The Peter Attia Drive - Qualy #6 - What are the best lab tests to request specifically for longevity

Episode Date: August 14, 2019

Today's episode of The Qualys is from podcast #04 – AMA #1: alcohol, best lab tests, wearables, finding the right doc, racing, 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. 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 

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So without further delay, I hope you enjoy today's quality. If you wanna get into like, if you could actually measure some things for longevity, but you really can't in a lab test that you would want to look at? So, if we're talking longevity purely in terms of lifespan, how long, you know, looking at someone's blood, can you get a sense of how long until they're going to die? The way to think about that. So, what you're not going gonna get on a standard blood test is any of the longevity genes.

I mean, you can get some of them, but you certainly ApoE would be one of the longevity genes. LP, LITLA would be a longevity gene in inverse, so the lower your LP, LITLA, the greater your chance of cardiovascular mortality. So the way I really think about longevity in blood is the three things that you're looking for in blood disease-wise are what is this person's risk of atherosclerotic disease?

So, heart disease or stroke. What is this person's risk of cancer? What is this person's risk of neurodegenerative disease? So, as you march down those things, you would say, well, cardiovascular disease largely driven by three things, lipoproteins, inflammation, and ethereal dysfunction. How much of that can we see in blood actually a lot? On the lipoproteins side, we can see most of what we want, which is the LP little A, the LDL, the small LDL, I'm talking particle number, not cholesterol, and the VLDL is alluded

to. On the inflammation side, we can see specific and non-specific markers of inflammation. So on the non-specific side, we can see things like fibrinogen, c-reactive protein. On the specific side, you can see things like ox LDL, LPPLA, two ox phospholipid, those things. Very helpful. Endothelial health is the hardest thing to see, but I include insulin here because I think that insulin isn't in of itself, actually toxic at high levels to the endothelium. And James O'Keefe just recently was on a paper that looked at cardiovascular health in patients with type 1 diabetes so that they were able to actually use the insulin doses that people were using as a way to actually assess the impact on the...

I came up with myocardium or endothelium. You can look at things like home assisting. We also look at something called asymmetric dimethylarginine or ADMA and SDMA, which are inhibitors of nitric oxide synthase. So the way I tell patients is the younger you are, the more your blood tells me about your risk of cardiovascular disease. So a 40-year-old person who otherwise doesn't have like some dramatic, you know, L.P. Little A through the roof or something crazy. The blood tells me probably 80, 85% of what I need to know. The older a patient gets, the more I would probably rely on things like CT&Gograms or even,

usually by the time they're older, a calcium score becomes less relevant. Calcium score can be somewhat helpful in a younger patient though, but it's, you know, the latest study I saw, which actually just was an editorial that came out two days ago based on a study in one of the atherosclerosis journals, was looking at 50% of patients that had events at the site of non-calcified lesions. Not a huge vote of confidence for how wide a low calcium score is that helpful. On the cancer side, I think that's really, frankly, where blood gives us the least insight. Until companies like Grail have fully functioning liquid biopsies

where you're looking at, I think Grail is probably looking mostly at RNA and DNA. Other companies have looked at circulating proteins. But until these liquid biopsies are there, we can't. We don't really have much insight into it. Also, virtually every cancer is a result of a somatic mutation, not a germline mutation. So knowing your genotype doesn't really help outside of a few outlier things like raca or lynch. So in cancer, it really comes down to understanding inflammation, which we've already addressed, and metabolic health, which, again, was also part of the cardiovascular stuff, though I didn't go into it. So, for me, minimizing hyperinsulinemia becomes very important.

And I suspect we'll probably have an entire discussion on the role of IGF in cancer and IGF BP3, because I think it's actually quite controversial, but that can also provide some insight. And then Alzheimer's disease, actually,, I think is more closely related to cardiovascular disease in terms of risk stratification. So first of all, knowing the patient's ApoE immediately gives me a bucket to put them in,

which is low, medium, high risk. I mean, that's, I don't call it that, but that's sort of how you can think about it. And then you look at the other dimensions of it, which is there's a vascular component to that disease, and that basically proxies what you're seeing in cardiovascular risks. So the more you can improve the cardio metabolic profile, the more you can improve that. Then there's the metabolic component period, which is kind of like the glucose utilization

part. And that sort of reverts back into all the metabolic stuff you see in cancer. There's an entire thing around toxins, which unfortunately is probably the one that we have the least insight into measuring. And you know, for very high risk patients, we do refer them to Richard Isaacson's clinic at Cornell, which is a dedicated high risk clinic. And certainly there, if the cognitive test warrants it, they'll do lumbar punctures and start to look at CSF for other markers, but obviously we don't do that.

And unfortunately, we don't have too many patients that are cross-mogeneating over there. I don't want to harp on this one, but I thought it was a good point that you brought up. You touched upon with the insulin and that some people will get their glucose tested. Every year, and they say, my glucose is fine. It's 82, or whatever it is. And if they assume that their insulin's fine too, because they're clearing their blood sugar and it's 82, can you explain just why you're not,

I mean, you're literally not looking at insulin, but insulin could be elevated, and you wouldn't know it. And usually the person walking around with a fasting glucose of 82 probably doesn't have a very high fasting insulin. It's the post-pran deal stuff you worry about. And then this gets more complicated because you then have to worry about, are you being misled by the test? So I'm sure many people are listening to this who are already aware of this, but I'm sure enough people aren't that it's worth the time. But if you take

somebody who's on a ketogenic diet or a very carbohydrate-restricted diet, it's more common than not when you do an oral glucose tolerance test on them that they will have this paroxysmal very elevated glucose, very elevated insulin after being challenged. So they'll have a low fasting glucose, low fasting insulin,

and then you give them the glucola and their glucose and insulin are sky high. I think I may have told the story once on a podcast about a guy I knew who had gone on a little carb diet and everything had gone great and bubble buy, lost a bunch of weight and got healthier and everything was amazing. And then his brother who had type one diabetes

needed a kidney transplant and he was a match. So they said, well, all right, we just gotta test you. Make sure you're not diabetic or anything before we take one of your kidneys. They did an OGTT and he quote unquote failed. And he called me at distress. And he was like, oh my God, I can't even give my brother a kidney and I said, well, here's the thing.

You gotta have him repeat the test. And you gotta refeed with 150 grams of carbohydrates. Just eat 150 grams of rice potatoes, whatever. For about three days leading up to the test, they repeated the test. Obviously, everything was fine. The next time you called me, he was leaving the hospital after the transplant, everything had gone well. The other thing with fasting glucose, by the way, that's kind of useless, is it's helpful

if your fasting glucose is 150. There's clearly a problem, but I get patients that get very upset or phosphorylated if they're fasting glucose is 105. And I got to tell you, now that I wear a continuous glucose monitor and I know my glucose 24 7, the difference between a fasting glucose of 90 and 105 in the morning is much more function of my cortisol level than it is anything to do with my insulin sensitivity or anything like that. So it's important to understand the role that even stress can play on glucose. And that's why I think fasting glucose is directionally interesting, but it's the insulin that gives you the

the more fine tune insight. 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 healthcare services, including the giving of medical advice. And note, no doctor-patient relationship is formed. 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, diagnoses or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they have

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