My take on Dr. Peter Attia
| By Dr. Ronald Hoffman
Like many of you, I enjoy podcasts. Rather than passively listening to whatever cable news or AM radio dishes up, I like to proactively use my time to garner knowledge. So, when I’m engaged in a monotonous task like cleaning, working out on the spin bike, walking to work, or stuck in traffic while commuting, I like to dial up an informative podcast.
Fortunately, Intelligent Medicine enables me to “auto-podcast” several hours a week. Obviously it’s redundant for me to listen to my own podcast, so I curate an assortment of pod luminaries who can expand my knowledge base.
One of my go-to’s is Dr. Peter Attia’s The Drive podcast. Attia is an MD whose avowed mission is to apply scientific principles to enhance longevity and well-being. He is the author of the recent best-seller Outlive.
I frequently get questions from my wonky Intelligent Medicine listeners who also follow Attia. “What do you think about him?” “Do you agree with what he just said about [pick a subject]?”
First, I want to emphasize that I have tremendous respect for Attia. He’s the consummate physician, with an encyclopedic knowledge of medicine. He also has an uncanny knack for translating complex science into practical recommendations. He’s an adept interviewer. And he walks the walk, implementing many wholesome recommendations—particularly around lifestyle, incorporating nutrition, sleep, and vigorous exercise—into his personal regimen. His energy is prodigious and his commitment is exemplary.
But I also listen critically. And I have to say, there’s a fundamental difference between our approaches to medicine and health.
While Attia is a master at critiquing scientific studies, I think he’s too subservient to “evidence-based medicine” (EBM) which enshrines double-blind placebo-controlled studies at the apex of scientific veracity. A recent critical review of EBM states:
“This evidence-based approach worked well for most of the patients; however, this one-size-fits-all approach does not consider the differences between each patient. Each human is different and is a complex form of various biological systems. There may be a significant subgroup of patients who have not responded to or benefited from the said processes and are subject to a bias of statistical insignificance. A substantial number of ‘human beings’ may be outliers and suffer from inferior medical treatment as they may fall away from the median or mean of the bell curve.”
And:
“Alvan Feinstein, who was described in the history of EBM as one of the earliest pioneers of clinical epidemiology, criticized EBM more than two decades ago in the following words: ‘The laudable goal of making clinical decisions based on evidence can be impaired by the restricted quality and scope of what is collected as ‘best available evidence.’ However, the authoritative aura given to the collection may lead to significant abuses that produce inappropriate guidelines or doctrinaire dogmas for clinical practice.”
And what of the bias that infuses many of the studies EBM relies on because of the pervasive influence of underwriting by drug or device makers?
Accordingly, Attia recently weighed in with his opinion about the widespread use of melatonin for sleep and jet-lag. Attia rehashes findings of a recent study that revealed that many melatonin supplements deliver active ingredient at variance with label claims—sometimes too low, sometimes too high.
In so doing, he hews to the conventional party line about the supplement industry—that it’s a “free-fire zone” in need of regulation. While there’s some truth to the assertion that certain bad actors offer poor quality supplements, this does not delegitimize the vast majority of responsible players adhering to stringent quality standards, whose brands I use, prescribe, and endorse.
Additionally, he argues that the body, under natural circumstances, produces only a small fraction of the melatonin offered in many over-the-counter products. He claims, with some plausibility, that this is “unnatural” and may have unforeseen consequences.
Yet tens of millions of people take melatonin with beneficial effects on sleep and jet-lag with few untoward effects. I weigh in on alarmist claims of serious adverse effects of melatonin—especially for children—in a recent newsletter article (“Is melatonin really poisoning Americans?”). Adopting the cautionary principle, I recommend that parents not give little Johnny or Jenny melatonin gummies to ease bedtime, nor is it a good idea to take it during pregnancy.
But I find disingenuous his argument that melatonin beyond trivial dosages like 0.1 mg is “unnatural”. The medical literature is rife with examples of how natural compounds can be deployed as nutraceuticals in doses far higher than might be obtained merely through diet: Think high-dose fish oil for cardiovascular disease; over-RDA amounts of B6 for carpal tunnel; and intravenous magnesium for pre-eclampsia, to name but a few of countless examples.
Even more paradoxical is the fact that Attia himself, by his own admission, takes high doses of creatine to support exercise performance—boosting his blood levels many-fold higher than natural (which is not necessarily a bad thing!). He’s also an advocate of Rapamycin, an immuno-suppressive drug popular as an anti-aging hack, and takes it himself. Surely, there’s no endogenous production of Rapa by humans. You can’t have it both ways. Does this not suggest that Attia has more buy-in for some aggressive interventions than others?
It gets worse. In his podcasts and his book, he claims that tools are now at hand to “eradicate” the leading cause of death in the U.S.—cardiovascular disease. By means of aggressive testing, beginning in childhood and repeated frequently throughout adulthood, he contends we can zero in on the risk factors for atherosclerosis, and correct them via pharmaceutical fixes.
It’s true that our options for addressing cholesterol and other cardiovascular risk factors are rapidly expanding—think new PCSK9 inhibitors that can take LDL down to low double digits, or novel drugs that slash Lp(a).
Attia reveals he has personally availed himself of these measures. Claiming to have discovered that he has a coronary plaque score of 7—that places him at some but still relatively low risk of cardiovascular disease, especially in view of his superb physical conditioning regimen and absence of such other risk factors as hypertension or elevated blood sugar—he admits to taking not only a high-dose statin, but also a PCSK9 inhibitor, which way exceeds current guidelines for primary prevention in an individual with his characteristics.
His retort might be that U.S. doctors are too timid in their recommendations. Hampered by their oath to “First, do no harm” (whose actual translation from the Ancient Greek is “I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.”), Attia thinks they should be more aggressive.
In this, he reveals a disposition more common to decisive surgeons than contemplative internists. In an article entitled “Can Your Personality Determine Which Medical Field Is Right for You?” medical specialties are characterized as follows:
- Managers (internists): They’re “story-seekers” as they focus on understanding clinical narratives.
- Fixers (surgeons): They fix specific problems and value technical skill and more-immediate outcomes.
- Diagnosticians (radiologists and emergency medicine doctors): They like to know something about everything.
Indeed, Attia’s medical training was in the operative suite as a surgical oncologist. With that background he now practices as a jack-of-all-trades primary care doctor, helming a pricey concierge practice for wealthy optimizers. He’s kind of a medical chimera, but I’ll acknowledge he combines many of the best attributes of all three.
When it comes to America’s second greatest scourge, cancer, Attia is no less proactive. He advocates early universal screening with biannual colonoscopies for everyone over 40, frequent mammograms and PAP smears, and whole-body MRIs at frequent intervals to spot nascent cancers. He has no patience for those who claim that routine PSA’s may be more trouble than they’re worth, claiming the benefits of early detection outweigh the downsides of overtreatment and false positives. He’s also keen on liquid biopsies—while acknowledging their limitations—for early detection of cancer.
In so doing, he sidesteps the problem of overdiagnosis. When cancer is detected early, there’s always the possibility of a “save”—permanent cure. For some cancers, that’s within reach. For other cancers, unfortunately, not so much. There’s also the potential that some cancers are so slow-growing that other life-limiting conditions will do you in before the cancer kills you at, say, 112. There’s evidence that the immune system keeps many cancers in check, or even causes them to regress without discovery or aggressive treatment. Our current “active surveillance” watchful waiting paradigm for some less aggressive prostate cancers validates withholding treatment that might cause life-impairing side effects like incontinence, impotence, depression, metabolic syndrome, and frailty.
Moreover, as all too many patients can attest, for every test and treatment, however well-intentioned, there are unforeseen consequences.
And, finally, there’s the unsustainable cost of all those tests and treatments; our healthcare system is already buckling. There are equity issues as well—as it is, millions of less well-to-do Americans receive substandard care.
Attia is aware of all these arguments, and he grapples with these dilemmas while making his case for being proactive. But sometimes, while listening to him, I long for more in-depth discussion of natural alternatives, or therapies that can be employed in an integrative “all-of-the-above” approach to common diseases. I guess that’s just not his remit.
Maybe that’s why many feel that Intelligent Medicine remains a valuable complement to the mostly high-tech innovations explored by Attia.
