The Key Biomarkers to Measure With a Blood Test | Dr. Casey Means & Dr. Andrew Huberman
00:00:00.000 | - What do you think are the three to five things
00:00:05.000 | that basically everybody, if they can,
00:00:08.660 | should know about what's circulating in their blood?
00:00:11.360 | I'm imagining LDL, HDL, this kind of thing.
00:00:15.100 | I guess ApoB is a big favorite of our friend Peter Attia.
00:00:19.060 | Fasting blood glucose, continuous blood glucose,
00:00:23.580 | post-meal, et cetera, just kind of evaluating
00:00:25.700 | how exercise, food, et cetera, impacts blood glucose.
00:00:28.420 | And then I'll leave the other categories open
00:00:30.220 | 'cause my point here is not to answer the question.
00:00:32.540 | That's what comes to mind.
00:00:33.380 | - You've got the big ones.
00:00:35.140 | So this is key is that every single person listening,
00:00:40.140 | I hope after this episode will go to their health record
00:00:44.660 | or send their doctor a message
00:00:46.520 | and at least get the following test.
00:00:49.140 | And the first seven that I'll mention are very basic
00:00:54.140 | and people might take umbrage to them
00:00:56.500 | because obviously there's a lot of debate about
00:00:58.740 | what's everyone's favorite lab test.
00:01:00.540 | But I think about it as what are the basics
00:01:02.940 | that everyone should know
00:01:04.020 | and then what's the next tier up
00:01:06.060 | that are easy to access and are cheap
00:01:07.780 | that'll give you a lot more richness,
00:01:09.780 | which you still might have to kind of fight your doctor for.
00:01:12.140 | So the first few that you will not have to fight
00:01:13.940 | your doctor for and are often free on an annual physical
00:01:16.220 | and literally define metabolic syndrome
00:01:18.700 | are fasting glucose, fasting triglycerides,
00:01:21.860 | HDL cholesterol, hemoglobin A1C, total cholesterol,
00:01:25.780 | waist circumference and blood pressure.
00:01:28.040 | - Okay, sorry, I hate to interrupt
00:01:30.100 | and my audience hates it even more,
00:01:31.500 | but I'm gonna just,
00:01:32.340 | could you just explain what each of those is
00:01:34.900 | and what it corresponds to?
00:01:37.020 | - Yes. - Great, thank you.
00:01:37.860 | - And I will say, first of all,
00:01:39.020 | the reason I'm choosing these,
00:01:40.340 | it's not even my own choice really, it's two reasons.
00:01:43.220 | One is that the two studies over the past five years
00:01:47.580 | that have shown us in large populations
00:01:49.580 | that the vast majority of American adults
00:01:51.580 | are metabolically dysfunctional use those biomarkers.
00:01:54.100 | So I think because of that, it's important to know them.
00:01:56.420 | And the two studies that I'm referring to
00:01:57.820 | are one from UNC in 2018,
00:02:00.300 | which showed that based on those biomarkers,
00:02:03.460 | 88% of American adults have suboptimal metabolism.
00:02:07.620 | And then a follow-up study
00:02:08.860 | from the Journal of the American College of Cardiology
00:02:11.140 | from last year showed that that number has gone to 93.2%
00:02:15.300 | of American adults are suboptimal in their metabolism.
00:02:18.460 | And these are the metrics that they use
00:02:21.900 | and they're very basic.
00:02:22.940 | If you had to pay out of pocket,
00:02:24.180 | they would be less than $100.
00:02:25.780 | So let's talk through them.
00:02:27.900 | Why they're great is because together,
00:02:31.720 | they give you kind of like a tapestry
00:02:34.060 | of what's actually happening inside the cell.
00:02:36.660 | If you choose to look at them that way,
00:02:38.860 | if you read the tea leaves of them,
00:02:40.900 | the doctors often, if they see all these lab tests,
00:02:45.540 | it'll be in an electronic health record.
00:02:46.980 | We've all been through this experience.
00:02:49.000 | They'll come up on the screen
00:02:50.140 | and there'll either be like a green, orange,
00:02:52.700 | or red color next to it.
00:02:54.460 | Like it's high, it's low, it's borderline.
00:02:56.660 | And the doctor will basically, it's very algorithmic.
00:02:59.100 | Oh, your LDL is high, we need to bring it down.
00:03:02.140 | Oh, your glucose is high, we need to bring it down.
00:03:03.540 | Oh, your blood pressure is high, we need to bring it down.
00:03:05.180 | But what I'm inviting people to do
00:03:06.300 | is understand a little bit about each test
00:03:07.900 | and then read the tea leaves
00:03:09.300 | of what it's telling us about our mitochondria.
00:03:11.980 | So let's start with fasting glucose.
00:03:15.420 | So fasting glucose, when you look at these studies
00:03:19.360 | that I'm referring to, they call optimal less than 100.
00:03:24.100 | So to define whether you were in that 88 or 93%,
00:03:27.300 | you had to essentially be in their optimal range
00:03:30.140 | for all biomarkers, not on medication.
00:03:32.180 | So I'll quickly run through what their ranges were.
00:03:34.980 | My ranges for optimal are tighter than these,
00:03:37.100 | but fasting glucose less than 100,
00:03:39.640 | triglycerides less than 150,
00:03:42.460 | HDL above 40 for men or 50 for women,
00:03:46.540 | hemoglobin A1C less than 5.7%,
00:03:49.760 | total cholesterol to HDL ratio less than 3.5 to one,
00:03:54.760 | waist circumference less than 35 inches for women
00:03:57.840 | or 40 inches for men,
00:03:59.160 | and blood pressure less than 120 over 80.
00:04:01.880 | If those things were in those ranges
00:04:05.380 | and you weren't on medication for blood sugar
00:04:07.420 | or blood pressure or whatnot,
00:04:10.120 | you were considered optimally metabolically healthy.
00:04:12.960 | That's now 6.8% of Americans.
00:04:16.220 | All of these biomarkers are easy to change
00:04:19.020 | in one to two months, I would say,
00:04:20.600 | with simple lifestyle habits.
00:04:22.180 | - Could you remind us what hemoglobin A1C is?
00:04:24.220 | I think most people are familiar with HDL cholesterol
00:04:26.560 | being the quote unquote good cholesterol
00:04:28.460 | and LDL being the bad cholesterol.
00:04:30.820 | And as I say that, I know I'm gonna get dogpiled.
00:04:33.380 | - Yeah, totally, yeah.
00:04:35.060 | - I'm not sure that I adhere to that.
00:04:37.180 | I'm not sure I don't adhere to that.
00:04:39.420 | I'm not sure about a lot of things,
00:04:41.260 | but I am sure that most people think of them that way.
00:04:44.940 | - So just to stay functional here,
00:04:47.560 | we'll frame it that way for now with the caveat
00:04:50.560 | that that might not be the whole story,
00:04:52.360 | isn't the whole story.
00:04:53.520 | But triglycerides, fat in the blood, fatty stuff.
00:04:57.960 | - What's so key to understand about the triglycerides,
00:05:01.180 | we don't wanna confuse triglycerides with eating more fat.
00:05:04.600 | Triglycerides are a storage form
00:05:07.400 | of excess carbohydrates in the blood.
00:05:09.880 | So this is why it can tell us something about,
00:05:12.160 | and I know you and Rob Lustig talked about this at length,
00:05:14.560 | but it's-
00:05:15.400 | - And Lane Norton.
00:05:16.220 | - And Lane, yeah.
00:05:17.060 | - Yeah, I mean, one of the things that's really tricky,
00:05:18.600 | gosh, is that the language around nutrition and health
00:05:21.760 | is complicated because people hear the word fat,
00:05:23.680 | they think body fat,
00:05:25.080 | but then they also think the macronutrient fat.
00:05:27.760 | We just need more words to better parse the reality.
00:05:32.760 | In biology, we call the two major groups of people,
00:05:37.280 | lumpers and splitters.
00:05:38.600 | Lumpers like to lump everything together.
00:05:40.640 | It oversimplifies and complicates.
00:05:42.360 | Splitters like to split everything,
00:05:43.880 | give a name for everything,
00:05:45.120 | individual name for everything.
00:05:46.520 | It complicates.
00:05:47.360 | And so there's a middle ground, right?
00:05:48.720 | There's a land of reasonable people and nomenclature.
00:05:52.760 | And unfortunately that does not exist on the internet,
00:05:55.340 | nor does it exist in any one specific subfield
00:05:58.240 | of medicine or science.
00:05:59.140 | I mean, so much of the confusion out in the world
00:06:01.440 | is because of a lack of adequate language
00:06:04.320 | in order to explain.
00:06:05.240 | Okay, so the triglycerides are a reflection
00:06:07.760 | of excess carbohydrate intake.
00:06:09.480 | - And how it's helping us with that tapestry
00:06:11.680 | of understanding the trifecta of bad energy
00:06:14.320 | is that if you think about it,
00:06:15.400 | let's just go back to that cell
00:06:17.360 | and that poor mitochondria
00:06:18.880 | that's being absolutely decimated by our environment
00:06:22.640 | and its capacity is low.
00:06:24.120 | Okay, so that mitochondria is like,
00:06:25.900 | I can't process glucose or fatty acids to ATP very well,
00:06:28.680 | so I'm gonna block their entry into the cell.
00:06:32.160 | So now you've got glucose rising in the bloodstream.
00:06:35.300 | So, okay, fasting glucose,
00:06:36.740 | that was one of our biomarkers.
00:06:37.800 | If that's going up,
00:06:39.040 | that is a little bit of that tapestry
00:06:41.020 | of maybe something's going on inside the cell
00:06:42.720 | that's blocking the entry into the cell,
00:06:44.160 | so it's rising the bloodstream.
00:06:45.280 | Okay, well, where's all that?
00:06:47.000 | The body does not want lots of glucose
00:06:49.200 | floating around in the bloodstream
00:06:50.400 | because it can literally independently cause
00:06:53.360 | endothelial dysfunction,
00:06:54.620 | which is basically blood vessel problems.
00:06:57.160 | It can cause oxidative stress in the bloodstream.
00:06:59.720 | It can cause glycation,
00:07:00.960 | which is sugar literally just sticking to things.
00:07:03.520 | The body doesn't want that glucose high in the bloodstream,
00:07:06.680 | so it converts it to triglycerides to be stored
00:07:10.560 | in a storage form of energy.
00:07:12.560 | That's a key point that I think is helpful to understand
00:07:14.820 | is that the body,
00:07:15.720 | it's always trying to like kind of keep things
00:07:17.660 | in the right range, so it'll convert things.
00:07:19.640 | So then triglycerides,
00:07:21.360 | a picture in your blood of glucose being high
00:07:25.000 | and triglycerides being high
00:07:27.200 | is very much should signal to everyone
00:07:30.840 | when they look at their labs
00:07:31.960 | that there's probably something going on inside the cell
00:07:35.880 | that's blocking the cell from being able to use and process.
00:07:38.440 | It's a sign of mitochondrial dysfunction
00:07:40.420 | and chronic overnutrition.
00:07:42.040 | Too much substrate, not enough processing,
00:07:44.080 | glucose is gonna go up, triglycerides are gonna go up.
00:07:47.000 | And so then if you kind of squint and read the tea leaves,
00:07:49.800 | it's like, huh, I think metabolic dysfunction.
00:07:51.800 | And what's fascinating is that the travesty
00:07:54.200 | in our healthcare system
00:07:55.280 | is that a patient might go into the doctor
00:07:58.400 | and their fasting glucose is 99,
00:08:01.520 | one point under what we'd consider the normal range,
00:08:04.200 | and their triglycerides are 149,
00:08:06.080 | one point under what we'd consider the normal range
00:08:08.600 | from these things.
00:08:10.500 | That doctor might say to that patient, you're totally fine.
00:08:13.820 | Both glucose and triglycerides are normal.
00:08:16.460 | But that's just really problematic
00:08:20.740 | because they're on the upper end of normal
00:08:23.000 | for both of those.
00:08:24.600 | And so really what that would say to me
00:08:26.260 | as someone thinking about the mitochondria
00:08:27.580 | is like this person is definitely
00:08:29.300 | metabolically dysfunctional.
00:08:30.720 | They're on the highest end of normal
00:08:32.660 | for both triglycerides and glucose.
00:08:34.420 | There's something,
00:08:35.440 | there's definitely insulin resistance going on here.
00:08:37.520 | I would much rather see that glucose at 73
00:08:40.660 | and that triglyceride at 50,
00:08:42.580 | which to me would say, oh,
00:08:44.340 | this cell's processing through energy, great,
00:08:47.220 | and things are moving through,
00:08:49.080 | and we're not backing up in the bloodstream,
00:08:51.180 | we're not converting to triglycerides.
00:08:52.580 | So that's where really optimal ranges get in.
00:08:55.020 | But so that's glucose and triglycerides.
00:08:57.900 | Why, if those are starting to creep up,
00:08:59.380 | it's a sign that something is happening metabolically.
00:09:02.140 | And then when we look at some of the other biomarkers,
00:09:05.140 | so hemoglobin A1c is really,
00:09:07.840 | so that's a marker that's looking at
00:09:09.520 | how many of the hemoglobin molecules
00:09:12.480 | that are in the red blood cells that carry oxygen,
00:09:15.080 | how many of those hemoglobin molecules
00:09:18.160 | have sugar stuck to them?
00:09:21.200 | And that's glycation.
00:09:22.960 | So you're looking at glycated hemoglobin,
00:09:25.560 | and you can imagine that if the concentration of glucose
00:09:28.280 | is higher over time,
00:09:31.040 | more glucose is gonna stick to red blood cells,
00:09:33.120 | and that's gonna create a higher percentage
00:09:35.220 | of glycated hemoglobin.
00:09:37.060 | So that's why that lab is represented as a percentage.
00:09:40.220 | So less than 5.7 is what we want.
00:09:43.220 | - You want those cells nice and smooth and slippery.
00:09:45.260 | - Nice and smooth, no sugar stuck to them,
00:09:47.100 | causing dysfunction.
00:09:48.440 | And because blood cells last for about nine to 120 days,
00:09:53.380 | hemoglobin A1c is giving us a basically a snapshot
00:09:56.920 | of average blood sugar levels over nine to 120 days.
00:10:01.420 | And if that average is higher, again,
00:10:03.540 | probably a sign that cells are rejecting glucose
00:10:06.440 | from the cell and it's causing a rise in the bloodstream.
00:10:09.500 | And then just talking about one other biomarker in that,
00:10:13.840 | that we talked about, which was blood pressure,
00:10:15.840 | people might say, well, how does blood pressure relate
00:10:17.900 | to like what's going on inside the cell,
00:10:19.720 | you know, in the mitochondria and whatnot?
00:10:22.700 | And a really, the fascinating link is that
00:10:25.040 | when that cell becomes insulin resistance,
00:10:28.200 | which again is a compensatory mechanism
00:10:30.700 | for mitochondrial dysfunction,
00:10:32.700 | the insulin is gonna rise in the blood
00:10:36.220 | 'cause the body's insulin resistant.
00:10:37.600 | So the body's gonna churn out more insulin
00:10:39.320 | to try and overcome the insulin block
00:10:40.880 | to drive the sugar into the cells.
00:10:42.240 | So insulin levels rise.
00:10:43.360 | Well, insulin is one of the key activators of nitric oxide,
00:10:48.360 | which is the molecule in the blood that dilates
00:10:51.160 | and relaxes blood vessels.
00:10:52.600 | And so when we become insulin resistant
00:10:54.560 | and we're not responding to that insulin signal,
00:10:57.940 | we end up getting less nitric oxide activity.
00:10:59.880 | So this is how kind of looking at even these very basic,
00:11:03.200 | very cheap biomarkers through the lens
00:11:05.680 | of basic cellular physiology,
00:11:08.320 | we can start to see, man, my body might be like underpowered.
00:11:12.200 | I might have a mitochondrial issue here.
00:11:14.760 | So that's a few of those tests
00:11:17.120 | that we really wanna shoot for.
00:11:18.640 | - Thank you for tuning in
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