#26 - AMA #3: supplements, women's health, patient care, and more

Episode Summary

Executive Summary: In this AMA, Peter Atiyah lays out his personal thresholds for interpreting labs, argues for more individualized and often stricter “optimal” reference ranges, and discusses women’s health, fasting/ketosis, medical training, podcast monetization, CGM/HRV use, and several supplements/drugs. He repeatedly emphasizes feedback, context, and biomarker-driven decision-making over population averages and simplistic nutrition or longevity claims.

Main Topics: Lab reference ranges and optimal biomarkers (Priority: 5/5): Atiyah explains why he often ignores standard lab reference ranges in favor of stricter, physiology-based targets for lipids, inflammation, glucose, thyroid, liver enzymes, uric acid, omega-3 index, desmosterol, and IGF-1. Women’s health and hormonal transitions (Priority: 5/5): He highlights underappreciated issues in women’s health, especially menstrual-cycle hormone swings, perimenopause/menopause, and possible thyroid disruption after multiple pregnancies, while criticizing dismissal of menopausal symptoms. Fasting, ketosis, and fertility/pregnancy (Priority: 4/5): Atiyah argues ketosis is not an ideal default for women trying to conceive and is uncertain during pregnancy, though it may help in metabolic disease or gestational diabetes depending on context. Wearables, CGM, and heart rate variability (Priority: 5/5): He describes CGM and HRV as powerful real-time feedback tools for behavior change, training, sleep, and recovery, and explains why CGM is more actionable than A1C for him. Supplements and medications (Priority: 5/5): He gives nuanced views on lithium, berberine, baby aspirin, statins/ezetimibe, and nicotinamide riboside, generally favoring evidence-based pharmacology and cautioning against overinterpreting supplement claims. Medical education and professional development (Priority: 4/5): He advises aspiring physicians to study what they love rather than pre-med, maintain balance, stay connected to patients, and remember the privilege and purpose of medicine. Podcast monetization and research funding (Priority: 3/5): Atiyah discusses needing to monetize the podcast to fund operations and research, preferring listener support or a network model over traditional ads to preserve integrity.

Key Arguments: Population reference ranges often reflect averages, not optimal physiology; he prefers tighter targets based on disease prevention and personal risk. Triglycerides, LDL particle number, CRP, uric acid, ALT/AST, fasting insulin/glucose, and thyroid markers should often be interpreted more stringently than lab cutoffs. IGF-1 should likely be cycled rather than kept chronically low; he now sees a U-shaped relationship and values rebound/regeneration phases. Women’s health is understudied, especially perimenopause/menopause, cycle-related mood symptoms, and the effects of repeated pregnancies on thyroid/metabolism. Ketosis may suppress reproductive hormones in women under energy restriction, so it is not a universal fertility strategy. CGM provides superior actionable feedback versus A1C because it captures average glucose and variability in real time. HRV, resting heart rate, temperature, and respiratory rate are useful for detecting overtraining, illness, alcohol effects, and sleep disruption. Lithium may have a plausible low-dose benefit, but high-dose use is risky and should only occur with close medical supervision. Berberine can lower glucose and may help LDL in select patients, but metformin is preferred when pharmacologic treatment is warranted. Baby aspirin’s benefit in low-risk people appears small; its use should be more selective than before. Nicotinamide riboside/NMN supplements are not yet convincing for raising cellular NAD in a meaningful way when taken orally. Medical training should be pursued with intrinsic curiosity and patient contact, not as a box-checking exercise for grades or MCAT optimization.

Data Points: Triglycerides target: below 100 mg/dL - Atiyah’s preferred threshold, stricter than the common lab cutoff of <150. LDL particle number target: below 1,000 nmol/L - He frames this as roughly the 20th percentile and preferable for prevention. Small LDL-P target: below 500 nmol/L - His preferred level, stricter than typical lab norms. Oxidized LDL target: below 40 - He says many labs consider <60 reasonable, but he prefers lower. CRP target: below 1 - He views this as a more optimal inflammatory target than common lab cutoffs. Uric acid target: below 5.0 mg/dL - He prefers this over lab ranges that may allow up to 6 or 7. ALT/AST target: below 20 - He считает current upper limits (~42–44 ALT, ~40 AST) too high. Fasting glucose target: below 90 mg/dL - Part of his preferred metabolic profile. Fasting insulin target: below 6 - His preferred fasting insulin threshold. 1-hour OGTT glucose target: below 120–130 mg/dL - After a 75 g glucose challenge, depending on body size/muscularity. 1-hour OGTT insulin target: below 20–30 - His preferred post-challenge insulin range. 2-hour OGTT glucose target: below 100 mg/dL - He wants glucose back near baseline by two hours. 2-hour OGTT insulin target: below 20 - Or roughly no more than 2x the one-hour glucose value in his framing. TSH target: 0.5–2.0 - Part of his “biochemically optimal” thyroid profile. Free T3 target: above 3.0 - He uses this as a sign against hypothyroidism. Reverse T3 target: below 12 - Included in his preferred thyroid pattern. EPA/DHA index target: above 8.5% - He says he now tolerates up to 10–12% if no side effects. Desmosterol target: above 0.5 - Used as a guidepost for cholesterol synthesis and statin monitoring. IGF-1 preferred range: roughly 60th–80th percentile - He says he no longer favors chronically low IGF-1. Podcast production cost: about $2,500 per episode - His estimate excluding his own time. Podcast monthly cost: about $10,000/month - Based on roughly four episodes per month. Lithium dose used in self-experiment: 600 mg/day - He says he took this under close monitoring before later reducing to low-dose OTC amounts. Low-dose lithium now: 10–20 mg - He cites groundwater/lower-dose rationale for current use. A1C range on him: 5.6–6.0 - He says beta thalassemia trait makes his A1C read artificially high. CGM-imputed A1C: 4.5–5.0 - Based on his average glucose, he believes this is his true range. Women’s cardiovascular disease: less than men, all else equal - He cites epidemiologic patterns and speculates iron may contribute. Alzheimer’s prevalence in women: 2 out of 3 cases - He notes this as a major underexplored sex difference. Gestational diabetes example: 3 pregnancies after partial pancreatectomy - He describes his sister developing gestational diabetes and later type 2 diabetes. Sister’s A1C improvement: from the 12s to the 5s - He attributes this to ketogenic diet/diabetes management over about a year. Aspirin study timing: about 3 weeks prior - He references a recent study suggesting low-risk aspirin benefit is small. Heart rate variability measurement: RMSSD - He explains this as the transformation used to quantify beat-to-beat variability. Fasting duration example: 7 days - He says his IGF-1 dropped to the 5th–10th percentile during a fast.

Pivotal Quotes: "I basically just disregard all the reference ranges when I look at labs and I kind of have my own set of standards that are based on my belief system around what should and shouldn't be the case physiologically." — Peter Atiyah: Explaining his approach to interpreting lab results and optimal targets. "I think doctors that completely disregard perimenopausal and postmenopausal symptoms in women... come to the conclusion, well, no woman should ever take hormones... are just equally knuckleheaded." — Peter Atiyah: A forceful critique of dismissive attitudes toward menopausal hormone therapy. "The first person to notice it was my wife... she said you're less of an asshole." — Peter Atiyah: Describing the perceived effect of lithium supplementation on his mood/behavior.

Implications: Listeners should expect Atiyah to favor individualized biomarker targets, real-time feedback tools, and cautious skepticism toward simplistic nutrition/supplement claims. The episode also signals future deep dives on women’s health, APOE4/Alzheimer’s, and NAD biology.