May 18, 2020

Diseases

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

"Metabolic health really matters. It is the common thread that links all of these chronic diseases." — Peter Attia

Read Time 21 minutes

In this “Ask Me Anything” (AMA) episode, Peter explains his framework for understanding what lab tests can (and cannot) inform us as it pertains to overall longevity, with a specific focus on atherosclerosis, cancer, Alzheimer’s disease, and the physical body. Additionally, Peter shares details into two patient case studies around cardiovascular disease, including how the lab results influenced his diagnosis and treatment plan for the patients. Once again, Bob Kaplan, Peter’s head of research, will be asking the questions. If you’re not a subscriber and listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or on our website at the AMA #14 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.

We discuss:

  • Important lab tests and reference ranges [2:35];
  • How lab testing fits into the overall objective of longevity [4:25];
  • A healthcare system set up to react to a disease rather than prevent it [8:00];
  • The four pillars of chronic disease, and the three components of healthspan [14:30];
  • Atherosclerosis—How much can labs tell us about risk? [18:00];
  • Coronary calcium score (CAC)—interpreting results based on your age [24:15];
  • Cancer—what lab work can tell you, and the future of liquid biopsies [28:00];
  • Alzheimer’s disease—what’s driving Alzheimer’s disease, and what labs can tell you about your risk [33:15];
  • Healthspan and the physical body—where lab testing fits, the endocrine system, and zone 2 testing [39:00];
  • Summarizing the usefulness of lab testing—where it gives great, reasonable, or lousy insight [43:15];
  • Patient case study—elevated Lp(a): Understanding ApoB, and how cholesterol levels get reduced [45:30];
  • Patient case study—familial hypercholesterolemia [59:30];
  • Coming up on a future AMA [1:10:30]; and
  • More.

§

Important lab tests and reference ranges [2:35] 

The following is from AMA #1

Peter’s top five lab tests:

  1. Lp(a)-P (or Lp[a] mass is a reasonable approximation).
  2. APOE genotype.
  3. LDL-P (or ApoB).
  4. OGTT with insulin measurements.
  5. ALT.

Honorable mentions: Hcy, hs-CRP, oxLDL, and oxPL, fibrinogen, Lp-PLA2, ADMA and SDMA are also really helpful to know. Estradiol (E2) as well. Knowing your family history can also tell you something about risk.

Peter’s preferred lab results ranges (which may differ from the “standard” ranges) …

{end of show notes preview}

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25 Comments

    • No: when you measure acidity in the urine, you don’t measure any *particular* acidic compound in solution — just the overall balance of acid vs. basic compounds in the solution.

  1. I have not listened to the pod yet — just read the notes and listened to the last couple of minutes to see what was teased for the followup — but based on that alone, this is great stuff, which I’ll be looking forward to listening to: thank you very much, Dr. Attia.
    You mention Lp(a)-P as being one of “Peter’s top five lab tests,” but don’t give a range in the table — please update (for both mass and particle number, since only the former is actually readily available). You might want to discuss rough conversions in light of:
    https://www.lipidjournal.com/article/S1933-2874(14)00307-9/abstract

    Also, one thing you don’t appear to have mentioned is 24 hour urinary C-peptide, which Dr. Attia has recommended as a possible readout of integrated insulin production on the pod and even suggested as a top test on his recent IHMC interview. Giving a recommended value in the Table for now would be great, and then discussion of this on a followup pod

    Finally: Peter, I was worried about your long silent period on social media, and it’s clear from your surfacing video on IG that you underwent some kind of personal crisis. I’m very sorry for the pain you and maybe your family have suffered, and despite the great value I get from your pods and other material, I want you to know that we all want you to take the time and put in whatever kind of personal investments you need to become whole (again) on all levels. Pillar #3, you know?

    • Agree 100% on the last point, Mikal. Peter, thanks for what you do — I know you will but do take much deserved and needed time for yourself and your family.

  2. When you say a person’s lab results are in the xth percentile, where is this coming from? What exactly do you mean? Also, I can’t find the ApoB app for iPhone. Is it still around?

    • Amy: the percentiles come from the population distribution of the patients being tested by the lab. So it’s the distribution of results for a given test in every patient that has been tested by LabCorp, or Quest, or whoever.

      apoB isn’t an app: it’s a lab value. apoB is the essential protein of an LDL particle, and since each LDL-P has one apoB in it, a given number of apoBs tells you essentially the same thing as LDL particle count.

      • Peter talked about an app called “ApoB” that was developed to determine which possible genetic mutations one has causing their hyperlipidemia.

      • @Mikkal R, thank for the reply. That’s what I was thinking but I’m an nurse practitioner and have been reading lab results for almost 25 years. The lab results never display the results as percentiles. I bet he calculates them on his own. I’ve seen some very specialized lab results reported as MoM- “Multiples of the Mean.”
        Regarding ApoB, yeah, I know it’s an LDL particle. During the podcast, he pulled up an app that he called ApoB on his phone to plug in results and get possible genetic reasons behind those results. Check the show notes and comments from others.
        A google search turned up this mention but I can’t find the app in the iPhone app store. “This clinical diagnosis is consistent with the findings from application of the de Graff/Sniderman ApoB algorithm (now available for Android and iPhones as the ApoB app).” found here- https://www.lipid.org/node/2182

  3. Thank you, Dr. Attia, for this very valuable and informative podcast. Your teaching on lipids and CVD has benefited many of my patients (and family) who are still referred to me, a dietitian, for a low cholesterol diet because of routine lipid screening. I wish your podcast were listened to by more doctors. Please keep up this important service.

  4. What and where is the App that Peter talked about in the podcast – that can calculate risk based on lipid #’s?

  5. Re: Liquid biopsies

    You said they’d be available in an investigative capacity. What is that?

    If you could order a liquid biopsy test today and my wife tested positive for a breast cancer undetectable by imaging could you move forward with the same treatment plan as if it were visible via imaging?

    • @Joshua- Per cardiologist Dr. Joe Khan’s 10-11-19 podcast (called Heart Doc VIP), normal is below 70 nmol/L. Over 125 nmol/L is high risk (per AHA/ACC).
      Canadian guidelines (2016) say above 75 nmol/L is abnormal.

  6. Great AMA! I especially liked the case studies. Helps a non-medical person like me follow the conversation better. Also, you seemed to skip what the intended use of the drugs were and the results you were hoping to see. I think a one-line summary at the end of each case would be great. For example, “So in conclusion, s/he had high ldl, …, we tried [drug name] because [drug effects or reason other drugs were not a good fit], hoping to see the [lab tests go below/increase/etc].” Just a suggestion, but regardless, thanks much for this AMA!!

  7. Bob,
    Thank you for excellent notes — as always.

    Please link to a spreadsheet with the key values: with the reference ranges but without specific patients’ values.

    Victoria

  8. Peter, could you please discuss in greater detail and share with us your Patient Questionnaire that you asked to your patients a few weeks prior to appointment?
    Thanks and regards

    Antonio

  9. Peter, could you please share a summary -excel type- of the Mentioned lab tests and its ranges ?

    Thanks again for this great AMA session

  10. Wow! I think I stumbled into some weird future science class! I tried to take a night class in grade 10 biology as a prerequisite into nursing a few decades ago but found it to be boring and just couldn’t stay with it. Since then I learned computer science was a much better fit for my logical brain, however after many health issues that sprung from 5 back surgeries I am on the disabled list partly due to short term persistent memory loss as a result of oxygen loss to the brain during an anaphylactic incident due to an allergic response to a latex catheter that had been inserted despite the health care center being informed of my extreme allergic reaction to latex. Within five minutes my entire body was swelling with extremely large welts and my eyes were quickly swelling as was my throat and my entire body was incredibly itchy and felt like it was on fire. Within 25 mins we were finally able to get the attention of the nursing staff to remove the catheter and yet 12 hours later I was still suffering with the negative effects and at which point I demanded to be taken to a local hospital and I was told it was a Sunday night at 1am and that I should just try to go to sleep that I would feel better in the morning. I told the overnight nurse that if she didn’t find a way to get me sent to a local emergency that I would be calling 911 myself (I had kept my cellphone with me thank goodness) I still don’t recall if she called or I did but I do remember remaining conscious until I was being loaded into the back of an ambulance and my husband met me at that point and road with us while I was being taken to the local hospital 5mins away. I remember the paramedic in the back saying “full lights and sirens” and I don’t remember much after that point. I knew my hubby was there and would look after me from that point and I couldn’t remain conscious any longer. Well sure enough it was clear my body was still suffering the effects of the anaphylaxis, when they tried intubation it was extremely difficult and over a couple of years later it became clear that I was suffering with the inability to store memories in the short term area. I saw a memory specialist and a neurologist several times before the diagnosis was finally given. I had two areas within my brain scans that showed as gray and when I asked what that meant they could not tell me, they could however reassure me that it was not in any way similar to dementia or Alzheimer’s. My brain was not similar to one that had been previously seen, honestly when I was first told that I burst out laughing I couldn’t believe what I was hearing! She couldn’t possibly be serious, could she?! Well yes she was and she explained that the brain was still a vast unknown entity. I remember leaving their office and thinking how can this be? I mean I’m not living in some outpost in the Australian outback or some third world country with very little medical knowledge, this was in Toronto, Ontario, Canada at one of the premier trauma centres in the country. How could so little be known about the brain I wondered. Well now I’m learning it’s not just the brain, I’ve recently been reading as much information as I can about diabetes and how the body works. My hubby was recently diagnosed with it and the first option that they are suggesting is bariatric surgery well I had that and I know your head has to be in the game for that and I know his is far from it. So I vowed to make him his healthy meals if he promised to stop eating out at fast food places and eating junk food(garbage stuff that I wouldn’t even call food and think it should be banned) so as I’ve been researching and following the keto lifestyle partly by nature given the diet that I’ve been on for years since my gastric bypass in 2005, I lost 200lbs and at the ten year mark had managed to keep 150lbs off which my surgeon considered to be one of his most successful patients ironically I considered myself a complete failure and was worried to even see him for that follow up and the only reason I was forced to see him was so he could be aware that I required gallbladder surgery and that I had been having problems with it for several years. He was not the one to do the gallbladder surgery but the surgeon wanted to make him fully aware of how my gallbladder likely should have been removed with the original roux en Y surgery. When I qualified for bariatric surgery I was extremely morbidly obese and had severe sleep apnea and was told I would likely have a cardiac event in the next year that would likely kill me. I didn’t hesitate I went fully ahead with the surgery. I had had five back surgeries previously and had had several months where I had laid in bed and could only make it to the bathroom and back, I was put on morphine for the pain and I was basically just an eating machine. I tried to eat properly and did most of the time I would have protein and a salad, but then I would feel sorry for myself and would eat more of a good meal or just the fact that I would eat often mostly from boredom. I’m now still at the 250 lb range it seems to be the weight my body is accustomed to I’ve managed to keep the 150lbs off because my highest weight had been 398. I had never gone over the 400lb mark and I’m still mortified that my weight had gotten that out of control, I tried every diet in existence from the time my body hit puberty it was holding the weight, and I would eventually go up and down with my weight at my lowest was 194 and that was when I was 18. I don’t remember being 150, 160, 170 it’s like I went from being a kid to being a size 18, 22, 26, 32 and then basically would buy whatever I could fit into. I hated shopping but I needed to look well dressed and tailored in order to look professional and with being a computer programmer and working at one of the top five banks a very polished conservative look was necessary. I remember every piece of clothing that I would buy would be dry clean only and so it cost a fortune for the clothes and to maintain them. It was such a frustrating experience and then having to pay for all the diet programs and the packaged foods that came with them. I always remember seeing below their advertisements *Result are not typical meaning the person that was showing their before and after photos were not typical so why in the world would I spend thousands of dollars to eat cardboard foods? I tried acupuncture and hypnosis. Ironically the hypnosis was very effective at getting rid of my 4-6 litre dependence on Diet Coke and switched it to water. That was with only one session, I remember her telling me she could remove my want to drink soda entirely and to the point that I wouldn’t even walk down the aisle at the grocery store she said she could be very effective at eliminating a particular thing and that’s how they could also stop people from smoking but she said it was much more of a challenge for dieting because you still have to eat. I was thrilled how she was able to remove my reliance on Diet Coke. To this day I still will not drink anything with carbon in it. I know I’ve always said I have a ton of will power and I’ve always known it I was an alcoholic I could just stop period. If food was like that I knew I could do that too but you just can’t stop eating, but now after reading Dr. Jason Fung’s information and other brilliant examples of intermittent fasting, perhaps that’s exactly what I should have done! To think I may have known the true answer to my success all those years ago but everyone would tell me I can’t starve myself and if I would try to go for a long time without eating I wouldn’t feel very well afterwards. Now before my gallbladder was removed I had been diagnosed with infection of the bile duct , infection of the pancreas and infection of my gallbladder. I was a very sick person although I didn’t present with a fever and actually at that time I went in to the emergency because I couldn’t take a deep breath and I was on a lot of morphine for the pain and I thought it was my back that was causing all the pain, and so while I was in the emergency room and them not understanding why my blood pressure was through the roof and yet I didn’t have a fever and they just assumed like I had that my breathing difficulties were due to pain in my back, which looking back on it now didn’t make a lot of sense. So a nurse had realized I had been there for 12 hours and hadn’t asked to get up to go to the bathroom despite them pumping IV fluids in to me. She asked me if I had to go and I said well I do feel bloated but I don’t feel like I could go, so she inserted a catheter (non-latex) and the bag filled incredibly fast and had to be changed I forget how many litres of urine came out in ten minutes but it was extreme so she told the doc who then ordered blood work and sure enough that’s how they figured out that I had pancreatitis and a bunch of other “itisis “ that I don’t know the names. So I’m thinking my entire organs could use a break and with what I’ve been learning about autophagy it may be the very thing I need to help heal because with having the infections that I have had I worry that any damaged cells could turn to cancer. So I’m willing to fast for as long as is necessary but because I was raised in the 1970’s with the idea that not eating is not good for you I wonder how long is the correct amount of time that I should fast for? I’ve been watching Thomas DeLauer because he has a lot of information on fasting the exact things to do just before a fast, during a fast and how to break the fast. Because he believes those things are every bit as important as the fast itself. That makes a lot of sense to me. So I happened to find your podcasts when I was searching for more information on autophagy. If you have any specific information that you think I should be exploring I’d really value your input. I find I’m just searching in such a random way for information and I’m trying to ensure it’s the most up to date information.
    I know this has been an extremely long text but as my oldest daughter says “ I don’t get texting” I think with my background I’m an extremely detail
    Oriented person and with my health background being so complex, I think the details are important. So I feel like I’m so unique and especially with the short term memory loss and the gray areas in my brain being so unknown. I’m retaining hope that perhaps there is some way to heal from within. Also I want a similar healing for my hubby because I want him to be around for a very long time. I know if he’s given the actual information related to his diabetes and how it can be reversed it provides a lot of hope and all through simply not eating and not having to
    Pay thousands of dollars for medication etc. How long would you recommend we fast for? I know you said three days is the minimum for autophagy and the maximum is 7 days other then water would you recommend other supplements? How many times a month would be the most advantageous? I would certainly love to be at my lowest weight ever for my daughter’s wedding next year. Any information would be greatly appreciated. Thank you

  11. I really liked the AMA #14 and the in-depth review of the Boston Heart Diagnostics test. I ended up getting one and have the opposite profile of the person profiled, (normal Beta-sitosterol and Campesterol but elevated Lathosterol – value 132). Presumably, this means a statin is in my future, are there other options?

    • Which test was it, do you recall? I am on their website but there are a lot and I don’t see one by the name that is on the case study.

  12. Peter and team:

    In case #1 here focusing on Lp(a) (as well as in previous Lp(a) discussions here on the Drive and elsewhere), Peter mentions that “not all patients with high levels of Lp(a) are at high risk”… Would Peter be able to double click on this? Specifically, what would be the mix of phenotypic / historic markers and blood lab levels that would elucidate this type of individual (ie. High Lp(a) but minimal elevated CAD/CVD disease from the condition)? I am aware of several ppl who are generally asymptomatic (<50 yoa, lowest percentile Non-HDL, moderate ApoB [presumably elevated from low percentiles via Lp(a) elevation], lowest percentile hsCRP, low/no/distant family history, CAC =0 etc.) but it is unclear what the actual risk should integrate to (and thus what is any treatment is desireable in a primary prevention setting)… Cheers

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