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

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.

00:00:39.340 Everyone, welcome to ask me anything or AMA episode number 15. Now in May, we released the

00:00:46.620 first part of our AMA focusing on my framework for analyzing labs. But in that episode, it took me a

00:00:52.840 little longer to get to some of the actual labs and we weren't able to cover as much as I wanted.

00:00:56.880 So this is a follow-up to that greatly appreciated episode. People had a lot of really kind things

00:01:02.020 to say about it. They really wanted more. And so it was a pretty easy decision to follow up and go

00:01:07.600 a lot deeper because in that episode, we really only got to cardiovascular labs. In this episode,

00:01:12.100 we kick it off with some of the stuff around insulin sensitivity, getting into some oral

00:01:17.120 glucose tolerance tests. We get into testosterone replacement. We talk about menopause and female

00:01:24.680 sex hormones, thyroid hormone, other metabolic stuff that can be gleaned from labs. Overall,

00:01:31.340 I found this to be a really fun episode and I'm really glad we did it. And also there were a couple

00:01:35.560 other pretty cool nuggets that Kaplan threw in here based on some questions from the previous one.

00:01:40.500 So before we start, of course, I need to remind everyone through the obligatory legal disclaimer

00:01:45.900 that this podcast is for general informational purposes only. It does not constitute the

00:01:50.800 practice of medicine, including the giving of medical advice. The use of this information and

00:01:55.900 the materials linked to the podcast is at the user's own risk. The content of this podcast is

00:02:01.300 not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should

00:02:07.320 not disregard or delay in obtaining medical advice for any medical condition they have. And with all

00:02:13.420 of that said, and without further delay, I hope you enjoy AMA number 15.

00:02:22.520 Welcome back to another AMA. We may consider this one a part two. I think it was back in May,

00:02:29.320 we had, let's call it part one, where a lot of questions came in about what lab tests should I be

00:02:34.960 getting? And I think that turned into, well, it depends. And actually it's more of how does Peter think

00:02:41.000 about labs. And we got into some really interesting case studies or patient cases on cardiovascular.

00:02:47.760 And I think that we wanted to get into more cases and didn't have enough time. So we're going to come

00:02:53.200 back and discuss a few more patient cases. But first we had some feedback from the first part one AMA,

00:03:00.460 where we got a couple of really interesting questions that I think we should address up top.

00:03:04.240 And so the first question that I have for you, Peter, is this one. When a patient is going in

00:03:09.620 for their labs, how long before the lab should they cease taking any supplements if they're taking

00:03:14.180 any? And should they stop taking supplements for labs at all? So, I mean, I think it really depends

00:03:20.160 on what the supplement is and what's the purpose of the test. But almost without exception in our

00:03:25.100 practice, it's the opposite. We'll check in with patients a month before a scheduled test to be sure

00:03:30.240 that they are on their supplements. And if they are not, we'll postpone the lab test until they

00:03:35.480 resume them. For most supplements, there's some biomarker that we would track. For example, if

00:03:41.680 we care about a person's homocysteine level as the metric we're tracking, then that's why we might be

00:03:48.720 giving them methylated B vitamins. So if we find out, hey, I ran out a month ago and I forgot to refill

00:03:53.420 it, it wouldn't make a lot of sense to repeat the information we already know, which is, hey,

00:03:58.600 when you're not taking a methylated B vitamin, lo and behold, your homocysteine is high. I'm trying

00:04:03.320 to think of an example of when I want someone to stop a supplement or a medication outside of when

00:04:09.200 I want to actually know how they look without it. But I think the more important point here

00:04:15.140 is you need to know how long it takes to see the effect of the intervention. And so, for example,

00:04:22.960 one of the longer tail things is looking at, for example, the omega quant test that we use to measure

00:04:30.880 EPA and DHA index. So this is a test that looks at the red blood cell membranes and measures the

00:04:40.100 amount of EPA and DHA, which are omega-3 fatty acids. We spoke about this on a podcast with Bill

00:04:45.840 Harris some time ago. That's a test that you use to assess either how much fish a person is getting

00:04:51.640 through their diet, like how much fish oil is coming in naturally, or in the case of most people

00:04:56.240 through supplementation. But you have to know that it could take up to three months to fully

00:05:01.680 assimilate the change you make to see that. So if you gave somebody that supplement and then tested

00:05:07.400 them a month later, you could be misled into thinking you're not giving them enough. Whereas

00:05:13.120 other things work very quickly. For example, a drug like Repatha, probably within two doses,

00:05:18.480 which is given over the course of two weeks would be sufficient to know if the drug is working or

00:05:24.340 not. So whether we're talking about drugs or supplements, the real question is knowing what

00:05:29.680 the period of time is it takes to see an effect and making sure that you're being thoughtful about

00:05:35.060 that. And again, I think the bigger issue is making sure that the patient didn't run out or didn't

00:05:40.200 forget to take it so that you're not scratching your head. And this happens to us still, despite all our

00:05:45.680 checks and balances, this still happens to us where we get labs back and we think, oh, this can't make

00:05:49.980 any sense. And then we talk to the patient and like, oh yeah, I ran out of that thing. Sorry, I forgot

00:05:54.760 to tell you guys. So that's our take on that. Okay. The next question is, you mentioned asking your

00:06:01.140 patients about their family history and how important that is. I know we got into that about

00:06:05.360 how important it is, how much you can learn from getting a family history. And this person asked,

00:06:10.420 what questions or information do you ask new patients on family history?

00:06:14.900 Oh, I'm glad somebody asked that question because it's something I feel so strongly about.

00:06:18.920 A lot of times patients will come in and they'll say, I have my 23andMe data. Is that all you need?

00:06:23.820 And I was like, actually, that pretty much tells me nothing. We'll take it. Thank you very much. And

00:06:28.680 we will scour the hell out of it. And we'll find out if you have a TOM40 SNP and that'll increase

00:06:34.580 your risk of Alzheimer's disease. And maybe you got a certain FOXO3 SNP and there's some

00:06:39.600 interesting stuff here and there. Obviously the genes that we think really matter, we're measuring

00:06:43.900 on our own, such as the MTHFR genes and of course the APOE. But what I say to them is, look,

00:06:50.540 this stuff doesn't mean jack compared to your family history. Once in a while, you'll see a patient

00:06:55.280 who's been adopted or has been estranged from some part of their family for which that's simply

00:07:00.420 impossible to know. And that is what it is. But for somebody who's not in that situation,

00:07:05.060 we actually give our patients a template to be filled out in advance of our first meeting.

00:07:10.440 And the template goes through the following. So for mother, father, both sets of grandparents,

00:07:16.900 and all aunts and uncles and siblings, we actually want to know everything that is knowable. So our

00:07:23.820 template is really painful for the patients. I will acknowledge that upfront. So starting with

00:07:28.360 cardiovascular disease, does anybody have a history of cardiovascular disease? Did they take

00:07:32.660 any medication for blood pressure, cholesterol? Did they ever have a stroke, chest pain, heart attack,

00:07:37.160 all of these kinds of things. We go through the same type of questions around dementia and then

00:07:43.100 cancer and then metabolic disease. Did they have diabetes? And then when we're talking about this,

00:07:48.760 because the reality of it is virtually nobody can show up with that level of granularity. So then

00:07:53.100 these become the questions we prod. And I think it's important to give patients that information

00:07:59.400 long before you see them. Nobody can show up to a first meeting with their doc and know that.

00:08:06.460 You'd have to be a freak of nature to have that information at hand. And it usually requires lots of

00:08:12.160 phone calls. And sometimes you're asking about relatives that have been long dead and or for whom

00:08:17.620 you've never met. So the more you know these things, the better. And it's also important to understand

00:08:22.720 context. You'll get some family histories that are full of cancer, but then you ask that second

00:08:29.020 order question and find out, oh, well, that person also smoked three packs a day. If you didn't know

00:08:34.260 that detail, you might be inclined to think, well, this person's family history of cancer is crazy.

00:08:39.740 But in reality, every one of the people who died of cancer was also a three pack a day smoker. So you

00:08:44.920 have to take that with a grain of salt. Similarly, the person who has a family member that died of

00:08:49.820 a heart attack at 50, well, it's really important to know a lot about that person. Is this a case of

00:08:54.740 LP little a, which can easily present in myocardial death at 50? Or was this somebody who was an

00:09:02.360 alcoholic and or a very heavy smoker and or had some other risk factor? So I don't have a simple

00:09:08.260 formula or template from this other than the more time you spend on it, the richer it is. And the more

00:09:14.400 you can potentially glean about what's really at the root of the genetic template that your

00:09:20.140 patients inherited. It may sound silly, but it's almost like doing a book report when you're young

00:09:25.240 and you're doing it on your dad or somebody like that, and then just extending it out. And then

00:09:29.020 you may learn some things that are really surprising. Like you're talking about your dad's

00:09:34.360 brother died of a heart attack at age 50, and then you found out they have more siblings and they had

00:09:39.140 cardiovascular disease. And it seems a little bit younger and realize like, if you haven't looked at it

00:09:43.720 before, that you can start to connect some dots there, just looking at family history rather than

00:09:48.160 looking at labs. I think it's a really important thing. I didn't even do my own until somewhat

00:09:54.440 recently in the level of detail that I would expect of a patient. And that was kind of humbling first to

00:09:59.600 realize, A, I hadn't done it, but two, to actually learn the information about the true mortality of all

00:10:06.480 the aunts and uncles. And even now, by the way, I can't really provide a single shred of insight

00:10:13.200 about how my paternal grandparents died because they died before my dad was even married. My dad

00:10:21.140 is potentially the world's single worst historian. So asking him anything about how his mom and dad

00:10:27.740 died, I might as well use a Ouija board. He just keeps rambling off things that make absolutely no sense.

00:10:33.840 So I can absolutely relate to my patients who come in and complain of the same thing,

00:10:39.340 which is I asked my dad how his parents died or asked my mom how her parents died. And

00:10:43.240 they just said they make up something that sounds completely nonsensical. So I truly have no clue

00:10:48.720 how his parents died. And frankly, I probably have no clue about a bunch of things in my family history.

00:10:54.120 So it's tough, but you do the best you can. And that information usually pays off quite a bit.

00:10:59.680 And you're looking for patterns. This is where a lot of the times you'll see that signature of

00:11:06.060 cancer. You'll see that signature of dementia, cardiovascular disease. And it also really helps

00:11:12.760 with understanding what to make of the findings you have in front of you. One in 10 people roughly

00:11:19.280 show up with an elevated LP little a, but the number by itself doesn't tell you how bad of a problem

00:11:24.900 it is. I mean, we know LP little a is bad, but is this a big problem or just a medium problem?

00:11:30.680 But the family history can often elucidate that. And the people who have a lot of sub 60 year old 0.99

00:11:37.660 cardiovascular events and elevated LP little a, boy, like you need to be acting on that in the most

00:11:44.040 aggressive manner. And then in the families where the LP little a is very elevated, but nobody's having

00:11:48.960 any events into their eighties. Maybe you don't need to be as aggressive.

00:11:53.780 I think that's a nice segue. When you talk about your dad, not being the best historian that

00:11:57.780 you may have talked about this in the previous podcast about a lot of this stuff when you're

00:12:01.980 talking about labs, but really you're trying to put a puzzle together where you have some pieces and

00:12:06.840 it's, it's like an investigation or you're a detective trying to figure out what are the things that we

00:12:11.880 should be looking for? And I think these patient cases are great examples of, you get this question

00:12:17.040 so often, Peter, what are like the top five lab tests that I should be looking at? And maybe you

00:12:21.200 have your five, put a gun to your head. You've got your five, but based off what those labs tell you,

00:12:25.700 you have 10 more questions that you want answered and they're not going to be answered within those

00:12:28.900 five labs that you just got. It might take you down a path. And so I think what we want to get to

00:12:35.440 here is we've got a couple, I think at least, yeah, we've got a few cases of OGTT or oral glucose

00:12:42.320 tolerance tests that I think that you do with most, if not every one of your patients.

00:12:45.940 And what information can that yield beyond a lot of people just use fasting blood glucose or even a,

00:12:51.680 even an oral glucose tolerance test with looking specifically at glucose and not looking at other

00:12:55.460 things like insulin. So are there any cases in particular that you would want to get into that

00:13:00.400 can help elucidate some of this stuff with OGTT? Yeah, Bob, as you said, the OGTT is a really

00:13:07.220 cumbersome test and there's a reason that it's not a test that is done commonly, certainly not with

00:13:13.460 frequent sampling and looking at glucose and insulin. In fact, when we began working with

00:13:19.140 our current lab, which is called Boston Heart Labs, they didn't even have a protocol for it and they

00:13:26.320 refused to do it initially. And it took us six months of arm twisting to even get them to agree to do the

00:13:34.260 test such that we could do it all under one rec form and have the information reported. That's

00:13:41.220 how cumbersome it was. So obviously I believe in this test or I wouldn't jump through the hoops to

00:13:47.800 do it. So what is the test? Thank you for listening to today's sneak peek AMA episode of The Drive.

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The Peter Attia Drive - August 17, 2020

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

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