determine starting position on the grid for race day. The Qualys are short (i.e., “fast”), typically less than ten minutes, and highlight the best questions, topics, and tactics discussed on The Drive. Occasionally, we will also release an episode on the main podcast feed for non-subscribers, which is what you are listening to now. Learn more: https://peterattiamd.com/podcast/qualys/   Subscribe to receive access to all episodes of The Qualys (and other exclusive subscriber-only content): https://peterattiamd.com/subscribe/  Connect with Peter on Facebook.com/PeterAttiaMD | Twitter.com/PeterAttiaMD | Instagram.com/PeterAttiaMD   

Welcome to the Qualies, a subscriber exclusive podcast. Qualies is just a shorthand slang for a qualification round, which is something you do prior to the race, just a little bit quicker. Qualies podcast features episodes that are short, and we're hoping for less than 10 minutes each, which highlight the best questions, topics, tactics, etc. discussed on previous episodes of the drive. We recognize many of you as new listeners to the podcast may not have the time to go back and listen to every episode, and those of you who have already listened may have forgotten. So the new episodes of the quality is going to be released Tuesday through Friday,

and they're going to be published exclusively on our private subscriber-only podcast feed. Now occasionally we're going to release quality episodes in the main feed, which is what you're about to hear now. If you enjoy these episodes, and if you're interested in hearing more, as well as receiving all of the other subscriber exclusive content, which is growing by the month, you can visit us at pteratia-md.com-forward-slash- subscribe. So without further delay, I hope you enjoy today's quality. So without further delay, I hope you enjoy today's quality. What exactly are you looking to achieve and monitor with your blood glucose monitor? Your CGM, your G6, which you, another product you probably, you love. I love the G6 and I'll talk about it all day long without, you know, receiving advertising

dollars to talk about it. You know, it's funny, the G6, along with the Aurora Ring, which I've talked a lot about, are these, and I've worn every wearable that there is. But they're the only two that seems sticky enough that I can't stop wearing them. Like, if I, like a month ago, I went to charge my Aurora Ring and I forgot to put it back on my finger when I went to bed. So I slept without it and I woke up the next morning

and realized I didn't have it and I didn't have the data. Like, it made any goddamn difference in my life. I was so pissed. The horror. I was like, God, how could you forget to put your ring on my side? There's probably a whole separate issue with that. But, and the same thing with like the continuous glucose monitor, I just, it's hard for me to imagine I used to not know my glucose in real time.

So there are a couple of things from it. The first is, it's a great way for me to control my behavior. And I know it's tempting to want to believe that I'm somehow impervious to the forces of bad food. But the reality of it is I am not. There was a day I think when I had a remarkable resilience and willpower, and I could do anything. Eat this, donate that, exercise like this, exercise. I could, I was a robot for so much of my life until three years ago and something just happened in 2015 and I just fell off the rails and I've never got back on. I simply do not possess the intestinal fortitude to be a robot anymore.

And I could speculate on several of the reasons for that, which I don't want to get into. But the long and short of it is, here I am. I am in an environment where like, you know, yesterday I was on a plane and they were handing out shit, cookies and bullshit. I really wanted a cookie. I think the only reason I didn't eat that cookie that was bigger than my head is because I knew I'd have to look at my CGM data after. So there is no more powerful behavioral tool for me than my CGM. Because in the end, I'm kind of a competitive person internally, much more competitive internally than externally, by the way.

And I just can't stand to see spikes of glucose. It just drives me nuts. And so, which is not to say I don't go off the rails sometimes. I absolutely do. We were in Fenway Park through the day, and I had fries. Now luckily, I had fasted all day and worked out, so I didn't actually experience a spike of glucose from the fries, so I got to have the fries

without the badness. But I was sort of ready for it. I was kind of bracing myself like, you might get a little testy seeing this thing. But that actually gets to the second point, which is it has allowed me to very eloquently calibrate how to tether activity levels, nutrient deprivation, the consumption of treats, and minimize the damage.

I don't know that I could drive a race car very well without seeing my RPM attack. Like if you plugged my ears so that I couldn't actually hear the rev of the engine and you took away my RPM attack and said, drive, could I still drive the car? Yes. Could I drive it half as well as I can drive it when I know exactly where I'm shifting at every moment where I need to shift? No, there's simply no way. Like, we're feedback machines. We need feedback. So I'm a huge CGM advocate and really looking forward to what the next few years will bring when these things can become a lot more affordable and a lot more accessible.

And the question is, can that be done without them remaining as medical devices? So the one I wear now is the Dexcom G6 is a medical device. It's an FDA approved device and it gives you a number that is, in this case, incredibly accurate. It's probably plus or minus 2 or 3 percent, specifically for the purpose of someone with diabetes being able to dose their insulin. The FDA will very likely not allow such a device into a consumer market because the concern would be that such a device could be used outside of a prescriptive relationship with a physician to dose insulin. So therein lies a whole bunch of issues that would basically, the way it would happen today

is the FDA would basically have to neuter the device, such that the information couldn't be used for treatment purposes, which means they either take away the real-time nature of it, which is what makes it so valuable, or give you a bunch of ranges and dilute the accuracy. Those are basically the two levers with which you could neuter one of these devices deliberately, which sounds crazy, right? Like, it's like the backwards step. Okay, I know you have a Zippo lighter.

We're gonna start using sticks instead. We're gonna rub them together. So, but all that said, hopefully, in an ideal world, the medical device becomes cheap enough that if you want that level of precision fidelity and real-time feedback, you'll just look. Doctors write prescriptions for way crazier things than CGMs, right? I mean, you got docs out there writing prescriptions for pain meds all day long and every hormone under the sun.

I don't think it's a big stretch to say, Doc, I need a CGM. And I think you might have mentioned this too in terms of what you are looking to achieve in monitor with your blood glucose. You might have said that it's a proxy for your insulin. And maybe you could explain why there isn't a continuous insulin monitor alongside your glucose monitor, because that would be a nice get if it actually exists. Yeah. And I looked into this a lot in 2011 and 2012,

but even met with the engineer. He's actually, I don't know if he's still there, but I don't remember his name now unfortunately, but he was, he might have been an Emeritus Professor of Engineering at UCSD, but he was actually the first guy to figure out actually how to do these real-time glucose monitors, what are called a point of care device. And actually took him out to lunch one day to pick his brain on, well, why don't we just

do this for insulin? And he was like, would that be interesting? And it was just funny to talk to him because he's an engineer like, well, why would he know that insulin would be as interesting as glucose or more interesting? And so we actually dug into this a lot. And basically, the short of it is, if you can't measure the assay using an antibody or enzymatic reaction that very quickly without any washing yields an answer,

you can't do it at a point of care device. An insulin is pretty hard to measure. So it was initially measured using something called a radioimmune assay. I believe today they're usually done with something called ELIZAs, which are these enzyme link, I'm not rattle off what Eliza stands for,

but it's a chemical reaction where you have to, put an enzyme on something, rinse it off, put another one on, rinse it off, etc. So in other words, it can't be done in a moment. So, absent that, I don't really see any direct way to measure insulin in real time. Now, I've had discussions with some companies who are interested in using CGM data to impute

changes in insulin. And I think that could be done, but I think it's a lot harder than people realizing you would need a lot of data to do it. Meaning, you wouldn't just be able to do it off the CGM. You'd have to do the CGM coupled with a lot of blood draws where you actually could basically build a regression curve off insulin and glucose to predict for future insulin. They're in May lie and answer down the line.

So absent that, a good proxy for having a low level of insulin is going to be a low level of glucose and a low level of glucose variability. And the CGM spits out those reports. So you go into... It low glucose variability, one might... Yeah, I don't know if people can see this, but I'm going to infer that the A1C might be telling you that. Although, the A1C is not telling you anything about the variability, but I don't know, let's talk about A1C in a moment, but you can see that I can spit out at any point in time

a 90 day, 30 day, 14 day, or 7 day report. And that report gives me average glucose and glucose standard deviation. That's the variability. So why is that relevant? Well, you could have an average glucose of 85, 95, whatever, with the standard deviation of 10, which is very low variability, or you could have the same glucose level with the standard deviation of 30. And those are very different insulin profiles. So you want to keep that balance closer.

I've largely discounted hemoglobin A1c in an absolute sense as a meaningful number. I think it's it's directionally tolerable, but mostly shit. And I know that because now I've used CGM in so many patients with calibration and compared it to A1C. And you realize that the A1C is really at the mercy of its most important assumption, which is a red blood cell libs for 90 to 120 days. Anything that takes it outside of that range leads to an over or under estimation of the A1C and therefore an over or under estimation of the A1c, and therefore an over or under estimation of the average glucose. And you can, with a A1c, theoretically, you can say, I have an A1c of 5.4 and you can impute

what your average glucose levels were, theoretically. Yeah, so the way the A1c works is you measure the A1c and you impute the average glucose. The way the CGM works is you measure the average glucose, which is actually all that matters, but you can impute the A1C. My A1C runs very high because I have this condition called beta thalassemia trait. So I have a bunch of these little... I think I talked about this in the podcast. One of the... Shit for blood. Yeah, yeah, that's the call. Yeah, your neck. Matty used to call me Shite for Blood. Always in a Scottish accent. You got Shite for Blood. So my little Shite bloods cells live a long, long, long time. They, I mean, I have no idea, but it's clearly longer

than 120 days. So my A1C is very high. The lowest A1C I've ever seen in myself is 5.6 and the highest is 6.0. So I'm basically just on A1C. I'm a prediabatic pretty much all the time. On CGM, when you take a highly calibrated rigorous, look, my average blood glucose imputes that

I would have in A1C between 4.5 and 5. That's sort of the range that I would live in. So that's a material difference. And again, I've seen that difference in both directions with patients using CGM. So my hope is that in 10 years, maybe that's ambitious, I would hope that the Hemoglobin A1C can't even be ordered on a lab, and everyone just has a CGM, you know, and it's like a trivial, little thing that, you know, even if you're getting a life insurance exam, you just wear the CGM for two months, and the data comes from that as opposed to actually measuring this

nonsensical number. I hope you enjoyed today's quality. Now sit tight for that legal disclaimer. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional health care services, including the giving of medical advice. And note, no doctor-patient relationship is formed.

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