Marek Health and similar

[Adammc192]

I’ve heard Austin talk about the nuance of getting blood tests and over interpretation on Sigma nutrition podcast.

However, I have seen the rise in popularity of companies like Marek Health where they advise complete blood panels and recommend lifestyle changes, supplements and or medication.

To be honest it’s attractive to me (although I’m in Europe and we don’t have quite that offering).

I recently got bloods done a few times for health reasons and my thyroid had come back normal but borderline low a few times. Same with my testosterone (it was around 330) and has never been higher than that. For reference I’m 31 and otherwise healthy, normal bodyfat etc .

My doctor said that was completely normal and dismissed even addressing it. I’m not looking to justify TRT (I actually compete in natural bodybuilding but haven’t in a few years). It hard to say if I have major symptoms, libido seems fine, anxiety and feeling low can be frequent enough but I don’t know what “normal” should be so it’s hard to compare. I have noticed I haven’t really gained any strength or size in a few years, since my last bodybuilding show in 2019 I’m probably about the same size but definitely weaker. Even on a powerlifting specific program tailored to me I can’t hit numbers I used to lift in my mid 20s.

Long story short, are these companies just giving us what we ask for and should I just listen to my GP saying that I’m in the normal range, or is there a case for “optimizing”.

[Austin Baraki]

I can't speak to your individual situation based on this information alone, but yes, these companies are "giving you what you ask for", or what "sounds good", not based on strong clinical evidence of benefit. I have had very negative experiences doing consultations and providing second opinions for patients who underwent a slew of unnecessary testing through companies like Marek, and received a giant PDF with recommendations for dozens of drugs or supplements to correct every single laboratory finding that was even borderline abnormal (or even at the upper or lower end of the normal range).

Not a fan.

[Adammc192]

Interesting, I must say it does sound appealing to the average male when they say things like your test could and should be a few hundred points higher.

What were your negative experiences? Was it just the prescription of drugs unnecessarily?

I assume you do not recommend people should be getting full blood panels to be “preventive” or “proactive”.

[Jordan Feigenbaum]

Interesting, I must say it does sound appealing to the average male when they say things like your test could and should be a few hundred points higher.

Definitely appealing, ignoring the fact that this doesn't actually matter. In other words, it is unlikely someone would notice a difference between a T level of 800 and one of 300.

What were your negative experiences? Was it just the prescription of drugs unnecessarily?

"Just" prescribing unnecessary medications and unregulated substances should be grounds enough for potential customers to be wary. Not to mention the laundry list of recommended meds are just copy and pasted for nearly all patients with zero regard for side effects, drug-drug interactions, safety (of unregulated agents), or clinical efficacy.

In addition, the practitioners miss the most basic issues in labs that actually require work up. They are incompetent in additional to being ethically bankrupt.

I assume you do not recommend people should be getting full blood panels to be “preventive” or “proactive”.

No, as this seems to cause more harm than good. There are a number of appropriate tests, exams, and interventions with good evidence for preventing disease. Sticking to those would be a great step rather than fund these idiots' scam.

[Jordan Feigenbaum]

Our podcast on screening:

https://podcasts.apple.com/us/podcast/episode-57-the-science-of-screening-do-you-really/id1199780143?i=1000437148529

We also have podcasts on TRT, hypogonadism, etc. that you might find useful.

[Adammc192]

That’s very interesting on the topic of going from say low normal range to high normal range. Given that would be a 200%+ increase, any particular reasons why you think one wouldn’t feel differently? ie more energetic, perhaps improved performance etc?

I did always wonder though what else is at play besides testosterone when it comes to muscle building. It seems to have such an important role but I’ve typically had low normal T but more than average muscle mass, all else equal.

With regards to screening, I completely understand the over or mis diagnosis. I often question was my own father’s treatment unnecessary, since he went from living an almost completely normal life with Hairy Cell to getting treatment that led to him passing within weeks of treatment commencing.

What I have seen lately is many coaches recommending blood tests to check for nutrient deficiencies and then using food/supplements to correct for this. I completely get the fact some plasma markers don’t reflect intake (sodium or calcium for example) but are there any cases to warrant this? This wouldn’t be for diagnosing diseases per se but your “bio hacking” type, trying to get everything perfect to perform/feel best.


Would you suggest just setting up a diet so that there are no deficiencies for clients and letting symptoms dictate testing (advised by doctor)?

As a registered performance nutritionist myself I can see where this can get tricky. Client complains of being tired, lifestyle changes but still the complaint remains. At what point might it warrant a recommendation to see their doctor?

[Jordan Feigenbaum]

Hey Adam,

A few points here:

That’s very interesting on the topic of going from say low normal range to high normal range. Given that would be a 200%+ increase, any particular reasons why you think one wouldn’t feel differently? ie more energetic, perhaps improved performance etc?

Energy levels, performance, libido, sense of well being, etc. do not reliably change based on T levels within normal ranges. The action of T on the cell is WAY more complicated than just T levels and the entire system is dynamic. Additionally, there is also significant variation in two tests taken in the same individual on different days. For example, a Total T level tested at one point being 500 and another time being 350 OR 675, result 2 may not actually be any different, since it could also be explained by the combined effects of analytical and biological variation increase from 600 ng/dL

I did always wonder though what else is at play besides testosterone when it comes to muscle building. It seems to have such an important role but I’ve typically had low normal T but more than average muscle mass, all else equal.

Yea, total T does not seem to influence hypertrophy or strength response to training, as evidenced by the fact that men and women have the SAME relative improvement in muscle mass and strength to a given training program despite wildly different T levels. T levels also do not predict training responsiveness.

What I have seen lately is many coaches recommending blood tests to check for nutrient deficiencies and then using food/supplements to correct for this.

To be blunt, this is bullshit and signifies a bad coach. I would happily debate these people publicly if we could agree that they would have to take down all information suggesting this course of action after being defeated in a debate.

Would you suggest just setting up a diet so that there are no deficiencies for clients and letting symptoms dictate testing (advised by doctor)?

If an individual has symptoms warranting a workup that includes (but is not limited to, typically) a nutrient deficiency, that should be included in the individual's workup. Symptomatic nutrient deficiencies are relatively rare in the developed world, such that I would not recommend micromanaging nutrition in this fashion.

As a registered performance nutritionist myself I can see where this can get tricky. Client complains of being tired, lifestyle changes but still the complaint remains. At what point might it warrant a recommendation to see their doctor?

I would recommend consultation with a physician rather than trying to manage it solo, as missing something like anemia - a very common cause of fatigue- perhaps due to malignancy or other nefarious process would be terrible.

Additionally, we did a 4-part podcast series on testosterone that you may be interested in that goes in depth on these things.

[Adammc192]

Energy levels, performance, libido, sense of well being, etc. do not reliably change based on T levels within normal ranges. The action of T on the cell is WAY more complicated than just T levels and the entire system is dynamic. Additionally, there is also significant variation in two tests taken in the same individual on different days. For example, a Total T level tested at one point being 500 and another time being 350 OR 675, result 2 may not actually be any different, since it could also be explained by the combined effects of analytical and biological variation increase from 600 ng/dL


Yea, total T does not seem to influence hypertrophy or strength response to training, as evidenced by the fact that men and women have the SAME relative improvement in muscle mass and strength to a given training program despite wildly different T levels. T levels also do not predict training responsiveness.

.

I have read previously about men and women essentially just starting at different baselines and hence the differences in muscle mass. However, what about this quite well-known paper: https://pubmed.ncbi.nlm.nih.gov/8637535/

Even the people who did not train had increases in Cross-sectional area.

And even just from anecdote, if someone uses 250mg of test a week, they'll probably get bigger. I understand that these are supraphysiological doses, but it must play an important role? In Brad Schoenfeld's textbook "The Science and Development of Muscle Hypertrophy" he states "the anabolic actions of testosterone are irrefutable".

Also mentioning this paper which showed more favourable outcomes in terms of lean mass with those at the higher end of normal range: https://www.sciencedirect.com/scienc...39128X16301052

It does also state in the book that higher muscle mass in men is likely due to higher testosterone but maybe Brad has updated his views with new information.

I will say that I know none of these say that going from low normal to high normal = increase in muscle mass.

Is it in your opinion that, trying to increase testosterone within the natural range is not worthwhile (once you are already following best practices with sleep, lifestyle, diet etc)?

Perhaps you cover this in the 4 part series which I see you released earlier this Summer, I started listening to it.

If an individual has symptoms warranting a workup that includes (but is not limited to, typically) a nutrient deficiency, that should be included in the individual's workup. Symptomatic nutrient deficiencies are relatively rare in the developed world, such that I would not recommend micromanaging nutrition in this fashion.

I am surprised at that, although hard to find clear data, I thought iron, folate, magnesium and vit D were relatively common. I don't get clients ever to get blood work (because I'm not trained to interpret it) but many will come to me a shopping list full of tests from head to toe asking me what I think, which usually I have to say work with your doctor. I just try get them to eat more a more balanced diet without monitoring the micronutrients too much.

With that said, what could you see as a downside if someone who was otherwise healthy got a vitamin and mineral test to see where they were deficient and the test was not validated? If it led them to eating more fruit lets say due to low Vitamin C or reducing their saturated fat duet to high LDL. I understand that most people should be trying to do this in spite of what test results say.

It is often difficult when you get clients coming to you who have been told by either other coaches or companies that they need these tests, it's seen as more evidence-based or a more personalised approach, while paradoxically many of these aren't based on science.

[Jordan Feigenbaum]

I have read previously about men and women essentially just starting at different baselines and hence the differences in muscle mass. However, what about this quite well-known paper: https://pubmed.ncbi.nlm.nih.gov/8637535/

Even the people who did not train had increases in Cross-sectional area.

Yes, supraphysiologic doses of T change the calculus here, as we're no longer within normal limits. People incorrectly relate what happens with high doses of T compared to variations in normal levels.

And even just from anecdote, if someone uses 250mg of test a week, they'll probably get bigger.

This is not generally true and has been studied in those without hypogonadism people, those with hypogonadism (now on TRT) compared to those without (and with similar total T levels). TRT -level doses do not generally increase LBM gains outside of those with hypogonadism.

I understand that these are supraphysiological doses, but it must play an important role? In Brad Schoenfeld's textbook "The Science and Development of Muscle Hypertrophy" he states "the anabolic actions of testosterone are irrefutable".

Yes, T is intimately involved in anabolic processes, but this doesn't mean higher is better. This particular quote may be taken out of context and does not support your position that changes of T WNL lead to different outcomes. He reflects this in his review on the hormone hypothesis.

Also mentioning this paper which showed more favourable outcomes in terms of lean mass with those at the higher end of normal range: https://www.sciencedirect.com/scienc...39128X16301052

That is not what the paper shows. This is a cross sectional study where they look at a population at a single point in time. There are no "outcomes", but rather just different metrics tracked.

T levels are somewhat representative of health status at the population level. In short, higher T levels WNL suggest a lower burden of disease (e.g. obesity, t2dm, etc.) than lower levels. We expect these people to have higher levels of muscle mass and lower levels of fat mass. Longitudinally, T levels are not predictive. We discuss this in the podcast series as well.

Is it in your opinion that, trying to increase testosterone within the natural range is not worthwhile (once you are already following best practices with sleep, lifestyle, diet etc)?

I think it is a waste of time and likely in error, considering heavy training will often reduce T levels anyway.


[quote]
I am surprised at that, although hard to find clear data, I thought iron, folate, magnesium and vit D were relatively common.[quote]

Vitamin D deficiency is a marker of health status and in general, outcomes do not improve with supplementation.

Iron deficiency is not common without anemia, which requires workup to confirm it's iron deficiency anemia and not some more nefarious cause.

Folate deficiency is near 1% in the United States.


[quote]
With that said, what could you see as a downside if someone who was otherwise healthy got a vitamin and mineral test to see where they were deficient and the test was not validated?[quote]

Unnecessary cost, additional workups may be necessary if an incidental result was found, and ultimately no change in management because these tests do not mean anything.

For your examples, low vitamin C on a vitamin test without symptoms is meaningless. LDL isn't a vitamin and mineral test and in general, we do recommend regular lipid screening for appropriate populations.

It is often difficult when you get clients coming to you who have been told by either other coaches or companies that they need these tests, it's seen as more evidence-based or a more personalised approach, while paradoxically many of these aren't based on science.

Yes, we agree with you. I think if we all work together, we can stop the cycle of this BS. That said, I saw an influencer (7m followers on IG) advertise full-body MRI scans this morning with a discount code in bio. Perhaps we're all doomed.

[Adammc192]

Brad did say in the book (I can't recall exactly) but it's unclear if going from lower to higher within the normal range is beneficial. I understand what you're saying now regarding lower T typically being a symptom of poorer health and perhaps muscle mass I suspect as a result.

I did listen to two of the podcasts you did on the topic and from what I gather listening to you speak, there does not seem to be any data on whether going from lower to higher is going to improve any outcomes in otherwise healthy people. Or are there any studies where they've looked at this? I imagine not as it sounds extraordinarily difficult to carry out. This was the reason for my very first question, I saw Marek Health promote a post by a big podcaster Chris Williamson who said T had gone from 500ish to 1000+ w/o TRT and he was feeling great, however likely placebo or due to the fact he's sleeping more.

The reason I linked the Bashin, 1996 paper was because the mean increase was approx 750% increase in T, if you went from 300 -> 800 it would be a 265% increase, which is not a million miles away, but thinking back I know that's not at all feasible unless starting from a medically impaired state.

Last question I have is regarding things that may have a negative impact on T levels. Sleep deprivation, RED-S, adiposity etc, if these all impaired testosterone, but someone's testosterone was still in the normal range, why are these problems (specifically regarding T levels). If trying to get your testosterone 20% higher in the normal range didn't have much impact on outcomes, then surely we could say 20% lower in the normal range wouldn't either? I understand there is nuance and individual response and that these things have impacts beyond testosterone levels, which may be a byproduct rather than a mediator in these situations.

I just find it difficult to hold the two thoughts at once "Trying to increase testosterone within the normal range likely won't make much difference" and "We should get 8 hours of sleep, weight train and eat sufficient calories to increase / maximise testosterone levels".. I know they're not your words, just my train of thought.

[Jordan Feigenbaum]

Brad did say in the book (I can't recall exactly) but it's unclear if going from lower to higher within the normal range is beneficial.

If he said that, that would require ample scientific evidence to support such a claim. At present, all evidence rejects it.

I did listen to two of the podcasts you did on the topic and from what I gather listening to you speak, there does not seem to be any data on whether going from lower to higher is going to improve any outcomes in otherwise healthy people.

The stipulation here has to be that people already have a normal T level and the increase they see is outside the reference clinical value. At present, no intervention studies have shown this is possible without supplementing exogenous T to supra-physiological levels. In other words, what you're describing does not really happen without many other confounding factors.

Other data regarding T levels and performance do not support the hypothesis that higher T WNL is better. I

Or are there any studies where they've looked at this? I imagine not as it sounds extraordinarily difficult to carry out. This was the reason for my very first question, I saw Marek Health promote a post by a big podcaster Chris Williamson who said T had gone from 500ish to 1000+ w/o TRT and he was feeling great, however likely placebo or due to the fact he's sleeping more.

Yea, this is likely a lie as "1000+" is outside the reference range for the majority of labs and does not usually occur without supplementation or lab error. In either case, I would not predict any improvement in outcomes based on this finding even if true.

The reason I linked the Bashin, 1996 paper was because the mean increase was approx 750% increase in T, if you went from 300 -> 800 it would be a 265% increase, which is not a million miles away, but thinking back I know that's not at all feasible unless starting from a medically impaired state.

Yes it is " a million miles away" as you're comparing supraphysiological doses of T to those within the normal physiological range. I am not sure how many other ways to say it, but within the normal range, there are adaptive changes occurring throughout the the body to keep the activity of T pretty steady. If total T goes down a bit, androgen receptor sensitivity goes up, the bound fraction decreases a bit, etc. If total T goes up, androgen receptor sensitivity declines, bound fraction increases, and so on. Once outside the range, the compensatory mechanisms are overwhelmed.

Last question I have is regarding things that may have a negative impact on T levels. Sleep deprivation, RED-S, adiposity etc, if these all impaired testosterone, but someone's testosterone was still in the normal range, why are these problems (specifically regarding T levels).

I don't understand the question, but I think you're asking why are these problems if they don't reduce T enough to cause hypogonadism? The answer is that there are many other problems caused by these conditions that do not require hypogonadism to be present. Sleep deprivation affects mood, appetite, memory, metabolic rate, etc. and so on even in the absence of hypogonadism, which it can cause in some cases.

If trying to get your testosterone 20% higher in the normal range didn't have much impact on outcomes, then surely we could say 20% lower in the normal range wouldn't either?

I think you're focusing far too much on testosterone here. There are many other mechanisms by which diseases can cause signs and symptoms that do not require hypogonadism.

I just find it difficult to hold the two thoughts at once "Trying to increase testosterone within the normal range likely won't make much difference" and "We should get 8 hours of sleep, weight train and eat sufficient calories to increase / maximise testosterone levels".. I know they're not your words, just my train of thought.

I think many in the industry place far too much importance on testosterone in spite of the existing evidence.

[Adammc192]

If he said that, that would require ample scientific evidence to support such a claim. At present, all evidence rejects it.

I think you might have misread this, he was agreeing with your statements.

Yes it is " a million miles away" as you're comparing supraphysiological doses of T to those within the normal physiological range. I am not sure how many other ways to say it, but within the normal range, there are adaptive changes occurring throughout the the body to keep the activity of T pretty steady. If total T goes down a bit, androgen receptor sensitivity goes up, the bound fraction decreases a bit, etc. If total T goes up, androgen receptor sensitivity declines, bound fraction increases, and so on. Once outside the range, the compensatory mechanisms are overwhelmed.

I had always assumed that supraphysiological testosterone had the same impacts as physiological T (but people just massively increased their levels with exogenous T). i.e. a 200% increase WNR naturally or via medication would lead to the same outcome. Like athletes supposedly using TRT but staying within a normal range (I don't know if that happens or is just a rumour). However, my knowledge of testosterone is very rudimentary.

I don't understand the question, but I think you're asking why are these problems if they don't reduce T enough to cause hypogonadism? The answer is that there are many other problems caused by these conditions that do not require hypogonadism to be present. Sleep deprivation affects mood, appetite, memory, metabolic rate, etc. and so on even in the absence of hypogonadism, which it can cause in some cases.

Yeah I didn't make it overly clear and it's not practically applicable, as you cannot separate the other downsides associated with sleep deprivation, obesity etc and focusing just on testosterone is overly reductionist as you alluded to. Basically what I meant was not are these things we should avoid, because that's obvious but rather are the reductions in testosterone futile if maintained WNR (and again I know they're not separable and it might be the answer).

If I flipped it slightly, you should weight train because it reduces the risk of sarcopenia, increases insulin sensitivity, increases VO2 max to an extent and... increases testosterone. Is the increase in testosterone meaningless in say an otherwise healthy person? Not to discount all of the other benefits of weight training.

I see it all the time, a myriad of ways to increase testosterone naturally, and while many of the recommendations do have positive benefits (more sleep for example) I get the impression that it isn't the the 20% increase in testosterone that is directly benefiting the person, but rather all the other benefits of more sleep.

And I know to sum all of this up that your testosterone doesn't just drop significantly without reason or independently of other issues (and therefore it might be impossible for you to answer these since you cannot uncouple that)

[Jordan Feigenbaum]

I think you might have misread this, he was agreeing with your statements.

It is possible that I misread that. Apologies if so.

Yeah I didn't make it overly clear and it's not practically applicable, as you cannot separate the other downsides associated with sleep deprivation, obesity etc and focusing just on testosterone is overly reductionist as you alluded to. Basically what I meant was not are these things we should avoid, because that's obvious but rather are the reductions in testosterone futile if maintained WNR (and again I know they're not separable and it might be the answer)..

In general, a health promoting lifestyle would be better than an unhealthy one- though the benefits are not solely dependent on T, if at all.

If I flipped it slightly, you should weight train because it reduces the risk of sarcopenia, increases insulin sensitivity, increases VO2 max to an extent and... increases testosterone. Is the increase in testosterone meaningless in say an otherwise healthy person? Not to discount all of the other benefits of weight training.

Training doesn't increase T levels, so I would not say that.

I see it all the time, a myriad of ways to increase testosterone naturally, and while many of the recommendations do have positive benefits (more sleep for example) I get the impression that it isn't the the 20% increase in testosterone that is directly benefiting the person, but rather all the other benefits of more sleep.

I would agree with that and, additionally, have serious reservations about the significance of a "20% increase in T". Going from 500 to 600ng/dL is not a clinically significant change.

And I know to sum all of this up that your testosterone doesn't just drop significantly without reason or independently of other issues (and therefore it might be impossible for you to answer these since you cannot uncouple that)

Again, I think you may be placing far too much importance on T levels. T levels are highly variable and do all sorts of things that we don't ever notice because the end effect is nil. The body is cool like that.

[Adammc192]

thank you, I have listened to the series now and it has certainly challenged some of my previously held assumptions