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

00:00:00.000 Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.

00:00:16.500 I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can

00:00:20.460 access the AMA episodes in full, along with a ton of other membership benefits we've created,

00:00:25.440 or you can learn more now by going to peteratiyahmd.com forward slash subscribe.

00:00:31.140 So without further delay, here's today's sneak peek of the ask me anything episode.

00:00:39.140 Hey everyone, welcome to another ask me anything or AMA episode. This is number 14. One of our

00:00:45.120 previous AMAs, I mentioned how I like to think about lab ranges and I might look at them in a

00:00:49.880 way that's not necessarily congruent with the way the labs themselves talk about them. And I talked

00:00:54.940 about doing potentially an episode about looking at labs and such. So this is that episode. So

00:00:59.800 this is a pretty big topic and we actually didn't cover as much as I thought we would before we ran

00:01:04.460 out of time on this episode. So in this episode, I talk very broadly, but I think comprehensively

00:01:09.760 and in a manner that's helpful to think about labs about my framework for what labs can inform and what

00:01:18.260 they can't inform. And again, even though that took longer than I thought it would take, I don't think

00:01:22.600 it makes sense to get into this discussion without starting with a foundation. And so I think you'll

00:01:27.740 find that interesting and hopefully it's the type of thing you don't have to go back and revisit over

00:01:31.580 and over again, but sitting through it once is a really good way to say, okay, if I'm going to go

00:01:35.860 to the trouble of doing advanced testing, what am I learning? And just as importantly, what am I not

00:01:40.280 learning? We then go into a couple of cases around cardiovascular disease. And that's pretty much where we run

00:01:49.280 out of time on this episode. It goes by really quick. And what we're going to do is come back

00:01:54.020 and just pick it up on the same thread going into other sorts of cases. So at the end of this episode,

00:02:01.500 I talk about what we're going to come back and visit. And of course, if based on this episode,

00:02:06.580 you have specific types of lab questions or scenarios, maybe as a more important way to think

00:02:11.540 about it that you want to dive into, please let us know. And we can obviously add that to subsequent

00:02:16.020 episodes. So before I start, I have to obviously give the obligatory disclaimer, which is that this

00:02:20.380 podcast is for general informational purposes only. It does not constitute the practice of medicine,

00:02:25.380 including the giving of medical advice. The use of this information and the materials linked to it

00:02:31.020 in the podcast are at the user's own risk. The content of this podcast is not intended to be a

00:02:36.020 substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in

00:02:41.960 obtaining medical advice for any medical condition they have. So with that said, and without further

00:02:47.220 delay, I hope you enjoy AMA number 14. Hello, podcasters. Welcome to another Ask Me Anything

00:02:58.320 with Peter Atiyah. This is your host, Bob Kaplan, asking your burning questions. This time around,

00:03:05.600 we've compiled the many questions you have on the topic of lab tests. I know Peter has answered a few

00:03:10.840 questions here and there, and actually on our first AMA, he discussed some of the best lab tests for

00:03:15.940 assessing overall longevity. We can possibly revisit some of those, but either way, we'll be sure to

00:03:21.340 include that information in the show notes. Peter has also left a lot of breadcrumbs in podcasts and

00:03:27.080 interviews where he'll discuss ranges and cutoffs he likes to see on a given test. And those values

00:03:32.840 might not always reflect the ones you might see on the report that you get back from a lab.

00:03:36.700 So I've actually gathered a bunch of those ranges. So one thing we can do is throw those into the

00:03:41.720 show notes of the episodes. They're all in one place. If you put those two topics together,

00:03:46.260 many people essentially want to know, what are the tests that I should be getting?

00:03:50.180 And what do the specific results of those tests tell me? A number of the questions we've received

00:03:55.120 really feed into the broader question of, how does Peter think about labs, both as a patient himself

00:04:00.640 and as a doctor who treats patients? What does a lab test actually tell you? What does it not tell

00:04:05.500 you? Where can you be fooled? How often should I get a particular test? How can one lab test inform

00:04:11.480 another lab test? What's the difference between normal and optimal? What tests are most useful?

00:04:17.140 What tests are useless? Why are we doing these tests in the first place? So those are all listener

00:04:22.700 questions. And so instead of just taking these questions in isolation, one by one, we thought it would

00:04:28.500 make for a much more useful podcast for Peter to actually walk us through his shtick on labs that

00:04:33.660 he gives to patients. And secondly, for Peter to share some really interesting cases he's experienced

00:04:38.700 with patients that can give us real world examples of how Peter thinks about labs and how it might inform

00:04:44.560 his decision making. So I guess, Peter, the first question goes to you, which is, if I'm a patient of

00:04:50.660 yours and you want to take a bunch of my bodily fluids, I guess my question is, A, why do you want to do 0.81

00:04:56.840 that? And B, what information are you trying to extract from that?

00:05:01.540 So I think every time I sit down to review labs with a patient for the first time, I usually take

00:05:08.400 a step back and try to put the labs in the context of how they fit into our overall objectives with

00:05:15.040 respect to longevity. And I do this through the lens of the way I've spoken about this before,

00:05:20.860 which is longevity has these two components, lifespan and health span by identifying the

00:05:28.020 components of each of those. And then looking at where labs have information or can shed light on

00:05:36.880 those things versus where they can't, you start to get a sense of where the labs are adding value and

00:05:43.260 of equal importance where you have blind spots. So I do think it is important to have this discussion

00:05:50.440 before we jump into the examples that we've pulled aside. So what is longevity? Again, longevity is a

00:05:59.840 function of two things. It's how long you live. And that's the part that's called lifespan and how well

00:06:05.580 you live. That's the part that's called health span. The lifespan part is easier to explain because

00:06:13.360 it's binary. A person is either alive or they are dead. The health span part, which we'll save for

00:06:18.840 second is a little harder to understand. Maybe harder to quantify is about right to say. I think

00:06:23.700 it's relatively straightforward to understand. Okay. So living longer is effectively going to boil

00:06:33.300 down to how long can you delay the onset of chronic disease? Many people have probably heard me say that

00:06:40.140 before, but I want to unpack that a little bit more. If we look at the centenarian literature,

00:06:46.620 and as you know, we have devoured that literature in the process of writing the book. In fact,

00:06:52.700 the one chapter of the book is entirely dedicated to centenarians. I think it's chapter four.

00:06:58.220 They've taught us a lot. So even though they turn out to be sort of genetic lottery winners,

00:07:03.560 people who almost through no action that they've taken are going to live to be a hundred or beyond.

00:07:10.440 And instead through some amazing luck that they've inherited a set of genes are still a very illustrative

00:07:17.300 population to study. And we learned a lot from them, but I think the single most important thing

00:07:22.760 we learned from them is they don't live longer. Once they get a disease, they just take longer to get a

00:07:29.580 disease. And that's really important. That's not obvious. If you haven't sort of dug into it,

00:07:36.520 it could easily be the case that centenarians acquire disease at the same rate and at the same

00:07:42.560 time as non-centenarians, but their superpower is living longer with the disease, being more resilient

00:07:49.040 to a disease once it sets in. But as you know, Bob, that turned out to not be the case. So when we

00:07:55.120 asked that question directly, the answer was overwhelmingly in the opposite direction.

00:08:00.440 And indeed their superpower is how long they can go before they get the first chink in their armor. 1.00

00:08:09.500 But once that disease sets in, they've basically been exposed to kryptonite and they are now just

00:08:16.260 mere mortals like the rest of us. So the way I described this in the book is they have a phase

00:08:20.560 shift. So they have a phase shift in time that delays the onset of disease. So if you want to live

00:08:29.380 longer, the mathematical equivalent function is delay the onset of chronic disease, not figure out

00:08:38.540 ways to live longer. Once you have chronic disease, it's worth noting that unfortunately the entire

00:08:44.740 healthcare system is mostly geared towards the opposite. Prevention is not really the mainstay of

00:08:53.000 medicine. Medicine has had its greatest impacts or its greatest efforts basically on what to do once

00:09:00.960 you have a disease, how do you live longer? So once you have Alzheimer's disease, what drug might

00:09:05.720 reverse the dementia or slow its progression? Of course, the sad reality of that is none. We spent billions of

00:09:16.180 dollars trying to answer that question and come up empty handed. Similarly, when we look at cancer

00:09:21.100 treatment, once you have cancer, what can you do? Well, unfortunately, we haven't made a lot of

00:09:28.040 progress in 50 years. So if you go back to 1970 and you look at what the long-term survival was of a

00:09:36.280 patient with metastatic cancer, and you compare that to today, the answer is almost the same. It's roughly

00:09:43.600 about a 5% improvement we've made in 50 years. Again, not great. And it probably speaks to the

00:09:52.940 challenge of treating a disease like cancer or Alzheimer's disease, where once you have it,

00:09:59.020 modern medicine doesn't seem to be able to do that much more today than it could 50 years ago to erase

00:10:06.860 it. So I think one place where we've seen the most progress on managing a disease once it sets in

00:10:14.240 is cardiovascular disease. And I could spend an entire AMA just discussing the differences between

00:10:22.720 cardiovascular disease and cancer and dementia. But part of it, I think, has to do with the fact

00:10:26.540 that atherosclerosis is much more of a continuum than dementia and cancer. And therefore, that coupled

00:10:33.420 with the fact that we have a far better understanding of atherosclerosis, I think, as complicated as a

00:10:39.940 disease as this is, and I don't mean to undermine people who study it for a living, it is far and away

00:10:44.920 a simpler disease process to understand than the other two major pillars of mortality. So that's a

00:10:52.220 long-winded way of saying, I hope I can convince a person that if you want to live longer, you've got to

00:10:58.280 figure out how to delay the onset of these chronic diseases. Not live longer once you have them.

00:11:04.920 I think it's a study by the group Thomas Pearls, which is, I think he's out of BU,

00:11:11.480 the New England Centenarian Study. We were looking a lot at a near-barzilize longevity genes project.

00:11:17.700 But Pearls has an interesting article where he talks about exactly what you just framed there,

00:11:22.200 where there are three groups. There's delayers, escapers, and survivors. And so you have the people,

00:11:29.060 so how many of these centenarians are delaying disease? How many are completely escaping some of these

00:11:33.900 chronic disease? And then how many are just living with it and have superpowers? And the majority of

00:11:39.700 the cases were, probably no surprise, they were the delayers. And so they were delaying disease, which

00:11:45.280 fits exactly with what you're talking about.

00:11:47.120 Yeah. And again, it's important for me to explain to patients that phenomenon. And you actually just

00:11:53.200 stated in about 31 seconds what it took me probably five minutes to explain. So I might have to start

00:11:58.420 bringing you in on these meetings. And then secondly, it's important to explain to them that this

00:12:04.080 approach, while conceptually logical, and I think once most people hear it, they're like, yeah, that

00:12:09.180 totally makes sense, is not congruent with how most people go to the doctor. And again, it's been

00:12:16.340 stated a million times before, we don't really function in a system of healthcare. We function

00:12:20.240 in a system of sick care, meaning we interact with our healthcare system in a manner that is,

00:12:26.000 once there is a problem, we seek help. And again, you know, I'm not one of these guys who likes to

00:12:30.780 rail against healthcare. And that's just not true. Look, that's just the nature of the way the system

00:12:35.800 works. The system works by identifying a disease and then label, you know, basically the more clearly you

00:12:44.580 can identify and label a condition, the more accurately you can provide a treatment for it.

00:12:50.040 And so that's the way we were educated. So medical education is predicated on this idea that

00:12:54.500 you put a label on a disease. And by the way, the entire financial system around it is predicated the

00:12:59.620 same way. You have to come up with a billing code that explains what a person has. This person has

00:13:03.880 hypertension. This person has dyslipidemia. This person has fill in the blank. So we have a code.

00:13:09.360 The code allows us to bill an insurance company for it. We peg treatments to these things and

00:13:14.840 that's the way we go. So everything that we learned in our medical training was based on this.

00:13:20.600 And it's not surprising then that when patients go to their doctors and say, Hey, I'm perfectly healthy,

00:13:26.300 but whatever, 40 years old, but I really want to do everything I can to live to be a hundred.

00:13:31.820 Most doctors would look at you like you had three heads. They can offer you sort of glib insight,

00:13:36.900 like don't smoke and quote unquote, eat well and exercise in those things. But how would we go

00:13:42.080 further? We have to sort of change the way we think about risk, which we'll come to in a second.

00:13:48.120 Can I ask one question? This is a, maybe a silly question or an uninformed question on those codes.

00:13:53.060 Are there codes for say pre-diabetes or pre-hypertension or on the road to metabolic

00:13:58.880 syndrome or even metabolic syndrome where you're essentially saying like, we need to do something so

00:14:03.220 this person doesn't develop one of those diseases or chronic conditions.

00:14:08.040 There's not a silly question and definitely things are changing.

00:14:12.400 Thank you for listening to today's sneak peek AMA episode of the drive. If you're interested in

00:14:17.500 hearing the complete version of this AMA, you'll want to become a member. We created the membership

00:14:22.200 program to bring you more in-depth exclusive content without relying on paid ads. Membership benefits

00:14:28.920 are many and beyond the complete episodes of the AMA each month. They include the following

00:14:33.700 ridiculously comprehensive podcast show notes that detail every topic, paper, person, and thing we

00:14:40.120 discuss on each episode of the drive access to our private podcast feed, the qualies, which were a

00:14:46.640 super short podcast, typically less than five minutes released every Tuesday through Friday,

00:14:51.400 which highlight the best questions, topics, and tactics discussed on previous episodes of the drive.

00:14:56.460 This is particularly important for those of you who haven't heard all of the back episodes.

00:15:01.880 It becomes a great way to go back and filter and decide which ones you want to listen to in detail.

00:15:06.680 Really steep discount codes for products I use and believe in, but for which I don't get paid to

00:15:11.720 endorse and benefits that we continue to add over time. If you want to learn more and access these

00:15:17.400 member-only benefits, head over to peteratiamd.com forward slash subscribe. Lastly, if you're already a

00:15:24.880 member, but you're hearing this, it means you haven't downloaded our member-only podcast feed where you

00:15:29.320 can get the full access to the AMA and you don't have to listen to this. You can download that at

00:15:34.640 peteratiamd.com forward slash members. You can find me on Twitter, Instagram, and Facebook, all with

00:15:42.440 the ID peteratiamd. You can also leave us a review on Apple Podcasts or whatever podcast player you listen

00:15:49.400 on. This podcast is for general informational purposes only and does not constitute the practice

00:15:54.580 of medicine, nursing, or other professional healthcare services, including the giving of

00:15:59.560 medical advice. No doctor-patient relationship is formed. The use of this information and the materials

00:16:05.640 linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a

00:16:11.980 substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay

00:16:19.080 in obtaining medical advice from any medical condition they have, and they should seek the

00:16:24.080 assistance of their healthcare professionals for any such conditions. Finally, I take conflicts of

00:16:29.820 interest very seriously. For all of my disclosures and the companies I invest in or advise, please visit

00:16:36.120 peteratiamd.com forward slash about where I keep an up-to-date and active list of such companies.

00:16:49.080 Thank you.

The Peter Attia Drive - May 18, 2020

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

Episode Stats

Summary

Transcript