AMA #3: supplements, women’s health, patient care, and more (EP.26) | The Peter Attia Drive

KEYPOINTS

• 01

  Lab reference ranges describe the average, not what's optimal

  Ranges are built from population distributions and drift as the population changes, so 'normal' increasingly means 'typical' in a country where most people are overweight. Attia argues it's backwards to aim for average on atherosclerosis, the most common cause of death, which is why he wants 'some alpha' on metrics like LDL particle number.

• 02

  Attia's stricter lipid and liver targets

  Instead of the standard triglyceride cutoff of under 150 mg/dL, he prefers under 100, ideally lower than HDL cholesterol (both in mg/dL). He wants LDL particle number below 1,000 nmol/L, about the 20th percentile. Although his lab's upper limits for the liver enzymes ALT and AST are around 40–44, he likes to see both below 20.

• 03

  He prefers an oral glucose tolerance test to HbA1c

  Attia calls HbA1c not particularly helpful. His targets: fasting glucose under 90 mg/dL and fasting insulin under 6. One hour after a 75-gram glucose drink, a reasonably muscular man should be under 120 (at most 130) with insulin under 20–30. At two hours, glucose should be back under 100 and insulin ideally under 20. He allows slightly higher values for smaller people, including many women.

• 04

  Thyroid testing needs more than TSH

  TSH only reflects what the pituitary senses. Attia finds it hard to call someone hypothyroid if TSH is about 0.5–2.0, free T3 above 3.0 and reverse T3 below 12, while acknowledging that symptoms matter alongside the numbers. Sex-hormone panels involve about nine markers, from DHEA, FSH and LH through to DHT.

• 05

  The menstrual cycle is the poorly understood variable in women's health

  Women's hormones swing sharply across a 28–31-day cycle. Attia describes drawing it out for a patient whose main complaint was PMS mood swings: progesterone drops around days 22–28, and in some women that withdrawal in the brain causes emotional instability. His message to her was 'you're not crazy', comparing it to depression caused by low serotonin.

• 06

  Women may respond differently to fasting and ketosis

  Attia expects to anger 'the keto herd'. His evolutionary argument is that high ketone levels signalled separation from food, a bad time to reproduce, so the reproductive system should be sensitive to them. He cites David Mangelsdorf's FGF21 data showing different male and female brain responses, with the pituitary among the few tissues involved. His takeaway is that women may need more caution with prolonged fasting or ketosis.

• 07

  Oral NR and NMN probably don't raise NAD where it matters

  Citing a Cell Metabolism paper by his medical-school classmate Josh Rabinowitz, Attia says tracer studies showed that oral NR and NMN were taken up and turned into NAD essentially only by the liver, 'not exactly the place you want it'. He considers IV NAD infusion clinics quackery, since cells can't take up NAD itself. Because NAD seems to be made in the cytoplasm and imported into mitochondria, he was 'completely unconvinced' the supplements do more than enrich their makers. He flagged it as a view David Sinclair would challenge.

• 08

  Low-dose aspirin is now a closer call

  Attia used to prescribe baby aspirin when a urine test showed high platelet activity plus one other risk factor, such as high Lp(a), Lp-PLA2 or strong family history. He takes it himself for that reason. A new trial in low-risk people found small risks but also very small benefits, roughly a wash. He says he'll be a little less inclined to prescribe it for otherwise low-risk patients.