00:00:00.000Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.
00:00:15.820I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can access
00:00:20.280the AMA episodes in full, along with a ton of other membership benefits we've created,
00:00:24.900Or you can learn more now by going to peteratiyamd.com forward slash subscribe.
00:00:30.600So without further delay, here's today's sneak peek of the Ask Me Anything episode.
00:00:38.960Welcome to Ask Me Anything AMA episode 91.
00:00:43.040Today we're going to talk about lab testing.
00:00:46.180Labs are often the first thing people reach for when they want an answer to probably the
00:00:51.700most important question imaginable, which is, am I healthy?
00:00:54.900objective, numerical, and come with reference ranges. So it's easy to treat them as a report
00:01:01.200card on your entire health status. But that instinct kind of oversells what labs can actually
00:01:06.960do. Their real utility is actually a lot more nuanced than that. So today we're going to walk
00:01:11.220through where lab testing is genuinely helpful, where it's useful but incomplete, and where it
00:01:17.620tells us very little or frankly nothing. And it gives you a framework for noticing the difference.
00:01:23.680So we're going to cover why people turn to labs to answer the am I healthy question and what that question really means in the context of longevity, how to use blood work for each of the major chronic disease states, cardiovascular disease, metabolic dysfunction, cancer, and neurodegeneration, and what labs are missing in each case, what labs can and can't reveal about the organ systems in our body and why more tests doesn't necessarily mean more useful information.
00:01:52.160why large direct-to-consumer panels and biological age scores can look sophisticated without
00:01:58.720necessarily changing a single clinical decision, how the picture changes when we shift from
00:02:04.040lifespan to healthspan, and why physical function, cognitive function, and emotional health mostly
00:02:09.180can't be captured in a blood draw. And we'll provide you with a practical set of questions
00:02:13.840to ask about any lab test so you'll know what it's actually telling you and perhaps more
00:02:18.860importantly what it isn't. If you're a subscriber and you want to watch the full video of this
00:02:23.060podcast, you can find it on the show notes page. And if you're not a subscriber, you can watch
00:02:27.200the sneak peek of this video on our YouTube page. So without further delay, I hope you enjoy AMA
00:02:32.000number 91. Peter, welcome to another AMA. How are you doing? Very well, thanks. Awesome. So today's
00:02:44.280AMA, we're going to focus on lab testing. And if you compile all the questions people send us,
00:02:50.060the vast majority of them will touch this topic at some level, meaning someone says,
00:02:55.420Hey, I just got blood work done. And the result of X was Y, what should I do? So I think it's not
00:03:01.320only a topic that is interesting. A lot of people care about, but it also seems like this is where
00:03:06.320people really focus on, you know, a report card of their health in a way. And so I think what'd
00:03:12.080be helpful is when we start is for you, when you work with patients, you're obviously reviewing
00:03:16.140labs with them often. And when you do it for the first time, you know, what do you hear from them?
00:03:21.540What do you hear that patients typically are hoping that these labs will tell them when you're
00:03:26.600going through that review? Well, I mean, I think people rarely say explicitly, Hey, I just want to
00:03:34.220know if I'm healthy or not. I mean, I think more broadly, there's a belief and over the years in
00:03:40.580anticipation of that, I've sort of preemptively addressed this on every first lab call, but the
00:03:45.980belief is that, hey, by the time we're done this exercise today, I'm going to know everything I
00:03:52.120need to know about my health. And obviously, you know, a subset of that, or at least subservient
00:03:57.760to that question is I will know if I'm healthy. Right. And again, it's a very understandable
00:04:02.420assumption to come in to a lab assessment with, because for the most part, when you've interacted
00:04:09.960with the healthcare system, the only routine maintenance things that tend to get done are
00:04:17.860lab testing. Now, of course, there's more than that, but we tend to think of imaging in a
00:04:22.580separate category. So obviously a woman who gets her mammogram every year would also consider that
00:04:27.400a part of her routine health maintenance. But for most people, when we interact with our doctors,
00:04:33.160we're doing so around lab tests. And again, they're objective, they're numerical, they have
00:04:39.460these reference ranges, I mean, all, all of these things about them make them feel like they should
00:04:44.700be complete. And I think there's another thing, which is that if you don't fall outside of a
00:04:51.700reference range and therefore nothing is getting flagged, I think people sort of assume, Hey,
00:04:56.320all systems are go, you know, the check engine light isn't coming on. So everything is, is,
00:05:01.520is okay. And I would say that that view has probably been amplified over the past few years
00:05:07.500because there is really no shortage of direct-to-consumer testing products out there.
00:05:12.400And that's kind of, I think, doubled down on that belief system, which is, hey, this is the thing
00:05:17.540you need to know. And if you buy our D2C product that will check your labs and frankly, even test
00:05:25.060lots of labs, we're going to have the solution to every problem. And so I usually just start by
00:05:32.080explaining where I think the labs are valuable, but also where their blind spots are. And I think
00:05:37.040that's an important discussion to have so that at the end of the lab discussion, I usually end
00:05:43.840up saying something to the effect of, look, we will know roughly a third of what we care to know
00:05:49.820about you, maybe a bit less, maybe 25%. And that's a very important 25%, but we have a lot of work to
00:05:57.200do to really kind of get under the hood of truly understanding risk across everything that we care
00:06:01.520about. And that's something we're going to dive into much more detail here today's AMA. But I
00:06:07.860think what may be helpful is kind of stepping back. You ask the question, you know, are you
00:06:11.700healthy? Right. And that's ultimately what people care about and want to know. And so when you're
00:06:17.300trying to understand the answer to that question for your patients, you know, how do you go about
00:06:23.140that? What are you, what are you looking at and what are you truly trying to understand around
00:06:27.940that core question of, am I healthy? I mean, look, I think you have to start with defining what that
00:06:34.180means. And I think there are different ways to define that. If you're talking to a patient who
00:06:41.720has just finished chemotherapy for cancer, then the definition really probably should
00:06:48.620center around that, right? It should be, am I NED? NED means no evidence of disease. So has
00:06:55.060the chemotherapy worked? Is the cancer for all intents and purposes gone? Are my blood counts
00:07:00.340back to normal? Because chemotherapy often wreaks havoc on the hematopoietic system.
00:07:05.420And that frankly might be all you care about, right? Am I not anemic? Have my white cells come
00:07:09.760back? And am I free of cancer? And that would constitute the definition of am I healthy at
00:07:14.920the moment? And so in our context, in our practice, which I actually think reflects what many people
00:07:21.440are hoping to achieve when they, when they think through this question, we are really trying to
00:07:26.820think about it through the lens of what are the threats to longevity. And again, longevity has
00:07:33.160this very, at least in our view, pretty clear definition. That's, that's pretty straightforward,
00:07:37.760right? Which is, it's the, it's the product of both lifespan and healthspan. And therefore,
00:07:43.620if you're, if you're in pursuit of better longevity, what that's saying is I want to
00:07:49.240live longer or I want to live as long as possible in as high a state of health as possible. And not
00:07:56.820having one of those things is insufficient. So living a long time in poor health, that's not
00:08:01.960optimal. And having a short life in high health is also not optimal. So we want both of those
00:08:07.780things. And we frame it through the lens of what are the impediments to those things. And it's
00:08:15.440actually a relatively finite number of things. So on the lifespan side of things, the impediments
00:08:21.600are the things that will shorten your life. So that is cardiovascular disease, cancer,
00:08:26.740neurodegenerative and dementing diseases, metabolic disease, accidental deaths. Those are really the
00:08:32.620big ones. Now, of course, there are also organ-specific diseases and things like that that
00:08:38.240can fit in there. And we would always address those when relevant. So a person can also die
00:08:43.720from chronic obstructive pulmonary disease, if they have a longstanding history of smoking,
00:08:48.260kidney disease, liver disease that is unrelated to metabolic disease, et cetera. So there are
00:08:53.440other things in there, but you're capturing most of it through what we just described.
00:08:57.880And then on the healthspan side of things, we're really talking about physical health. And so
00:09:04.320that's, you know, freedom from pain, strength, endurance, excellent mobility, basically the
00:09:11.220ability to do anything you want physically and different people will have a different threshold
00:09:16.440of course so some people will have very high aspirations there and others will have modest
00:09:21.340aspirations and therefore they'll have a different standard for what constitutes healthy then there's
00:09:26.360a cognitive component to that which is the ability to to engage with your with your brain right so
00:09:32.620this is everything from processing speed and short-term memory and long-term memory executive
00:09:37.480function, all of those things. And then there's an emotional component, which is, again, made up
00:09:42.420of many things, but it includes sense of purpose, happiness, strength of relationships, emotional
00:09:48.100resilience, high distress tolerance, all of those things. And as we go through this exercise,
00:09:54.920we feel that health constitutes everything I just talked about. And then we talk about how does the
00:10:02.820lab result help those things? Is it informing those things? And if so, great. And if not,
00:10:09.100then do we have another way that we can look at those things?
00:10:12.900And so before we kind of dive into labs, as it relates to each of those kinds of major diseases
00:10:17.280and categories you laid out, I think from a high level, how do you think about like a single
00:10:24.140snapshot of someone's lab? So if you're meeting with a patient for the first time and you have
00:10:28.900their labs from the week prior, right? How informative is that compared to if you have
00:10:35.120the labs from a week prior, as well as like a longer history of all the random times that they
00:10:40.900went to the doctor? Well, I think there are a couple of things embedded within that. The first
00:10:46.880is reliability of a lab. So if you only have a snapshot, if I only saw your labs, Nick,
00:10:53.620from today or last week, and I had no access to anything else, it would be really difficult
00:11:01.520to make a decision, even in the context of something that was abnormal, because I truly
00:11:09.440don't know if it is abnormal or if it's just actually a laboratory error. So you always have
00:11:16.940to have that in the back of your mind. And that's much easier to evaluate when you have longitudinal0.88
00:11:21.560data. Furthermore, even if I know that it is not aberrant, if I know that, hey, that result is
00:11:32.080actually what it says it is, I don't necessarily know how long it's been abnormal. And in some
00:11:37.720cases that might matter. So I'll give you an example. If I see that your C-reactive protein is
00:11:43.660three, and if this is a highly sensitive C-reactive protein, that would be quite elevated.
00:11:48.700And then let's assume I just immediately repeated the test and lo and behold, it was three, not a lab error. Okay. But is it just three this week? I mean, maybe you're sick. Maybe you were vaccinated two weeks ago and this is still some lingering level and it's coming back down, but it was, you know, 42 weeks ago. But your baseline is, you know, 0.5.
00:12:10.020I can't figure out if this is sort of chronic inflammation or if it's reactive, if it's going
00:12:16.160up, if it's going down. So it would be difficult for me to sort of weigh in and say that we're
00:12:21.560going to, you know, implement this playbook that we typically implement for people that have high
00:12:26.060inflammation. The same I think would be true for something like ApoB or LDL cholesterol.
00:12:31.600So if your LDL cholesterol is, let's say it's 160 milligrams per deciliter, that's very,
00:12:37.160very high, right? That would put you above the 80th percentile. If that's just that high because
00:12:43.480you've gone on a diet in the past, you know, three months that has you mainlining saturated fat and
00:12:50.080your ApoB and LDL-C have gone up, you know, that's kind of a different situation than if it's been
00:12:56.100that high your whole life, which might actually suggest you have a genetic condition that's
00:13:00.200driving that. So I think longitudinal data are valuable, but you also have to work with what
00:13:05.820you have. There are some people who come in with very little longitudinal data, and you still have
00:13:11.460to make decisions based on the information you have. Obviously, there are certain things that
00:13:15.320you don't need to check more than once, LP little a, APOE, or any other genetic test, assuming that
00:13:21.100the answer you got is correct and the lab was done. So I don't know, hopefully that answers
00:13:25.940your question, that it's a bit of both. No, for sure. And I think it will be helpful now
00:13:31.920to kind of go through the major chronic diseases one by one that you laid out earlier and just
00:13:37.680talk about, okay, where are labs helpful and where do they kind of leave a picture still unpainted?
00:13:44.100So let's start with the biggest killer, cardiovascular disease. So what do labs tell
00:13:49.300us and how helpful are they in understanding someone's risk of this disease? Thank you for
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