Key Moments
AMA #3: supplements, women’s health, patient care, and more (EP.26) | The Peter Attia Drive
Peter Attia MDKey Moments
Peter Attia discusses lab reference ranges, women's health, fasting, medical training, HRV, and supplements in this AMA.
Key Insights
Optimal lab reference ranges often differ significantly from standard ranges, focusing on health outcomes rather than population averages.
Women's health, particularly hormonal fluctuations during reproductive years and menopause, is less studied and understood than men's.
Fasting and ketosis may impact female fertility and hormonal regulation differently than in men due to evolutionary biological responses.
Medical training requires a shift in perspective, emphasizing genuine passion for learning and resilience through mentorship and self-care.
Heart rate variability (HRV) and continuous glucose monitoring (CGM) provide actionable, real-time feedback for personal health optimization.
Supplement efficacy varies, with some (like Berberine) showing promise for specific applications, while others, like oral NAD+ precursors, lack robust evidence for efficacy.
The science behind aspirin, saturated fat, and carbohydrate intake is evolving, necessitating a move from broad recommendations to personalized approaches based on biomarkers.
OPTIMIZING LABORATORY REFERENCE RANGES
Peter Attia emphasizes that standard lab reference ranges are typically based on population averages and often too broad for optimal health. He advocates for more stringent personal targets, such as lower triglyceride levels (below 100 mg/dL), lower LDL particle numbers (below 1000 nmol/L, ideally below the 20th percentile), and specific ranges for markers like C-reactive protein and uric acid. This perspective shifts from merely identifying disease to optimizing physiological function and preventing future illness. Attia clarifies that these "optimal" ranges are based on his clinical experience and understanding of disease pathophysiology, not just statistical norms.
UNDERSTANDING WOMEN'S HEALTH AND HORMONAL CHANGES
The discussion highlights that women's health is significantly understudied, particularly concerning hormonal fluctuations. Unlike the gradual decline in men, women experience profound hormone shifts during their menstrual cycles and a more abrupt decline during perimenopause and menopause. Attia stresses the importance of recognizing how these hormonal changes, including estrogen, progesterone, and testosterone withdrawal, can impact mood, energy, and overall health, cautioning against the dismissal of hormone replacement therapy based on outdated or misinterpreted studies like the Women's Health Initiative.
FASTING, KETOSIS, AND FEMALE REPRODUCTION
Attia expresses caution regarding fasting and ketosis for women, especially those trying to conceive or during pregnancy. Evolutionary biology suggests that in times of famine (indicated by elevated ketones), reproductive hormones like FSH and LH are suppressed in women, not men, to reduce reproduction. While acknowledging that pregnancy in ketosis is possible and may have occurred ancestrally, he questions its long-term optimization. He suggests that for many, avoiding processed foods and sugar is a more balanced approach than strict carbohydrate restriction unless medically indicated.
ADVICE FOR MEDICAL STUDENTS AND RESIDENTS
For aspiring medical professionals, Attia advises against solely focusing on pre-med studies in college. Instead, he recommends pursuing a subject of deep personal interest to foster genuine mastery and passion. Once in medical school, he suggests overcoming the initial frustration of memorization by offering help to younger students, which can re-ignite enthusiasm and provide perspective. Maintaining balance through activities outside of studying is crucial, as is frequently reconnecting with the core reason for pursuing medicine: the profound privilege of patient interaction and care.
LEVERAGING TECHNOLOGY FOR PERSONALIZED HEALTH INSIGHTS
Attia champions the use of technology like continuous glucose monitors (CGMs) and wearables such as the Oura ring for real-time, actionable health data. He finds CGMs invaluable for behavioral control, helping him make better food choices by visualizing the impact of dietary intake on blood glucose. Similarly, HRV data from Oura provides insights into recovery, stress, and the effects of lifestyle choices like alcohol consumption or late-night meals, enabling iterative self-experimentation to optimize sleep, readiness, and overall well-being. He notes their potential to become more accessible consumer tools.
SUPPLEMENTS, PHARMACOLOGY, AND EVIDENCE-BASED DECISIONS
Attia discusses supplements like Berberine for its weak AMPK activating and PCSK9 inhibiting properties, noting its potential benefit for specific individuals with lipid metabolism issues. He prefers pharmacologically robust drugs like metformin when appropriate due to their regulatory oversight and consistency. He expresses skepticism about the efficacy of oral NAD+ precursors (NR and NMN) for increasing cellular NAD+, citing research suggesting they are primarily utilized by the liver and not efficiently transported into other cells. For supplements he trusts, brands like Jarrow Formulas and Pure Encapsulations are mentioned for their quality control.
NAVIGATING THE COMPLEXITY OF CARDIOVASCULAR RISK AND LONGEVITY
The conversation touches upon the evolving understanding of cardiovascular disease, including aspirin's role, which Attia now views with more nuance for low-risk populations due to recent studies showing minimal benefit offsetting small risks. He also discusses his personal approach to lipid management, which has involved statins and ezetimibe to aggressively lower LDL cholesterol, inspired by his family history of heart disease. He highlights the importance of considering multiple factors beyond lipids, such as inflammation and endothelial health, in mitigating cardiovascular risk.
LITHIUM, HEART RATE VARIABILITY, AND PERSONALIZED INTERVENTION
Attia shares his experimentation with low-dose lithium for mood stabilization, influenced by observational data on groundwater lithium levels and mental health. He emphasizes the critical need for medical supervision due to lithium's narrow therapeutic window and toxicity potential. He also elaborates on heart rate variability (HRV) as a key metric derived from wearables, which he uses to fine-tune his training, sleep, and daily readiness. HRV data helps him identify the impact of lifestyle factors, allowing for personalized adjustments rather than relying solely on generic advice.
CRITICAL CARE INSIGHTS AND THE VALUE OF FEEDBACK LOOPS
The discussion includes reflections on critical care medicine, highlighting its reliance on rapid feedback loops between interventions and physiological responses. This immediate feedback, exemplified by ventilator adjustments or drug titration in the ICU, accelerates learning and skill development. Attia likens this to his own data-driven approach, emphasizing that real-time feedback, whether from a CGM or HRV monitor, is essential for effective self-management and optimization. He also notes the value of immersive experiences, like his father's ICU stay, as accelerated learning opportunities in medicine.
THE FUTURE OF HEALTHCARE: PATIENT EMPOWERMENT AND DATA INTEGRATION
Attia underscores the importance of patient engagement and data literacy in modern healthcare. He feels that patients who are deeply involved with their health metrics and actively participate in their care derive the most benefit. He envisions a future where integrated data from various sources, particularly CGMs, could replace less informative metrics like HbA1c. The ideal scenario involves empowered patients working with physicians who embrace a comprehensive, personalized, and data-informed approach to health and longevity.
Mentioned in This Episode
●Supplements
●Products
●Software & Apps
●Companies
●Organizations
●Books
●Drugs & Medications
●Concepts
●People Referenced
Common Questions
Peter Attia prefers triglycerides below 100 mg/dL (and ideally lower than HDL cholesterol) and LDL particle number below 1000 nmol/L, which is more stringent than typical lab reference ranges.
Topics
Mentioned in this video
Peter Attia's assistant, responsible for aggregating questions for the AMA podcasts from their blog and Twitter. Also serves as host/interviewer.
Mentioned as someone Peter Attia had a discussion with about LDL controversy, which will be addressed in a future podcast.
A researcher and podcaster who also uses an entirely listener-support model for her content.
Mentioned alongside Charlie Munger for their annual meetings and philosophy of trust in partners' judgment.
A longevity researcher with whom Peter Attia had a discussion about sirtuins and NAD+, relevant to nicotinamide riboside supplementation.
A researcher involved with the company ChromaDex and a proponent of NR supplementation, who appeared on Dave Asprey's podcast.
A researcher from Texas (possibly UT Southwestern) whose remarkable data showed differences in male and female brains based on changing FGF21 levels.
Mentioned as someone Peter Attia had a discussion with about LDL controversy, which will be addressed in a future podcast.
A researcher Peter Attia plans to have on the podcast to discuss the EPA DHA red blood cell index.
A neurologist at Cornell who runs a preventive clinic for Alzheimer's disease and will be interviewed on a future podcast about ApoE4 and Alzheimer's.
A friend and podcaster who suggested Peter Attia start his own podcast and also produced an episode on 'how to say no elegantly'.
A friend and fellow podcaster who encouraged Peter Attia to start his podcast.
A friend and peer who uses an entirely listener-support model for his podcast and advised Peter Attia on this approach.
Mentioned with Warren Buffett for their annual investor meetings and his characteristic 'I have nothing to add' response, which Peter Attia aspires to.
A psychiatrist and friend of Peter Attia, who is highly experienced in using lithium as a mono-therapy for high-risk bipolar patients and advised Attia on its use.
An author who wrote a piece criticizing a moderate carbohydrate intake meta-study for its epidemiological flaws.
Peter Attia's medical school classmate whose lab developed a tracer to track NAD+ intermediaries, concluding that oral NR/NMN mainly affects the liver.
Mentioned as someone who previously discussed IV NR on his podcast with Charles Brenner.
A brand of sparkling mineral water, mentioned by Attia as a product they drink during recording but are not paid to advertise.
An FDA-approved continuous glucose monitor (CGM) that Peter Attia uses and highly recommends for its accuracy and real-time feedback.
A wearable device that Peter Attia uses religiously to track sleep, recovery, heart rate variability, and other metrics.
An amino acid that seems particularly potent in impacting IGF-1 levels.
A plant-derived extract that acts as a weak AMPK activator and PCSK9 inhibitor; used by Attia for patients with high LDL particle numbers. Recommended brand: Thorne.
Nicotinamide adenine dinucleotide, a coenzyme involved in metabolism. Its cellular uptake mechanism suggests oral precursors might not be effective for systemic increase.
Another popular precursor to NAD+, which Attia believes (based on new research) is largely ineffective orally, with uptake primarily in the liver.
A methylated resveratrol, supposedly more bioavailable, but its high fat solubility means it needs to be taken with bile for effectiveness.
A popular precursor to NAD+, which Attia now believes (based on new research) is largely ineffective orally, with uptake primarily in the liver.
An extreme pathological case involving pulsatile hormones, making it difficult to infer what is happening from hormone levels alone.
Fibroblast growth factor 21. Changes in its levels showed differences in male and female brain responses, particularly in calorie-restricted, ketotic states, affecting FSH and LH in women.
Proprotein convertase subtilisin/kexin type 9, an enzyme that degrades LDL receptors; berberine is a weak inhibitor of this enzyme.
A principle suggesting that the simplest explanation is usually the best, applied to the evolutionary advantage of women stopping reproduction during famine.
A low-carbohydrate diet mentioned for its initial weight loss effects, but how its effectiveness can change over time.
A genetic marker that increases risk for Alzheimer's disease, to be discussed in a future deep dive podcast.
A drug whose historical issues with birth defects led to a long period where women were virtually excluded from medical studies.
A cholesterol absorption inhibitor that Peter Attia previously took in combination with Lipitor to maximally reduce lipoprotein burden.
A pharmacological agent that acts as an AMPK activator, which Peter Attia prefers over berberine for its consistency and regulatory oversight.
Compared to baby aspirin, which has a far lower risk of causing gastric mucosal destruction due to its enteric coating.
A statin medication that Peter Attia previously took to reduce cholesterol synthesis, combined with Zetia for optimal lipid lowering.
University of California San Diego, where an emeritus professor of engineering developed the first real-time glucose monitors.
Mentioned as one of the prominent schools that adopted a 'problem-based learning' approach in medical education.
The institution where F.M.D. (possibly Valter Longo's, the name is garbled) was influenced by his mentor regarding IGF-1.
The first institution mentioned for adopting a 'problem-based learning' approach in medical education, which Harvard later borrowed.
Hospital mentioned where Bob Kaplan's father was in the ICU, providing a personal example of critical care learning.
University where Richard Isaacson works as a neurologist, running a preventive Alzheimer's clinic.
One of two primary supplement companies Peter Attia relies on for product quality and efficacy.
A recommended brand for EPA/DHA supplements, if not pursuing the pharmaceutical route.
Social media platform previously used by Bob Kaplan to collect AMA questions, described as 'super painful'. Later used for informal polls on podcast monetization.
A company that Peter Attia advises and invests in, which helped his sister reverse type 2 diabetes through a ketogenic diet.
Compared to a potential podcast network model where listeners pay a subscription to access content.
A company associated with Charles Brenner, producing NR supplements.
One of two primary supplement companies Peter Attia relies on for product quality and efficacy.
A recommended brand for EPA/DHA supplements, if not pursuing the pharmaceutical route.
A brand recommended for Berberine supplementation.
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