The Peter Attia Drive - Qualy #24 - What are the “ABCs” of Alzheimer’s prevention?

Episode Date: September 13, 2019

Today's episode of The Qualys is from podcast #18 – Richard Isaacson, M.D.: Alzheimer’s prevention.   The Qualys is a subscriber-exclusive podcast, released Tuesday through Friday, and published exclusively on our private, subscriber-only podcast feed. Qualys is short-hand for “qualifying round,” which are typically the fastest laps driven in a race car—done before the race to determine starting position on the grid for race day. The Qualys are short (i.e., “fast”), typically less than ten minutes, and highlight the best questions, topics, and tactics discussed on The Drive. Occasionally, we will also release an episode on the main podcast feed for non-subscribers, which is what you are listening to now. Learn more: https://peterattiamd.com/podcast/qualys/   Subscribe to receive access to all episodes of The Qualys (and other exclusive subscriber-only content): https://peterattiamd.com/subscribe/  Connect with Peter on Facebook.com/PeterAttiaMD | Twitter.com/PeterAttiaMD | Instagram.com/PeterAttiaMD 

Welcome to the Qualies, a subscriber exclusive podcast. Qualies is just a shorthand slang for a qualification round, which is something you do prior to the race, just a little bit quicker. Qualies podcast features episodes that are short, and we're hoping for less than 10 minutes each, which highlight the best questions, topics, tactics, etc. discussed on previous episodes of the drive. We recognize many of you as new listeners to the podcast may not have the time to go back and listen to every episode, and those of you who have already listened may have forgotten. So the new episodes of the quality is going to be released Tuesday through Friday,

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So without further delay, I hope you enjoy today's quality. We try to keep it simple, so the ABCs of Alzheimer's Prevention Management, it sounds kitschy, but I really think ABCs actually fit. So A is anthropometric, we look at body fat, we look at lean mass, we look at visceral fat, where is the fat, you know, I learned a lot of this stuff, we really take a deep dive. It's not just about weight and BMI, like that's just like the worst. No, it's about body fat, where is the fat metabolic, reactive, yada yada. Then the B is for biomarkers, blood-based biomarkers,

specifically cholesterol markers, especially the deeper dive. I just want to take my hat off to you, Richard. You do more detailed lipid profiling than most cardiologists do. I remember the first time I sat down with you. I was fully expecting you to just whip out like the LDL, HDL, triglycerides, or this. And you went deep. I mean, you had APOB, you had LDLP, you had particles subtype. You really got into it. And I was like, why is the neurologist knowing all of this stuff when every cardiologist seems to like still be in the dark ages on this? And it drives me crazy. You know, it's interesting. We have four cardiologists now in the practice. Actually one who listens to the podcast, I can give him a shout out. She probably shouldn't say his name, but what's not his name?

What's up? Really great. I actually, he's been a great, he's a patient, but he's been a mentor and a teacher to me too. And you know, we have cardiologists in the practice. And one who's like totally anti, like what are you ordering? And he's still anti all that stuff, but he really wants to know his numbers and he really wants me to interpret it, but for his patients, I don't use this stuff. What are some of the other biomarkers you focus on? So the forming categories are cholesterol, but deep dive cholesterol.

Inflammation, however, there's just four inflammation labs and they're just not great, but it's just in our panel. So what are you looking at besides CRP and Fibrinogen? Do you look at IL-1 or IL-6, TNF? Yeah, I wish. Baby steps. It's myeloproxidase and LP-PLA2, which I don't exactly know what to do with, but yeah, Fibrinogen, interesting and high-sincidous CRP.

Now that I see all the results in our outcomes, HSCRP is probably the most informative, but you know, something like myeloproxidase is a risk factor for vascular cognitive impairment later. That's a new study. So I don't exactly know what to do with the inflammatory markers, but we're checking them. And what stands in the way of adding some interleukins to that?

Some of the money, Benjamin's. I would love to get better nutritional biomarkers, which we'll talk about. We do it in the serum. We absolutely need to do it in the red blood cell, but we need to send it to a different place in a different FedEx account. And this is the thing,

and I'm just gonna get back on my soapbox, Goddamn it. I'm allowed to do this, I guess. This is the one perk of having your show. If you're listening to this and you're in some way touched by Alzheimer's disease either because you have a family member who's got it or you're concerned about anything like that, and you're considering like funding research

in Alzheimer's disease, I can't emphasize enough the importance of funding the type of research that Richard does, whether that means funding Richard directly or somebody else because Alzheimer's prevention is so underfunded, it is an embarrassment to this disease state. And I've had patients who have said to me, you know, a loved one just passed away and I'd like to throw $100,000 at something for Alzheimer's research. And I think to myself, luckily those patients like to give that money to you because you can do more with a hundred thousand dollars in your clinic. Immediately. A hundred thousand dollars doesn't buy you five animals to do a study on a drug that has

a ninety nine point six percent chance of not working. Let me repeat that. The success rate of pharmacology for Alzheimer's disease is 0.4%. In other words, 99.6 of drugs brought forth to treat Alzheimer's disease are abject failures. Now, if you are interested in the philanthropic side of Alzheimer's disease and you want to put more money in that pot, you must ask yourself the question, which is, what is the definition of crazy? Is it throwing more money into the same pile that's taking the same approach to a disease that's not working, or is it possibly looking to this novel idea of Alzheimer's prevention?

Okay, rant over off the soap box, let's go back. And it's funny, like, if I would have had $75,000 more three years ago, I would have had $75,000 more three years ago, I would have had the right biomarkers, so I could definitively say about which omega three, which this, which that, I could have, for $75,000, we've gone through $8 million in five years. Okay, it's not too bad, actually.

I mean, for a major research program, five million of it philanthropy, three million NIH and other grants, $75,000 extra, I could have definitive evidence about, which omega-3s to take is it ALA, DHA EPA, I think it's DHA and EPA, but I wasn't doing the right biomarkers because I couldn't forward the right test.

So for the littlest tiny investments, we have a data set with 3,000 pieces of data on every patient. We have such a deep phenotypic characterization. I have thousands of pages of data. I don't know how I'm going to write this up. I need to hire two full-time people for $50,000 per person. We can turn out papers, you know, two papers every few months.

So the take-home point is in an imprecise world, in an imperfect world where I don't have unlimited funds, we have to be cautious. So we've done the best we can. But oh, man, I wish if we could have TNF alpha and interleukins and CD50s and I wish we could do that. Yeah. And I think the way to think about this, again, if you're listening to this and you're trying to understand how should funding be allocated, you have to think about this as how would you hedge, right? So I'm not suggesting for a moment that no effort should be made at doing research around Alzheimer's treatment. I mean, the disease is devastating

and you don't have to meet but one person who suffers from this disease to think we should be throwing heaven and earth at figuring out how to treat these patients. The question is how would you balance that portfolio? Because right now that portfolio is about 99 to one. 99.9 dollars are going into treatment, 0.1 dollars going into prevention. I'm asking simply what if it were 90-10?

What if it were 90 dollars that go into treatment and 10 dollars into prevention? In reality, I think if it were 10-90, we'd move the needle even more if we were willing to acknowledge that, hey, a lot of people can't be helped right now, which is an awful message to consider. So anyway, I do think that prevention suffers from a number of things. It's way squishier. There's always going to be a bias against the idea that you can get people to change behaviors, lifestyle behaviors. In other words, it's one thing to get a patient to take their pill.

It's quite another thing to get a patient to change the way they sleep, the way they meditate, if they do it all, the way they exercise, the way they eat. These things are harder to do. That's the downside. The upside is, if you can do those things, I think the evidence is pointing to, you can have a much bigger impact. Oh, yeah. And if, when you do this precision medicine approach, where you look at their cholesterol inflammation metabolism, we'll talk about in a second nutrition biomarkers, genetics, and you take all these factors and you look at their body fat and you look at their cognitive function, which we'll talk about the A, Bs and Cs. You can then give them a personalized precision medicine plan and they end up getting that

right plan and then the outcome is better and then they're going to have positive reinforcement to where they're going to have positive reinforcement to where they're gonna keep doing it. I have people that say, I haven't been able to lose weight my whole life. Are you doing the wrong thing? You're on elliptical for 20 minutes, three times a week. That's not gonna get you to lose weight,

that may get you to maintain yourself a little bit, but not really, you need to do high-intensity interval training, you need to lose body fat, here's your fat, here's your this, here's your that, when you attack it with knowledge about the non-one size fits all approach, and the N of one do everything and everything based on your individual biology and genetics,

that's when a person can have the most success. When they have success, it's positive reinforcement. Yeah, and I think seeing those biomarkers improve, I saw three patients today in clinic, and in all cases we're reviewing labs and it's really I love it. Yeah, they really like to be able to especially the ones that dial into this stuff that think Oh wow, look at how this change led to that but not this and what do I need to do more

here and I mean I guess in the end one of the challenges is you and I both have a luxury that not not a lot of doctors too which is we have small practices that allow us that luxury of time. And so hopefully some of these other tools you're developing will allow physicians to be able to scale themselves a little bit by saying, look, I, you know, Dr. Smith might not have as much time as Dr. Isaacson to sit down and spend an hour with each patient going over this stuff, but I can at least point

a patient to a tool that can help streamline this process Yeah, when I'm sleeping without any PR without near anything just because the way the internet works When I go to sleep and wake up my ex girlfriend with the phone the phone thing who I was trying to show off and impress She said well you work so much and every time you give a lecture you okay fine, but Make money while you're sleeping. Well, it's the same thing I want to help people and educate people. I'm sleeping. You're at AC7 patients in a day, sometimes five,

because it takes a lot of time. But when I'm sleeping over 1,000 patients are on that free education website with two hours of interactive educational content about Alzheimer's prevention, that's how we impact lives. So I'm hoping that we can increase that from 1,000 to 8,600 patients while you're sleeping. I would get the reference nurse. We'll get the reference to that. So does my pocketbook. Absolutely. So and it's everything's free

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