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

Hey everyone, welcome to a Sneak Peek, Ask Me Anything or AMA episode of the Drive podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com subscribe so without further delay, here's today's sneak peek of the Ask Me Anything episode.

Hey everyone, welcome to another Ask Me Anything or AMA episode. This is number 14, one of our previous AMAs. I mentioned how I like to think about lab ranges, and I might look at them in a way that's not necessarily congruent with the way the labs themselves talk about them. And I talked about doing potentially an episode about looking at labs and such. So this is that episode. So this is a pretty big topic, and we actually didn't cover as much as I thought we would before we ran out of time on this episode. So in this episode I talk very broadly, but I think comprehensively and in a manner that's helpful to think about labs, about my framework for what labs can inform and what they can't inform. And again, even though that took longer than I thought it would take, I don't think it makes sense to get into this discussion discussion without starting with a foundation. So I think you'll find that interesting, and hopefully it's the type of thing you don't have to go back and revisit over and over again. But sitting through it once is a really good way to say, okay, if I'm going to go to the trouble of doing advanced testing, what am I learning? And just as importantly, what am I not learning? We then go into a couple of cases around cardiovascular disease, and that's pretty much where we run out of time on this episode. It goes by really quick, and what we're going to do is come back and just pick it up on the same thread going into other sorts of cases. So at the end of this episode, I talk about what we're going to come back and visit. And of course, if based on this episode you have specific types of lab questions or scenarios, maybe is a more important way to think about it that you want to dive into. Please let us know and we can obviously add that to subsequent episodes. So before I start, I have to obviously give the obligatory disclaimer, which is that this podcast is for general informational purposes only. It does not constitute the practice of medicine, including the giving of medical advice, the use of this information and the materials linked to it in the podcast are at the user's own risk. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they have. So with that said, and without further delay, I hope you enjoy ama number 14.

Hello podcasters. Welcome to another Ask Me Anything with Peter Attia. This is your host Bob Kaplan, asking your burning questions. This time around, we've compiled the many questions you have on the topic of lab tests. I know Peter has answered a few questions here and there, and actually on our first ama, he discussed some of the best lab tests for assessing overall longevity. We can possibly revisit some of those, but either way we'll be sure to include that information in the show. Notes Peter has also left a lot of breadcrumbs in podcasts and interviews where he'll discuss ranges and cutoffs he likes to see on a given test. And those values might not always reflect the ones you might see on the report that you get back from a lab. So I've actually gathered a bunch of those ranges. So one thing we can do is throw those into the show notes of the episode so they're all in one place. If you put those two topics together, many people essentially want to know, what are the tests that I should be getting, and what do the specific results of those tests tell me? A number of the questions we've received really feed into the broader question of how does Peter think about labs, both as a patient himself and as a doctor who treats patients? What does a lab test actually tell you? What does it not tell you? Where can you be fooled? How often should I get a particular test? How can one lab test inform another lab test? What's the difference between normal and optimal? What tests are most useful? What tests are useless? Why are we doing these tests in the first place? So those are all listener questions. And so instead of just taking these questions in isolation one by one, we thought it would make for a much more useful podcast for Peter to actually walk us through his shtick on labs that he gives to patients, and secondly, for Peter to share some really interesting cases he's experienced with patients that can give us real world examples of how Peter thinks about labs and how it might inform his decision making. So I guess Peter, the first question goes to you, which is if I'm a patient of yours and you want to take a bunch of my bodily fluids, I guess my question is a why do you want to do that, and B, what information are you trying to extract from that?

So I think every time I sit down to review labs with a patient for the first time, I usually take a step back and try to put the labs in the context of how they fit into our overall objectives with respect to longevity. And I do this through the lens of the way I've spoken about this before, which is longevity has these two components, lifespan and health span. By identifying the components of each of those and then looking at where labs have information or can shed light on those things versus where they can't, you start to get a sense of where the labs are, adding value and of equal importance, where you have blind spots. So I do think it is important to have this discussion before we jump into the examples that we've pulled aside. So what is longevity again? Longevity is a function of two things. It's how long you live, and that's the part that's called lifespan and how well you live. That's the part that's called health span. The lifespan part is easier to explain because it's binary. A person is either alive or they are dead. The health span part, which we'll save for a second, is a little harder to understand. Maybe harder to quantify is a better way to say it. I think it's relatively straightforward to understand. Okay, so living longer is effectively going to boil down to how long can you delay the onset of chronic disease. Many people have probably heard me say that before, but I want to unpack that a little bit more. If we look at the centenarian literature, and as you know, we have devoured that literature in the process of writing the book. In fact, one chapter of the book is entirely dedicated to centenarians. I think it's chapter four. They've taught us a lot. So even though they turn out to be sort of genetic lottery winners, people who, almost through no action that they've taken, are going to live to be 100 or beyond, and instead, through some amazing luck that they've inherited a set of genes, are still a very illustrative population to study. And we learned a lot from them. But I think the single most important thing we learned from them is they don't live longer once they get a disease. They just take longer to get a disease. And that's really important. That's not obvious if you haven't sort of dug into it. It could easily be the case that centenarians acquire disease at the same rate and at the same time as non centenarians. But their Superpower is living longer with the disease, being more resilient to a disease once it sets in. But as you know, Bob, that turned out to not be the case. So when we asked that question directly, the answer was overwhelmingly in the opposite direction. And indeed, their superpower is how long they can go before they get the first chink in their armor. But once that disease sets in, they've basically been exposed to kryptonite and they are now just mere mortals like the rest of us. So the way I describe this in the book is they have a phase shift. So they have a phase shift in time that delays the onset of disease. So if you want to live longer, the mathematical equivalent function is delay the onset of chronic disease, not figure out ways to live longer once you have chronic disease. It's worth noting that unfortunately, the entire healthcare system is mostly geared towards the opposite. Prevention is not really the mainstay of medicine. Medicine has had its greatest impacts or its greatest efforts basically on what to do once you have a disease, how do you live longer? So once you have Alzheimer's disease, what drug might reverse the dementia or slow its progression? Of course, the sad reality of that is none. We've spent billions of dollars trying to answer that question and come up empty handed. Similarly, when we look at cancer treatment, once you have cancer, what can you do? Well, unfortunately, we haven't made a lot of progress in 50 years. So if you go back to 1970 and you look at what the long term survival was of a patient with metastatic cancer and you compare that to today, the answer is almost the same. It's roughly about a 5% improvement we've made in 50 years. Again, not great. And it probably speaks to the challenge of treating a disease like cancer or Alzheimer's disease, where once you have it, modern medicine doesn't seem to be able to do that much more today than it could 50 years ago to erase it. So I think one place where we've seen the most progress on managing a disease once it sets in is, is cardiovascular disease. And I could spend an entire AMA just discussing the differences between cardiovascular disease and cancer and dementia. But part of it, I think, has to do with the fact that atherosclerosis is much more of a continuum than dementia and cancer. And therefore that coupled with the fact that we have a far better understanding of atherosclerosis, I think as complicated as a disease as this is, and I don't mean to undermine people who study it for a living, it's. It is far and away a simpler disease process to understand than the other two major pillars of mortality. So that's a long winded way of saying, I hope I can convince a person that if you want to live longer, you've got to figure out how to delay the onset of these chronic diseases, not live longer once you have them.

I think it's a study by the group Thomas Pearls, which is, I think he's out of bu the New England Centenarian Study. We were looking a lot at Nir Barzilai's Longevity Genes project, but Pearls has an interesting article where he talks about exactly what you just framed there, where there are three groups. There's delayers, escapers and survivors. And so you have the people. So how many of these centenarians are delaying disease? How many are completely escaping some of these chronic disease and then how many are just living with it and have superpowers? And the majority of the cases were, probably no surprise, they were the delayers and so they were delaying disease. Which fits exactly with what you're talking about.

Yeah, and again, it's important for me to explain to patients that phenomenon. And you actually just stated in about 31 seconds what it took me probably five minutes to explain, so I might have to start bringing you in on these meetings. And then secondly, it's important to explain to them that this approach, while conceptually logical, and I think once most people hear it, they're like, yeah, that totally makes sense, is not congruent with how most people go to the doctor. And again, it's been stated a million times before, we don't really function in a system of healthcare. We function in a system of sick care. Meaning we interact with our healthcare system in a manner that is once there is a problem, we seek help. And again, you know, I'm not one of these guys who likes to rail against healthcare. And that's just not true. Look, that's just the nature of the way the system works. The system works by identifying a disease and then label. You know, basically the more clearly you can identify and label a condition, the more accurately you can provide a treatment for it. And so that's the way we were educated. So medical education is predicated on this idea that you put a label on a disease. And by the way, the entire financial system around it is predicated the same way. You have to come up with a billing code that explains what a person has. This person has hypertension, this person has dyslipidemia, this person has fill in the blank. So we have a code. The code allows us to bill an insurance company for it. We peg treatments to these things and that's the way we go. So everything that we learned in our medical training was based on this. And it's not surprising then that when patients go to their doctors and say, hey, I'm perfectly healthy, but whatever, 40 years old, but I really want to do everything I can to live to be 100%. Most doctors would look at you like you had three heads. They can offer you sort of glib insight like don't smoke and quote unquote eat well and exercise in those things. But how would we go further? We have to sort of change the way we think about risk, which we'll come to in a second.

Can I ask one question? This is a maybe a silly question or an uninformed question on those codes. Are there codes for say pre diabetes or pre hypertension or on the road to metabolic syndrome or even metabolic syndrome, where you're essentially saying like we need to do something so that this person doesn't develop one of those diseases or chronic conditions.

There's not a silly question. And definitely things are changing.

Thank you for listening to today's Sneak Peek AMA episode of the Drive. If you're interested in hearing the complete version of this ama, you'll want to become a member. We created the membership program to bring you more in depth exclusive content without relying on paid ads. Membership benefits are many and beyond the complete episodes of the AMA each month. They include the ridiculously comprehensive podcast show notes that detail every topic, paper, person and thing we discuss on each episode of the Drive. Access to our private podcast feed the Qualys, which are a super short podcast, typically less than five minutes, released every Tuesday through Friday, which highlight the best questions, topics and tactics discussed on previous episodes of the Drive. This is particularly important for those of you who haven't heard all of the back episodes becomes a great way to go back and filter and decide which ones you want to listen to in detail. Really steep discount codes for products I use and believe in but for which I don't get paid to endorse and benefits that we continue to add over time. If you want to learn more and access these member only benefits, head over to Peter Attia Md.

Subscribe.

Lastly, if you're already a member but you're hearing this, it means you haven't downloaded our member only podcast feed where you can get the full access to the ama. And you don't have to listen to this. You can Download that@peterattiamd.com members you can.

Find me on Twitter, Instagram and Facebook all with the ID Peteratti md. You can also leave us a review on Apple Podcasts or whatever podcast player you listen on. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services including the giving of medical advice. No doctor patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take conflicts of interest very seriously. For all of my disclosures and the companies I invest in or Advise, please visit PeterAttiamD.com about where I keep an up to date and active list of such companies. Sam.