#124 - AMA #15： Real-world case studies—metabolic dysregulation, low testosterone, menopause, and more
Episode Stats
Words per Minute
182.02287
Summary
In this episode of the Ask Me Anything (AMA) podcast, Dr. Peter Atiyah and his co-host Dr. Kelly discuss the role of lab tests in assessing blood glucose, insulin resistance, testosterone replacement therapy, and other metabolic biomarkers.
Transcript
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
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.
00:13:54.000
If you're interested in hearing the complete version of this AMA, you'll want to become a member.
00:13:58.420
We created the membership program to bring you more in-depth exclusive content without relying
00:14:03.980
on paid ads. Membership benefits are many and beyond the complete episodes of the AMA each month,
00:14:10.400
they include the following. Ridiculously comprehensive podcast show notes that detail
00:14:15.120
every topic, paper, person, and thing we discuss on each episode of The Drive. Access to our private
00:14:21.560
podcast feed. The Qualies, which were a super short podcast, typically less than five minutes,
00:14:26.920
released every Tuesday through Friday, which highlight the best questions, topics, and tactics
00:14:31.740
discussed on previous episodes of The Drive. This is particularly important for those of you who
00:14:37.240
haven't heard all of the back episodes. It becomes a great way to go back and filter and decide which
00:14:42.440
ones you want to listen to in detail. Really steep discount codes for products I use and believe in,
00:14:47.720
but for which I don't get paid to endorse. And benefits that we continue to add over time.
00:14:52.880
If you want to learn more and access these member-only benefits, head over to
00:14:56.740
peteratiamd.com forward slash subscribe. Lastly, if you're already a member, but you're hearing this,
00:15:03.700
it means you haven't downloaded our member-only podcast feed where you can get the full access
00:15:07.900
to the AMA and you don't have to listen to this. You can download that at peteratiamd.com
00:15:14.040
forward slash members. You can find me on Twitter, Instagram, Facebook, all with the ID,
00:15:20.740
peteratiamd. You can also leave us a review on Apple podcasts or whatever podcast player you listen
00:15:26.940
on. This podcast is for general informational purposes only and does not constitute the
00:15:31.820
practice of medicine, nursing, or other professional healthcare services, including the giving of medical
00:15:37.540
advice. No doctor-patient relationship is formed. The use of this information and the materials
00:15:43.180
linked to this podcast is at the user's own risk. The content on this podcast is not intended to be
00:15:49.320
a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard
00:15:55.480
or delay in obtaining medical advice from any medical condition they have, and they should seek the
00:16:01.640
assistance of their healthcare professionals for any such conditions. Finally, I take conflicts of
00:16:07.360
interest very seriously. For all of my disclosures and the companies I invest in or advise,
00:16:12.640
please visit peteratiamd.com forward slash about where I keep an up-to-date and active list of such