Dr. Peter Attia
Appearances
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So if you can't regulate yourself, it's very difficult to regulate the do's and don'ts. But even absent just length of life stuff, it impacts quality of life, which is this idea of healthspan as well.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I guess that's just my slightly different way to frame it, but it's a little bit more MISI in that we talk about the behaviors, the exogenous molecules that target diseases, the exogenous molecules that target aging.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I take a few, right? So I take some that are disease-specific, right? So I take a PCSK9 inhibitor, I take bampidoic acid, I take an SGLT2 inhibitor, and then I take at least one that is purely just based on the belief of its capacity in geroprotection, which is risrapamycin. And also the SGLT2 inhibitor, I think, is probably just broadly geroprotective.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And we can even talk about that a little bit in terms of the success of one of those molecules called kanagaflozin in the interventions testing program, the ITP, which I am sure we'll talk about in the context of NAD as well.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I take eight milligrams once a week for as long as I can tolerate it, but I usually have to take breaks. Why is that? I get these vicious aphthous ulcers, little mouth sores. Canker sores. Yes. About 10% of people get them. It's paradoxically the only biomarker we probably have. So I secretly rejoice in knowing that at least I'm getting a good batch of rapamycin.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
By virtue of these miserable side effects. Interesting. So in reality, what it works out to is I'm probably on it for two months and then off it for a month. On it for two months, off it for a month or thereabouts.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah. I mean, you know, and this will be an important theme today, right? It's like we can talk all day long about mechanisms and theoretical arguments for why it would work. And I think my conviction around taking rapamycin is less about sort of looking at the molecular explanation for why RAPA works, although I find that to be quite convincing.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And why does the inhibition of mTOR stimulate autophagy? Why would that suppress senescent cells? But truthfully, my conviction around mTOR is far more based on the experimental data, something that is actually sorely lacking in the NAD story, which we'll discuss. So the experimental data are far more convincing, right? Which is when you look at
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
the administration of rapamycin or its analogs, for example, everolimus, when you look at the administration of these molecules to organisms that are as close as possible to the species of interest, were the species of interest.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So looking at mammals such as mice and small primates, looking at fruit flies, looking at worms, and even looking at yeast, although that's so far from us that you would argue that's the least important. You see something that you don't see for a single other molecule, which is uniform life extension. No other molecule has done this.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
It's very important to understand there are only two interventions, full stop, that have ever extended life across those four categories of eukaryotes. Caloric restriction. And rapamycin. Very important point, right?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah, which fortunately aren't that frequent. I don't feel anything, and the very few of my patients who take it, because maybe 10% of my patients also take it, I've never heard... Actually, that's not true. I've probably heard two people say they feel better on it, but I don't know what to make of that. Maybe they do, and maybe that's just a placebo effect.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah, that's a good question, Andrew. I don't know. I don't think we know. We do know that there's one other really important readout we're waiting for, which is Matt Kaberlin's dog aging study, which is going to be an exciting readout in 2026. We're also waiting for another readout out of the University of San Antonio, looking at another trial. in mammals.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And again, I think those two will be really interesting, right? Because we have a ton of, we have just an overabundance of mouse data that are so reproducible and reproducible in really good mouse models. As you know, I'm sure from your work, the model you choose matters, right? In an ideal world, you want to use a mouse model that is
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
you know, not inbred, that is more closely related to what we care about, which is ourselves. And so when you see many labs getting the same result over and over again, regardless of how they do it, you really start to believe there's a signal there.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So now to be able to see this in a higher order mammal and ultimately in companion dogs, which is where Matt Caberlin is looking, I think that's gonna be really exciting. And I've often said to my patients, look, in 2026, I'm either gonna feel a lot more conviction about taking rapamycin and prescribing it to some of my patients, though, again, not most,
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Or I'm going to have a second look at this and say, maybe we just shouldn't be taking this, right? Because I do think that the dog study is going to be more telling.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
It is going to go on. Initially, there was insufficient funding to do the study in an adequate way. Then it turned out there was a shortfall of about $2.5 million. um, to do the, the study that Matt really wanted to do. And then actually a group of us raised that money for Matt and did that.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So, uh, me and a few of my patients and a couple of other folks came together and put the money in to close the gap. But yes, there has been, um, what, what, what, what did get pulled back by the NIH inexplicably and, um,
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
in my view, totally incorrectly, was the ongoing surveillance program, the funding for the ongoing surveillance program that would allow this type of work to continue and to allow greater follow-up on this.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yes, unfortunately, until we can get more funding, we're not going to be able to maybe do as much as we'd like to do and understand this, which again, when you look at some of the things that are funded, it's hard to believe that there's not a more interesting question right now in biology than this drug that seems so promising.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Why we wouldn't want to know if this is something we should all be taking is kind of a mystery to me.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I don't even know if it's in red blood cells. My intuition is, I've never looked to be honest with you, but given that red blood cells have a different metabolic pathway where they're purely glycolytic, they wouldn't have the need for it in the way that others would, but they might because they still undergo redox potential. It's possible NAD is in every single cell.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Right, so NAD is, again, one of the most ubiquitous molecules in the body, and most of what it does, and I mean most, meaning like somewhere between 500 and 600 pathways of it, utilize NAD as a cofactor. Meaning that it's not consumed in a chemical reaction, but rather it serves as an electron shuttle. So NAD and NADH basically play catch with electrons.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And that's 99% of what NAD is doing in the body. And for that reason... NAD is so tightly regulated in the body. The levels of NAD in the cell are really tightly regulated, and that shouldn't be surprising. Just as glucose, really tightly regulated. pH or hydrogen ion concentration, really tightly regulated. We as a species cannot survive outside of a very narrow band of pH, right?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
If it's below 7 or above 7.8 on a 0 to 14 scale, we die, full stop. Similarly, NAD is managed across all ages and across all physiologic conditions in a super tight band. There's another place where NAD shows up, and that shows up as a substrate, right? So cofactor means used coenzyme, used but not consumed, recycled. That's 99% of it.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
A small fraction of it is used, and it's used by these things called sirtuins that consume NAD as an actual substrate in the process of DNA repair. Yeah. And maybe we can go into this, but this is really where the story picks up.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah, so let's use another example of what the gold standard is here or what a great example is. So I recently did a podcast with Dina Duval from UCSF on clotho, which is an amazing scientific story. And it's a great story because it shows how accidents can lead to great discoveries, right?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So there was a researcher in Japan who was really interested in understanding hypertension, high blood pressure, and they had created a mouse model where they were trying to knock out certain sodium channels to see if they could perturb blood pressure.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And then there was this one strain of mouse with this one knockout that died really, really quickly. And it developed like devastating neurodegenerative disease and died very quickly. And like a good scientist, he didn't say, well, that sucks. I'm going to discard that one because it didn't give me what I wanted, which was the blood pressure change.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And he kind of went and figured out what was going on. And he figured out that there was a certain gene that he had hit that wasn't a sodium transporter and instead was this other gene. He named it clotho. So you had this one piece of evidence right now, which was if you knock out that gene, you kill an animal very quickly. Now, that doesn't mean it's a longevity gene.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
You have to do the other experiment to your point. You have to overexpress that gene and ask the question, do you live longer? And sure enough, when they overexpressed that same gene that they had just knocked out and killed the mouse, the thing was living 15% to 20% longer.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah, so that's how you can say, well, that's a longevity gene.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So let's go to the Sirtuin story. So it goes back to the late 90s. Matt Cabral, and again, this is amazing, right? So you have this guy who's like the leading authority or one of the leading authorities on the work going on today with rapamycin, along with one of his colleagues, David Sabatini, and a few others. But when Matt was a postdoc, he did an experiment in a strain of yeast.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I think it was the W303 strain of yeast. And he overexpressed Sirtu. And lo and behold, the yeast lived longer. Now, a year later, someone else in the same lab took a different strain of yeast and calorically restricted them, and they also lived longer. I forget the name of that. I forget what that strain was. It was something 316. It was a different strain of yeast.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
At that moment, again, this is about 25 years ago, a hypothesis emerged, which was we have two different strains of yeast. And in one of them, when you overexpress SIR2, this gene, they live longer. And in this other strain, if you calorically restrict them, they live longer. The understandable hypothesis was caloric restriction, which we had known was life-extending, is working through sirtuins.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
That hypothesis sort of fell apart about four years later when Matt Caberlin, again, this time with Brian Kennedy, did another experiment in a different, yet a third strain of yeast that allowed them to test hypothesis because there was a problem with the story I just told.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
When you took the 303 strain, this is the strain that when overexpressing SIR2 lived longer, if you took that strain and you calorically restricted them, no change. That's odd. Even more odd is when you took the 316 strain and this is the strain that lived longer with CR, if you overexpress SIR2, no change. So right off the bat, the story didn't make sense.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But it was further solidified that that story didn't make sense when Brian and Matt published in 2004 in yet a different strain. God, I'm blanking on the name. It's like BY4742. These don't matter. If you calorically restricted them, they lived longer. If you overexpressed SIR2, they lived longer. If you did both, they lived even longer. It was additive.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Again, further suggesting that overexpression of SIR2 and caloric restriction independently and separately extended lifespan. These are parallel pathways. They're parallel pathways. For reasons that honestly escape me, Andrew, there are still people who maintain that the benefit of sirtuin overexpression is through the caloric restriction pathway and vice versa. And that's wrong.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
My reading of the literature, in addition to every person I have talked to on this who works in the space, including Matt Kaberlin, who has done the most research on this, is that there is no evidence that caloric restriction and sirtuins operate through the same pathway. And in that sense, I think,
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
There's relatively uniform agreement that caloric restriction extends life across the model systems we discussed. What about in humans? What about it specifically? Does it extend life?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
The joke is you probably will live longer and it will feel even worse. Caloric restriction, which by the way, there are real debates about whether it will extend life in humans because it will clearly, I shouldn't say clearly, I think it would be a very safe bet that severe caloric restriction will absolutely reduce the risk of most chronic diseases.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I think there's very good reason to believe that if an individual constitutively consumed 25% fewer calories than they were meant to eat, their risk of cardiovascular disease, cancer, Alzheimer's disease would go down. The problem is what things go up. What does that do to your immune system? What does that do with respect to sarcopenia? What does that do to your risk of falling? Yeah, frailty.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah, exactly. So you trade one set of diseases for another. It's not at all clear that lifespan goes up. And by the way, when you even look at some of the wild, like some of the animal literature where they're using different strains of mice that are not inbred and they don't put them in hermetically sealed situations, they don't live longer.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So it's not always the case that caloric restriction extends life. And therefore, well, it's safe to say caloric restriction probably reduces the onset of chronic disease that might not translate to an all-cause mortality benefit based on those downsides. But all of that said,
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I think the whole sirtuin story got off to an incorrect start where it basically lopped on to the CR story, which was, hey, we've got this thing CR that we've known since- Chloric restriction. Right. Chloric restriction. We've got this thing, which for 50 years we've known has a signal that really says it's life extending.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And we've got this yeast where it works and this other yeast where sirtuin activation works. Oh, it's got to be sore. But again, if you go through the story in detail, as I just did, There's no evidence whatsoever that sirtuins have anything to do with caloric restriction and vice versa.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Now, none of this gets to the question you raised yet. That's just all, that's all prologue, right? That's like, where did this story come up? But then the question becomes, well, if you believe that sirtuins are truly a factor that drives longevity, how can you activate them? How do you activate a sirtuin?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So we have to now simultaneously start to hold things true in parallel that may or may not be true. So we want to then ask the question, do we believe that what we saw in yeast, which I think is the only reproducible finding I can draw, meaning this is a reproducible finding, in many but not all strains of yeast, if you overexpress sirtuins, the yeast will live longer.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So let's park that in the parking lot as a very likely statement. you would then say, well, if it does it in yeast, does it do it in flies? Does it do it in worms? Does it do it in mammals? You want to be able to check those three boxes because again, that's a billion years of evolution. So if something works across a billion years, we'd be much more confident it works in us.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah, and the only one that I can find that has demonstrated a survival advantage is one particular transgenic mouse experiment that overexpressed SIRT6, and it did indeed for the male mice increase lifespan by 10% to 15%. So this is one transgenic mouse model that overexpressed SIRT6, and the male mice lived 10% to 15% longer. The female mice did not.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I don't remember, Andrew, to be honest with you. I'd have to go back and look at the paper. I don't know if it was muscle specific or whole body specific.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Right. So again, just to summarize that, that's 2012. We have this one transgenic mouse. You put SIRT6, you overexpress SIRT6, and all of a sudden, the males were living 10% longer. Again, to be clear, the females didn't experience a difference. And that's not uncommon or unheard of in longevity research. There generally are sex-specific differences, and you always have to read the fine print.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
The first thing I always look at in a study when I see a difference in sexes, or frankly, any difference in longevity, but it's always great when they parse them out by sexes, is how long did the controls live? But I went back and actually looked at the Kaplan-Meier curves on that exact study, and yes, indeed, I think that's a real effect.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So let's take stock of now two pieces of information that I think we could say is probably true. It is probably true that in a handful of strains of yeast, if you overexpress SIRT, you are going to live longer. that tends to be completely independent of caloric restriction. That's the single thing I can say with the greatest confidence.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And there is at least one transgenic strain of mice that if you get it to overexpress a different SIRT, SIRT6, but again, these are homologues throughout the species. So we don't have to get, I don't think we need to get wrapped up in SIRT2 versus SIRT6. You will at least make the male mice live longer, but not the females.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Actually, you've hit two of the big three right off the top. We believe that when sirtuins are activated, they're improving mitochondrial biogenesis. They are increasing DNA repair. So that's probably the biggest one. And by the way, that's sort of what brings us to the NAD story. And also reducing SASPs, right? So the soluble products of senescent cells.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So in other words, those are all three good things, right? So you tamp down on senescent cells, you increase mitochondrial biogenesis, and you increase DNA repair. Those would be all great things to do. And we think that sirtuins are probably doing all of them.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Well, I mean, I think we know that as we age, it's just a stochastic process, right? Like given the ubiquity of DNA replication and the fidelity of the system, which is high, very high, but not perfect, there's going to be mistakes. Actually, this is an interesting question. So in 2016, I went to Easter Island with David Sabatini and Nav Chendal and Tim Ferriss.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So the four of us just took a trip to Easter Island to see the birthplace of rapamycin. So it was kind of like vacation slash science journey. That's a nerdy vacation. It was awesome. And so just picture hiking around this incredible island, just talking about science all day.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But this was an interesting question that I posed to Nav and to David, which was, why do we see such a clear and present association with cancer as we age, and why is it so nonlinear? So it's not just that cancer goes up with age, it goes up like that. And I said, I'll offer two hypotheses, which is more compelling.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Is it simply that as we're aging, DNA replication, again, taking a step back for the listener, cancer is a genetic disease. Meaning, by definition, it is sort of the canonical problem with cancer is a genetic mutation that leads to two properties of a cell. The inability of the cell to control replication. So it interrupts cell signaling. So cells replicate but then don't know when to stop.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And then... the introduction of the capacity to spread, this property called metastases. Those are the two hallmarks of cancer. So we know that that only happens in the context of genetic mutations, but why does this happen later in life and not at the beginning of life with very few exceptions? And so the question is, is it because over time mutations compound?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Is it because there are more mutations as we age? Or is there a third issue, which is All of those things are happening normally, and they're no more abundant when you're 80 than when you're 20, but your immune system can't detect them as well. And the truth of it is, we didn't come up with an answer, but it's probably all of the above.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So it's probably that as we are aging, we are undergoing more DNA damage, or at a minimum, the DNA damage we're undergoing is less amenable to repair. And that's part of the thesis here. Part of the thesis here is as we're aging, we are less and less able to repair DNA.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And one of the arguments that put forth, although we're not quite ready for this part of the story yet, but I'll just say it now and we'll come back to it, is we don't have enough of the substrate that the sirtuin needs to repair DNA, and that substrate is NAD. So again, remember at the outset I said, look, there's two big categories to think about NAD.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Most of what NAD is doing is operating as a cofactor for electron shuttling. That's the NAD, NADH, electron transport, electron accept, blah, blah, blah, blah, blah. Okay, not consuming NAD, just using it to pass electrons back and forth. But then over here we have this other category where we use NAD as a substrate. It gets broken down, and that's what the sirtuins are doing to repair DNA.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Okay, so if that's true and if NAD levels are declining with age, it's a logical conclusion that should we give more NAD, right? If you're running out of substrate to repair DNA and DNA repair is an important way to thwart aging, it all makes sense. So we'll keep that over there. But before we do, I want to come back to one other story. which is the story of sirtuin activators.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So what's the most famous sirtuin activator of all time? What is the heavyweight champion of sirtuin activators that has taken up 99% of the bandwidth in this space? It's a lovely little chemical called resveratrol.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Okay, so resveratrol, which gained a lot of fame and notoriety because it happens to be found in trace elements in the skin of grapes and therefore shows up in wine, gained a lot of notoriety about 20 years ago when one lab doing one experiment somehow was able to convince some people, including a very large pharma company, that resveratrol increased lifespan.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So the thesis was resveratrol activates sirtuins. Sirtuin activation is important because of all the things we just said, right? It improves mitochondrial biogenesis, it suppresses senescent cells, and it enhances DNA repair. So if you have something that is such a potent activator of sirtuins and you give it to a mouse, that mouse should live longer.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Now, lots of experiments were done that couldn't find that. But one experiment was done, but it was an interesting experiment. I've discussed this at least on two podcasts, including one with Rich Miller, who runs the ITP, the Interventions Testing Program, which later tested resveratrol and found that it did categorically nothing.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
In this one experiment that worked, the investigators took a bizarre mouse model where they force fed it an enormously high fat diet. And in doing so, they created such an abundance of fatty liver that the livers of these mice encroached the chest, the thoracic cavity of the mice. So the mouse died prematurely because they couldn't breathe.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And in that particular mouse model, resveratrol rescued the mice. So again, let's just assume that all of that is correct. And it's possible that there were even errors there. But let's just assume that's correct. Let's assume. So this is resveratrol delivered orally? Yes. In the food? Yes. Very high doses. Mega doses. The equivalent of barrels of grapes.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Exactly, like doses so high you could, if you recall, we're both of an age that's old enough to remember this. There was this period of time when people thought this was the explanation to the French paradox, right? Why on average do the French live longer when they consume so much wine? And the answer was, it's got to be the resveratrol.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Turns out that's not true at all because yeah, you would need to be drinking your body weight in wine a day to get the doses of resveratrol that were needed to produce this effect.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But for whatever reason, there was an effect, which is if the thing that was going to kill you was your liver being so full of fat that it shot up into your chest so you couldn't breathe, which I've never seen a human, no matter how bad their fatty liver has been, where that's been the case, but if that's the problem you're going to face, it's possible, at least based on this one mouse experiment, that you are gonna live longer.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But again, it turned out that there was no other replication of this in mouse models that matter. And that always comes back to the ITP, the Interventions Testing Program, which is the most robust tool we have scientifically to measure these exogenous molecules. So the ITP is an NIA-funded program that runs out of three independent labs.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And by independent, I mean they're each doing the experiments independently, but they're in sync with doing the experiment, but they're doing it in triplicate. So you have three labs, three great labs doing the experiments in triplicate. And when they did the resveratrol experiment, and they did it in combination with the people who found the result of that study.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So they consulted these people and said, what dose should we give? And they said, do this, do this, do this. And they did it and nothing. There was no effective resveratrol. And that result has been consistent across the board. So that's also a very important part of the story, which was
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
If resveratrol was a sirtuin activator, and I don't know if it really is, it clearly has no effect on lifespan with the one little asterisk that says, unless your body weight is 50% fatty liver, then maybe it does.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So let's see, let's just take stock of where we are in this story. We've got the whole yeast sirtuin situation, which is at least in some yeast, sirtuin overexpression lives longer. No evidence that that works through caloric restriction. Truly no evidence. That's been known for 20 years now. That paper was published in 2004.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And that was a follow-up to papers that had been published in 2002, 1999, et cetera. Later on, you'd have the 2012 transgenic mouse study. So now the question is, okay.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
How do you activate sirtuins? Well, yeah. Or more to the point, why don't we just give people NADs? Okay. So again, the NAD story is NAD levels are declining with age in most tissues. It appears most prevalent in the skin of all places. And I think we should come back to this because there's one interesting finding associated with augmenting NAD levels in the skin. And my
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
thought is, I wonder if it has to do with the fact that skin experiences the greatest decline in NAD.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
On average, skin over the course of your lifetime will see about a 60% reduction in NAD, whereas other tissues, and this is now based on animal studies, the brain might see a reduction by 15 to 20%. And the same would be found even in humans looking at the blood. So if you just sample...
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
you know, whole blood in people at the age of 20, 30, 40, 50, 60, 70, 80, you're going to see about a 20% reduction in NAD.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
In animals, yes. Obviously in humans, we're not doing that experiment, but yeah. Now, here's an interesting point. In 2015, a study was published in PNAS that looked at NAD levels in whole blood over time, and it found indeed NAD levels were going down about 10% to 20% over four decades or so. But that same study said NADH levels were going up by the same amount.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Explain the role of NADH for people. NADH is the electron acceptor. So let's maybe take a step back. Why are you and I sitting here talking and not dead? Because we have enough NAD. Right, right. What's going on, right? So you and I ate something at some point in the foreseeable past that contained chemical energy. So we ate something that was organic. So it had...
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So primarily fats and carbohydrates contain carbon-carbon bonds and carbon-hydrogen bonds. And those bonds contain a ton of energy. But how do we liberate the energy? So we break it all down into these constitutive molecules, namely glucose on the carbohydrate front and free fatty acids on the fat front.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And then our bodies break those things down further into smaller molecules that get shuttled into the mitochondria where the lion's share of our energy liberation comes from. And what we do is we take that chemical energy that is stored in a carbon to carbon bond or a carbon to hydrogen bond, and we turn it into electrical energy.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And people have heard this term, it's called the electron transport chain. So there are these four complexes in the mitochondria. And there's an inner membrane and an outer membrane across which these mitochondrial, these large mitochondrial complexes reside.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And what they're doing is they're building up a huge electron gradient by breaking them apart and taking the electrons and transferring them between NAD and NADH so that at the end, they can do another trick, which is transfer those electrons to AMP, ADP, and ultimately make ATP. The finished product is water and carbon dioxide.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So we eat and we take that chemical energy in food, we utilize oxygen in the mitochondria to make ATP, carbon dioxide, which we breathe out, and water, which we breathe and pee out. So what NAD and NADH are doing is playing an absolutely essential to life role in facilitating the transfer of chemical energy to electrical energy back to chemical energy.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
ATP is just taking it from one chemical form in food to the electrical form as the intermediary in the mitochondria. back to an electrical form of ATP. So you and I are walking around flush with ATP, which as we sit here right now, we're constantly firing off phosphates, again, now turning the chemical energy back into electrical energy and away we go.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So yeah, this whole NAD, NADH thing is like, it's as central to our existence as any form of respiration. So my point, let's go back to the story. The story was NAD levels are going down as we age, but NADH levels are going up, suggesting that the total amount of NAD and NADH is the same.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And what's declining as we age should less be thought of as a reduction in NAD and should more be thought of as a reduction in what's called redox potential, the ability to do what I just said.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So when people say NAD levels decline with aging, the answer is, yeah, but what's really declining as we age, and this kind of comes back to what you said at the very, very outset, like what's happening at the cellular level, I think what's happening is our mitochondria are not as good as we age and we have less redox potential.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah, and I'll take a step back from this first to say the following. Again, because this topic is so confusing, I think it's just worth reminding everybody of what we now, everything we've said and where it brings us, right? So I'm not going to repeat the whole sirtuin thing. Let's just leave that alone.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah, it's basically like once you establish that we think sirtuins matter, even though they don't work through caloric restriction, and that's about the single most obvious thing I can say, they might still matter. Even though we don't have things that we figured out can activate sirtuins, like resveratrol, we don't seem to have things that we can give you that activate sirtuins.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
We're now onto the next part of the story, which is, okay. Sirtuins matter. They don't seem to matter. We think sirtuins matter because of a few of these overexpression experiments. And we're making a big leap that because they mattered in yeast, they're going to matter in us. That's a huge leap for which there's zero evidence. Right.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And the reason I'm being such a hard ass about this, Andrew, is- I spend so much time fielding questions on this that I realize we just have to talk about this in the most detailed fashion possible so that people understand why. Because it is just too easy.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
There's this great quote by JFK that I'm going to paraphrase that is basically, people enjoy the comfort of opinion without the discomfort of thought. Right.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So we need to sort of, this is a podcast to get people to think and understand the entire history of this field so that they can actually make an informed decision about a supplement that I'm going to argue has very little scientific basis for its justification.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And we should talk about both healthspan and lifespan benefits when we get to that part. But...
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
To bring us up to where we are now, where you are with, should people be supplementing NAD, we're basically at the point where we're taking a lot of leaps of faith and saying, because NAD levels are going down and redox potential is going down, we believe supplementing NAD in one form or another makes sense. But before we do that, we should acknowledge something.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yes, NAD levels are going down, but we have no reason to believe that raising NAD levels will correct a problem. In other words, if the body operates between this level and this level of NAD, and if you go below this level, you die, and you go above this level, you die, and levels as you age go like this, Do we believe that raising them to this does anything?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
There's no evidence that says it does. So that's a leap of faith. It's okay to take leaps of faith. You just have to know you're taking a leap of faith. Okay, so leap of faith number one is the sirtuin thing. Leap of faith number two is the caloric restriction thing. Leap of faith number three is this matters in our species, the species of interest.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Leap of faith four is the whole sirtuin activator thing. And now this leap of faith is if we just increase NAD levels in us, it will produce a positive benefit. Okay, so now how do we do that? Now you get into the tactic. Okay, there were three ways to do it, as you said. One is you can intravenously take NAD. By the way, you could probably also orally take NAD.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
It would just break down in the gut into its constitutive products and then probably reform. But for the purpose of how people actually do this, they intravenously get NAD because it's not orally bioavailable. Or as you said, they orally take two precursors, NR and NMN. My personal view on this is there's not really much of a difference in what you do.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
In other words, at the end of the day, all of these things are generally going to increase NAD levels in the blood.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
My understanding is that- Have you done intravenous NAD? I sure have. Did you experience a niacin flush?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
By the way, do you know how many people have said to me that because of that experience, they know it must be doing something good? Oh, my goodness. To which I'm like, why don't you spread your legs? Let me kick you right in the nuts. That's going to feel even worse. Is that doing something good?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Like the fact that something feels so awful shouldn't be used as an explanation for why it's doing good physiologically.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
By the way, if you translate, the doses that they give mice in the studies where they're testing the efficacy are typically on the order of 500 to 1,000 milligrams per kilogram. Whoa. Yeah. I'm 100 kilograms. Yep. Well, okay. So picture that the next time you're giving yourself some NAD or NR.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Imagine you had to take it at the mouse doses, right?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So let's try to use data to answer the question, right? So this is exactly the thing that the ITP, the Interventions Testing Program, was designed to test. Again, if people are interested in this, they should go back and listen to my two discussions with Rich Miller where we go through gory detail of every molecule that has gone through the ITP.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
The ITP is hands down the most rigorous tool we have for testing molecules in anything other than the species of interest because we can't do these experiments in human. We cannot test lifespan interventions in humans for the obvious reasons. What is the next best thing? Well, it turns out it's doing it in a non-inbred mouse in triplicate in three institutions.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
You can't get more rigorous than this. The ITP has tested probably north of 50 molecules, meaning it has done the same experiment for 50 different molecules, and very few have extended lifespan. And the notable failure is NR. NR was tested, and I believe it was tested at a very robust dose, either 500 or 1,000 milligrams per kilogram, and there was no extension of life.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
There was no improvement in health span. There was no change. Megadose NR, placebo, same result. Conversely, let's consider some of the successes of the ITP, rapamycin. When you give rapamycin, the first time they did it, because they had a hard time formulating the rapamycin, they weren't able to start it until the mice were like 21 months old, which is very old for a mouse.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
That's like a 60 year old mouse. And at that point, they almost aborted the experiment because they were like, well, what's the point? Nothing is gonna work when you start this late, including caloric restriction, by the way, although it has worked in one experiment. But nevertheless, it worked. And when you gave Rapa that late in life, it still worked.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Then they redid the experiment and they gave it earlier. It worked. Kanagaflozin, as I mentioned, which is an SGLT2 inhibitor, it worked. Acarbose, a drug that inhibits glucose absorption, worked. And interestingly, didn't require weight loss. So the thesis behind giving Acarbose to the mice was it's a caloric restriction mimetic, a CR mimetic. And
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
It worked, but the treatment mice weren't any lighter than the non-treatment mice, which actually goes back to something you said at the very outset, which suggested that tight glycemic control independent of weight is a longevity benefit. The same was true with the SGLT2 inhibitor, canagliflozin. SGLT2 inhibitors cause you to pee out more glucose.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Acarbose prevents you from absorbing in your gut. So two different ways to regulate glucose. Neither of those experiments resulted in a lower body weight for the mice, and yet they both lived longer. Again, there's something very important about regulating blood glucose. The other thing that worked is 17 alpha estradiol, and it only worked in male mice.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So again, suggesting that, well, we can come back to that. It's more than we want to get into at the moment. But the point here is there are very few molecules that have withstood the scrutiny of the ITP. It's a high bar. Metformin failed, by the way. And the ITP is specifically for offsetting aging. Is that right? It is lifespan, but it also looks at some measures of healthspan.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But it's primarily, it is the gold standard for lifespan. Yeah.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah, so let's talk about that. So in 20, I don't remember what year it was. It was somewhat recent. A study was published looking at NR with something called terastilbene. So terastilbene is believed to be a sirtuin activator, like resveratrol. So commercially available product called BASIS, and it was tested. It was a three-arm study in humans. roughly 30 people per arm.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So decent size study, right? This is a big study. So you take 100 people more or less with fatty liver disease. Now this was documented with an MRI of the liver. So they're looking at hepatic fat in the liver by MR. And using this type of MRI, if your hepatic fat index is over 5%, that's a high enough degree of what's called steatosis that you have fatty liver disease.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Now, of course, this is not a digital thing. It's an analog, right? There's a spectrum to this. So you start with just fat accumulating in the liver, but as more and more fat accumulates, you start to get inflammation that results in scarring and fibrosis, and ultimately you would get to cirrhosis.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So just keeping back your mind, the threshold at which we would say you're in the danger zone is once you hit 5%. So this study randomized people to either a placebo or a regular dose of this product or a double dose of the product. And I can't remember exactly how much is in the product. I think it's either 250 or 500. So then that would be what the regular group got of NR.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And then the other group was getting 2X that. So it's either 250 and 500 or 500 and 1,000. I don't recall. They also looked at something called the, they looked at many things, right? So they looked at all sorts of biomarkers. And the primary outcome for the study was, did you see a reduction of this hepatic fat via the MRI? So what happened?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So they did the study and lo and behold, there was no difference. There was no difference in anything. So at high dose, at low dose, there was no difference in how much hepatic fat you had at the end of the study. There was no difference in body weight. There was no difference in inflammatory markers.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
There was no difference in glycemic markers, glucose levels, liver function tests, any of those things. So in that sense, it was a null study, but they did one sub analysis, which again, you have to be very careful of because a sub analysis is not a primary outcome, but it's kind of a way to go and parse the data.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And they did find one statistically significant finding, which was if you limited the analysis to people who had a hepatic fat score below 27%, Remember I said, once you're above 5%, you have fatty liver disease. Well, they had people anywhere from 10% to 40%. But if they looked at people who were below 27%, in the low dose group, there was a statistically significant reduction in liver fat.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
If it sounds like I'm machinating, I am. Let me say it again. If you limited the analysis to people who had below 27% on this hepatic fat index, the people who got the full dose had no difference. They averaged 20% at the beginning of the trial and 19% at the end, no statistically significant difference. The placebo group averaged 20% at the beginning, 20% at the end.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But the single dose of the drug went from 20% to 15%, which was statistically significant. It's not clear that that's clinically significant, which is a pretty consistent theme in this type of research. Never confuse statistical significance with clinical significance. If I gave you, if your blood pressure is 160 over 100,
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
and I give you a drug that lowers it to 157 over 97, that could be statistically significant if the variance is small enough between people in the study. It has no clinical significance. I haven't changed the course of your life. So again, that to me is one of the two big findings that people point to to say, aha, there was some benefit in fatty liver disease with this.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But again, when you read the fine print, which I just vomited out to you, I don't think anybody is looking at that going, oh, we just found the solution to NAFLD. The second study that people point to a lot was 2021 or 2022. This came out of a group at Wash U, I believe, and they looked at NMN and they looked at glucose disposal. So in this study, they asked the question,
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
We're going to take two groups of people. You're going to get a placebo for a period of time or you're going to get NMN for a period of time. And we're going to then do what's called a type of glucose challenge where we look at how well you dispose of glucose with and without insulin infusion. And in the placebo group, you would look at pre and post glucose.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So pre and post placebo treatment, was there a difference in glucose disposal with no insulin? No. What about with insulin where you would expect to see much more glucose disposal? No difference. But when you did that with the NMN group, there was a statistically significant increase in glucose disposal with insulin infusion, but it was quite small.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
In other words, it was clinically very insignificant. And just to sort of figure out how insignificant it was, I went back and actually looked at some of the red light data. Because there's an interesting study that shines red light on a person's back and then does an oral glucose tolerance test. Yeah. And you can actually reduce like postprandial glucose by 8%. Is that meaningful? Not really.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I mean, not in this patient population because these people were all pre-diabetic and they had very high glucose. So- It was, again, another example of something that was statistically significant, but not clinically significant. And the same thing was true in this study, right? But again, people would probably point to these two studies because they're in humans.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And you had this one, if you squint and look really hard and take a sub, sub, subset of the analysis on this one measurement, we saw a response of hepatic fat going from 20% to 15%. which is still 3X above the threshold to have fatty liver disease. And in this other study, you had this very, very modest reduction, pardon me, increase in glucose disposal.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But I mean, there's a saying in my sort of mind, Andrew, which is like, if you have to resort to really interesting statistical machinations to see something, there probably isn't something very interesting there. Right.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So it's generally regarded as safe. It has an FDA designation of grass, which means it is not regulated. Generally recognized as safe. Right. And so that means anybody can sell it. The FDA will have no oversight. They're not telling you whether – they're not going to put a stamp on it that says what they're selling is what it is.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And you can't make a claim about it that isn't validated by some sort of study. So honestly, Andrew, I think the whole NMNNR debate is irrelevant. Yeah. I think it's just a commercial debate. I think it's literally just posturing about how can I carve out a different market? I don't think there's a scientific reason to favor one over the other.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
There's one benefit I could find. There's one benefit I could find that I think is genuineness. There are a few other really insignificant ones that fall into the category of goofy studies that cherry pick by data mining. Okay. So there's studies that like gave people NMN and looked at a shotgun approach of many different things. Like did it change LDL cholesterol, HDL cholesterol, triglycerides?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And the answer is, oh, look, there's a small decrease, but it was totally insignificant clinically, even if statistically significant. And Oh, it increased your six-minute walking test or whatever. It's like a six-minute walk test or whatever in people who are in their 20s is irrelevant. It had no change in VO2 max. It had no change in any meaningful metric of performance.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
one test, one study I could find that actually had what looked like a signal to me. And it was a study that looked at skin cancer rates with, and I can't remember if it was NR or NMN, but honestly, I don't think it matters because I think they're basically equivalent.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
By the way, I just did this exercise because my daughter, her 16th birthday is around the corner. And we take a picture of her every single year at the minute of her birth. So we have a picture of her every single year holding a clock that says 3.56 at 3.56 p.m. because that's when she was born.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So this one study found somewhere between a 60% and 80% reduction in basal cell and squamous cell carcinomas. Now, it found no difference in melanomas. So again, you know this because you just did a podcast on this. Melanoma is the skin cancer that kills you. But that's not to say that, you know, squamous cell and basal cell carcinomas aren't problematic. They can be very, you know, deforming.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
They can require pretty aggressive surgeries to address them. And so if indeed there is something that can reduce the risk of basal and squamous cell carcinomas, that may be a rationale for taking it.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
They are very common and they are very clearly associated with sun exposure in a way that even melanoma is more complicated and has a genetic component and there are other things going on. But squamous and basal cell carcinoma are very clearly related to sun exposure. As you said, they're quite common.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And so, you know, personally, that's an experiment I would like to see repeated because if indeed NR and or NMN reduce the risk that significantly of squamous cell and basal cell carcinomas, I think you could make a case that if you're an individual who's at risk for those things, clearly I'm not, right? Like I've never had a sunburn in my life.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I don't work outside, so it's like, it wouldn't matter to me, but there are a lot of people for whom either their skin color makes them more susceptible or their pastimes or frankly their line of work makes them more susceptible. Maybe there is a case to be made for it there. If you could literally take 60 to 80% of your risk away on squamous or basal cell carcinoma, that could matter.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And by the way, I don't know if this is true, but you may recall at the outset, At the outset, I said that when you look at all the tissues in the body where we see a reduction in NAD, do you remember what had the biggest reduction? It was skin.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So there's a part of me that wonders, like, is the reason that the only place we see a really good signal potentially for NR and NMN supplementation is in a skin cancer? Although it's not melanoma, which is the one we'd really want to see. I mean, if this reduced the risk of melanoma, I would take it, right? Because even though I'm dark skinned, I'm still susceptible to melanoma.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So I just wonder, that could be true, true and unrelated, but that's the first thought that crossed my mind when I came across that literature was, I wonder if the enormous reduction in tissue NAD in this particular tissue explains why maybe there is a benefit to it.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And I just went through and pulled each of the last 16 of them from the day she was born all the way up. And you're right. the biggest changes are actually in about the first 10 years. The difference between being 13 and 14, 14 and 15, 15 and 16 becomes incrementally less and less and less, whereas going from two to three and three to four and four to five are ridiculous changes.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
By the way, just going back to the group that have decided that $1,000 for an NAD infusion and dripping it in over two hours is a good use of their time. What do you think would be the improvement in their lifespan if they spent that two hours exercising? Significantly greater. Interesting. All right. And less expensive, but yeah.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
If you had an extra two hours a week to choose between paying $1,000 or $700 for an NADU infusion or lift weights for an hour, go for a half an hour walk and listen to your favorite podcast like the Huberman Lab and then eat a meal for half an hour. I can just think of so many better ways to spend time and money. But anyway, let's not digress.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So again, you might have a slight dose issue, but at the end of the day, you're giving NR. NR is freely taken up into cells. It turns into NAD. So this is all a big sort of shell game of how do you get NAD up. And again, I think we've established and we can agree that there is an increase in NAD, at least in the blood and probably in the liver, when you take exogenous NAD or a precursor.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I don't know that that's really- Specifically cells like skeletal muscles, right? I think based on Josh Rabinowitz's work, I also had Josh Rabinowitz on the podcast to talk about this. And I trust Josh on this much more than I would trust any marketing material. Sure. Because he doesn't have a dog in this fight, right? He just does the work.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
What Josh's research showed, which is basically NAD flux research, has demonstrated that, look, the liver is probably the place of greatest uptake in addition to blood, and that's about all we know. It's not clear how much of this is getting into other cells.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So, I mean, that's, the rest of it is just, you know, I think rearranging deck chairs on a Titanic as far as like, how much does it really matter? And again, I don't even think it's worth arguing about whether NMN or NR is more bioavailable because to your point, you can sort of adjust the dose.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And I trust that whatever you're taking, NR or NMN, you are getting some NR into the cells and that's being converted to NAD. But we still keep coming back to the jugular question. Does that matter? Does increasing intracellular NAD matter when the system is so tightly regulated? I think what you see is a lot of marketing material that tries to make the case that you can do it. Great.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I'll grant you that you can do it. Does it matter? Does it matter in lifespan? The answer appears to be unambiguously no at this point. Does it matter in healthspan? I think that's what we're discussing.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Well, I mean I think the bigger issue is like you can't do the longevity experiment in humans. And I'm sure that these companies that sell this – and I honestly – I don't follow this space. I don't know how many of these companies there are out there. I can name two because five years ago, which was the last time I really dug into this, I knew who the two dominant players were.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
For all I know, there could be 20 companies today that are selling NR and NMN. I don't know any of them.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I don't think actually that was a scientific decision. I think that was more of a lobbying decision from an IP protection standpoint.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah. I mean, again, I think the strongest argument I could make based on the data would be potentially on the basal cell and squamous cell carcinoma risk reduction if indeed those results are reproducible. Again, that would be justification, again, for the right individual. Wouldn't be a justification for me. Might be a justification for somebody. But really the rest of it is –
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Why do you need to do experiments on this if you're selling a supplement when you don't need to make claims to sell a supplement? Like if it's a drug, you have to have an indication. You can't sell a drug without rigorous trials that demonstrate both safety and efficacy. I do think it's pretty safe to say that I do think NR and NMN are probably safe.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
There has been some voice around the idea that NR could increase the risk of cancer.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I think that's probably fair. I don't think there's been a well-done study in this entire field is part of the problem, right? So – and that's probably too harsh a statement. But this is not a field that's like – That's necessarily lending itself to the rigor that you would in pharmacotherapy. And I think there are probably – you mentioned Charles Brenner.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Like I think Charles does good work, right? And he works on many things, not just this. Yeah. And by the way, I don't think – I don't hear Charles out there saying that NR increases lifespan.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah, that's my understanding of his position as well, is that I think he firmly agrees with what I laid down at the outset of this, which is there is no meaningful, logical connection between the relationship of sirtuins, caloric restriction, and NR. That's a shell game that is empty. And you're right.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I mean, I think part of the reason why I think there's much better research going on with rapamycin is that there's really no commercial interest in rapamycin. Like nobody's going to make money selling rapamycin. Because it's so cheap? Well, yeah. And it's actually not cheap, but it's a drug that is off-patent. So this is a drug that was approved by the FDA 25 years ago.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So generic forms are inexpensive enough that nobody- Believe it or not, they're not. This is the irony of it, is generic. So Rapamune is the brand drug that was initially approved in 1999. And today, if you go and buy rapamycin, you're going to not buy rapamune. You're going to probably buy generic sirolimus or rapamycin. And yet it's surprisingly quite expensive.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Now, it's not enormously expensive because you're not taking much of it, but it's about five bucks a milligram. That's pretty expensive. So if you're taking eight milligrams a week, that's 40 bucks a week is probably what I spend on rapamycin. That ain't cheap relative to, you know, and it's cheaper than some things I take, but it's not cheap.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But the point is, like, nobody has a commercial interest in rapamycin. It's sort of an irrelevant drug, but the interest is scientific. The commercial interest is in what we call rapalogs, which are analogs of rapamycin that are being investigated by a number of companies to look at new indications. For example, immunity, immune function.
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Rapamycin historically is thought of as an immune suppressant because that's the context in which it was approved for patients undergoing organ transplantation.
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But I think Joan Manick and Lloyd Clickstein, when they published that paper in 2014 using everolimus, where they took a group of 65-year-olds and randomized them to either a placebo or different doses and dosing schedules of everolimus, found an enhanced immunity in response to an influenza vaccine, which again was, for me, that was the turning point. That's when rapamycin went from
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
something that was interesting based on the first ITP in 2009 to maybe we should be taking this in 2014. So between 2009 and 2014, I was kind of looking at the curiosity of rapamycin and saying, well, cool that it worked in mice. I don't think humans should ever consider this to that study, which was like, wait a minute, something's different.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
if you take rapamycin as a human, at least every day, it seems to suppress your immune system. But if you just pulse it once a week, as they did in that study, it seems to improve immune function, which again means it's an immune modulator. It can go up or down on the immune system. That was really the hypothesis that emerged from that experiment. And so now the question is, could you design
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
drugs that are more specific to mTOR complex one, which rapamycin is not, but you can get around that by dosing it intermittently. And then of course, you know, is it a drug that has efficacy in terms of other things that can be tested in humans that are not longevity? Because you can't test lifespan in humans, obviously.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
It's a very fancy camera system where it's got a million cameras on you and you go through this whole exercise. How high can you jump? How far can you throw? It was awesome. And then it gives you a movement age. Andrew, I was 22. I believe it. I mean, I should feel amazing. Do you actually think I move like a 22-year-old? I mean, are you freaking kidding me?
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I bet you if I went and did that again tomorrow, I'd come back at 31 or something. There is so much nonsense in this type of testing. It is just, you know, look... there's probably something to be said if I do that and I come out at 22 as I did versus 92. I would grant you that if you took 150 year olds and you put them through a movement test,
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
The ones that really, really are struggling will come out older. And the ones that really, really are doing great are going to come out younger. So great. I guess it's nice. I guess I move reasonably well for a 51-year-old. But it's simply impossible to believe that I can do today what I could do when I was 22 with respect to movement and strength and power, which is what that was assessing.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
You're doing a lot of jumping, single leg jump here, do all this kind of stuff. Balance testing, all sorts of things. I guess I would say the gold standard for any of these biologic aging tests has to be the following. What is a better predictor of remaining years of life, chronologic age or biologic age? That's, to me, the most important standard. So how old are you chronologically?
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I turned 49 in six weeks. Okay. So I'm sure your listeners will not like to hear this because they would probably hope and believe that you are immortal. Some might want to hear that I'm going to be taken out soon. Yeah. But let's just grant your mortality as a given. Based just on your chronologic age, an actuary would come up with a pretty decent prediction of how long you're going to live.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Now, I would argue that that's a crude assumption because it doesn't take into account the fact that you're metabolically healthy, that you do all of the things that you do. But just based on the fact that you are a man who is 49 years old and who doesn't smoke, Those three things would give me, if I were an actuary, a very good prediction of your life expectancy.
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Because I'm not an actuary, I don't know the exact number, but my guess is it would be predicted at this point at another 37 years.
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah, maybe. I might take a slightly different angle on that. But let me go back and make one point, and then we'll come back to this point, which is actually really interesting.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Well, as you said, it's very difficult to contemplate finitude. So I actually want to talk about that because I think it's so interesting. But I just want to make this point about the actuarial point, right? So let's just say actuarially your expectation is 40 years more at this point because you're 49, you're a male, and you don't smoke.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So we believe you have somewhere between 35 and 40 more years of life. predicted on the basis of your biologic age. That's it? That's all I got? You're going to live to whatever, 88 to 91 or something. I'm making that up, but that's like, okay.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So now let's pretend you went and did a biologic age test. Okay. So let's say you did that. And let's say it came back and said you're 25. So if I had a 25-year-old male non-smoker in front of me, what's his life expectancy? Well, it's about 60 to 65 years. Does that mean that you, Andrew, have 60 to 65 more years of life based on a fact that your biologic clock says you're 25?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Do you believe that? No way. No, of course not. Now, this would be an easy thing to test, not in humans, but you could do it in mice. Interesting that, to my knowledge, that experiment hasn't been done. Right out of the gate, when I look at people talking about their biologic age, well, I'm actually 60 years old chronologically, but my biologic age is 35. Um, my response is who cares truthfully?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Like, is that a good thing? Yes, probably. But does it, is it, is it, is it tangibly measurably meaningful like to have a biologic age of 35 versus 40 versus 30 if you're 60? I don't think, I think we're, we're applying a very false level of precision to something that might only need to be directionally true. Secondly, we don't really yet understand the biologic noise in that measurement, right?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So there are lots of things that we measure that are really noisy. So if I measured your, I don't know, let's think of something that's very biologically noisy, your triglyceride level. Like your triglycerides are pretty noisy unless I do something very important, which is standardize it by how long it's been since your last meal.
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Like if you ask me right now what my trigs are, I have no earthly idea because, you know, I probably ate three hours ago. And I don't even remember what I ate, how much fat was in it, how much carbohydrate was in it. I have no idea. So the only way you could really get a triglyceride measurement and put any weight to it is if you've been fasting for 8 to 12 hours.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
then we can at least say, hey, a triglyceride level of 50 milligrams per deciliter is excellent, whereas a triglyceride level of 120 milligrams per deciliter is lousy. But if you measured my trigs today, meaning at this moment, and they were 150, that could be totally reasonable, even though at fasting levels I'm at 50.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So we know that because we know exactly what goes into the triglyceride measurement. But when you look at a biologic clock that takes into account your glucose level, your vitamin D level, your epigenetic marker here or there, those are very noisy things. So how do I know when I measure it in you now versus when I measure it in you a year from now, I captured you in the exact same space?
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I mean, I don't. So it's for that reason that I just have a very hard time putting any stock in this. Now, does that mean that in the future we won't find some benefit in this? I think we probably will. I do think of all the things that go into it, probably the epigenetic part of it would be the most interesting, but again,
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
what most people don't understand is sort of a dirty little secret is how difficult it is to measure the, and to sequence the epigenome, right? So to my knowledge, none of the companies that are doing this, I may be incorrect on this by the way, but the last time I looked, which was about a year ago, not a single company was correctly sequencing the epigenome on these things.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So they were not able to accurately say what, they were giving you an average representation of your methylation, but they weren't going base pair by base pair and actually sequencing this the way we would sequence the genome. So again, it's so much noise in this system. And I just think it creates a little bit of a distraction for people, truthfully.
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So I would frame it slightly differently because I like categories to be more MISI, mutually exclusive, collectively exhaustive. So I don't know that I would formulate it that way, right? I might say, look, category one are sort of the essential behavioral things that you have no choice but to engage in whether you want to or not, right? So you have to eat, you have to sleep, you have to move.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Let's just keep this all in context. So the NRC recommends that a human being, or at least an American, should expose themselves to less than 50 millisieverts of radiation a year. Okay, so that number doesn't mean anything to somebody. So let me give people a sense of what that means. So how many millisieverts of radiation do you and I receive? Because we both live at sea level.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So just ambient radiation living at sea level is one millisievert a year. Okay, so we just chewed up 2% of our annual allocation. What if you moved to Colorado? Now you're a mile up. That increases you from one to two millisieverts a year. Okay. What if you had a CT scan of your chest, a CT angiogram? Well, it depends on where you got it done.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
If you got it done at a really good place with a fast scanner and great software, probably three millisieverts a year. If you got it done at a place that's sort of average might be 10 to 15 millisieverts, pardon me, per scan. Now, here's what's really interesting. By the way, I'm totally fascinated by this question, which is how much radiation is too much.
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
A DEXA scan, by the way, you can't even measure how many millisieverts you're getting. So a DEXA scan is like less radiation than a cross-country flight. So it's super, super, super low, less than an X-ray or anything like that. People who work in nuclear plants, I'm told, I haven't looked at the primary data on this, but I've talked to people who incessantly do this.
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So it's possible I'm a little bit off on this, but I'm told that these people are at 10 times that level of radiation exposure and sometimes higher. They're not getting 50, they might be getting like 500 millisieverts a year. Yet interestingly, they're not at an increased risk for cancer. I'm not sure what to make of that.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But it suggests to me that we probably don't need to worry about things like airport scanners and flights. In fact, even if you look at pilots who do constant flights across the poles, because you're going to get the most radiation going over the pole, to my knowledge, there's no convincing data that suggests those people are at an increased risk of cancer either.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And they're obviously at the upper end of what a civilian would experience in terms of radiation. So I'm not convinced that that's something we should be stressed about.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I want to go back to what you were saying earlier about what you need to do in your 90s versus what you're doing now. So you said you think that in your 80s and 90s, you're going to have to work harder to preserve the vitality that you have now.
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So I would say that, yes, you're going to have to work hard in that last decade of life to preserve those things. But I think it's the work we do now. that sets the stage for that. It's the foundational work that we do in this period of our lives. You and I are only a couple of years apart, but I think this is the critical decade.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
It's in your 50s to your 60s and in your 60s to your 70s that I think is the deciding time. 50s to 70s. 50s to 60s. Yeah, 50s to 70s. So what is it about this window that you and I are just entering now and why is it so important? I think it's important because we're getting to that point where aging does start to show up.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Like I think if you and I are being brutally honest, like we're kind of half the men we used to be. And again, that just means like, look, like a night of poor sleep. shows up more, right? When you were working in the lab, as hard as you were describing it, you could probably walk through walls when you were exhausted.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
You need to do more self-care. You need to be more mindful of what you're eating, how you're sleeping, how you're recovering from those workouts, because we still do hard workouts, but recovery plays a greater role. In other words, we're just not quite as resilient as we used to be. I was telling somebody the other day, they asked me about my residency.
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
You just have a choice in do you want to do those things correctly or not correctly? Or do you want to do those things in a manner that promotes health or erodes health, right? So again, there's nobody listening to us who doesn't eat. But again, you can choose how much you eat and what you eat and when you eat.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I don't think I'm being hyperbolic when I say this. I couldn't do one month of what I did for five years. I really couldn't do it. There's no way I could go back to that level of sleep deprivation for a month, let alone five years. That's just a fact of aging, I think. But what we have to do during this period of time is build up as much physiologic reserve as possible.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And so the important thing is we have to stay in the game because compounding makes such a difference, right? So we're still young enough that we can actually put on muscle mass, right? Now, that's not always gonna be the case. It's gonna be very difficult to add muscle mass when you're in your mid to late 70s. It's doable, but it's very, very difficult.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So instead, we wanna be putting on as much muscle mass as we can. And increasing or at least maintaining strength as much as we can. Again, probably increasing it is unlikely. Clearly, we're not increasing power as we age, right? Andy Galpin has talked a lot about this. The atrophy of the type 2 muscle fibers, the 2A muscle fibers, really start to atrophy in your 20s and 30s.
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So I know I don't have a fraction of the power that I used to have. And I know that because my vertical jump is literally half what it was when I was a teenager.
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And it doesn't matter how good it was. My point is like, if you know what your vertical jump was at 18, 19, 20, and then you do it today, I mean, it's literally 50%. And that's one of the purest tests of power. So power's going down, strength is going down, but not as much. Muscle mass is actually not, because remember, that's the order in which you lose things, right?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
You're going to lose power, strength, and size of muscle. But again, size still matters. It's still a glucose sink, all these other things. But what we don't want to do is, you know, be out of the game, right? What we don't want to do is injure ourselves and get a setback that becomes very difficult to recover from.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Because when you're our age, if you're inactive for months at a time, it's going to be two to one or three to one ratio of inactivity to activity to get it back. What about energy?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
There's nobody who's alive who isn't moving because locomotion is life and the absence of life is the absence of locomotion. But you can certainly choose to move very little. You can choose to move a lot and you can choose to decide on how you move. You alluded to it already, right? You can move in a certain way that puts your aerobic system in a zone that maximizes fat oxidation.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
No, and when you have kids, you're going to be even more starkly confronted with that. Because actually, it's one of the things I am most amazed by when I look at my kids, especially the youngest ones, the boys who are 7 and 10, is what I just describe as spontaneous outbursts of energy.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
like their inability to sit still, their kinetic desire to just, like they will, like if we're, I remember once we were kind of walking through a mall and we're walking through the mall, they are sprinting ahead of us, sprinting back, sprinting ahead of us, sprinting back. Like imagine if you and I were walking through the mall and I just started running ahead and running back.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
You'd be so sore the next day. But it's like, it just wouldn't occur to me to ever run unless being chased, right? Like, it's just, I mean, like, we now live a life like I think our ancestors did, which was, you know, if we're not deliberately in the business of moving for a reason, like you're exercising, you're going for a walk for the sake of going for a walk, like...
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
It wouldn't occur to you go and expend energy for no reason. And yet kids do this. It's amazing. And look, it's going to go down by the time you're a teenager. Like just going from being, you know, sort of 10 to 18, there's probably a significant reduction in spontaneous outbursts of energy, let alone where we are now. And it's a great question. Maybe it's NAD. I mean, I don't know.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Again, it's just so hard for me to imagine that any supplement or any drug, including rapamycin, which I think is the most promising geroprotective drug we have, is I just can't imagine that those things even compare to what good sleep, good exercise and good nutrition do for your energy levels and vitality. And the reality of it is all three of those things are hard to do.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Especially if you're an adult, especially if you have a real life. You got kids, you got a job, which is presumably many people listening to us right now. There's very few people listening to us right now whose only purpose in life is to take care of their health. Everybody's got something else they have to do, which means you have competing interests for how do you take care of yourself.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
We call that zone two. You can move at a level where you consume incredible amounts of oxygen at your maximum aerobic level. You can choose to move in a manner that that uses resistance and gravity against you and all those sorts of things. Similarly, we all have to sleep, right? Matt Walker would probably tell us the number of days you could go without sleep before you would literally perish.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So to sleep is not easy, right? Like we all are busy as hell. We don't want to have to stop what we're doing to undergo a nighttime routine, to put ourselves in the right head space, to be able to sleep, do all the things necessary, give ourselves that eight hours in bed to hopefully get seven, seven and a half hours of sleep. Even people like me who like exercise, I know you like exercise,
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
It still is a sacrifice in terms of time. And for many people, certainly for me, food is the hardest of these all, right? If left to my own devices, I'd eat fricking Froot Loops all day.
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
That's my hypothesis. Do you notice a seasonal change in that? Do you experience it more or less in one season or the other?
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Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But again, you have a lot of choices in how you do it. So anyway, I agree. That's kind of category one, but that's kind of the way I would frame it. And then I would put in category two, sort of what are the molecules that you would exogenously take to try to impact any of those systems? And maybe, and again, I'm not saying my framework is correct and yours isn't.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
What about the reverse causality there? Do you think it's possible that they have a system of high energy that makes Jocko who he is or makes these people who they are? And as a result of that, they're able to work out five o'clock in the morning.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Well, I don't... I don't take that many. So top five would be a pretty exhaustive list. I think the other supplements that I take, I do take EPA and DHA. In the form of liquid or capsule fish oil? Capsules. Not because I have an affection for capsule over liquid. It's just going to increase my compliance. I've done both.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And I noticed when I was taking liquid, because you're storing it in the fridge, it's just one more step removed. And I was just less likely to remember to take it twice a day. I take, Theracumin. And there's some reasonable evidence in MCI patients that Theracumin improves cognitive function.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I'm just saying, this is the way I think about it. I would then say, what are the molecules that I could take that specifically target disease processes? So I kind of think of like, if you want to live longer, And I described this, I think, in chapter four of Outlive. That turns out to be mathematically equivalent in the modern society to delaying the onset of chronic disease.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So I think there's a relatively low downside to the hypothesis that Theracumin may preserve cognitive function. Again, I wouldn't put that in the category of like beat the table for it, right? I think it's just, you know, reasonable evidence. I do take vitamin D because interestingly, despite the fact that I'm outside every day, without supplemental vitamin D, my levels are surprisingly low.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
How much do you take? I take 5,000 IU. And that takes me from kind of a level of 30-ish to a level of 50-ish. Mm-hmm. Um, and there's, you know, there's a lot of debate about how high vitamin D levels should be. That's a whole separate podcast. We could, you know, waste time on that in 10 years. Yeah. My appetite to talk about that one. Uh, let me think, what else do I take?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Cause I sure, oh, I do take methylfolate and methyl B12. Um, and again, the, the, the rationale there is, um, I do think there's some evidence that elevated levels of homocysteine are bad in and of themselves. So there's no denying the fact that elevated levels of homocysteine are associated with bad things.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
That's unambiguously clear, meaning there's an association between badness and homocysteine. What's not clear is, is it causal? Now there's definitely one mechanism you can point to, although, again, mechanisms are what they are. We just spent how many hours talking about mechanisms that theoretically make sense that never pan out.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But mechanistically, homocysteine will inhibit the clearance of something called symmetric and asymmetric dimethyl arginine. Have you heard of these things, SDMA and ADMA? So ADMA and SDMA regulate nitric oxide synthase.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
and homocysteine impairs their clearance and therefore when you have high levels of homocysteine, it results ultimately in impaired nitric oxide synthase and therefore lower nitric oxide. So this has been proposed as at least one mechanism by which homocysteine might negatively impact vascular disease.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And we also know, by the way, that ADMA and SDMA are cleared by the kidneys, and therefore this is also proposed as one of the mechanisms by which impaired kidney function impacts vascular health. Because that's a known, right? If your kidneys don't work well, your risk of heart disease goes way up.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So this is now proposed as a link between what we observe with homocysteine and impaired renal function. So we know that if you take methylfolate and methyl B12, you're going to lower homocysteine. That's abundantly clear. So the thinking is that that might actually lower ADMA, SDMA, and raise nitric oxide synthase. Again, relatively low cost, low risk analysis.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
you know, thing to take at modest doses. I also, there's probably some evidence that over supplementing vitamin B is problematic, especially B6. So I don't think- Because of peripheral nerve damage. Exactly. So I don't supplement B6. I'm just taking a bit of folate and methyl B12. Let me think what else do I take? Because I do take a couple other things.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Oh, I take magnesium L3 and 8 and ashwagandha for sleep. I take slow mag, which is just a magnesium chloride, slow releasing version of magnesium. And I take methyl, pardon me, I take magnesium oxide. So I take magnesium in three forms. So I'm long magnesium. You're carpet bombing with magnesium. Yeah, I'm big on magnesium, right? Yeah. Great for bowel function.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Now, that wasn't true 100 years ago. 100 years ago, if you wanted to live longer, a few things had to be true. You couldn't die during childbirth, because that was a huge hit on mortality. And then you had to not get an infection or succumb to trauma. And then maybe 150 years ago, that was the case.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Great for – I mean I don't know the last time I had a cramp in my life. It's been years since I've had a cramp despite exercising in a really hot place like Austin, Texas where I'm sweating like there's no tomorrow. Whether you call it a supplement or not, I take like electrolytes. I take Element, which I should disclose I'm an investor in that company. So I drink an Element a day.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I take creatine monohydrate, five grams a day. I take AG most mornings. Oh, and I take Pendulum, the probiotic. Got it. Yep. As far as I know, there's no other probiotic that has any meaningful effect on the body outside of Pendulum, right? Because if you buy the argument that a probiotic for your gut needs to have anaerobic bacteria in it, there's no value in giving you aerobic bacteria.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So you have to have something anaerobic. So Ackermansia... which works through the GLP-1 butyrate pathway, is anaerobic, and Pendulum's the only company that can make it. I have no affiliation with this company. I think you should have the CEO, Colleen Cutcliffe, on your show. She's an actual scientist, and she's fantastic, and...
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
It's a really interesting story how they kind of developed this and how difficult it is to actually make an anaerobic bacteria. And so this is kind of an odd company because it's a supplement company, but they have to basically adhere to pharma GMP conditions to make it because of the anaerobic vats that you have to use infused with nitrogen to be able to make an anaerobic bacteria.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
So anyway, so I take three of their products. I take something called glucose control. I take polyphenol and I take acromantia.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But today, most of those things are taken care of by antibiotics, sanitation, and the modern miracle of childbirth in this era. So now for you and I to live longer, we basically have to delay the onset of cardiovascular disease, cerebrovascular disease, cancer, neurodegenerative disease, dementing diseases, and metabolic diseases. We have to delay the onset of those things.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
The longer we delay the onset, the longer we will live full stop. So you can use everything that you talked about in the first category plays into that. But you also have this other category of where you can take molecules that specifically target those things. You can take metformin or an SGLT2 inhibitor or a GLP-1 agonist and you will directly impact those things.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I like steak more than lobster. That's a relative discussion. Exercise, sleep, nutrition, emotional health is the question of what was the heading of the Titanic. Okay. So I just want people to understand the magnitude of what we're talking about.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
How you eat, how you sleep, how you train, and how you take care of your mental health is the equivalent of what direction was the Titanic going with respect to the iceberg. All this supplement bullshit that we just talked about is equivalent to were they serving lobster or were they serving steak and was the band playing this song or that song?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
I'm not saying those things don't matter, but just put them in the context of the direction the Titanic is going.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Yeah, I would say the same. I don't remember who said this, but someone, maybe it was Nassim Taleb said, don't tell me what you think, show me what's in your portfolio. Meaning people who pontificate about this stock versus that stock, he's kind of like, assuming it was him that said this, he's like, okay, I don't care what you're telling me, tell me what you own.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
That's going to show me your conviction. So through that lens, look, I'll show you my conviction on exercise. I'll show you what I do. I'll show you my conviction on sleep. This is what I do. I'll show you my conviction on all these other things. I mean, I don't take these supplements. Full stop. I don't take them because I can't afford... It's not that I can't afford them.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
It's not that they're any inconvenience to me to take them. I... passionately do not believe they do anything for me, and why would I waste time, money, anything on something that I really don't believe makes a difference?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
You could take a PCSK9 inhibitor or a statin or bempadoic acid. You will directly impact those disease processes. You will delay the onset of those diseases and you will reduce the mortality associated with them.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Now, again, I am always happy to be proven wrong, and I am very happy to say that two years from now, five years from now, we could be doing this exercise again, and in the presence of new information, maybe I'm not taking rapamycin, and maybe I am fist-fulling NR and NMN. Possible. I will reserve the right to change my mind for the rest of my life in the presence of new data.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
But as it stands today, I do not take these supplements and I have no foreseeable plan to do so until information changes.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Then I would go to a third category that says, are there exogenous molecules that you can take that don't target a disease per se specifically, but we're going to put them in a category called geroprotective, which is they target hallmarks and pathways of aging that you've described. So we talk about all of these things that occur in an aging phenotype where we see more inflammation.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
We see a greater abundance of senescent cells. we see reduced nutrient sensing capacity of mTOR, which you described as probably the most important nutrient sensing system in our body. So we have these somewhere between nine and 14, the number just keeps changing arbitrarily, but it doesn't really matter. We have these central things that everybody would agree define what an aging phenotype is.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And can we use exogenous molecules to target those specifically? You gave one example, which I would argue is the single best example, which is rapamycin. So rapamycin targets a very specific hallmark of aging. And we can talk about what the experimental evidence is to suggest that that makes you live longer. So I would sort of say those are the big three categories.
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
And then basically the fourth category you could just say is like, how do you put them all together and how aggressive do you want to be in culminating those? Of course, none of this touches on
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
Another area that I want to talk about that we won't talk about today, which is like, how does all that factor into kind of emotional health and happiness and wellbeing where, you know, none of this other stuff matters if you're kind of unhappy. And so you have to, and you've done so many podcasts on that topic, right?
Huberman Lab
Dr. Peter Attia: Supplements for Longevity & Their Efficacy
You've had Paul Conti on where you kind of go through the understanding of ourselves and our minds and why that's also a very important part of it, because it actually does impact how long you live. Because if that piece isn't working, it's very difficult to regulate the first bucket. Because the first bucket takes so much work.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I thought you were going to ask me to do it to you earlier when you said this is not an appointment. I literally thought you were going to whip your junk out and have me check.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
We're just not going to look at a bunch of things. But I do want to stick my finger in the inguinal canal. That's what I'm saying. Yeah. And I'm going to make you cough.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I don't know. But I will say this. I can't tell you how many rectal exams I've done, and then I realized... I mean, technically, a good a good urologist will tell you that their finger is good enough to truly feel a prostate cancer that would otherwise not be picked up on a PSA or some other test. And I'll take them at their word. But I think for the rest of us who don't do 20 a day.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah, I just I don't think my finger is good enough. You know, don't say that. I mean, I'll work harder.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
They've said like, look, man, you know, there's always that one case that slips through the crack where the guy has a normal PSA. No pun intended.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
But they're like, yep. If you feel a certain type of super hard nodule on the prostate, that would be suspicious. Damn.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Plank, yeah, there's like a bunch of basic tests everybody should be able to, we should be able to see the people do. I completely agree.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I think my thinking is always evolving. I would say if I were writing that book today, I would actually kind of add a fifth horseman, which is anything that pertains to a weakened immune system. So I'm just getting over a cold because I have three kids and two of them are young. So basically I'm always in the face of like some virus, right?
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
So twice a year, I always get some stupid cold and it's no big deal. It starts in my throat, blah, blah, blah. It gets into my lungs. I hack up a bunch of junk and then I'm fine. But, you know, anyone who's been around older folks realizes that that's the kind of thing that can tip them over the edge when they're 80 years old.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
It was sort of my daughter's born. And then I'm realizing, actually, I'm not that healthy. Even though I exercise a lot, I'm actually not that healthy. And those two things were what kind of got me to be pretty obsessed with just trying to figure out how to – not die prematurely. The kids do that.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
You know, a really bad infection, a flu, COVID, things that us, you know, 50-year-olds laugh at can become deadly. And so from a research perspective – This is something I'm super interested in is how do we regenerate the immune system? So I'm in my 50s. My immune system is also in its 50s.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Would it be amazing if when I'm in my 80s, I could still have an immune system that's maybe like in my 50s or 40s? The effect that that would have against mitigating the risk of fatal pneumonias, infections, and even cancers is huge because the immune system is the first line of defense against cancer.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah. And it wasn't very successful because it's so nonspecific. Oh, yeah. Cancer is the only way for the immune system to eradicate cancer is it has to you have to get the very, very, very specific T cell that recognizes exactly that cancer. And you have to figure out a way to make enough of them that it does. you know, wins that war. And that rarely happens spontaneously.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I mean, the cases are, you know, documented in the literature. They're so rare, but we now have drugs that can make that happen in about 10% of cases, which is huge. Yeah.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
How do you think you can bolster the immune system or like, I mean, it depends on, I don't know how technical the audience wants to get into this stuff, but, um, So stop me when this has become unbearable. For sure. So we have DNA. Okay. Okay. So everyone's heard of DNA. DNA is the code that tells every cell how to make a protein.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
So what tells DNA to turn on and off are something called methylations, little carbons that stick on the backbone or something called the epigenome. So DNA is regulated through this methylation pattern. Okay. And as we age, that changes. So we can look at a T cell, which is the type of cell that fights a cancer or an infection, and we can say, that's what an old one looks like.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
That's what a new one looks like. Even though the DNA is the same, the epigenome above the genome, this methylation pattern looks different. And so the question is, what if we took the methylation pattern of an old T cell and made it look like a young T cell? Would it revert into a young T cell? So to me, that's certainly top two or three most interesting questions in aging research today.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
That's what regulates it. Exactly.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
So it's affected just naturally through aging. So the passage of time affects it, but so does anything in the environment. So whether you exercise, whether you smoke, whether you have diabetes or not, all of those things, good sleep, bad sleep, high stress, low stress, anything can tweak that in the right or wrong direction.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
But the gravitational pull of age is huge. And that's the one I'm most interested in is like how would you – Because even the healthiest 80-year-old has nowhere near the immune system of an unhealthy 30-year-old.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah, you can't. Age is not. Just can't do it. Yeah, father time is undefeated, as everybody said.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I don't know that there's an age I would do it. I mean, I think the things that I would, you know, I had a long talk with a patient yesterday about this exact question and he's pretty young. He's like 36, um, does not have kids, but wants to have kids. So that's a huge consideration. So in his situation, I would say like TRT is not a good idea.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Um, I, I suggested that he banks sperm and if he wants to go down that rabbit hole, um, And by the way, I don't think he needs to because I don't think his level, his levels are like kind of 50th percentile. He's not terribly symptomatic.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I would kind of eke out a bit more time, but I would rely on hormones that are going to ramp up his body's production of testosterone as opposed to just giving him testosterone, which will shut off his body's supply. Forever? No. And it also, it's not something that happens overnight. Like, you know, he'd have to be on testosterone for a while before he would shut down his own production.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I think you gotta, I think you gotta, you know, take every case individually, but if a 30 year old has his, his has testosterone that is so low that it's impacting him, I think you have to start by asking why, right? Like how bad is his sleep? How bad is his stress? How bad is every other factor going on? I mean, when I finished, um, God, when I was,
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
leaving my residency, my testosterone was 227, I think, which is insanely low. That's only two and a half times higher than a woman.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Damn, that's crazy. No, that's for the rectal exam, so you just don't get the... That's true, that's true. You wouldn't want to wake my dad's finger. No, but the reason is pretty clear, right? Because I was sleeping 28 to 30 hours a week.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Right? So, you know, horrible sleep deprivation is going to make it really difficult to make appropriate levels of testosterone.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I think probably a little bit, but the causality is much more in the opposite direction, meaning the horrible sleep is destroying the production of testosterone and growth hormone. But of course, at the time, it never occurred to me to do anything about it. And once I was in a job where I could actually sleep each night, lo and behold, my testosterone kind of normalized.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I think you should not go to. I'm trying to think of the right analogy. If you if you walk into a store that only sells hammers, everything's a nail. Right. So so I think if you walk into a tea shop and all they do is male hormone optimization, I would say buyer beware because they even if they internally have the best of intentions, like I just don't think they can get out of their own way.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I also think you should be very wary of going to a place for any sort of therapy where they're selling you the therapy.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
here's precision supplements for you and you alone how do you think they're like how much of that is kind of generic and do you think some of those companies are really dialed in or like um i i don't doubt that there are ways to kind of sort of optimize supplements around biomarkers um i just i'm not sure that it's as precise as people want to believe i certainly don't think that
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I actually think you can do a lot of supplement optimization off really basic blood work. Certainly, a stool sample is not necessary because most probiotics can't even provide the bacteria you need to impact it. I mean, your diet has a far greater role. Your fiber content has a far greater role on your gut biome and things that you'd be measuring in stool.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Um, and obviously saliva, blood, urine can measure things that are relevant and interesting. Um, there aren't that many things that I think are worth taking. Like I think, yeah, if you're low in vitamin D and you're not getting enough sunlight, that makes sense, but that's a pretty simple blood test. If your homocysteine is elevated, um, yeah, you probably should take some methylated B vitamins.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
And if you drop it by more than five or six points, you're probably doing a lot. If you're Omega levels are low. Fish oil probably helps if you're not willing to eat three servings of fish a week. Right. But the true basics of this are really simple. And then there's other supplements that probably make sense for most people. And you don't even need to test for them.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Like anybody who's active could probably justify taking creatine. Yeah. And there's no blood test that's going to tell you whether or not you need it. We just know that, you know, to fill and saturate total body stores, you're going to need three to five grams per day. Yeah.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah. Again, it's just if you're playing the game of optimizing... you're going to get a benefit, probably about a 10% boost in performance for intensity and like super short intensity, i.e. the creatine phosphate energy system. So kind of like high bursts of, you know, 10 second work and then anaerobic stuff.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Shouldn't impact the A1C, though.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
It's not going to improve much aerobically, but, and you'll also get a little hypertrophy benefit because the muscles will get bigger when they bring more water. That makes sense.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah, I think this is where kind of social media really distorts reality. And the example you give is a great one, right? So if your health sucks and you're trying to figure out where you're gonna find an extra two hours a week to do some form of self-care, The last thing you need is some idiot influencer telling you to spend more time in the sauna and cold plunging.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I can promise you that is not the first, second, third, fourth, or fifth best use of your time if you only have two hours a week. How would you break it down then? If you've only got, so I would start with, let's do the absolute basics of blocking and tackling. So first thing I want to know is, are you getting at least seven hours of sleep a night?
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Well, it takes a while. No one wakes up diabetic, but also most people don't recognize that it's a 10-year journey for most people. Really? To get there, yeah. So what, I have like four more years of prediabetes? I mean, I think that's impossible to predict for any one person, but we definitely know that disease is so much more complicated than people, I think, historically have thought of it.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Because if you're not getting at least seven hours of sleep a night, it's going to be very difficult for you to do anything at your best.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I don't know. If a person says, I feel really well, and there are these, I link to them in the book. There are a whole bunch of surveys you can get for free that just have you do like, you know, these are validated surveys that kind of go through daytime drowsiness and stuff like that.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
If you're in bed seven to seven and a half hours a night, ideally eight, and your little sleep tracker says you're sleeping seven, but you're not happy with your stages, I wouldn't put a lot of stock into that unless you feel that there is a problem. But if you're like, no, I feel fine, and I fill out all the two surveys, and they said I'm doing fine, ignore the data. That makes sense.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
And stop wearing the tracker. I know. I've got to stop. Done with the tracker. I was checking every day. I'm like, 43 foot. Yeah. Like it just creates more anxiety. It's just red. I see red numbers. Yeah. Fuck. I, I haven't used, I haven't used one of those in a longer time than I can remember. Yeah. So, um, so just do the next bucket. Yeah.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
So then the next bucket I want to know is what are, you know, what's your physical activity level. So let's say this is a person who's got none. They're doing none. And they say, look, I've only got two extra hours. I'm putting that entire two hours into exercise. So I'm going to say, we're going to do four 30 minute workouts a week. And I,
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Again, I'd have to know more about the person, but it could easily end up being, we're gonna do two cardio sessions a week. We're gonna do two strength sessions a week. One of those cardio sessions per week is gonna be kind of aerobic-based training, where you're going at the same intensity the whole time. It's not that high. You can still sort of almost carry out a conversation.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
It's a little hard to talk, but you could. And then the other cardio session I would do, say three days off of that, would be more interval, kind of like what you were describing. So let's get on a, you know, if you're at a gym and they have one of those like, you know, air bikes, do something there, be on a treadmill, be outside, it doesn't really matter.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Like the goal, like this person will get so much benefit from two hours a week of exercise that it almost doesn't matter what they do. And then the other two days a week, I'd have them do two 30-minute whole body workouts at a gym where they never stop moving. So if you're doing it at home, it might be push-ups, pull-ups, wall sits, something like that.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
If you're at the luxury of being at a gym, you might just rotate machine to machine to machine and never stop. And that would just bring huge dividends. And then the last thing I'd do is, in addition to that, is just do a quick audit of their diet. Are you overweight? Are you adequate weight? Are you underweight? That determines whether you need to eat more or less.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
And then are you getting enough protein? And honestly, I wouldn't make it much more detailed than that. And so look, with just a little bit of that insight, you've made better use of two hours a week. You've got them to stop worrying about their sleep. You've maybe changed three little things in their diet. I promise you that person in three months is gonna feel significantly better.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
And then maybe, by the way, at that point, they're like, you know what? I wouldn't mind doing three hours a week of this exercise thing because I'm feeling kind of good. And you know what? I kind of want to dial the diet in a little bit more. But again, the problem is too many people are consuming information that says, oh my God, you need to be on this supplement.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
You need to be on this supplement. You need to be doing 30 minutes of this type of sauna and 20 minutes of this type of cold plunge. And people are like, shut up. Yeah. I can't do that. Yeah. I mean, and to be clear, I love sauna and I love cold plunger, but it is like the 20th thing on my list of 21 things that is a part of my routine.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
People have historically said, well, I mean... Type 2 diabetes is your pancreas can't make enough insulin, you can't get enough glucose out of your blood into the muscles, and eventually we just cut off some arbitrary number. We just say once you reach a certain level of blood glucose, then you have type 2 diabetes. But, you know, to me that's just not a great way to think about it.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
We were meant to move. We were. And meant to be outside. That might be the other thing I would add is figure out a way to do something outdoors, like whether it's a quick walk or incorporate some of that exercise outdoors.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Do you skate? Nope. I do not at all. Have you ever? Nope. And it's funny. I mean, growing up, I was certainly of that age when a lot of kids were skateboarding. I don't know why. It just never appealed to me. Yeah. I was sort of busy in my own little world. My daughter did for a little bit. She's 16 now, but she did probably like when she was 12, 10, 11, 12. She was pretty into it. Yeah.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
The coolest thing I've picked up recently, though it's not a physical activity, but I'm freaking obsessed with it, is chess. Really? Holy cow. You pretty good? No, I'm horrible. I mean, I'm just learning. But I love it. Like, I can't stop playing. I just can't stop. Who are you playing against? I'm just playing my boys. Really? Literally, just the three of us. Phone chess or physical chess?
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
No, on the board. That's good. Writing down every move, studying our moves after. Really? Like nerding out, watching YouTube videos. I'm obsessed with this guy, Magnus Carlsen, who's the best chess player in the world. I've heard of him, actually, yeah. Dude, I can't stop watching chess porn. Really? Can't stop. That's awesome. You know how YouTube figures out what you're about?
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I think of it as a continuum and a spectrum. And prediabetes is a step along the way, but we also know that the lower your blood sugar, the better. So five point seven is better than five point eight is better than five point nine. But even though we would call you, quote unquote, normal at five point six, I would argue five is much better than five point six.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Like my videographer for our podcast, he comes, he pulls me aside like three weeks ago. He goes, Are you getting into chess?
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
He goes, because I'm managing our YouTube channel, and it only populates just pushing chess stuff all day.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I was like, idiot, I can't stop. It is good for your brain, though. I stay up at night watching chess videos.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Oh, it's awful. I'm like, it's 9.30. I should go to bed. What's your opening move? What do you go with? Oh, I'm typically like E4. But I like to castle really early, so I'm going to try to castle within about three or within four or five moves if I'm doing a kingside castle.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
One of my boys is super aggressive, so the games are quick because he just comes out swinging. Does he really? No, he swings. I like that. He goes for the fences. And then the other one is so conservative and so thoughtful that the games take like so long. And I got us a little time or two. So I'm like, buddy, you have two hours to make the first 40 moves or you're disqualified. That's good.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah, yeah, yeah. That's good. Yeah, you got to think on your feet. And the younger one, the one who's super aggressive, is so competitive. Like if anyone in our family ever makes it and becomes like great, it's him because you can't like hit the fire is insane. Really? When he loses, he tears up his sheets. And I'm like, buddy, you shake my hand and we had a good game.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
He's just losing his mind that he lost a game of chess.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
They are truly infinite. That's crazy. It's a computationally infinite problem.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
damn or as close to i mean i shouldn't say infinite right in that ai can yeah but but it's from a from a practical perspective i think it's infinite damn that's awesome that is cool how i'm gonna try it my kids are too young for that we my daughter did a like your oldest is six four oh four okay four six we could be six is doable four i did chess we did one of those big ones we're on vacation we did one of those like you know those like
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I once made the mistake of in a game, like one of my older one, the one who's more conservative, like he had, you know, he had a rook, knight, bishop in the back that hadn't moved. And it was like 25 moves in. And I'm like, buddy, those guys over there are standing there like they got their thumbs up their butts. And now those two boys cannot stop saying that.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
They just walk around every, anytime someone's not moving, why do you have your thumb up your butt? And my wife's like, why do you say this stuff to them? Like, you can't say anything like that. They're just going to say whatever you say.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Our youngest one, this is the super aggressive one, so it's not surprising. I think he was like three. We get a call from the preschool, and they're like, yeah, you got to come and get him. My wife's like, what's going on? They're like, he said the F word. Whoa. Whoa. My wife's like, oh, I'll be right there. They made you get him for that? Yeah, I'm like, this is a misunderstanding.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
And my wife's like, first of all, the kid is obsessed with rhyming. So he almost assuredly was like, truck, truck, fuck, or something like that. And the woman is like, nope, nope. He's actually the first kid we've ever heard use it properly. Oh, no. They're like, what was the situation? And they're like, well, he was in circle time. And we were telling all the kids they had to be quiet.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
And he wasn't being quiet. And we're like, hey, if you're not quiet, you're going to have to get up and leave. And he wouldn't be quiet. So we got up and made him leave. And he stood up apparently and just goes.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah. It was like a, he's on probation now. I mean, we ended up finding another preschool for him that he did great in.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah. I guess I can see it from your point as well.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
These biologic clocks things are such a scam. It is incredible. I love it. No, I love it. I love it. It's brilliant marketing. It is.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
When I think about like, what is the, what is the thing that's going to kill me fastest? I think it's undoubtedly stress. I just think, I think it's the most insidious killer in a way because it's the hardest thing to measure directly. You can sort of measure some of its indirect actions like on blood pressure and blood sugar, which both go in the wrong direction when stress is high.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
But I think there's even components of it that just, even when blood sugar and blood pressure are normal, I still think it's just doing something to your brain probably and to your heart. And again, I don't think anybody would feel good living in a zero stress environment. So it's mostly just about kind of managing how one responds to it. And I think it goes beyond just stress.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I think it's sort of like just overall like satisfaction in life and contentment and, you know, enjoying your relationships with people. You know, I interviewed this guy on my podcast, Bill Perkins, who wrote this incredible book. It's one of my favorite books. It's called Die With Zero. And he writes about how
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
You have basically like, you know, you have time, you have money and you have experiences. And sorry, he starts about through health. So health, time and money.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
And you're not optimizing for the most of any one of those. You're optimizing for the net of fulfillment.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
So too many people miss that, right? They're just like working, working really, really hard to get as much money as possible or as much fame as possible. Or they're like maniacally focused on their health. And that's the only thing they think about. Right. Or they're just trying to, you know, live as long as possible or make as much time for certain things.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
But it's kind of like how you put all those things together to optimize around fulfillment. So in this book, he writes about this idea of like people aren't doing the equation correctly.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
They're deferring too many experiences when they're young to do when they're old, but then they don't realize when they're old, their health is actually, they're not actually able to do it when they have all the money in the world. They can't go and take the incredible vacation or if they can, their kids aren't with them or their kids aren't young.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
So I think it's just kind of reframed a lot in my mind and made me realize that when our kids are young and we are incredibly healthy, that should be the time that we invest more in fulfillment and experiences as a family. Um, which has just been a, you know, a completely different mindset for me from where I was most of my life.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
This is breaking news. This is so timely.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I think it's hilarious. I think it is. This is the first standing podcast I've ever done.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Honestly, I think I have better posture than I normally do.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I feel like we're doing a political debate the way they're angled at each other, too. You know what I mean? I feel like I need a moderator to ask me a question. That's the only thing. It would have been a little better if it was moderated. If the discussion was moderated and more heated.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I wouldn't mind a teleprompter next time if you wouldn't mind. Teleprompter is nice. I want a teleprompter there. Moderator there. Right. More for sure.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I got a text message literally on the way over here from a buddy who just got a vasectomy yesterday. And we had recommended the urologist to him who was going to do it. So he goes, look, I just want to tell you, man, literally the best experience ever. The guy was incredible. So funny. You know, he's got me draped like over the table.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
So like, you know, he's like there's a drape like I'm laying on my back.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
It's like you're sterile. I want to keep you sterile. Right. And the guy walks in the room first time he hasn't seen me, doesn't see my face. He just sees my my my schlong and he goes, oh, I remember you. But he was like, but it was just all jokes. And so he says today, he goes, you know, look, honestly, zero pain at all. But don't tell my wife.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I am going to milk this as 10 out of 10 pain for another week.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
That's a good question. I don't know how many days. I don't know how many days. I don't know.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah, medicine 2.0 versus medicine 3.0, yeah.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah, but still important. I mean, we still want medicine 2.0. Medicine 2.0 will take care of a problem when it shows up. And if you're in a car accident, you break your leg, you get pneumonia, you want someone who knows how to deal with those problems. But it's a very different system from, hey, how do I...
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
take a guy whose hemoglobin A1C is 5.5, who no one, everyone thinks is just perfect, but I think he's on the path to actually, you know, being diabetic in 10 years. And why would I wait till he's staring down the door when I could just make the changes now?
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Oh, actually, that was a slightly longer swim. But yes, now I know the story you're talking about.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
cancer, neurodegenerative diseases and dementing diseases like Alzheimer's disease and metabolic disease. That's me. That's diabetes, right? And they overlap. So when you have type 2 diabetes, your risk of those other diseases goes up by 50%. So one sort of feeds into the other. And also if you have cardiovascular disease, your risk of dementia goes way up. Oh, really? Oh, yeah.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I think that was like 25 miles or something.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah. I mean, I don't know that that's related to the A1C per se, but fluctuating levels of blood glucose make it just a little more difficult. And some people are more sensitive to it than others. Some people, you know, they can eat all the carbs in the world and it doesn't seem to phase them.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
And a lot of people are like, no, the moment I go to slower carbs or just no carbs at all or just more complex carbs, my energy levels normalize and so too does my attention.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
What do you think is going on here? Why is she naked? And who are these guys?
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Oh, that's interesting. I see that now. I thought she was picking up apples, but maybe she's washing her hands in the pond. One could only guess why. But the...
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah, it's the rainbow crucifixion. I don't know my biblical history well enough. I would embarrass myself if I asked dumb questions. But is there a rainbow after the crucifixion? After the crucifixion?
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
How do you feel about that? She was very sweet. She said, she just, she didn't say your fat. She goes, you need to work on being less, not thin.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
No, I thought it was three days after this.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Can you imagine how brutal the world was when we crucified people? I think about it all the time. How lucky are we to live in this candy-ass world of softness?
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Like, those guys were thieves, right? Yeah. Like, today, you wouldn't even go to jail in most cities.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
And by the way, that's only 2000 years ago, which in the arc of human history is yesterday. Nothing. That's nothing.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Think about if you could be you or you could be the king of England 500 years ago.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
with like you know now it sounds great until you get like a dental abscess and you realize there's no ac there's no heat the food sucks yeah like i i don't think you're going to be the king of england 500 years ago i think the food still sucks in england now yeah that's a good point because you could probably pre-fish and chips yeah that would fucking that would actually suck i i never thought about being like the king of another country
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
It kind of was because water was so contaminated, right? Yeah. So you basically had two broad cultures that emerged from either the fermentation of water, right, and alcohol to get rid of the bacteria, or tea, right? You have sort of the rise of the sort of tea culture where you boiled water. Mm-hmm.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
But yeah, the idea that you were just going to go and drink water was like, I mean, the fact that we're sitting here drinking this is incredible.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah. Fucked up. No one, no one put two and two together. They didn't understand exothermic chemical reactions. Yeah.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah. And, and, and part of it is like, you know, what gets measured gets managed. And so medicine 2.0 measures lifespan as the ultimate outcome, which is, that's been productive. That's, that's a good thing to measure. I don't, I'm not suggesting we shouldn't care about lifespan because 150 years ago, lifespan was 40 years. Today it's 80. That's insane.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
We doubled lifespan and that's all due to medicine 2.0.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Basically figuring out how to not kill women when they gave birth to children, how to keep babies alive when they were born, how to fight infections, how to wash our hands. And a little bit of stuff around trauma and critical care, like you doubled human lifespan. But we're not managing healthspan. And so part of the argument is, okay, we've done pretty well on lifespan.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
We could do better, but we really have to manage healthspan. And so if we think about things that make up healthspan, it's sort of like how much muscle mass do you have? How strong are you? How much endurance do you have? How much flexibility and balance do you have? How quick is your cognitive performance? How happy are you? How are your relationships? How much joy do you have in your life?
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
I had actually already left medicine at that point. I had been out of medicine for three years. I was working at that time. God, what was I doing? I was working at an energy company, I think, or maybe I was in finance or something. But I had nothing to do with medicine. But that was right around the time my daughter was born as well. And so I think that was kind of the one-two punch.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
These things are softer and squishier. Some of them are pretty easy to measure like VO2 max and muscle mass and strength. Some of them are harder to measure like cognitive performance. But if you don't measure something, there's no chance you're going to manage to it. And I would just argue we have to slightly tilt in the direction of doing more on that front.
Matt and Shane's Secret Podcast
Ep 534 - Outlive (feat. Peter Attia)
Yeah, let me see how long you can dead hang for. Let me see your grip strength.
On Purpose with Jay Shetty
5 steps To Find Your Purpose (The Fast Track To Build The Life You Want)
Acknowledge that there is surprisingly little known about the relationship between nutrition and health. And people are going to be shocked to hear that because I think most people think the exact opposite.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I will typically head right into my office at that point and do my first scan of email and then just address anything that needs to be addressed. And then actually at that moment in time is when I can turn my attention to whatever my most important task of the day is from a creative perspective. So that's when I can do my best writing, editing, thinking, writing.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I've done my prep for the day before, the night before, or for that day. So I know which patients I'm talking to. I've already gone through all that stuff. And then I'll typically go and exercise. What time? It depends. But probably now it's like 8.30. So I'll work out. So I don't schedule anything until 10 or 11 in the morning. So I just have a hard rule.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Unless I have a call in Europe, then I'll typically do that at 7.15, the second the boys and my daughter leave. But assuming I don't have a European call, it's going to be 10 or 11 is first scheduled meeting. And so if it's 10, I need to be in the gym by 8. If it's 11, I'll go 8.30. And then I like to try to get a quick sauna in for 20 minutes and then get ready for work.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So work from 11 to 5, 5.30, and then help with dinner. um, goof off a little bit after dinner, again, play some chess, just, you know, kind of hang out with the kids. It again, depends on the season, right? So in the summer you get a little more leeway.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
We go outside, we'll play baseball or we'll, you know, do something, um, in the winter, you know, or during school, you know, it's maybe more directed towards kind of the, the, the night routine. Um, once the kids are down, I'll typically work again, um, for another, um,
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
one to two hours and then kind of like to spend the last hour before bed off work just you know vegging hanging out with my wife you know watch netflix maybe do a sauna if we if i didn't do one earlier in the day right on boring life man hey that sounds pretty that sounds pretty good to me but uh peter i just want to say thank you for your time thank you for coming i learned a ton from you and i hope to see you again well thanks for having me best of luck
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So we just have to acknowledge that that's a good thing. And yeah, it still makes some mistakes. So the majority of people who are conducting this research are good people. They have varying degrees of competence and varying blind spots. But for the most part, when...
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, I got into archery first just because I really love precision things. Um, and I was just looking for another hobby and something to do and get really into. So I'd been doing archery for a couple of years and really enjoying it and really just enjoying it for the art of learning how to shoot a bow and arrow. And then a buddy invited me on a hunt. And I was kind of ambivalent.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
multiple different labs over multiple decades conduct multiple types of trials and the answers largely point in the same direction, you're sort of inclined to think that there's probably not much of a signal in the other direction. Now, when it comes to pharmaceutical stuff, There's a different pathway, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So here, pharma does need to pay independent investigators to do research because of the regulatory pathway to get drugs approved. Now, we might see in the new administration a revision of how some of that is done. I think that there have been mistakes that have been made in the way drugs are approved. I don't think it's nefarious. I don't think it's a conspiracy.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
People are very quick to attribute conspiracy to what I think is more readily attributable to incompetence at times, truthfully, or just people acting in their own best interest, right? Like, you know, water always follows the path of least resistance. So just because water goes down there doesn't mean like, oh, there's a conspiracy that the water is going down there.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
No, like that's what gravity and less resistance means. So... As one example, I think that there should probably be fewer barriers during the lead up to approval, but more barriers post-approval. In other words, I'll give you one example. It's a controversial example, but I feel strongly about it. Paxlovid was a drug that was approved to treat people with COVID, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
This was a drug, I believe it's a Pfizer drug. So if you got COVID, they would give you Paxlovid. And it was approved very quickly. But I think ask any doctor who's been prescribing Paxlovid for patients with COVID, the drug doesn't work. Like, it just outright doesn't work. And by the way, it might even increase your risk of getting subsequent COVID.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And while I can appreciate why the FDA wanted to see that drug approved quickly because of the way the world looked then, and especially if you're trying to treat people who are uniquely vulnerable to COVID, which would primarily be older people,
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I think where a lot of trust was lost in that it would have been great if they did follow-up studies that six months later said, hey, this drug's been in the world today for six months. It's not working. We should pull the drug because a lot of money is getting wasted. And frankly, a lot of people are being put on a drug. It's not harmful, but it's not helpful.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So why would we have a non-helpful drug out there? So again, I know that that's a bit of a long answer, but I hope that I'm communicating the nuance of the situation, which is it's not black and white.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I was like, I mean, okay, I get it. Like, I think it'd be pretty cool to kill something that you eat. And I think we just got lucky. You know, we went to a place in Hawaii that was amazing and got to hunt a type of animal that is very difficult to hunt called axis deer. that is not only very difficult to hunt, but is very invasive to the state of Hawaii, incredibly destructive.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, this is a topic I've put more work into than I wish. And I say that because It's not something I'm really interested in, to be honest with you. There are lots of things I'm interested in. This is not on the list, right? But I've had to put a lot of interest into it.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I've had to put a lot of time into it, I suppose because of the position that I have found myself in, where people are saying, hey, Peter, you're a very, very public-facing physician, and you're not in the quack category. There are lots of quack physicians out there, but we want to hear what you have to say. I also have a personal interest in it because I have three kids. So what have I learned?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, I've learned that there are certain, so first of all, this is another topic that is not going to be a popular topic because people don't love gray. They want black and they want white. Nothing in science is absolute. It is all probabilistic. So there are very, very, very high probabilistic certainties and there are very, very, very low probabilistic certainties.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So for example, I know that if you have a certain type of infection and I give you this type of antibiotic, the probability that it will cure that infection and save your life is exceedingly high. It's 99%. But I can't say with 100% certainty that every single person that has this infection to whom I give this antibiotic will be cured. Can't say that. That's not how biology works.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And biology is the messiest of the sciences. So with that stated, I think there are some high probability certainties out there with respect to vaccine. I think there were some really gray areas and I think everybody needs to ask the question, what am I optimizing for? So I will start that question with you, right? What is it you are most afraid of as you think about vaccinating your kids?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
What is the mistake you're worried about? What are you afraid of and what are you hoping to achieve?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So let's just take those two examples. I think the second one's a lot easier because I think the answer there is I would put it a little more in the more certainty category. Although I think the previous one as well we can address. So when it comes to the COVID vaccine, one of the concerns, particularly with the mRNA vaccines and particularly more so with the Moderna one than the Pfizer one was,
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And so it's a win for the state. It's a win for the people of Hawaii. It's an important part of population control. And it turns out that I would say along with elk, it's probably the most delicious sort of wild game there is. And then the rest is history. You sort of get hooked on it after that. How often do you hunt?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
you saw an above the baseline increase in myocarditis, in particular in young men. So myocarditis is an inflammation of the cardiac muscle. Now, you always have to remember when you're vaccinating millions of people, there's going to be background noise. People get myocarditis all the time. And you can get any sort of viral infection and get myocarditis.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I've known countless people and seen in the hospital and been around people who have got myocarditis for no reason other than they got an infection. So you have to know there's a baseline level of this going on. But it really appeared that in particular for young men, teenagers and in their 20s perhaps, there was an uptick. following that particular vaccine in the incidence of myocarditis.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
To be clear, most of those men recovered without event. I think that the real mistake of policymakers at the time, because this would have been about 2022, was not acknowledging that, right? Like to acknowledge that is basically to say, hey, this is biomedical science.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Things happen and we don't always know when we do studies on a few thousand people, what's gonna happen when it reaches a million people. Because if the signal is so small that it's only 0.1% of people, you're not going to pick that up at a thousand. You gotta be able to do a million and you're not gonna do that until it's out in the real world. So why not just acknowledge that and say, hey,
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
That's a risk we should be aware of. And we should weigh that risk against the benefit. Because what's the harm to an 18-year-old healthy male when he gets COVID? Well, we can quantify that. We know what that risk is. We've seen enough variants of COVID to know that. Is that risk worth that trade-off?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And I think reasonable people, when presented with that set of facts, can make their own decision. I know my decision for my kids in that setting when confronted with that information. And it might not be the same as the next person, but that's okay. We just want people to be able to make reasonable decisions based on reasonable information.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But when it turned into, there's nothing wrong with it, there's nothing wrong with it, you know, the sort of denying it, I think that cost a lot of credibility. And when parents got demonized for asking the question and saying, hey, should my six-year-old who's completely healthy really get this vaccine? And they got turned into bad people for that. I think that was a huge mistake. And again, I...
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I can tell you, taking care of countless people, I have patients that ran the spectrum across there. I had patients that said, I want me and my family to get every single vaccine there is. And I had other people that said, we're not touching this thing with a 10-foot pole. And my job was not to talk anybody into or out of anything.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
It was simply to make sure they understand and can quantify the risk of both decisions and to be there and help them think through it. And that's it. So, I hope that answers your question on the myocarditis. Yes, there was indeed a real signal. In absolute terms, it wasn't big, but in my opinion, it was not worth the risk to young males. That was my personal opinion.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I don't think it was worth the risk. And that means, as such, I did not vaccinate my kids because they were otherwise healthy. I also feel very fortunate that we live in a state where it was not mandated and therefore we didn't actually have to pay a heavy price for it. So I also have empathy for people who live in draconian states where these things were shoved down their throat.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You know, I would say these days I'm busier than I would like, so I probably went on five, probably went away for four or five hunts this year. But luckily in Texas, we can hunt locally as well. We actually have access deer in Texas, so I can do some local hunting there as well.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But, you know, when you live in a great state like Texas, They tend to defer to what the parents think is right, at least in this regard, around a COVID vaccine. And we just felt like, hey, it wasn't necessary. Our kids are super young and healthy. Why put anything else into them that they don't need? That said... I take a different point of view on other vaccines.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I think there are a number of vaccines where the risk of not vaccinating them is so much worse than the risk of vaccinating them. The one in particular that I have looked into more than all others combined is indeed MMR. Because I think every parent who has been, and I say this word deliberately,
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
misled by the fraud that came out of a guy by the name of Andrew Wakefield will always have in the back of their mind the lingering concern about autism. So Andrew Wakefield was a guy who has been more than discredited. So I say this again with complete
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
he has been more than discredited for what he did to completely and deliberately and fraudulently manipulate data to make a case that the MMR vaccine caused COVID. You mean autism? I'm sorry, caused autism. I've done a complete podcast on this, so if people are interested, I interviewed the journalist who's done great work on this, and we kind of go through all the work. His name is Brian Deer.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Not a pro-vaccine guy, by the way. Doesn't care about vaccines one bit, despite the fact that people have tried to make him the face of MMR. He's like, nope, I just care about science. And this guy was the worst example of bad science. So I can tell you with a very high degree of confidence without wasting the next three hours, why the MMR vaccine is safe.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And furthermore, why I think kids who don't get the MMR vaccine are really at risk of getting diseases that are much, much too significant to ignore. An area where I do, sorry, you're going to ask a question and I'm going to go to another direction.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I was just going to say, now let's talk about an area that I would put in the middle, because right there I'm saying on the one hand, again, I didn't think the COVID vaccine made sense for young, healthy kids. I really do think the MMR vaccine absolutely makes sense for all kids.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So here's an area where I think the system has kind of broken a little bit, and it's the use of the hep B vaccine for kids early in life. So today, if a child is born in the United States, they are going to want to give them their first of their hepatitis B shots while they're in the hospital.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Now, that has never made sense to me biologically because unless the mother has hep B, in which case that makes sense because the risk of transmission is very high. And to be clear, hep B is an awful disease. So I'm not minimizing hep B at all. We have no treatment for it. We have no cure for it.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Yeah, although it's funny. They're the only two places in the U.S. it exists, is Texas and Hawaii. But it's a pretty different animal than Texas. It's a bigger animal based on its diet. In Hawaii, it's smaller. And for whatever reason, it It seems just a little more skittish in Hawaii. But it's a totally different hunting experience. So in Hawaii, you're hunting in the mountains.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
If you have hepatitis B, the risk of getting cirrhosis and needing a liver transplant or the risk of getting what's called hepatocellular cancer is very high. So you don't want hep B. but it's a bloodborne transmitted disease. Like you're not going to catch it in the air.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So if a child is born to a mom that doesn't have hep B, the risk that that kid's going to get hep B in the first five years of their life is virtually zero. And for that reason, I don't see the need to subject them to that vaccine immediately.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But I also understand where the medical community is coming from, which is saying, hey, we don't want to miss an opportunity to give a vaccine because if we don't give it now, this kid might never get it. So there's a policy decision that needs to be made by people there. Personally, if it were me, I'd like to see it studied.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
This is where I actually would like to see the NIH fund an experiment, because I'm genuinely curious. Is it safe to give children that many vaccines that early in life, or should we limit them to the ones that are absolutely essential, where we know, hey,
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
measles mumps rubella smallpox polio these are devastating diseases and especially if you have a kid that's going to go to daycare where they're going to be around a lot of kids and the risk of transmission if there's an outbreak is non-trivial so again we want to eradicate smallpox and polio mmr probably don't get eradicated but we want to protect kids against them
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And Hep B strikes me as something like, I don't think we need to do that right away, but I'd like to see it studied. So that's kind of three extreme examples of how to think about this. But as you can tell, given that it just took me 10 minutes to explain those three things at a superficial level, nobody wants to have this discussion. They just want to be black or white.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Are you pro-vax or are you anti-vax? What about neither? I have a nuanced approach to every single one of these if you're willing to sit down for three hours. Yeah, yeah.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, and the other thing, to your point, is some kids are going to have no problem. They're going to sail right through it. But you don't know if that's your kid. I mean, at the end of the day, you're sort of – your goal is to figure out what's the best thing for your kid and whatever you can do to kind of minimize that risk.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And of course, the doctor is looking back at you and your wife saying, yeah, look, we're not opposed to spreading this out, but how do I know we're going to keep you on schedule? Now, there's also some nefarious stuff that I understand why it takes place, but the optics of it are really problematic. And that is that Medicaid reimburses physicians for vaccinations.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
It's pretty amazing.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So you'll hear that, and people who are really in the anti-vaccine camp will point at that and say that's a blatant conflict of interest. And the answer is, it is and it isn't. It's not at all uncommon for Medicare and Medicaid to reimburse physicians
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
to incentivize them to provide good care to patients right so just as if you have high blood pressure and you're on medicare you might have a physician who's being reimbursed if they can control your blood pressure better that's viewed as a win-win your life is better because when your blood pressure is lower there's less chance of a heart attack or stroke
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
The medical system is better off because you're now going to cost the system less money by not having a heart attack or a stroke. And they want to reward the physician by saying, here's an extra $100 because you managed to get Sean's blood pressure down. So everybody agrees that that's kind of a good system.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But when you now go into Medicaid and you apply that to doctors who are getting paid to vaccinate kids— Well, a couple of things change, right? The first thing is we don't know the answer to the question you asked. Like, I don't know. I certainly don't know the answer. And I say this with humility. I don't know that anybody does.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I don't know that anybody knows we should just be ramming all the vaccines in the kids on day one to maximize them and make sure compliance is the highest versus can we take a more nuanced approach and spread them out? So right out of the gate, you take away some certainty So you lose a bit of the moral high ground to be able to say, I should be paying you to do this.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Whereas in as much as you can have certainty in biology, I have pretty high certainty that if your blood pressure is normal, you're way better off than if your blood pressure is high. So that, again, becomes problematic, but you can see how it can get twisted into something that it's really not.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Oh, that's a very, very sophisticated erudite question. I think a couple of things. I think one, look at people who are comfortable talking about uncertainty. So the more that a person is willing to speak in uncertainty, Versus certainty. I tend to believe them a little bit more, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So when a person tells you that it's their way Like you have to eat this food and it's like it's this is anything that's not this is gonna kill you but like Versus well, we didn't we you know, maybe maybe not like so so so that's one thing and then I think the second thing is you always have to mine for what a person's conflicts are financial conflicts, so
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
i think it should be required that anyone who describes themselves as you know a health influencer slash whatever like whatever you call people in this category they should all have a clear page of financial disclosures it should be unambiguous exactly what what companies have they invested in do they receive pay for promotion do they receive financial kickback or remuneration when they talk about a product
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
All of that should be fully, fully disclosed. There should be no ambiguity about that. So I would say those are two really important ways to understand the credibility of who you're listening to.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Um, I mean, the first sport I fell in love with was hockey, which is pretty, um, pretty typical in Canada. Probably at the time, honestly, there were, today I'm sure kids will have more of a well-rounded sporting background with, you know, the NBA is there, but yeah, it was pretty much just hockey growing up. From a very young age until, uh, until, until my second love came, which was boxing.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Boxing?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
What did they do? Um, so my dad, uh, ran a restaurant and my mom worked at the restaurant with him. I mean, she, when I, when she, when they came over, you know, she worked at a, at a checkout, you know, worked in a, like a variety store, grocery store at the checkout. Um, and then by the time I was born, she was mostly working at the restaurant with my dad. Any brothers, sisters? Yep.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I got a younger brother and a younger sister. So I was the last of three. You guys get along? Very well, yeah.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
No, no, not at all. Yeah, I think I was a bright kid when I was young. I was put into a gifted program. But my mom says when I was in fourth grade, the program lost its funding. So I got put back into the normal program. And she says that's when things started to go not so well. So I think that was fourth or fifth grade.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Again, I don't really remember much of this, to be completely honest with you, Sean. But my mom says I just got very bored in school. And my performance started to sort of go down. I started to... really kind of clash with teachers a lot. And I think by the time I got to high school, just really had zero interest in school.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I didn't have a choice but to be there, but I had no interest in it at all by that point. You had to enter trouble? I did, but not that much because fortunately by that point I had gotten into boxing and boxing was, I mean, I think it saved my life because I think it really kept me focused on this goal. I mean, I wanted to be a professional fighter.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And even by the time I was 14 years old, I mean, I was training six hours a day. Wow. So I was, you know, training in the morning, training middle of the day at school, training when I got home. And so it was my life was basically training and working at the restaurant.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
No, I think it plays more of a role today. I feel... pretty lucky that I can get away with eating mostly wild game or animals that are eating what they're meant to be eating. So I also have a friend in Austin who's got a large property and he farms, you know, in a sustainable way, everything else that we eat. So even the bacon that we're getting is coming from pigs that are, you know,
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I mean, I didn't socialize. I didn't go. I didn't have time to do anything else. You know, I was working at the restaurant and I was training. I mean, you say it saved your life?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, because I think, like, I look at a lot. I look at, like, I don't think, I think I had poor judgment as a young kid, which a lot of young boys have. And I look at some of the kids that I grew up with and I see where they wound up. And... I just don't know which side of that fence I would have been on, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I mean, there are kids I grew up with that were 10 years after high school or in jail for armed robbery. You make a dumb decision. You can do a dumb thing and change your life forever. And I don't have the confidence to say I would have never been one of the guys that made that dumb decision or been at the wrong place at the wrong time.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Because I also don't, like, I don't look at myself, I certainly didn't look at myself back then as a leader. I don't think I was a huge follower, but I was mostly just in my own world. But I think if I wasn't in that world, I could have easily wanted to impress one of the older, tougher kids. And that's how you get sucked into these stupid, stupid things.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And it could be stupid things like, there was a kid in my high school And we used to play this game, which was so idiotic, where we would jump into the subway trains and play chicken to see who could get out last. And sure enough, one of the kids didn't get out. Oh, shit. And so, you know, you just like... Did you see that? No, I wasn't there. But I knew his brother very well.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Because the kid that didn't get out was a year younger than us. It was a younger brother of one of our friends. And I just think like... man, there's so much luck involved in not ending up in the wrong spot. So again, I think for me, boxing and martial arts as well, because I was doing both by the time I was in high school, they just became an amazing thing for me. I ended up hanging out with
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
people who were older, right? Because you're, you know, it's not a place for a lot of kids at the time, right? This was, I'm hanging out with grown men. So you're sort of seeing these guys who have jobs and, you know, I think they were just a good influence on me.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, I was super serious about it. So when I was in 12th grade was when I did make a decision to not become a professional boxer. And it was really because of this teacher I had. So when I was in 12th grade, I had this teacher who really made a big difference in my life.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
that are not going through the usual process. I certainly hope that as more and more people are becoming aware of, it's hard to be healthier than the animal you eat. So you've got to be eating an animal that was pretty healthy to begin with. I hope that there are more and more economic choices for people to do this. Because right now it's a bit niche, right? Not everybody can go out and hunt.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And again, I'm really grateful for that because even though I was pretty good, statistically speaking, you have to think in terms of probabilities, statistically speaking, I was going to wind up brain dead, right? Very few people are going to hit escape velocity in a sport like boxing.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, you know... For reasons that I don't know, I still kept taking math. I think I deep down kind of liked it. And so he was my math teacher, Woody Sparrow. And so this is, you know, 12th grade, I'm taking math and I'm actually doing reasonably well, right? Like I'm not... you know, top of the class or anything, but I'm doing well. And I just like the guy.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Like, he's funny, but he's got like kind of an edge to him. And middle of the year one day, he says, hey, can you come in tomorrow morning before class? I said, sure. So I came in and he said, you know, Peter, I heard you're not going to university. And I said, that's right. And he said, you know, I think that's a mistake. But he didn't lecture me, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
He didn't give me the, you know, you're crazy not to go to university. He gave me the, he said something else, which was very touching. And he said, look, I think it would be, I think it would be, I think, how did he word it? I think it would be a waste because I think you have an unbelievable amount of potential. And I just think you should revisit the decision not to go.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I think you have a real gift for mathematics that you don't quite see yet. But I think, you know, I just think you should be open to the idea of doing something. And there was something about that. I mean, that undoubtedly planted a seed in my mind that over the rest of that year, I kind of changed everything.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
my thinking, came back for this fifth year of high school to take all of my prerequisites to then apply to go to university and actually set out to emulate him. So he was actually an engineer before he came back to teach math. So I went off to the same university he went to to study both engineering and math.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You know, it's super tough. Like again, I think about how lucky I am. I only really had one horrible concussion. Um, it was really bad. Um, I was I was hurting for about three months like literally my head hurt for three months I couldn't turn my head that even at that speed.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
That's how badly I was contused And so I feel insane gratitude again, like how many times could my life have ended and it's really funny I remember being in the hospital because I spent two days in the hospital after this one and I this neurologist comes in and he's like, oh, and by the way, the worst part of this story, Sean, I was already in university at this point. Oh, really?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Yeah, yeah, yeah. Like this was already after I decided I'm not going to be a professional boxer, but I couldn't let go of the drug. Like it was still, I still wanted to fight. So at this point I was like training and I was like, I would fight lots of guys in the same day. So on this particular day, I had lined up three opponents for two rounds each, and I'm fighting them at increasing weight.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So it was in the fifth round, I'm fighting a guy 25 pounds heavier than me, and I just could not get out of the way of this guy. And I mean, you know, and it didn't even knock me down. It was just at the end of five rounds, I was like, yeah, I don't feel right. Let's call it a day, Mike. So this doctor comes in and he goes, he was just apoplectic. He's like, I heard you're a smart kid.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
My brother grows cattle and it's pretty awesome. So he lives on a farm and he basically regeneratively farms his cattle. And he and his family are only going to eat one a year. So they're selling all the rest of them and they're just kind of cycling through it.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Like, what are you doing? What are you doing? Do you understand what this is doing to your brain? And I never thought about it. I was like, yeah, I never really thought about it. What is it doing? Yeah, that's a really interesting thought. So to answer your question, I'm torn because I think that boxing teaches you something about yourself. And it's probably true of other forms of fighting.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I just don't know. And I did a lot of boxing, obviously a lot of martial arts and a lot of Thai boxing. I never did MMA. I never did. or any of the other stuff that kind of rolls up into what we see today. But I would guess it's true of any combat sport is you learn how to control your fear. You learn what it is like to be alone in the ring with someone who wants to hurt you.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I think there's something really valuable about that. Now, my boys both do jujitsu. They've been doing BJJ since they could start. I love that they do that. If they wanted to box, I would love it. I just don't know if I'd want them to spar. I'd love for them to learn how to hit. But I also realize if you're not getting hit, you're not really learning how to hit unless you're also being hit.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You're gonna develop a lot of bad habits if you're hitting without the risk of being hit. That said,
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
i just don't think it's worth it i think i'm happier that they do bjj um and and that they're you know that their brains are being spared if they came to you and they wanted to start boxing or striking would that be a hard no no it wouldn't uh you know we have a heavy bag hung up and every once in a while they're like dad show us how you can hit this thing and i'll hit it and they'll be like whoa um which by the way i can only do for like 30 seconds
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
That's how bad I am today. I can look good for 30 seconds. So I would love it if they would learn, but do I want them in the ring taking hits? I don't think so.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So when I finished engineering, I was getting ready to go and do my PhD in aerospace engineering, which had become the convergence of my interest in math, and I had done mechanical engineering. And then I had a total change of heart and decided I wanted to do medicine. And so that kind of derailed me because then I didn't have any prerequisites to apply to medical school.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But these are animals that literally just eat grass, just run through a pasture all day, and then when their life ends, it ends in the least stressful way possible, which is to say they don't know their life's about to end until they get shot in the head, which I know sounds harsh to people, but it matters, right? It matters that an animal dies in the least stressful way. Why is that?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And you have to take this test called the MCAT. It's like the SAT, but for medical school. So I hadn't done any of that stuff. So I had to take an extra year to do it and apply to medical school.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Yeah, so it's... It's one of those things where there was an instant when it happened, so there was a single moment where I realized it, but it was predicated on a year of angst. So I don't know which it was. You know the story about the guy hitting away at the stone, and it's like on the thousandth hit, the stone splits, and you realize it wasn't the thousandth hit. It was the 999 before it.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
It just happened. So I'd say that the year of angst was really...
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
my something i was struggling with i was just kind of like i felt like this tug like i wanted to help people i wanted to work more directly with people but i really loved i loved the problem solving and and whatnot that we were doing in engineering but i felt this tug kind of in my heart to do something with people and i just couldn't figure out what to do and it's interesting like medicine never actually crossed my mind so i was
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I mean, I had crazy ideas. I was like, should I be a social worker? Which, of course, if anybody knows me, they would laugh hysterically at the idea of me being a social worker. I thought about, should I be a lawyer? I had all of these ideas for things that I should be doing. And I went and talked to people who did these things. These weren't like idle thoughts.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I mean, I was out there talking with people of all of these professions saying, hey, why you know, I'm trying to figure out, am I going to be good at that? Am I going to be good at that? Am I going to be good at that? And medicine never once entered that calculation until one day I happened to be in the hospital visiting somebody and had this experience.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And I was like, it just kind of hit me in the face. I was like, oh my God, medicine, that's the thing I should be doing. What was the experience? So at the time I was volunteering, the whole time I was in college, I volunteered for kids who had been abused. And I was in the hospital visiting one of the kids.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And I was in the waiting room, and I was eating my lunch, and another patient, an older woman, came up and sat with me. And I...
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
she had been shunned by a group of patients at another table it was kind of weird i don't know why but they wouldn't they didn't want her to sit with them so she came and she sat with me and we we sat there and had a pleasant conversation while i ate my lunch and waited for the nurse to come out and get me to go in and visit the kid that i was visiting and when the when the nurse came out to get me the woman said she i think she assumed i was a doctor but then realized in that moment i wasn't she goes oh
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
i should have realized you weren't a doctor no doctor would sit here and have had this nice conversation with me for this long and i remember thinking boy that's sad if that's true but it it just all kind of clicked in that moment which was maybe maybe medicine maybe being a doctor would be the right way for me to apply both my my interest and love in problem solving and science but but with this kind of more human connection and then
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Look, I think that there's, you know, if the end of an animal's life is incredibly stressful, there are a lot of stress hormones that kind of go through an animal's body. And I can't tell you that that necessarily makes a difference in the health of the meat, but it certainly does make a difference in the flavor. I also think there's just something to be said for the humanity of it, right? Mm-hmm.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Yeah, 10 years later. 10 years later.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, so then I went to medical school. And then you go to medical school and you decide what do you want to specialize in. And you don't figure that out until you're in your third or fourth year of medical school. And by that point, I decided I wanted to do surgery. And then you pick a place to go and do surgery. And I wanted to go to the best place that was the most hardcore place.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And that was this place in Baltimore called Johns Hopkins. And because one of the things that made Johns Hopkins so great, and to this day, is both the combination of having
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
The high volume of surgeons who do really complicated operations, in this case, operating on the liver and the pancreas for cancer, and at the same time, it's in a really, really rough inner-city area, so you get a lot of trauma. And as perhaps grotesque as it sounds, it's really important for surgeons to train
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
trauma areas because you learn so much about how to fix the human body when the human body is getting shot and stabbed every day and at a place like Hopkins I think at the time I was there it averaged 16 penetrating traumas a day Wow so if you've met now think about that I'm on call every third night for trauma So now think about how many stab wounds and gunshot wounds you're taking care of.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
This is how you learn to have ice in your veins and you're unemotional about it. It's like, what's coming in? What do we need to do? How do we stabilize this patient? Can we fix them? Let's go. And so, again, you don't get that experience at all the hospitals, right? But people who will pick programs that really emphasize in that are going to go there.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So I went there and really honestly just had a very special experience. I mean, really can't say anything negative about the place I was at, right? This wasn't like – I mean, I had amazing mentors there. The surgeons at Hopkins were – legends. My co-residents were incredible. I mean, I'm sure it's like what you feel like being in the Seals. Like you were with the best of the best.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
It's the best 1% of the best 1% that all came to this place, not because Baltimore is a pretty city, but because this is the best training we're gonna do. But I just, I became really frustrated with the fact that I did not feel like I was moving the needle one bit. And I felt like everything I did was a day late and a dollar short. and it just didn't matter.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And that meant, like, I felt like it didn't matter on the cancer side. Like, you could do the most perfect operation on somebody to remove the cancer, but you didn't get every cell out because you couldn't. You know, they were still going to die 18 months later. And sometimes even on the trauma side, it would be really tragic. You would...
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You know, you would use 60 units of blood and operate for eight hours to save somebody. And then the next month, the guy would be out there and get shot in the head. Jeez. You know, you would see this. You would see this from time to time where, you know... So I just felt very frustrated. And... I just thought the system didn't make sense to me. And my wife, I was newly married at the time.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You know, we are omnivores, right? We do eat plants and animals. But we don't have to be cruel about it. And I think we should all aspire to eat animals that have lived the best life that they can. And when their time comes, their time comes in the simplest and cleanest way.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
My wife said incredibly wisely, she's like, look, we've only been married for a year. I've only known you for four years, but you don't strike me as a person who can live in this state. Meaning, only two things are sustainable. You either need to fix the system that we're in, So you have all these complaints and grievances about why the medical system isn't right.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You should fix it or you should leave it. But if you sit here and just keep bitching about it, like your life is over. And, you know, I spent the next six months thinking about what she said and then just decided to leave.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I'm talking about gunshots, stab, gunshots, stab, stab, stab. Sometimes never. I mean, I had some pretty bad failures. I'll tell you this. One of my last nights as trauma chief, so I left on June 30th. The residency year runs July 1st to June 30th. So even though I decided to leave, By March, I stuck around for the last three months.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So I remember it was like April 14th, meaning I've got like six weeks left in all of my medical training at that point in time. And I was the trauma chief that night for pediatric trauma. And we get a call, it's early in the evening, it's like seven o'clock at night, MVA, motor vehicle accident. but no vital signs in one of the two.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So it's two, I don't know anything other than it's two kids driving and one of them seems totally fine, one of them's got no vitals. The one that's got no vitals is coming to my trauma bay. So I go down and this boy comes in and he's got, maybe I convinced myself, he's got a pulse, he's got a thready, thready pulse. And now, so we run a code on him. We can't get him back. I get an x-ray.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I see that his aorta is a bit wide. You know, you're running through your mind. What's going on here? What's going on? Why do I not have vital signs in this kid, right? Is this head trauma? His pupils are a little bit big. So that means there's probably something wrong with the head. His aorta is a bit wide though. That means he could have torn the aorta.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So when you have blunt trauma, when you have massive deceleration, and in the case of this car, they had the right of way going through an intersection and some idiot T-boned them. So massive deceleration can shear the aorta. So he could be literally bleeding into his aorta. So I have to make a decision. Do I open this guy's chest to try to figure out what's going on?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Which, by the way, is not the answer. But I don't want to let this kid die yet, and it looks like he's dead. So I keep running the code. I keep running the code. We keep pumping more epinephrine into him. We keep doing everything. And it's my job to call the code, to say, time of death, call it over. And I just can't bring myself to do it. I'm like...
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
No, no, no, we gotta keep going, we gotta keep going. I'm just feeling this overwhelming sense of sadness. And we finally call the code. And I, you know, it's very unusual. Normally you'd walk out as quickly as possible because they have to get the body out because you have to make room for the next trauma to come in. You don't know when the next one's coming in. So you can't have that.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You can't have too much time with a body just sitting there. So they have to cover the body up, get it out, clean the floor off. And there's a mess everywhere. There's, you know, we've put a million central lines in him at this point. There's needles, blood everywhere.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And I remember leaving the trauma bay and going into the stairwell and just completely breaking down, which was very unusual, right? Normally, you just don't even think about it. But I was absolutely, I couldn't put myself together. And then the nurse came and said, hey, you know, can you go talk to the mom? And I was like, yeah, yeah. So now the mom and all the relatives are in a room.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
They only know that they're, turns out I realized these are two brothers. The victim who was in the passenger seat is 14. The brother was 17. He's fine by the way, he doesn't have a scratch on him. And the mom just knows your boys were in a car accident. And I go and tell her what's going on. And I mean, it was the most difficult thing of my life.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I still remember, you know, when you're wearing scrubs, they have a little pocket on them. She grabbed onto me and tore the pocket off the scrubs. I'd never had somebody do that. And I spent... I probably spent two hours with him that night. And I was very fortunate that nothing else came in that night. Like I had the time to sort of be there. And I'm not sure why. I don't know what it was.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
His name was Malcolm. I don't know what it was about Malcolm's case that devastated me. I also went to his funeral five days later, which I'd never gone to the funeral of a trauma patient before. I'd been to the funerals of patients, but never a trauma patient. Because you don't usually have a connection to trauma patients, right? You don't know them. They come in and they die. You don't know them.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But I got to know a lot about Malcolm's life. And at the funeral, when I walked past the casket, I don't think his mom expected to see me. And when she did, she lunged at me, grabbed me. And I kid you not, she grabbed me so hard, she tore the pocket off my dress shirt, just as she had torn off the scrubs five days earlier. And it's interesting.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I learned more about Malcolm at that funeral that day than I obviously would have ever imagined knowing. And the story is just even more tragic when you realize what an amazing kid he was and what he meant to his family. It's interesting. So a relatively poor black family And he was this incredible student. And he was going to a really special school because of his exceptional abilities.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And that's why his brother was actually driving him. Like, you know, he couldn't go to the local public school in inner city Baltimore. He was going to a school in the northern part of Baltimore. And he was, you know, he was the jewel of his mom's life. Man, man.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Pick the right person, I think, is literally the single most important thing. I mean, I think that's not sufficient, right? You still have to do work. But if you don't get that piece right, I think it's harder. And there's no one right person. That's obviously sort of silly. So there's like an operating window, I think, in which you can marry people. I think I just got really lucky.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Like, I think that's the theme of my life is just obscene luck. But I just didn't understand at the time how lucky I was to meet this woman and how much she could kind of tolerate all of my challenges and all of my focus and how relentless I could be and how difficult I could be. And so it took me a few years to figure that out. But once I did, yeah, I just think like, I get it.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I think it's a second or third order term. I think the first order term, if you want to just take a step way back and say, okay, what do we know is 100% true about nutrition? The answer is not a lot, right? Despite what health influencers might try to tell you, there's very little that we know is kind of what I'd call capital T true.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You see these people that are in their 90s that have been married for 70 years, and you hear them talking about each other like they can't imagine living without each other, and you think, really? I mean... He's that special? She's that special. But now I get it. Now I get it. Now I understand, you know?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And my wife will tease me all the time and she'll say, you know, she'll say, oh, you sure you don't want like some young, hot 20-year-old wife? And I'm like, absolutely not. You know, because it's, I think once you get to a certain point and you've been through enough tough stuff together, you really understand what it's about. How'd you guys meet? We met at Hopkins.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
We met two days after 9-11, actually, because we were still kind of in lockdown in the hospital. At the time, it wasn't clear what the damage was and how, like, would we still need to be on standby for bodies? And of course, it turned out that that wasn't the case at all. Interesting. Wow, so did you treat a lot of those victims? No, no, that's the point.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Like, nothing came up from the Pentagon, nothing came down from New York. I mean, people were incinerated. There was nothing to treat. Jeez, jeez.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So we know that eating too much food, regardless of what that food is, is not healthy. So we know that once the body is consuming calories in excess of what it can store safely, and different people have a very different genetic capacity for what that means. You and I could be different in that regard.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, when I wanted to leave medicine, I wanted to get as far away from medicine as possible. And I wanted to go and get an MBA. But I was in so much debt that the thought of more debt to go to business school for two years was not very appealing. I met somebody actually when I was on call one night in the ER, another resident. And they told me about this place called McKinsey.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So I learned about it. It sounded like a great place where basically you get paid and you get to learn all the stuff you would learn through an MBA. And so that's what I did. And so I ended up out on the West Coast and working on math problems again, but in the financial banking section.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Eventually, yep. How did that happen? Initially, just through my own kind of interest in trying to figure out my own health.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You know, once my daughter was born when I was 35, I, you know, thought about, hey, I gotta, you know, I'd been always interested in performance, obviously, and, you know, you mentioned it, swimming and all sorts of crazy escapades, but had never really thought about health per se.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And so I wanted to just better understand my own risk of initially cardiovascular disease, because that's the disease that runs most rampant in my family. And as I just became deeper and deeper in terms of my interest in understanding that, I wanted to start applying it to help others. And so I began to slowly sort of start working with other patients.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Because I'd never let my medical license lapse. The one thing someone gave me advice when they left, they said, hey, I know you think you're done with medicine for the rest of your life. Just take the test every two years. Keep your medical license. You'll be grateful you did, which was sage advice.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Because I think if you let the thing lapse, it can be a bit of a grind to reacquire a medical license. So that's kind of how I kind of slowly came back into it. And you have three kids? Yeah. How old are they? 16, 10, and 7.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, you have to make some sacrifices, right? So there are just certain things I don't do. I don't... I don't have a lot of idle time. And I think that idle time can be beneficial. I think there's value to doing nothing. And unfortunately, I don't have a lot of nothing time. I also don't have a lot of hanging out time. And it sometimes means I come across as a little bit aloof.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
In other words, you and I might have a different ability to put fat into the subcutaneous area around our waist, which, by the way, is a safe place to store excess energy. But at some point, any person will begin to exceed that, and they'll start to put fat into places where it should not be.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And when people say, hey, you want to get together? My answer is usually no. No offense, it's not you. But on the hierarchy of work and family, I just don't have the time, right? I don't... everything I do has to be somewhat measured.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And so between the time I make for exercise and hobbies and spending time with my kids and like once a month, I want to have a special day with each of my kids individually, right? Once a month? Once a month. So that means like going away, for example, like take my kid to Disneyland if that's the thing they want to do. Take my daughter... To L.A.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
if she wants to go shopping or take, you know, my son is really into Harry Potter, so we're going to go to Harry Potter Land. Like, I want to have a real special day with each of my kids once a month. So when you start, I mean, there's only 30 days in a month. Like, that's one of them gone, right? If I want to have a date night with my wife every single week, that's one night a week gone.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And I say gone, not that it's a bad thing. I'm just saying, like, there's only 168 hours in a week. and I'm going to sleep for this many of them, and I'm going to exercise for this many of them, and I'm going to work for this many of them, there's not a lot of hours left. So that's probably how I get away with it. I don't watch TV.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I don't know the last time I watched anything on TV that wasn't Formula One. Like Formula One guy. Formula One is the only thing I pay attention to. I have not watched a single football game, literally not a single game of football in I don't know how many years now. Yeah, and you are very similar with the TV aspect. Do you race?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I drive quite a bit on the track, but not as much as I used to or not as much as I would like to. So in an ideal world, I should be on the track two to four days a month. That's not happening right now. So I probably spend more time in the simulator now. And realistically, if I'm on the track this year, I'll probably do... 16 days total and the whole year on the track.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
My favorite cars are formula cars, so like a Formula 3 car, but also I love, you know, like Porsches and, you know, all sorts of cars.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So it's a term that I use throughout the book to describe kind of an evolution of medicine, right? So I contrast it with medicine 1.0, because you can't have a 3.0 if you didn't have a 1.0 and 2.0. And... So maybe it's easier to kind of explain what 1.0 was, what 2.0 was and is, because 2.0 is the dominant system of medicine today. And then what am I proposing as 3.0 for where we go?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Fat should never be in your liver, it should never be around your organs, it should never be marbling inside your muscles, it should never be interwoven in your pancreas, around your heart or around your kidneys. Those are the danger zones. And once fat starts to accumulate there, which will happen in any form of excess energy, awful things are going to happen.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So medicine 1.0 was medicine through all of human history, basically until the end of the 19th century. And so for the longest period of, you know, for hundreds of thousands of years, whatever we thought of as medicine, this 1.0 system, wasn't a scientific thing, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
It was ideas that were based on beliefs that we had at the time that I think were understandable given that we didn't have a scientific process. So it meant that diseases were believed to result from the gods or from bad humors or from these sorts of ideas. And therefore, the treatments were usually pretty ineffective.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You know, it wouldn't be uncommon for them to bloodlet people if someone had a fever or to bore a hole in your head if you had a headache. I mean, things that we would look back at today and say, that's crazy. Well, yes, but they didn't know any better, and that was medicine 1.0. And, you know, people lived pretty awful lives today.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I think if anybody's feeling sorry for themselves, which I think we're all prone to, myself included, we should just remind ourselves that we weren't born a thousand years ago. How lucky to just be alive today.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
If you're still feeling sorry for yourselves, how lucky if you're listening to this and you live in the United States or you live in some part of the world where you have the freedom we have. Now, You think about how people just died all the time, right? They died of infectious diseases. There was probably a 30% chance that a woman was going to die during her lifetime giving birth.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Just astonishing hardship. All of this changes about 140 years ago with a handful of seminal improvements. One is a real codification of a scientific method. Remember, science is a process. So I really get frustrated when I hear... People talk about science as a thing. It's not a thing. It's a process. It's a way of thinking.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
It's a way of making observations, taking guesses as to what it is that is accounting for the observation, designing a hypothesis that can be tested in an experiment. conducting an experiment and measuring the results of the experiment against what would have been predicted by the hypothesis and then, if necessary, revising the hypothesis and coming up with better and better theories. That's it.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
That's what science is. Everything I just said is all you need to know. That's the scientific method. And that didn't exist. That is a man-made creation. Very important to understand that. It's a brilliant creation. I would argue it is the single most important creation that allows us to exist today. It allowed us to figure out that washing your hands was a way to prevent spreading disease.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
It allowed us to figure out that there were organisms that we can't see with our naked eye, like bacteria and viruses, that are killing us. It allowed us to create medications to treat those things. So just on the basis of those few things I said, we basically doubled human lifespan.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And it doesn't matter if you're eating farm-to-table or if you're eating McDonald's. Now, one could argue, If you are eating highly processed foods, it's an easier path to get there. And I agree with that. I think there's reasonable evidence to suggest that The more palatable, the less nutrient-dense, the lower quality the food, the easier it is to overeat.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
just by figuring out how sanitation, addressing infant and mother mortality, treating infections, you know, all of these things had a huge difference. That is what I call medicine 2.0. Medicine 2.0 was heralded in with that discovery. Medicine 2.0 basically says, look, we treat a disease when we see the disease.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And the playbook for Medicine 2.0, again, has been really successful for acute conditions. Trauma is another one, right? Think about what a soldier in theater today can survive relative to what they could have survived in World War I or World War II. especially World War I and even the Civil War. Let's go back.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
If you want to make it a medicine 1.0 to medicine 2.0, consider a Civil War versus soldier today, totally different experience in terms of what's a survivable injury. Again, the advances in trauma and critical care are insane. The problem is those things have not extended to...
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
life life extension vis-a-vis chronic diseases so most people that are listening to us right now are going to die from basically one of four things cardiovascular disease including you know heart attacks and strokes cancer dementing diseases and metabolic diseases. Type 2 diabetes, fatty liver disease, those things.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
That's literally like 80% of people listening to us are going to die from one of those things.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Alzheimer's, vascular dementia, other neurodegenerative diseases like Parkinson's disease and things like that. So those are all chronic diseases and we have not made great progress on any of them with the exception of cardiovascular disease. We're doing a much better job on that.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
People are definitely getting heart attacks later in life and you're more likely to survive your first heart attack today than you were 25 or 30 years ago. So 30 years ago, uh, roughly two-thirds of people would not survive their first heart attack today, slightly more than half will. But I would still argue that all of these results are kind of unacceptable, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And that we should be able to do better. And so now to your question, apologies for the ramble. The first and most important pillar of medicine 3.0 is you have to be able to be better at treating chronic disease because chronic disease is what's going to kill us today. And again, this is a privilege, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
We've done so well at treating acute diseases that we've now earned the right to have to focus on chronic diseases. But the current medical system was not designed for it. The economics of the system aren't built around it. And again, this is not a conspiracy theory. You get all these sort of health influencers that want to turn this into a big pharma conspiracy theory.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
No, it's not a conspiracy theory. It's simple economics. You have a billing system that is predicated not on keeping people sick, but on treating people when they get sick. I get so frustrated when I hear people say, oh, big pharma has the cure for cancer. They just don't want it out there. They want you to be sick. That is hands down the dumbest thing I've ever heard.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
If big pharma had a cure for cancer, they would happily profit on it all day long. The bottom line is cancer is really, really, really hard to cure once it's taken hold. The far better strategy to address cancer is to catch it early or prevent it altogether. And that's not in the purview of pharma.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
They're not in the business of doing that any more than the guy who runs the car wash is in the business of making me dinner. They're different businesses. So, medicine 3.0 has to come up with a better way to treat chronic disease. And though I won't get into all the details, but I write about it extensively in the book,
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You can mathematically prove that the way to treat chronic disease is to delay its onset. Those are mathematically equivalent. So you want to live longer without disease, not live longer with disease. So medicine 2.0 aims to keep you alive longer with chronic disease. Medicine 3.0 says that method will fail. You have to delay the period of time before someone gets a disease.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But we just shouldn't lose sight of that objective, which is you don't want to eat too much. And of course, you don't want to eat too little, although that's less of a problem today. We should acknowledge it's still a problem. I think the second order term is You've got to make sure you're getting enough protein for adequate muscle protein synthesis. I always joke about this and my wife teases me.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
The second big principle of medicine 3.0 is you have to treat this thing called healthspan as much as you treat lifespan. So lifespan is the thing that I think most people intuitively get is like how long you live, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Are you going to, you know, if your parents are still alive, you could say, yeah, my parents are 85 and 80 and hopefully they're going to live another five years and that's their lifespan. But there's this thing called healthspan, which is not as easy to measure, but is more important, which is what's the quality of their life. physically, cognitively, and emotionally.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And so how do you preserve and maximize healthspan? This is another very important principle of Medicine 3.0. Medicine 2.0 does not acknowledge healthspan beyond a very cursory way to describe it. But there's a saying, which I'm sure is true in the military just as it's true in all of medicine and business, what gets measured gets managed. And in medicine 2.0, you manage to lifespan.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
That's the metric everybody's focused on. But in medicine 3.0, you have to pay just as much attention to quality of life. And if you manage to that, how much muscle mass do you have? How strong are you? What's your VO2 max? What's your reaction time? What's your cognitive performance? What's the strength of your relationships? That's part of emotional health.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
All of those things figure into the quality of your life. And medicine 3.0 says we should be managing to those just as much as we manage to life expectancy.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Interesting. So it sounds like more of a preventative approach. It's preventive, but it's also very proactive, and it's much more broad in its focus. It's not just about how long can I keep you alive? It's how long can I keep you thriving?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So it's the leading cause of death for, in the United States, it's the leading cause of death globally, and it's the leading cause of death for men and the leading cause of death for women. So even though I don't think it gets that much attention because maybe because it's so common, we just sort of tune it out a little bit.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
We can't forget, you know, 19 million people a year globally are dying from cardiovascular disease. Now this is, certainly tragic and ironic given that of the four chronic diseases, it's the one that A, we have the best understanding of, and C, we probably have the best treatments for.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So, you know, we can come back to metabolic disease, because I think a lot has changed there, but we certainly understand what the drivers of cardiovascular disease are. And there's several, right? So lipids, blood pressure, smoking, poor metabolic health. Those are the big, big, big drivers, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So if you're insulin resistant, if you have high blood pressure, if you have high what's called ApoB, which is a particular measurement of lipids, if you smoke, those things are going to drive your risk through the roof. There are people who can certainly get away with having one or two of those things not optimized.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But if you're in the business of trying to prevent the disease, you want all four of those things fully optimized. Some of those are purely behavioral. Some of those are done through medications. We talked about blood pressure as an example. Lots of ways to control your blood pressure without pharmacology. But if you need pharmacology, it's also pretty easy to manage it that way.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So that, you know, really it shouldn't be the leading cause of death. It just simply shouldn't be. But most people don't have the right timeline on it. They don't realize how long this disease is brewing. So how old are you? 42. Okay. So, you know, the probability that a 42-year-old's arteries, let's just say tragically you died in a car accident tomorrow.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You can't walk through the hospital hallway and interact with people in the final years of their life and find anybody saying, I wish I had less muscle mass. So we all have to remember that gravity is working against us as we age, and sarcopenia, which is the loss of muscle mass, osteopenia, the weakening of bones, all of these things are enormous causes of age-related morbidity and mortality.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
If they did an autopsy on you, the likelihood that your coronary arteries would look perfect is very, very low. We know this because during Vietnam, they did autopsies on all these young men that were 18, 19, 20 years old. who obviously were killed in combat, so had nothing to do with their hearts, and they did not have perfect coronary arteries. They all had some evidence of disease.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And those guys were not going to die of heart attacks for another 40 or 50 years, to be clear. But what it showed us was how long it takes for this disease to progress below the naked eye. So in the instant that a person has a heart attack, there's an enormous and abrupt change with clotting factors and all these sorts of things. But all of that is precipitated by decades of buildup.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And by buildup, I mean sort of impossible-to-see processes that eventually can become visible on certain elaborate scans. We do want to start preventing this stuff early by managing those four variables. And if we do, I think we get to take that one off the table.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Yeah, so again, you look at each of those risks individually. So first, someone's smoking. If they are, I want them to not smoke, and we're going to do whatever steps we have to do to get them off cigarettes. What's their blood pressure? Again, if someone's got elevated blood pressure, first-line therapy is not to turn to medication. It's actually to look at exercise, sleep, and weight.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Those three things can fix blood pressure in many cases. But if it can't, the amount of medication we have that can address blood pressure without inducing symptoms. Because that's the other thing you always have to think about, right? Anytime you're giving somebody a medication, you have to be able to do it in a way that it doesn't create another problem.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And a lot of the early generations of these drugs, they cause problems. They'd make you feel horrible in some other way. So if your choice is walk around with high blood pressure, even when you've corrected for body weight, exercise, and sleep, or don't, you're better off fixing it, even if it means taking medication. Metabolic health, I think, is the toughest one to fix, truthfully.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And it requires everything from being in energy balance, doing the right kind of exercise, so the right balance between exercise that generates muscle mass and exercise that generates energy.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
the ability for the muscles to soak up glucose that's kind of one of the important functions of the muscle besides the obvious structural components but the muscles are a huge reservoir for glucose putting glucose into muscles is a super important job that drives so much of our health And then the fourth one is managing these lipids.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So this APOB marker, which is a very simple blood test, measures the total concentration of all cholesterol-carrying molecules in the body that are harmful. So not all the molecules that carry cholesterol in the body are harmful, but a subset of them are, and that's how you measure them.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And again, that can be addressed through diet, but if it's not, again, you want to lower those things pharmacologically.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Yeah, so that's a great one, right? So if you're a smoker, I don't think there's anybody out there who's smoking who thinks it's good for them. So really the challenge there is not the, what do I do? It's how do I go about doing it?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
How do I go about a smoking cessation plan, which we could talk about another, we can talk about that as much as you want, by the way, because it's a topic I'm very interested in. Are we talking just cigarettes? Are we talking cigarettes, cigars? Marijuana. So cigarettes are the lion's share of this problem because of just the volume, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So if you're a cigar smoker, you're probably smoking like, first of all, a lot of cigar smokers aren't inhaling the smoke all the way into their lung. And so it's just generally not posing the same risk. It still is risk. But nothing's probably going to be the risk of taking 25 cigarettes a day and smoking them, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So even people who are smoking weed are not typically smoking nearly enough to get there. Now, when you get into nicotine replacement products, you want to always be able to differentiate them into with and without tobacco.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And so adequate protein intake, in addition to adequate caloric intake, are the two most important pillars. Then you can start to go, okay, Peter, I get that. Now tell me what to do. And then believe it or not, I think we get into a highly variable way that the body works. There are some people who do incredibly well on diets that are very high in carbohydrates.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So if a nicotine replacement product is derived from tobacco, like snooze, it still carries a ton of risk. Nowhere near as much risk as a cigarette. So cigarette is still the A plus risk. But if you're consuming snooze, you're still getting a lot of the carcinogenic risk. It's just going to be subject to your mouth as opposed to your lungs.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So when you want to get somebody off smoking, you want to create a real awareness of what they're doing. You want to understand. And so typically the first thing we'll have people do is just journal. When is it that you pick up a cigarette? What happened that made you want to pick up the cigarette? By the way, this will work for any habit, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
If you're trying to understand why you're eating so much junk food. Let's just start with a few weeks of noting every time you go into the pantry for Pringles. What predisposed you to do that? Was there something stressful? Did you have a thought about something? Were you bored? Were you actually hungry? What created the urge?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
There are others who do incredibly well on diets that basically omit carbohydrates altogether. I was one of those people, by the way, for three years from 2011 to 2014, I was on what was called a ketogenic diet. So that meant for three years, I think I had carbs once. Literally one day on my wife's birthday, I had three pieces of cake.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Another one of the things you do is you start disconnecting the urge from the behavior. So let's say you're a smoker. We would say, hey, Sean, every time you feel this urge to go out and get a cigarette, I want you to not do it, but set an alarm for 15 minutes and then go out in 15 minutes. In other words, I'm not going to stop you from smoking.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I'm just going to uncouple the urge from when you do the thing. So that becomes important. Nicotine replacement is a very important part of smoking cessation. There are lots of ways to replace nicotine, right? You've got little patches, I mean, little pouches there. I've got my toothpick here. We've got patches, gum, all sorts of ways to go about doing it.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Each of them has their pluses and minuses. I did a whole podcast on this. that gets into the itty-bitty nuances of this. But the bottom line is, nicotine replacement, very, very powerful tool, because nicotine, if derived from a clean source, like a synthetic nicotine, doesn't carry any of these cancer risks, at least We can be very confident that that's true.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Certainly not from a lung cancer perspective. There may be other risks. So we should be mindful about how much nicotine we do consume. But it allows you to deal with what the addictive piece was. And then the final thing is understanding the oral fixation that a lot of people have with a cigarette.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
By the way, I think that's why kind of the nicotine toothpicks are kind of nice is for many people, it's just, it's a bit of an oral fixation with a nicotine containing thing. There are also different classes of antidepressants that can be very helpful with people that are quitting smoking. So we'll put that aside because it's self-evident that one should not smoke.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But the sometimes to how to do it is easier said than done.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, when it comes to smoking, we know that after a certain number of years, depending on how long of a smoker you were, your risk of heart disease and cancer will return to baseline. It will. It will, yeah. Now, again, you might not get there because depending on how long you smoked, it could be 30 years before you return to baseline.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So if you're a 50-year-old who's quitting smoking and you've been a pack-a-day smoker for 40 years or, you know, say 30 years... you might not make it to 80 without some event. So we still act with enormous vigilance in people who are former smokers.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
In our practice, we treat former smokers and smokers identically when it comes to cancer screening, because even though we know the risk is coming down in them, we just assume it's still quite high. And so we will still screen them very aggressively for every cancer that we can treat. even maybe against the advice of sort of medical authorities in terms of how aggressively we'd look at it.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
The same is also true for cardiovascular disease. We do see that over time, that risk will return to the baseline risk. But remember, as you're aging, what's happening to your baseline risk? It's going way up. Age is the single biggest predictor of risk for both cardiovascular disease and cancer. Okay. Yeah.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And aside from that, the only form of carbohydrates I had was lettuce and some berries. But otherwise, it was all protein and fat. I did very well on that diet. It served me incredibly well. But for some people, it did not. And that's fine. When you start to get into kind of...
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So you never want to escape the fact that even though you're quitting and that's driving risk down, age is driving it up. So you never really want to take your pedal off the metal when it comes to prevention.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Exercise is very important. Again, the benefits of exercise when it comes to brain health, metabolic health, heart health are probably the most obvious. I think when it comes to cancer, it's less obvious. Of all the four diseases, I call them the four horsemen in the book, I think cancer is by far the one we understand the least in terms of what's driving risk.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So we know that metabolic disease drives risk. So obesity and type 2 diabetes clearly driving risk. We have some ideas as to why, but beyond that and smoking, we don't have a great sense. And I don't think there's anybody who's listening to us right now who can't relate to the idea that otherwise completely normal, healthy people still get cancer.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I'm sure you know people who are 40, 50 years old, picture of health, and they still get cancer.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, and I would say this, once you've got your house in order, health-wise, it's the biggest risk. Because you can drive the risk down of metabolic disease, of cardiovascular disease, and even of neurodegenerative disease, especially dementing diseases. We can drive these down. People often ask me, Peter, your whole life is this longevity thing. How are you going to die?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And I say, honestly, it's going to vary by decade. But if you said to me in the next decade, if you had a crystal ball that said, Peter, you're not going to make it to, I'm 52, you're not going to make it to 62, why? There's really two things. It's cancer and accidental death. You know, I mean, they're going to get cancer and succumb to it, or I'm going to die in an accident.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
That would be 90% of what would kill me in the next decade. Okay. So you're not alone, right, in feeling that way. That's a rational fear. Fortunately, given your age, you're 42, your 10-year mortality from cancer is still very low. It's probably in the 2% to 3% range. But that's not zero. Right.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Some of the stuff you've been exposed to, I'm sure.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Some of the more minutiae that people tend to fixate on, it's a little bit of majoring in the minor and minoring in the major. The evidence gets squishier and squishier. The arguments get more and more mechanistic and less based on actual data. So you can make a plausible argument that maybe you shouldn't eat that type of fat in favor of this type of fat.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Yeah, I mean, I think the only thing you can do is you sort of have to decide, am I willing to trade that anxiety for another anxiety? Because you're going to have to deal with some anxiety. So anxiety one is, I'm just going to worry about it, but I'm not going to go looking.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Anxiety two is, I'm going to do everything in my power to screen and look for this, but I'm very likely going to find a bunch of things that aren't cancer. Those are called false positives. So which of those, and this is a very individual decision, but which of those gives you more stress?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Are you more stressed just sitting here worrying about it, or are you going to be more stressed if we turn over every stone, screen the hell out of you, and find a bunch of things that ultimately will not be cancer, but we're going to have to chase them down? Which one of those is more anxiety provoking?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Do you get... Well, again, it's a very personal decision, just like we were talking about with the vaccines earlier. There's not a right answer. And if every single patient I'm talking to I'm not trying to impose my will on them or my beliefs or even what I do. I want to help them understand probabilities. This is the probability of you getting any of these types of cancers.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
this is the probability of this test that we do giving a false positive. This is the probability of it giving a false negative. And again, we know all of this stuff. Like we know for every test we do, there are these two mathematical terms. One is called sensitivity and one is called specificity. So if you do that liquid blood, so what you're referring to, I assume is a liquid biopsy.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So it's a blood test that's doing a pan screen for cancer. That test has a sensitivity, which is the probability that if you have cancer, it will pick it up. The sensitivity for a liquid biopsy is very low. For a stage 1 or stage 2 cancer, it's probably on the order of 30%. That's it? That's it. For all cancers, it's probably on the order of 50%, sensitivity.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Conversely, the specificity, which is the probability that the test comes back negative if you are free of cancer, is very high. The specificity on those tests typically runs about 99.5%.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Now, when you know those two numbers, sensitivity and specificity, and you know the probability that you have cancer out of the gate, what's called the pre-test probability, which says you're a 42-year-old man, you don't smoke, but maybe you have a slightly higher risk because of your exposure to chemicals, blah, blah, blah, blah, blah. Your pre-test probability is 3%.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But there's no actual outcome data to the effect. So maybe time will tell. But I tell people that they should probably focus on the areas where we have far more evidence of doing X is beneficial, doing Y is not. For example, around exercise, sleep, and other things like that.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Knowing the pretest probability, the sensitivity and specificity allows us at any point in time to calculate what's called positive and negative predictive value, which means if this test comes back positive, how likely is it you have cancer? And it's going to be very low. The whole takeaway of that whole spiel is the PPV, or positive predictive value, is going to be like 10%.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So even if that test came back positive, there's a 90% chance you don't even have cancer. The negative predictive value is going to be very high. The negative predictive value is going to be above 99%. So if it comes back negative, you can feel really comfortable if you're negative. Okay. Comes back positive, and this is what I got to earlier.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I don't even let people do these tests if they're not willing to live with the consequences of a false positive because the likelihood of that happening is actually pretty high.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, I'll tell you. I'll give you a really horrible story of a false positive. I was just talking to somebody the other day who went and got a whole body MRI and it found something in his thyroid that looked a little suspicious. And to be clear, the thyroid gland is notoriously difficult to image, notoriously difficult.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
It is so glandular and so prone to over-representation of cancer that we see false positives all the time in the thyroid. I just tell patients, 10%, 20% chance we're going to see something in your thyroid. In this case, saw something in his thyroid. His doctors recommended a thyroid ultrasound and a biopsy. So they did the ultrasound. They did the biopsy.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Now, normally at that point, that's the end of the line. The thyroid is really easy to biopsy. You can feel it. Under an ultrasound, it's like shooting fish in a barrel. Pull a couple cells out. No cancer. You're fine. Sorry for the inconvenience. We'll see you in a year. But in this case, when they did the biopsy, they're like, it might be cancer. We can't fully tell.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And they recommended removing the half of the thyroid. So they did. Now they did the surgical operation. They took out his half thyroid and it came back. It was totally fine. Now, is this a life-changing surgery? No. Can you live without half your thyroid? Yes. But that's an example of what can go wrong. Now, how do I choose to live with that degree of uncertainty?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Personally, because of my risk appetite, I make the decision to screen. I screen myself very aggressively. So I do get a whole body MRI every year. I'm very aggressive with the frequency with which I do colonoscopy. I do liquid biopsies every year. I'm religious with my skin exams.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And again, some of these things are low risk, like the risk of a skin exam means I'm losing a couple moles I didn't need to lose, who cares? But a colonoscopy is a huge risk. I shouldn't say huge. I mean, it's just a very non-zero risk. But again, I consider it a bigger shame to get colon cancer and to miss a colon cancer. Something that's, you know, third leading cause of cancer death, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So truthfully, I got a little bit of food fatigue. And it wasn't that I was craving to eat pasta and rice and potatoes again, but I was craving just a wider variety of fruits and vegetables and things that were basically going to kick me out of ketosis. And so I did. And I'm super happy to be eating what I eat today, which is basically I'm pretty much an in-the-middle eater, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I want to make sure I'm not going to succumb to colon cancer. So, you know, I don't have an answer for you, but I could walk you through every number and let you make the best answer for you.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Probably depends a bit on family history, which really speaks to risk. Colon cancer is an easy one to talk about. So it used to be that traditional screening for low risk individuals was 50. I'm very grateful to see that that's been lowered to 45. So that means now people can get insurance to cover them five years earlier. And I think that matters a lot.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Personally, I would lower it to 40, although I understand maybe on an economic basis why it doesn't make sense. But as an individual thinking about yourself, look, I still think 3% to 4% of colon cancer deaths are in people younger than 40. That's a staggering statistic. People just don't think of young people getting colon cancer. And yet, you know, they do.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So, I would say somewhere between 40 and 45 is probably the right time for a person to get their first colonoscopy, unless they're high risk, in which case you want to be treated earlier than that. So, if a person has ulcerative colitis or Crohn's disease or a family history of colon cancer, things of that nature, I would be doing it even sooner.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, unfortunately you can't, and to be clear, baseline, I said baseline risk. So you're never gonna take your coronary arteries back to what they looked like when you were 10 years old, right? So what we really aim to do is stabilize the progression of atherosclerosis. And so depending on what sort of screening modality is used to measure,
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And the most common one that's used is something called the calcium score, but there's a more advanced test called a CT angiogram. So they're both CT scans, but the calcium score just runs over the body, doesn't put any contrast in, and is just looking to pick up the light of calcium. It's not a very granular test, but if you have any calcium in your coronary arteries, we know that's bad.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
That's not a good test to measure progression because it's not a very accurate test and it can easily be over-interpreted. So if a person's calcium score is 100, if you had a calcium score of 100 at the age of 42, that's a four alarm fire. Even though 100 is not a very high number, that number could easily be 4,000. At the age of 42, it should be zero all day, every day.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But if it was 100 and then five years, and we started treating the heck out of you, and five years later it was 130, that would, in my mind, not constitute progression because of how crude the test is.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Now, if they use a more granular version of that test called a CT angiogram, it's a more high-resolution CT scanner where they use intravenous contrast. Now you get to look more at the coronary arteries, and there you can get more subtle descriptions of what's going on.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But the truth of the matter is when you're treating the causal risk factors, we don't tend to fixate on the imaging as much as we fixate on function and the reduction of risk markers. So if you showed up at 42 with a calcium score of 100, there's no doubt in my mind that at least one of those four factors is out of whack. We're going to fix it. We're just going to fix it. Non-negotiable.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And in five years, even if your calcium score has gone up a little bit, we are still very confident we've halted the progression of the disease.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Yeah, again, we can talk about what is absolutely known. What is unambiguous is smoking, obesity, diabetes are driving the majority of what we see as preventable risk.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So that's the only thing that I would say we know with a very high degree of certainty.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Cigarettes. Cigars? Mostly cigarettes. Okay. Yeah. Now, cigars, even if you're not inhaling, you're still increasing your risk of oral cancers and things of that nature. But yeah, when we talk about a person who smokes a cigarette that they're inhaling, that's increasing the risk of many forms of cancer, not just lung cancer. Although it's increasing your risk of lung cancer geometrically.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So if you're overweight or obese, if you have type 2 diabetes, if you smoke, any combination of those things is... increasing your risk of multiple forms of cancer. They're not all the same, by the way. So the cancers that are predisposed or the ones that risk is going up dramatically for type 2 diabetes and obesity overlap with some of the lung cancer, but there's some different ones as well.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I wouldn't say I'm on a high-carb diet. I wouldn't say I'm on a high-fat diet. I don't pay attention to any of it. You know what I pay attention to? I pay attention to how many calories am I eating? How much protein am I getting? Are the sources of my food as good as I can make them on a given day on average? Yes. Okay.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Everything thereafter that, we are at a lower level of certainty. So I did a lengthy, lengthy deepest deep dive I've ever done, certainly top three deep dives I've ever done in my life into microplastics on a podcast a few weeks ago. And I can tell you that the evidence that microplastics, PFAS chemicals, PM2.5s are causing cancer, PM2.5s are sub-2.5 micron particles in the air that we inhale.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
The evidence that they can cause cancer is... modest. It's not very strong, but it's also shouldn't be ignored, right? I wouldn't throw it out and say, ah, come on, it's all fine. The question is, what do you do with that information? Like, how hard should one work to avoid all of these things? Because it's impossible to avoid them, period.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
We couldn't imagine a scenario whereby a person could completely be free of microplastics. Even if you said something as ridiculous as, I'm going to move to the Antarctic. Well, you wouldn't be able to because the protective clothing you would need to prevent you from dying in that environment would expose you to microplastics. So we're going to be exposed to microplastics no matter what.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Um, but there are a bunch of things you can do to like either inconvenience yourself in time, money, some other variable and reduce it a lot. So, you know, um, I actually made a video kind of recently about this, which is like, what's my 80-20 view of how to do this? And it's some obvious stuff. So one, don't store food in plastic containers.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So if the restaurant's trying to give you your food in plastic container, just don't take it home. At home, throw out your plastic storage containers, splurge on Amazon for the glass storage containers, and just use those. Don't heat up anything in plastic. So my kids, because they still throw cups, will still have a few plastic cups.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I'll put cold milk in there, but I would never put anything hot into there. And frankly, I can't wait till we're kind of done with plastic cups in general. One big splurge I did was I got rid of my drip coffee machine, which just had plastic all over it, and I swapped it out for a machine that is all glass and metal.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And by the way, all the biomarkers that any human is capable of checking, they're looking fine. I will use that to make sure I'm doing it correctly. If something were to change, I could revisit it. But I don't think that the incremental leanness that I might have had, because that was certainly a difference. For me, being on a ketogenic diet, I mean, I was...
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So it still makes a drip coffee, but the hot water is only exposed to metal and glass. Which, again, anytime hot water was exposed to plastic, you're really increasing your risk. So that's an expensive coffee machine, but it's a one-time cost.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Another thing was, and we had already done this before, but I do think this is a worthwhile investment for people who can afford it, is putting in a reverse osmosis water filter in the home and drinking out of that. Huge source of microplastics and other chemicals that you want to avoid.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Another thing that you can do, which again is a big cost, and this is not something everybody necessarily should do, but especially if you're indoors a lot, is moving your air filtration system up to HEPA level. Okay. Again, that's a cost. There's a real cost in doing that. Not in the filters themselves. They can be relatively inexpensive.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But in the HVAC machines that need to blow them are pretty expensive. So standard residential HVAC units typically aren't powered to do it, so you'll have to upgrade them. Okay. Little things like, it sounds silly, but like I don't take a plastic bottle into the sauna. I use a glass bottle. I don't even keep a plastic lid on it. I just don't want anything heating up plastic.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Those are, oh, I switched out my water bottles in, I used to ride my, if I'm riding my bike outdoors, you know, cyclists have plastic water bottles. I just found a company that makes steel ones. So those are kind of the big things. So again, a lot of it's a single upfront big cost, right? You know, the water bottle is like 40 bucks, which is a total ripoff, but whatever.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So single big upfront cost, but then after that, you're kind of done thinking about it. And that's probably getting rid of two-thirds of it. Now, I'm doing that out of what's called the precautionary principle. Not doing that because I'm telling you this stuff causes cancer and heart disease. I don't know. Interesting. But the cost of mitigating it is low relative to the cost of being wrong.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And again, let's say you're on a road trip, and you're parched, and you pull over at a gas station, and your choice is to stay parched or drink the water out of the plastic bottle. Drink the water out of the plastic bottle. That's better than getting a kidney stone. Okay. Right? Like, again, people have to remember the dose effect of this stuff.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Like, I get, I'm amazed at how people completely lose the forest for the trees sometime on this thing. And they all of a sudden become so fixated on, I can't ever touch anything that touched plastic, and yet they forget to work out. Like, remember the priority list, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Probably not as much as health influencers want you to believe.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
That's a bit of a gross oversimplification. The truth of the matter is Cancer feeds off glucose. Glucose is the simplest breakdown product of all carbohydrates or virtually all carbohydrates. The evidence that sugar is uniquely carcinogenic is virtually non-existent, despite, again, what every anti-sugar health influencer wants you to believe. The evidence is awful for that statement. But...
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
probably six or 7% lower in body fat than I am today. Wow.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
sugar almost undoubtedly drives people to overeat. And there are really compelling biochemical reasons for that and decent experimental reasons for that, especially in animals, that High sugar diets will drive overeating, and overeating certainly drives cancer. But cancer does not have a unique ability to consume fructose, which is the actual part of sugar that makes it sweet.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So if you eat a bowl of rice, that's all glucose. If you eat sugar, it's half glucose, half fructose. Well, the cancer does not have a unique ability to consume the fructose. It just consumes the glucose. So you could frankly argue that rice is more carcinogenic than sugar. Except for the fact that, again, as I said, maybe sugar drives people to eat a little bit more. Okay.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But sugar is, pardon me, the bigger driver of cancer from a nutrition perspective is likely the growth signals that are very prevalent with obesity and type 2 diabetes. So it's undoubtedly much more the high levels of insulin than the high levels of glucose that are problematic when you're trying to prevent or minimize cancer risk. Okay. Let's move into dementia.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, we can definitely prevent some of it. I don't know that it's entirely preventable, just like I don't think any disease is entirely preventable. The closest of the maiden diseases that I think is... I think, again, I think type 2 diabetes and extreme metabolic disease and heart disease are the most preventable. I think the other two are less so. But we know a bunch of things, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Well, again, I think I'm pretty privileged in that between my access to hunting, you know, we were talking about this year, very fortunate that I had two elk tags. So not only am I going to feed my entire family with every form of elk you can imagine, right? I mean, we've got elk sausage, we've got elk steaks, we've got ground elk for burgers. I actually had to give away 500 pounds of meat.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
We know that... there are a number of behaviors that really, really reduce your risk of dementia. So you can invert that statement and say that doing a lot of those things helps you prevent dementia, right? So what are those things? So exercise has the most potent effect on reducing the risk of dementia. I mean, it's profound, actually. So there are lots of reasons that that could be the case.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
It could be that when you exercise, your muscles make these hormones called myokines, and that myokines are basically pro-neuron, right? They promote neuronal growth. Exercise produces other... Hormones and proteins. So something called brain natriuretic peptide. Another protein called clotho is made. We have a spike in clotho by about 15% right after we exercise.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
We know very clearly through experiments in everything from mice to monkeys that when you inject people with those proteins, they die. They transiently have an improvement in cognition, and even when you give those things to people or to animals in the early stages of cognitive impairment, it reverses it. So there's a whole bunch of reasons that are profoundly beneficial.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Of course, exercise also plays an amazing role in metabolic health and vascular health, which again are two of the biggest risk factors for dementia, metabolic health and vascular health. We look at other things that can get in the way of brain health is disrupted sleep. So a person who doesn't sleep enough or a person who doesn't get a high enough quality of sleep.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So again, anything that we can do to improve sleep duration, quality staging, et cetera, it's going to be important. All the things that hurt the heart hurt the brain. So ApoB, blood pressure, smoking, we talked about metabolic health. Those things are bad for the heart. They're bad for the brain.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So reducing ApoB, keeping blood pressure normal, not smoking, being metabolically healthy, exercising are, I mean, that's the playbook. And again, people really want there to be some special nootropic agent out there that you can just take that is going to just, make your brain perfect, and it's like you're rearranging the deck chairs on the Titanic.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
The most important thing is not to hit the iceberg. Don't hit the iceberg. That's the most important step. And those are the things that we just talked about.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I'm not familiar with that. I am familiar with a lot of the – both the stories and certainly some of the reports, case reports of the benefits of iboga and ibogaine on alcohol consumption. on opioids even more potently. Very difficult to ignore. In other words, I really think there's something going on there.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I had so much this year. So... So, yeah, I'm in a fortunate position where because of my hobby, I have access to that. But I don't tell people to fixate on that, right? I mean, if you don't have access to farm-to-table, you can still go and buy at your grocery store grass-fed. You can spend a little more and go grass-fed instead of grain-fed. And I think that's a worthwhile trade.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I actually just spoke with a patient who came back from a long retreat in, it was either Mexico or Costa Rica. I think it was in Mexico. He was there for a week and You know, it's interesting. I always ask people when they do this, what are you in search of? What was the reason for it, right? Out of curiosity, of course. I'm not judging the experience.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And he kind of went in there without a very clear objective. He wasn't going to solve a problem. But he said it's very interesting. He came out of it and he was like, yeah, I just don't have any appetite for alcohol. That's what happened to me. So you didn't go in there specifically for that reason.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
This is an experience of 10 minutes long, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But, yeah. That alone should also help your anxiety. I think it did. Marijuana is a very interesting drug where for a high number of people, in the short term, they think it's giving them a reduction of anxiety, but it's actually compounding their anxiety.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I had a woman on my podcast who talked about this at length, and she talked about the number of patients where if she can just get them to stop marijuana for... a month, they're going to start to break the cycle of their anxiety. And of course, there are lots of people who use marijuana quite regularly have zero issues with anxiety.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So again, I think like most things in mental health, it's really complicated to understand susceptibility windows. Like, why is it that one person, when they use this drug, something negative happens, another person can use the same drug and actually something quite positive happens? What's the susceptibility of that? We're really in our infancy of understanding these things, to put it mildly.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You can still spend a little bit more and say, look, I'm going to opt into something that's organic that has embed fan antibiotics without having to go all the way to farm-to-table. But if you live in an area... where you can find a local farmer and say, look, I'm going to commit to half a cow this year with my family or, you know, a quarter cow or whatever is typically how they'll do it.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Certainly nothing directly. Now, look, you could make some indirect cases. And by the way, I don't include MDMA as a psychedelic because it's technically not a psychedelic. It's an empathogen, so it doesn't distort your perception. But as I'm sure you're aware from interviews you've done, I mean, MDMA is probably the more promising of all of those agents when it comes to treating PTSD.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And it would be hard to make a case that if you took an individual who's suffering from PTSD and you freed them from the grip of that through MDMA-guided therapy, that you aren't not just reducing their risk of near-term issues that are associated with PTSD, but also long-term issues, including cognitive decline. So again, I think there could be indirect and adjacent benefits of this.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I just think with each psychedelic, as with each drug, you have to know the operating window of the drug, right? So like take something that's really obvious and predictable, like Tylenol. So when was the last time you took Tylenol for a headache or something? It's been a long time. All right. But you know how it works. Your kids get a fever, you give them Tylenol, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
It has a really predictable operating window. You're like, I'm going to give this to you. You're going to feel better. Can't give you too much or I'll hurt your liver. If I give you too little, you're not going to feel anything. But this is the dose at which it works. Advil. Take an Advil if you pulled a muscle or something. Like super, super predictable. MDMA, pretty predictable drug, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Like for most people, somewhere between about 75 milligrams and 125 milligrams is going to produce a remarkably consistent effect. Now you layer that in to the right setting with the right therapist, with the right intention, you start to get amazing clinical results with people. Now, when you start to look at psilocybin, LSD, oh, it starts to become a lot less predictable.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You can give the exact same dose to two different people or to the same person in two different settings, wildly different result. Now go one step further and start talking about ayahuasca. I mean, all bets are off, right? Like it's not even one molecule, right? Does that in any way diminish that people have life-changing effects on these things?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
No, but there's a real buyer beware on these things in my mind. And I do think that, Again, I don't follow this space nearly as much as I used to. But if I think about where my interests in this space were seven or eight years ago, I felt like there was maybe just a little too much indexing on these things or the panacea. Everybody needs a shaman.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I mean, I think that's a great option.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Everybody needs to be doing ayahuasca all the time. And my view now is that's just insanely irresponsible. And I think for every great story you hear about someone, one, how often is the change durable? And B, what does the graveyard look like of people who have been kind of ravaged by some of these things? I think Iboga, Ibogaine and Iboga are really interesting. And actually, if I could...
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
make one wish of the FDA, it's that I really wish that they would reclassify it to permit it to be studied for addiction. Because I don't know how we can live in the world today where we see more than 100,000 people in this country die from fentanyl overdoses a year. And we aren't interested in trying to free people of that addiction.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And by the way, some will say, well, but iboga is very dangerous and you can run into cardiac toxicity. And it's like, yes, all of that is true, but it can be done safely. Um, And the toxicity that comes with it has to be weighed against the toxicity of an ongoing opioid addiction.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Yes, I have not done iboga, but I've done most of the others. And for what reason? You know, usually trying to solve a problem, trying to address a demon. And I've had... Some incredible experiences that have changed my life forever have given me compassion in areas where I never thought I could have it. Can you share that? Yeah, yeah.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I think one of the most powerful experiences I ever had was probably 2017. So, and I didn't go into this experience knowing what was going to happen, but I had a remarkable vision of something in my childhood that was quite unremarkable. But it was, and I'm sure you've heard this from people who have
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Used high doses of psilocybin, but you sort of disassociate so you are no longer experiencing this thing from Your viewpoint is where you were and I'm trying to think how old I was I was probably 13 So I was no longer 13 I was me as an adult but I had lifted up to the top of the room and I was now watching me as the child with
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
with my father, and I was watching something, an interaction that we had, but through a totally different lens, which was through his eyes. And I saw the world through his eyes, and I gained a compassion for him that has endured to this day in a way that I'm so grateful for. And it was, you know, I mean, it was...
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Woke up I remember waking up and thinking someone had spilled water on the floor and realized it was my tears Wow, and I couldn't understand how there was so much water on the floor after this many hours I mean it was such a profound experience that said on the opposite side of that Sean I've had experiences with some of these agents that have I described them as Guantanamo Bay for my soul just horrible experiences
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Do you continue to do those therapies? No, I honestly think I have extracted the value that can be extracted from them and I'm grateful for it, but I do not believe that there's any more value to me to be extracted from those agents, with the exception of MDMA. I still think MDMA, because of its very gentle, forgiving nature, offers a wonderful opportunity to kind of heal oneself a little bit.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But I think, I'll never say never, but I'm not at all eager to re-engage with any of the others. What about you?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And that's what I was confusing. Sorry. It's 5-MeO that's the 10-minute ride. Yes.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
yeah there's a there's a book by this title that talks about the difference between altered states and altered traits and the idea here is every time you do one of these drugs it alters your state obviously but unless it's altering a trait i.e once the effect of the drug is gone Is it going to change the person I am? Does it make me a better person?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
If it doesn't, that's a litmus test that you shouldn't be doing it. And so that is the standard I hold myself to on these things. I have no interest in just having my state altered. If it's not going to address a trait, I don't care. I actually like the state I'm in. I don't need to run from this place unless transiently doing so is going to help me fix something. That's a great way to put it.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
What's the fourth one? Metabolic? Metabolic disease. So this is everything from insulin resistance, fatty liver disease, type 2 diabetes. And this is, in many ways, probably the one that's growing at the fastest rate. So in the year you and I, well, I guess I'm 10 years older than you, but roughly when you and I were born, you know, we're talking 1% of the US population had type 2 diabetes.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
It's 10% today.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You know, obesity rates have doubled in that period of time. So something's broken, right? Something is broken. And if you have type 2 diabetes, your risk of all-cause mortality is 40% higher. Your risk of getting any of these other diseases is up to 50, in some cases, 100% higher. not to mention the personal toll this takes, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Yeah, so again, the term studies obviously is pretty broad. So if you look at most nutrition research that's trying to answer the questions that I think people want to know, they aren't actually funded by industry. They're typically funded by NGOs. They're funded by NIH. And, you know, The list of people who's going to be more critical of NIH than me is not a very long list.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
That doesn't count all the other stuff, the blindness, the impotence, the amputations of digits, like all the other stuff that comes with this, the cost of the healthcare system. I mean, we could rattle off everything about this, right? So what is it that's going on?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Like, you know, because obviously there's an association between weight and metabolic health, but it's not an ironclad association, right? And we know that weight by itself, excess weight by itself, is not the problem.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
It really has to go back to kind of that thing we talked about before, which is some people can store a lot of excess energy in the form of fat without it becoming metabolically toxic, without it kind of going into those other parts of the body where it leads to these horrible compensations. And I do think that the majority of this problem stems from nutrition.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I think exercise can alleviate much of it. And as people are becoming less and less active at just kind of baseline activity level, they're more susceptible to bad nutrition. Sleep factors into this more than most people realize. So if you're sleep deprived, your susceptibility for everything goes way up, including, I mean, I'm sure you know, I know this from back when I was in residency.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So every third night you're not sleeping, that next day, my eating pattern was worse. I had more cravings, I would eat more crap, and your cortisol levels are through the roof. I mean, there's just a whole bunch of bad things that happen when you're not sleeping. So, something about our food system isn't working. I don't think it's... I think it's actually more the obvious stuff, honestly.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I don't think it's... I don't believe it's red dye in the foods. I think all that stuff is like... Those are rounding errors, right? I think the real issue is we... We culturally eat too much in this country. We do have a lot of processed food, and we eat a ton of it. And any American who has spent time abroad will recognize immediately the difference in food.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Yes, the food quality is better elsewhere, but there's a totally different culture about how much you eat, when you eat. The size of portions, everything is geared and kind of rigged against us here. And I think that's probably the single biggest factor that's driving it. Coupled with like, again, just to give you a little example, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
you don't see places like Costco in Europe the way you would see it here, right? Because over there, you're going to go grocery shopping twice a week and you're going to just, you know, the fridges are smaller over there, right? They're not supersizing everything.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So as much as people want to point to seed oils and red dyes and you're eating too many animal products, you're eating not enough animal products or whatever, like I don't, The data just don't support that. The data suggests it really comes down to we just eat a lot more calorie-dense foods in way higher quantities than other people do. Now, of course, they're catching up to us.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So in fairness, the rest of the world is doing their best to catch up to the United States because we certainly export the best of our food ideas. So you don't, you know, there's a lot of talk about seed oils these days. I'm actually in the process of trying to engage, and I have engaged two people on this debate. So I won't name them, but you can probably figure out who they are.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But two people on either extreme of this debate, and I'm actually trying to bring them on my podcast for a moderated debate. Now, I think podcast debates usually suck. And the reason is people can make up whatever they want, and you can't fact check them in real time. So I've never actually watched a debate on a podcast that I didn't think was an absolute garbage waste of time.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I've been quite critical of things that the NIH has done, in my view, not correctly. Also, you could argue maybe I'm conflicted. I did my fellowship, my postdoctoral fellowship at the NIH, so I spent two years there. And so I know the merits of NIH. It's a remarkable system that gives the United States an insane competitive advantage in biomedical research.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So in going to these two guys, I said, look, I don't have any interest in adding to the volume of crap out there. So if we do this, we're going to do it by my rules. And my rules are as follows. The question of what is being debated will be very, very clearly articulated a priori.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
All the research that each of you will use to address the question will be pre-submitted such that everybody can review it. So this is how a court works, okay? So you will submit all of your data to you, you will submit all of your data to you, and both of you will submit it to me and my research team.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
When a person is speaking in the debate, if they are citing a study, they may only cite from what was pre-submitted. There is none of the pulling out of one's ass that is rampant in the podcast space when it comes to debates. And everything you say will be fact-checked. So beware. If you're making something up, we will fact-check you.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And we will insert fact check and correction every time you misspeak. Wow, when's that coming out? We haven't, I mean, we're still trying to get everybody to agree to this. And it might not happen, you know? I mean, I've tried to do this for vaccine safety. I've tried to do it for seed oils. I would like to do it for sugar. There are lots of topics we want to do it for.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But, you know, when push comes to shove, it's hard to get people to commit to that kind of rigor.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Is it the anti-seed oil guy or the... I won't say for sake of who these folks are, but I will say that even getting to agree on the question has been difficult.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I hope that happens. But it's really easy to just kind of blame your favorite boogeyman. Yeah. But when push comes to shove, like what is the data? What is the data?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I think it's easier to talk about it through the lens of what does the output need to be. I think too much of exercise is talked about the input. You need to do this many hours of this, you need to do this many hours of this. And that's obviously a very helpful way to talk about it because it's easier and it's actionable. But it's better to at least start with what's the objective.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And the objective is if you at least just look at the top level of the data, you want to have muscle mass that puts you at about the 75th percentile of the population or better. The two easiest ways to measure that is something called appendicular lean mass index and fat-free mass index. These can both be derived from a DEXA scan.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
That's a body scan that very quickly measures how much fat, muscle, and bone density you have. And so that's one of our first optimizations. We really would love to get everybody to be at or above the 75th percentile of muscle mass. Now, that's not going to be possible for everybody. There are some people whose build is so slight.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I mean, we have patients that come in our practice who are literally at the third percentile for muscle mass. I don't expect those people to ever get to the 75th percentile, but I bet I can get them to the 40th or 50th percentile over a few years. Second thing is you want to hit certain metrics of strength.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And, you know, so you should be able to carry some fraction, depending on how old you are, your body weight or some fraction of it for a certain period of time, right? You should be able to do a wall sit for a certain period of time. And again, you can discount this over time. As a person ages, the standard goes down, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Like, no other country on the planet has what we have access to, right? So we talk about things like, why is the US military so far superior to every military on the planet? Is there a second place? The gap between the US and everybody else is so enormous. And a big part of it comes down to investment. And I would say the same is true from a biomedical research perspective.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So when you were coming out of buds, my guess is like you could, I mean, you were Superman, Wouldn't hold you to that standard today. But there's a standard for a 40-year-old, a 50-year-old, a 60-year-old, a male, a female, etc. And so if you rattle off what all these standards are, I would say that becomes a very important thing that we want to be able to hold ourselves to.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And we'll come back to how you get there. There's a measurement that is a very accurate way to determine what a person's maximal aerobic capacity is. It's called VO2 max. It's typically measured either on a stationary bike or on a treadmill when someone's hooked up to a mask that measures oxygen concentration and volume of air consumed, and you can calculate how much oxygen was consumed.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
When you know that, you can tell a person where they are relative to people their age and their sex. And we have a very high standard for what we white think you want to be. We might say, look, I want you to be at the 97th or 98th percentile for your age and sex with respect to VO2 max. And then there are other markers of baseline aerobic fitness, what's called zone two.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And we would say we have a standard for what we would want you to be able to do, how many watts we would expect you to be able to put out relative to your body weight for an hour under these conditions. And so we can rattle off a whole lot of these goals. And then we can come back to your question of how should one do that?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And I don't tend to prescribe like you got to do this many hours of exercise. What I then do is I say, how many hours a week can you exercise, Sean? You tell me what you're willing to do. Not for one week when you're being a hero. Like tell me what is sustainable for you for the next year. And then if you came back and said, look, man, my kids are one and three. I got this podcast.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I'm doing 20 interviews a week. I got this business thing. I got this business thing. I can't do more than six hours a week of training right now. I'd say, okay. We're going to work with six hours per week, and we might not get you to those goals within a year, but we're going to put you on the right path, and this is how we're going to balance the portfolio.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
If you came back and said, I can only do three hours per week, I'm going to be like, oh, God, okay. We're probably not going to make that much progress, but unless you're starting from zero. If you're starting from zero, three hours a week is pretty awesome.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
But if you're a reasonably quasi-fit person who's at about the 50th percentile, we're not going to make huge progress in three hours a week, but we're not going to take any steps backwards, and that's important. And if you come in and say, I'm going for broke, man, you got me for 12 hours a week, then it's a totally different training program. How often do you exercise? I mean, almost every day.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I didn't exercise today because I had to, you know, fly in and then I'm going to fly back tonight. But I did today's workout yesterday. So, I mean, my schedule is set up to exercise pretty much every day. But at least twice a month, there's kind of a forced day off due to travel.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Right now, let me think. Maybe eight hours a week. Eight hours a week? Yeah. What kind of exercising? These days, it's mostly just cycling and resistance training. I'm going to resume swimming again in a couple months. So I think I'll probably increase to about 12 hours per week total training time by... spring, summer, and I think just bring swimming back in permanently to my life.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I haven't swum in a long time and I kind of miss it. And I also think it's, you know, kind of going back to something you said earlier, like how do I spend my time? Swimming will be a form of exercise where I'm killing two birds with one stone. Well, I'll get the exercise, but it's also a bit of a mental health check. Whereas when I'm on my bike, I'm usually, like, I'm indoors.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Nobody can even invest a quarter of what we invest in this.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I'm listening to a podcast or an audio book. I'm not really turning it off. I'm trying to learn. When I'm strength training, I've got music on, so I'm kind of focused on what I'm doing there. But swimming is, as you know, you probably spend a ton of time in the water. You only hear the water. You hear yourself breathing, and you hear the sound of the water.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So that's why I'm kind of excited to get back into swimming, and that'll probably take me up to 12 hours a week.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
No, I mean, I think just asking themselves questions, you know, like trying to, trying to understand the root of, of, of what's going on. Like what, you know, uh, how can I name my emotions? Right. Um, why do I feel a way? Why do I feel the way I feel? Who am I? Uh, who do I feel connected to? Who do I not feel connected to? Um, So I think just being kind of curious is a very important step.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I think this is an area that comes a lot easier to women than to men. I think men, particularly young men, just don't necessarily possess the vocabulary sometimes to even think through some of this stuff. And I think you get into trouble for it, right? You end up... Going down a road where you can poison relationships because you didn't know better, right? Because you didn't know how to act.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Maybe you didn't have a role model in that way. And I think there's different ways to do it. I mean, you can, you know, I think in my case, the issue was, you know, workaholism, perfectionism, anger being great tools that were highly valuable when I was young that start to become maladaptive when you get older.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
And then you have kids and then you realize, you know, what served me well when I was a 16-year-old is not going to serve me well when I'm a 46-year-old.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Look, a lot of people If you spend two minutes with them asking them questions, you can figure out they don't have an issue with their sleep. Their sleep is great. There are a couple of really great surveys you can take online. There's one called the PSQR, which is probably the most important one anyone should take.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
So if you just Google PSQR and go and take this survey, it asks you a bunch of questions and it'll pretty quickly tell you if you have a sleep issue. And if you do, then you kind of want to get into the, well, what's going on, and just start doing some accounting. Like, what time do I go to bed? Am I consistent in my bedtime? Am I consistent in my wake-up time? How many hours am I getting in bed?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Because if you're not even spending seven and a half to eight hours in bed, yeah, you're probably going to be shortchanged in sleep. Because it's hard to sleep more than 90% of the time you're in bed. So I try to be in bed for eight to eight and a half hours to get seven and a half to eight hours of sleep. And of course, nowadays, tracking devices are ubiquitous, so you can measure data.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
with reasonable accuracy, like how you're sleeping, what staging you're getting, and things like that. And then there's just a whole bunch of really, really straightforward sleep hygiene things that everybody, I think, should be doing. And everybody knows what they are. I could rattle them off, but I don't think anybody would be surprised by them. It's just a behavioral challenge, right?
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I don't think there's anybody who's going to listen to us who's going to think, wait, I shouldn't be looking at my phone before bed? So everybody knows that, but sometimes it's just hard to make the discipline of not looking at your phone for, let's say, an hour, two hours before bed. Having a bedtime routine. Keeping the room really dark, really cold. Not having electronics in the room.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
Not eating before bed for maybe three hours. Not having alcohol before bed. All these things... make such a big difference. And then when you stack them all together, it's like, you're gonna sleep well. And then of course, there's always a subset of people where after doing all of that stuff, sleep is still problematic. And then a sleep test can be really helpful.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
You know, you do learn that, hey, a person might have sleep apnea And even if they lose weight, it doesn't fix, or maybe their normal weight, because there are still people who get sleep apnea that are of totally normal weight, even though it's a condition that disproportionately afflicts people who are overweight. And then, yeah, you give that person a CPAP machine and it changes their life.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
No, I don't think so.
Shawn Ryan Show
#181 Peter Attia - The Science of Longevity, Nutrition Myths and Medicine 3.0
I like to get up early, make coffee. In an ideal world, have 15 minutes with my wife where we're sitting in the dark, having coffee, catching up. Kids are up then, getting the kids ready for school, so making breakfast. In a really good day, get a chess game in with one of the boys before school. Get the kids off to school. Right now it's about 7.15.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
Death is inevitable, but the rate of decline is very much up to us. The drawback that young people have is they only begin to realize the inevitability of the decline when it besets them. So your team that came in for testing that are in their 20s, when I'm looking at these results, there were issues that were uncovered that were a concern.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
And I think that that's a mistake. I think that training under very heavy load should not be done under great fatigue. Interesting. We'll talk about that as well.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
And does it matter? Well, I think the second question is easier to answer than the first. I do think it matters. The why is probably multifactorial, and the why is just as important as the fact that it is. In other words, the fact that it's declining is both relevant for the fact that a very, very important hormone that has –
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
incredible benefit to men and women by the way is going down and we have to come up with an answer to that right like so how do we address that do we address it medically where we replace that hormone exogenously meaning we give you that hormone directly or do we try to fix the underlying problem so if you want to do the latter you have to know what the underlying problem is now at the population level the best answer as to why testosterone levels are declining
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
And unmistakably, they are. So the data here are unambiguous. There's no debate on this fact. The debate is around the why. I believe that the best answer probably has to do with two things. One is increase in body weight and body fat specifically in men. and some combination of reduced quality of sleep and sort of disruption to sleep. So why are those two things relevant?
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
So when you increase body fat, two things are happening. One is you're increasing inflammation and you are reducing the amount of testosterone that gets to stay in the form of testosterone because part of the testosterone gets converted into estrogen. So with body fat comes more of this process called aromatization or converting testosterone into estrogen.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
So if you think about what those two things are doing, if you have more inflammation, that reduces your ability to make testosterone, and you have more capacity to turn the less testosterone you make into estrogen, the net result of that is both of those things are reducing your total pool of testosterone.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
If you couple that with lower quality sleep, and I'm not talking about over the last three years. I'm comparing like now to say 40 years ago. And what are all the reasons that people might have poorer quality of sleep now? I think there were many, but obviously phones and social media and just the stimulation of the world we live in probably plays a greater role in that.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
Sleep is when we make these hormones, right? So we make follicle-stimulating hormone and luteinizing hormone at their maximum amount during sleep, and those are the hormones that are driving the production of testosterone.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
So what we've seen in many of our patients when they have low testosterone, because there's a test you can do to see if their testosterone is low because their body can't make it, or because their brain isn't receiving enough of a signal to make it. This is a very easy thing to determine medically.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
Unfortunately, most people aren't subjected to that level of testing because they go to these testosterone shops on street corners that are just giving everybody testosterone. But if a physician is curious enough to understand that, you can give a patient a drug or a hormone called HCG. HCG is luteinizing hormone, which is one of the hormones made by the brain.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
So if you come and you see a man who's got very low testosterone, and you can't understand why, you give him luteinizing hormone. If he still has low testosterone, you know that he has what's called primary hypogonadism, which means his testosterone is low because his testes can't make testosterone.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
Conversely, if you give the man luteinizing hormone and all of a sudden his testosterone goes up, he has secondary hypogonadism. I mean, you could mix the primary secondary there, but really the terminology doesn't mean anything. What matters is he can make testosterone, but... for some reason, his brain isn't giving his body the signal to do it.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
And that's a classic finding in a person who's under high stress and or not sleeping well. So that's a long-winded answer to your question, but I think that those are probably the greatest contributors to this.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
Now, people have talked a lot about what about microplastics, what about other environmental factors, what about other factors in nutrition beyond just the ones that would contribute to excess body fat. The evidence there is less compelling, but I don't think we should discount it. But I think that if those things are playing a role, it is probably much smaller than what we just talked about.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
worse food choices for sure and i was like is that like dopamine dysfunction no it's probably more due to insulin signaling so um we know from really good experimental studies that when you sleep deprive people they become insulin resistant And the more insulin resistant a person is, the less they're able to access their stored energy.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
So higher insulin resistance means greater difficulty accessing stored energy. So if you wake up and you have successive days of poor sleep and you're becoming somewhat insulin resistant, you're going to want to eat more because you're not able to access your own natural stores of fat, which is where we want to go for energy.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
So if you look at one experiment that was done out of the University of Chicago, they took healthy subjects, young subjects, and sleep deprived them for hours. somewhere between 10 and 14 days. So not a huge period of time. And they only let them sleep four hours a night, which by the way, I know a lot of people who are doing that for years at a time.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
In that 10 to 14 day period of time, their insulin resistance was worsened by 50%. In other words, they do an experiment called a euglycemic clamp where they inject them with glucose to see how effectively they can put glucose into their cells. That's the hallmark of insulin sensitivity is how well you can put glucose into your muscles when it's infused in you.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
I wish I could say one thing. There's probably a few things, and maybe that's not good. Maybe the most successful people in life only think about one thing. I would say one of the things I'm thinking a lot about is how to translate Outlive into a delivery system, obviously digitally, that...
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
And their capacity to do that was reduced by 50% after such a short intervention. So I think sleep restriction and unhealthy sleep is a very underappreciated cause of metabolic health and weight gain. And then by extension, these other things we're talking about.
The Diary Of A CEO with Steven Bartlett
Anti-Aging Expert (Peter Attia): Anti-aging Cure No One Talks About! 50% Chance You’ll Die In A Year If This Happens! Boost Testosterone Naturally Without TRT!
Yeah. I mean, look, I've said this before and I'm not the first to say this, so I'm paraphrasing others, but if you really stop to think about it, sleep doesn't make a lot of sense from an evolutionary perspective. Right. Like if you go back in time a few hundred thousand years, why would we have spent a third of our life unconscious? It didn't serve our purpose.
The Diary Of A CEO with Steven Bartlett
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You can't mate, you can't hunt, and you can't defend yourself. So you have to believe that if we could have evolved out of it, we would have done it. And we didn't. So that means that whatever it's doing, it must be really important. I mean, core essential to our existence. While I will completely acknowledge that different people have a different necessity or requirement for how much they sleep,
The Diary Of A CEO with Steven Bartlett
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I still think that many people underestimate how much they need.
The Diary Of A CEO with Steven Bartlett
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Well, they're very similar to the types of things you're thinking about, and I love how you've got specific examples. So I really like playing with my kids, right? So I can imagine that in my marginal decade, I'll have grandkids that are the age of my kids, right? Yeah. And, you know, maybe a bit older, but as I'm even getting towards that marginal decade.
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Okay, so playing sports is really, really fun. I really like playing, especially because when I grew up, like I played hockey because I grew up in Canada, and then I immediately went into kind of boxing and martial arts, and those became my life. So now playing sports that I didn't play much as a kid is really fun. Like I'm really enjoying baseball. I'm really enjoying soccer. And –
The Diary Of A CEO with Steven Bartlett
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And so when you play these things, you realize this is not an easy thing to do when you get old. Like to sit in the goal and actually like stop a ball when a kid is blasting at you full stop, you have to be able to move around. So again, like I would love to be able to play soccer, throw a football, throw and hit a baseball as long as possible.
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You can get into movements that are much simpler, but if I can do all of those things, I'm in great shape. Now, of course, to be able to do that, I also need to be able to do a lot of things that many people also can't do in their marginal decade, like sit on the floor, get up off the floor under their own power, walk up X number of flights of stairs, having the strength to do that.
The Diary Of A CEO with Steven Bartlett
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basically operationalizes what is in that book in a manner that allows people to, with as little friction as possible, implement the solutions for themselves. So basically, how do you live a longer life? How do you age as gracefully as possible and maximize your health span?
The Diary Of A CEO with Steven Bartlett
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I like doing that. certain things. Like I like archery a lot. So it's, you know, I want to be able to pull a bow back, obviously not at the same poundage as the current bow that I pull back, but I would still like to be able to pull a 50 pound bow back in the final decade of my life.
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No one in the final decade of their life ever said, I wish I had less strength and I wish I had less endurance. So you cannot be too strong and you cannot be too fit. The only time that one would throttle back on the pursuit of those is A, if doing so is coming at the expense of something else, either with respect to your health or your life.
The Diary Of A CEO with Steven Bartlett
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And two, if the pursuit of that at such an extreme level produces risk of injury.
The Diary Of A CEO with Steven Bartlett
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So in other words, could I be stronger than I am today? Yes. I'll give you an example. We know that in resistance training, the sweet spot for pure strength is one to five reps. When your goal is to maximize strength, you need to be pushing one, two, three, four, five reps. Once you start thinking about hypertrophy, muscle size, we're starting to think about seven, eight, nine, 10, 11, 12 reps.
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And ignoring it doesn't lead to a good outcome when you're 65. But a lot of people have this issue, so it's okay to speak freely about this. Yep. The biggest concern is that Dr. Peter Attia is the go-to physician for high performers, celebrities, and anyone serious about unlocking the science behind a longer, stronger, and healthier life.
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Once we start thinking about muscular endurance, we start thinking about north of 15, right? Those are the general patterns of resistance training.
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Okay. Lower weight. Yep.
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So, again, we could go into much more detail around that. But just to finish the point here, why do I not do much training at one to five reps? In fact, these days I don't do any training at one to five reps anymore. Why? Because to train at one to five reps comes at a risk, especially for heavy compound movements.
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So I'm OK getting a little bit less of a strength benefit while still, of course, getting stronger, but training at a higher rep load. So I'm targeting eight to 12 reps with one to two reps in reserve. is basically how I'm doing my resistance training. That means every set I'm doing, I would expect to get to within about one rep of failure somewhere.
The Diary Of A CEO with Steven Bartlett
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I think the other thing I'm focused on that is related to that, of course, but distinct, which I know your team got to participate in a little bit this week, was kind of how to train people for their marginal decade, right? So this idea of we're all going to have a last decade of life.
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So today when I lifted, I don't think I did less than seven. I didn't do more than 12. And the weight was always titrated so that I was either failing, almost failing, or one rep away from failing somewhere in there. And I was adjusting the weight constantly on every exercise to get there, with the exception of one exercise. I did push-ups was one of the things I did.
The Diary Of A CEO with Steven Bartlett
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Push-ups are kind of more in the muscle endurance. Obviously, I'm doing more reps when I was doing push-ups. But pretty much everything else was in that range. So again, I'm not fully maximizing strength anymore because the cost of it might be a little bit high in terms of injury risk.
The Diary Of A CEO with Steven Bartlett
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Similarly, I'm not strength training 24-7 because I need to make time to do my endurance training and other types of training.
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I resistance train three times a week.
The Diary Of A CEO with Steven Bartlett
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Yeah. Why? Because, you know, again, the intensity of my training is not that high, at least three days a week. So the three resistance days are pretty hard because I'm really only doing each body part once a week. So when I'm doing it, I'm really... I'll spend that 90 minutes really kind of hammering those body parts. Three of those days are just zone two.
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So three of my four cardio days are zone two days where I'm doing, you know, I'm on a bike and I am riding at... a level of intensity that actually allows me to still talk. Not talk like I am now, but talking in sort of a strained way. So for me, that's about a heart rate of 140 beats per minute. And that's just not taking a huge toll on me. Those are almost like recovery days for me.
The Diary Of A CEO with Steven Bartlett
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And then one day a week, I do a really, really hard VO2 max day. And that's a really hard day. That burns a lot of matches. That's tomorrow. Not looking forward to it already.
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No, I don't. So it's four days of cardio, three days of resistance. Now, that's going to change in the summer when I'm going to add three days of swimming.
The Diary Of A CEO with Steven Bartlett
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It wouldn't really serve a purpose. So I know a lot of people do that. I know a lot of people will say, hey, I'm going to do a little bit of a warm up on this treadmill or the step master before I lift. But I actually have a pretty strong point of view on how we should warm up to lift.
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And I don't think walking on the treadmill or running on the treadmill or being on the stair master on the bike is a great prep for the lift. I think it's better to warm up for a lift doing movements that prepare you to lift. So for example, like if it's a leg day, so Monday's leg day, right? So what am I going to do? I'm going to start by doing a bunch of core stabilizing stuff.
The Diary Of A CEO with Steven Bartlett
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I call it the marginal decade just so that we can get comfortable talking about something that people don't like to think about. And I'm convinced that ignoring it and not thinking about it doesn't lead to a good outcome. Instead, if you prepare for it and train for it like an athlete trains and prepares for their sport, you'll have the best version of that possible.
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So I'm going to do a whole bunch of this dynamic neuromuscular stabilization stuff. So you get into basically these baby positions and you really learn to activate your core as you move around in a six-month position and stuff like that. Thank you. Thank you. Thank you.
The Diary Of A CEO with Steven Bartlett
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Thank you. Thank you. Thank you. Thank you.
The Diary Of A CEO with Steven Bartlett
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Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.
The Diary Of A CEO with Steven Bartlett
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Yep.
The Diary Of A CEO with Steven Bartlett
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Last decade of life. Again, it's this weird thing where most people don't know the day they've entered it, but most people also realize at some point when they're in it. I thought a lot about it. This was sort of a big epiphany that I had in 2018 when I was sitting in the church at a funeral of the parent of a friend of mine who I realized had declined so much during the last decade of their life
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Thank you.
The Diary Of A CEO with Steven Bartlett
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that even though they were alive, they weren't enjoying life. The things that they loved to do, in the case of this individual, play golf and tend to the garden, they couldn't do. They just physically couldn't do it, right? They had injuries, they had aches and pains. And when they couldn't do those things that gave them pleasure, they retreated from life.
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There are lots of exercises that are great for balance. Anything that produces instability is great because it's, you know, for lack of a better term, I've heard it described as problem solving for your foot.
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Right? So if you think about being on any unstable surface, even if you're just walking on an unstable surface, so if you were to
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look at a person's foot their lower leg actually as they're walking on a surface that's constantly changing so like a gravel path or something like that you're going to see like if this were my lower leg you would see the musculature of the lower leg constantly adjusting to it and so yeah i'm i really enjoy things that force that type of training do you do flexibility stuff
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Yeah, so I'm actually naturally a pretty lax person. So I don't do any stretching, if that's what you're asking. But all of the sort of stability and dynamic stuff I do incorporates movement at end ranges. So I'll give you an example of why I think the notion of flexibility might be a little bit misunderstood here.
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If you ask a person to stand up and with their legs straight touch their toes, most people would say that's a great test of flexibility in the hamstring, right? And most people can't do that. What they don't realize is everybody's hamstrings are long enough to allow them to do that. The reason they can't do it is their central nervous system will not release them to do it. Does that make sense?
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And I don't think there's a person listening to us who can't appreciate that because they've witnessed it, right? They've seen it in a parent, a grandparent, a loved one. And I don't know, there was just something about that moment, which is often the case, right? It's usually like years and years of thinking about something and it crystallizes in an instant.
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Interesting. Their central nervous system won't release them to do it. That's right. It doesn't feel safe for them to do it. Now, how do I know this? Because if you take a person under general anesthesia, you can put them into almost any position possible. So if you took a person under general anesthesia, laid them on the operating room table, you could lift their leg up to here.
The Diary Of A CEO with Steven Bartlett
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When they're awake, you couldn't get it past here. When they wake up from surgery, will they have a torn hamstring? Not at all. They won't even know their leg was moved. The difference is when they're under general anesthesia, their brain is not sending a signal to the leg that says, don't lift. So why is the leg, why is the brain doing that to the individual?
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This is how I learned it on a personal level. So about six years ago, I had tweaked my back and had just done a unnecessarily heavy set of deadlifts and just pushed it a little too far. And I was kind of nursing this sort of you know, just very, very tight QL. I was completely jammed up.
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And I came in to do some training with a friend of mine who's one of the guys that, actually, he is really the guy that introduced me to this thing called DNS, dynamic neuromuscular stabilization. And I mean, I was stiff as a board. I couldn't, you know, get past my knees bending forward. And I'd been hurting for like three days.
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And we went through a series of exercises for 40 minutes, which included me laying on my back with my legs up, him leaning on top of me. So my feet are here on his chest and doing isometric pushes while working on generating intra-abdominal pressure. And after an hour, yeah, maybe 40 minutes of this type of exercises, I was palms on the floor.
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Now, how do I go from not being able to get to my knees to palms on the floor in 40 minutes with three days of horrible back pain? The difference is when my back was hurting, my body was not going to let me go down. The body was saying, no way, your back, I'm protecting you because you are not stable. You're not gonna go any further.
The Diary Of A CEO with Steven Bartlett
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And what we went through with this exercise and a series of exercises was basically, I mean, I'm oversimplifying this and sort of anthropomorphizing it, but letting my brain know it's okay, you're stable, you're stable, you're stable. The back is safe, the back is safe, let him go. And then, ah, I'm palms on the floor. So I love testing this.
The Diary Of A CEO with Steven Bartlett
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Sometimes I'll just wake up in the morning and do five minutes of breathing exercises when I'm stiff as a board and just get into a position on the floor.
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Because that's really how – the breathing is how I kind of create this cylinder in my abdomen to sort of push the floor of the cylinder down as the pelvic wall. The diaphragm is the cylinder top. And then the entirety of my abdomen is the wall of the cylinder. And so I kind of go through these exercises every single day, usually on my back, actually. That's kind of like part of my warmup.
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And it's just a way to kind of ground myself around creating concentric pressure in the abdomen.
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But in that moment, I realized, aha, the way to avoid this is to train specifically for that decade. And the best model for how to do that is to look at athletes because every athlete trains with specificity. So think of like all the different types of athletes you would know.
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So on Monday, Monday is pure lower body. Okay. And Wednesday is arms and shoulders. And Friday is chest and back. Okay. Super simple. Like nothing, no rocket science. An hour? I mean, it's like an hour and a half of lifting plus maybe 20 minutes of the warm-up stuff. So on the chest and back day, how many chest exercises are you doing?
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Yeah. Okay. And I'm just super setting them. And I'm going to do maybe five sets of each, so five working sets. So there's a lot of warm-up in there too. And I'll also do some other stuff like some med ball slams or things like that as well. Okay.
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I don't know. I mean, I think it's a very net positive thing, though. I mean, I do think that there's more and more people that are taking up things like rucking and running and, you know, finding camaraderie in these things. The only thing I hope is that people are doing it in a manner that's sustainable and safe and allows them to do it indefinitely.
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So, you know, I'm always hopeful that whatever thing that people are doing, they're not injuring themselves because, again, rule number one is don't get injured. The name of the game is to play the game as long as possible.
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I think most people will be familiar with the idea that we are obligate anaerobes, which in English means we cannot survive without oxygen. Okay. So why is that? So oxygen is absolutely essential to catalyze the chemical reaction that turns food into a currency for energy called ATP. So everybody's probably heard of ATP. ATP is the money, the currency of energy in our body.
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Anything that interrupts the production of ATP is fatal. So an extreme example of that is cyanide. Everyone's heard of cyanide as a poison. If you take cyanide, you'll be dead within seconds because cyanide blocks one of the transporters in the production of ATP. So it just gives you a sense of how critical it is to have an infinite and abundant supply of ATP. Oxygen is also essential for that.
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So if you think about like a sprinter or a basketball player or a football player, they are so different and very little of their training looks like the other guy. And the reason for that is they're doing something very specific, right? The sprinter has a goal, which is to move 100 meters as fast as possible. That's it. And that requires a certain set of skills.
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That's why without oxygen, you can only survive for a couple of minutes. longer than you can without cyanide, but not much longer. So how does it work? So we breathe in air and that air goes into our lungs and that air goes through our lungs into these distal things called capillaries where hemoglobin is bringing the waste product called carbon dioxide back to the lungs and there's a gradient of
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Partial pressure between oxygen and carbon dioxide such that a switch takes place. The air that we breathe in delivers some of its oxygen to the hemoglobin molecules. And the carbon dioxide diffuses off that into the air. And we breathe out air that is lower in oxygen and higher in carbon dioxide than what we breathed in. So if I go, that was high oxygen, low carbon dioxide. Whew.
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That was low oxygen, high carbon dioxide. And that's happening every second of every day. That oxygen, that hemoglobin molecule that's carrying oxygen is carrying it to every cell in my body because every cell in my body needs oxygen. And that cell in the body is taking the oxygen to run that chemical reaction to make ATP, and it's shuttling back carbon dioxide.
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And it's just the most incredible thing in the world to imagine how frequently this is happening. And the more you exercise, the more you consume oxygen. So oxygen consumption is a proxy for energy demand. So... We can measure this. Now to do so, you have to put a mask on because I have to be able to measure very precisely two things.
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I have to be able to measure exactly the flow rate of air going in and out of your mouth. And I have to be able to measure very precisely the concentration of oxygen coming out. If I know those two things, I can calculate how many liters per minute of oxygen you are consuming. So you and I sitting here right now are probably consuming less than half a liter a minute.
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So call it 500 cc a minute of oxygen right now, because you have to consume some to be alive. And look, I'm moving my arms around and you're nodding and taking notes. So if you're sleeping, you might be consuming 300 milliliters of oxygen per minute. That's the lowest level. If you were to get up and we were to walk around here, that number might go up to 800 milliliters per minute.
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If we were to walk a little more briskly, we might be at a liter per minute of oxygen. If I said, let's go out in the parking lot and jog, well, we might get up to like 1.5 liters per minute. We pick up the pace a little bit, we'll get to two liters per minute. If I start really, really running us hard, we're gonna get to three and a half, four liters per minute.
The Diary Of A CEO with Steven Bartlett
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I had a big epiphany at a funeral of a friend of mine who I realized had declined so much during their last decade that when they couldn't do those things that gave them pleasure because of injuries, aches, and pains, they weren't enjoying life. I call it the marginal decade. Wow, okay, so what are the most important parts of my health that I should be thinking about for longevity?
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Well, at some point, I am going to push you so hard that you will achieve your maximum level of oxygen consumption. And if I push you any harder and faster, you won't extract more oxygen from the air. You may go faster, but you will do so through a process that does not involve the consumption of oxygen.
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You will do so through an anaerobic glycolytic pathway, but you will have achieved your maximum consumption of oxygen. And that number has a very special name. It's called VO2 max. So VO2 max measured in liters per minute is the maximum amount of oxygen you can consume.
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And the only way you can measure that again is to have this mask with very, very fancy apparatus that measures both of those things I said, and you have to be stressed hard. So we typically do this on a treadmill or on a bike. So your colleagues that came into 10 Squared yesterday, they did it on treadmills. They ran.
The Diary Of A CEO with Steven Bartlett
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And the footballer has a totally different goal. Yes, he has to be able to run fast for short distances, but just being able to run fast would not produce superior results. And then the basketball player would be different. And then the skier would have a totally different set of skills. So I said, well, who's the most well-rounded athlete out there? It's the decathlete.
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And they ran them and ran them and they ran them until they couldn't go any faster. And then we measured how many liters per minute of oxygen they were consuming. Now, that answers what VO2 max is. So the next question is, Does this matter?
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Well, the short answer is we don't have a single metric of humans that we can measure that better predicts how long they will live than how high their VO2 max is. And it's not even close, to be completely clear. So if you compare somebody who is in the top 2% to someone who is in the bottom 25% for their age,
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The difference in mortality is 5x 500% Yes, 400% technically because with hazard ratios you you you go To to a 2x hazard ratio is 100% I guess yeah So let's look at you. So yes, see you've pulled this chart out, which is one of my favorite charts. Okay, so you oh By the way, there's one other thing I should state we normalize this by weight
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Okay. So we always divide that number of liters per minute by how many kilograms you are. So the number is actually reported as milliliters per kilogram per minute.
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Okay. All right. So if we look at somebody who is your age, male, 30 to 39... If their VO2 max is below 35 milliliters per kilogram per minute, they are in the bottom 25%. Conversely, if they are at 53 milliliters per kilogram per minute, they are in the top 2.5%.
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So to be clear, if you take a 35-year-old man, and one of them has a VO2 max of 53, and the other one has a VO2 max of 35, there is a 400% difference in their all-cause mortality over the coming year.
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That's right. Now, this becomes more and more profound as you age, because the all-cause mortality ratio for a 35-year-old is incredibly low. It's like 1%. So that means you're comparing 1% to 4%. It's not that big a deal. But when you get up to my age, so I'm two decades older than you. So now the low bar, the bottom quartile, is less than 29. The high bar is more than 50.
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Well, my relative mortality in the next decade is probably 2% to 3%. So now multiply that by four. Okay. When I get into my marginal decade, the low bar is 18. The high bar is 36. That's a 2x difference in VO2 max. A 4x difference in mortality is huge when the all-cause mortality for an 85-year-old is going to be the one-year mortality for that person is more than 10%. Yeah.
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Because that guy's got to do 10 different things really well. Now, he or she doesn't have to be the best in the world at those 10. In fact, they never are. but overall they're considered the best athlete because of the diversity and breadth of what they can do. And so I said, that is our model.
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So one of the things that we do is we sort of think through this, not just through the lens of mortality, which is what I just walked you through here, but also healthspan, which is kind of what you were talking about earlier with the graph of strength and disability. So we have another figure that we show people that on the x-axis shows age, and on the y-axis shows VO2.
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And it has a whole bunch of lines that come across that show various activities. You know, if you want to be able to run a six-minute mile, you have to have a VO2 that's very high. If you want to be able to run an eight-minute mile, a 10-minute mile. If you want to be able to climb a flight of stairs without getting out of breath.
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Like it shows all of these different things and you see what the required VO2 is. I think, in fact, we might even have these graphs in here. Yeah, right there. So we put your dot on the graph and we say, if you stay where you are, meaning right at that green curve, you're in for a great life. Why? Because even when you're in your 80s, you're still going to be able to do all of those things.
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Yeah. So he did both a Zone 2 and a VO2 max test. So Jack got on the treadmill. And there's a protocol for how you warm somebody up. You really want them to be able to get to a maximum effort. You don't just put them on a treadmill and crank it up. You take your time getting them up there. And he had an amazing result. So his VO2 max was 4.1 liters per minute.
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And he achieved that at a heart rate of 204 beats per minute, which is higher than what was predicted for his age. If you normalize it by his weight, he was at 56.5 milliliters per kilogram per minute. So when you look at his age, because he's in his 20s, he was at about the 97th percentile for his age, meaning his VO2 max was higher than 97% of people his age.
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And so out of the gate, that just tells us from a longevity standpoint, our goal is to keep him there as long as possible. I mean, we're so ambitious with our patients and clients that we actually want them to be, as an aspiration, to be two decades younger at the top 2%. So if you're 50, you wanna be VO2 max north of 53.
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So what is the centenary in decathlon then is I say to you, Steven, one day you are gonna be in your marginal decade What do you want to be able to do physically, athletically in that last decade?
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And then the other thing we do is we check on something called heart rate recovery. So in 60 seconds post VO2 max, how long does it take? How many beats does their heart rate come down in one minute? This is also a very powerful predictor of mortality because it's a huge indication of what's called parasympathetic sympathetic balance. So it's basically a question of,
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How much is their autonomic nervous system in favor of sort of a stress response versus a recovery response? And so the gold standard here, we want to see people that can recover at least 30 beats in the first minute. He did pretty well. He recovered 28 beats. You know, if you're really, really fit, you're going to be 40, 50 beats of recovery within the first one minute. It's incredible. Wow.
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Then we tested his lactate levels and we ran him for what we called zone two testing, right? So zone two is his aerobic base. This is where he should be spending 80% of his training, 80% of his cardio training time should be in this energy system. So it's Hard enough that it's not just pure recovery, but not so hard that it's pushing energy systems that are higher.
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This is a pace he should be able to hold for an hour. And he should certainly feel like he's working, but not feel it too much. Technically, it's also a place where he's got maximum fat oxidation. So we do this also in the same measure on a treadmill. This is a bit more of a complicated test because you're titrating between how he feels and what his blood lactate levels are.
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Maybe not to get too complicated in the weeds on that, but we're simultaneously looking at the ratio of how much carbon dioxide he produces to how much oxygen he consumes. Mm-hmm. That tells us how much fat he is using in his own body. And we look at that number and he maxed out at 0.77 grams per minute, which is very good. One gram per minute of fat oxidation is exceptional.
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So 0.7677 is pretty darn good. His lactate hit about 2 millimole, and he achieved this running at 7.3 miles per hour. So again, there's a lot to unpack in there, but that gives us a pretty good sense of his level of fitness. And for a guy in his 20s, that's really good fitness.
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Yes, yeah. But even this test is about – we normally would separate these two tests on two separate days. Okay. So people who come to 10 Squared are not from Austin. They're from all over the place. So they come in for two days of testing, and you've got to sort of figure out a way to take a person who's not necessarily that fit and allow them to do these tests.
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So it's kind of broken up over to a couple days so they can mix it with the strength testing and all the other stuff.
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So the truth of the matter is, looking at his stuff here, I would say I think you've got the endurance thing really covered. In his case... There were other issues that were uncovered during his intake that were of more concern. And this is a matter of like now what we think of as portfolio management, right?
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So when your VO2 max is in the top 2%, when you're fat oxidizing 0.7, you know, almost 0.8 grams per minute, and he's got a heart rate of 165 to 170 when he's in zone two. I mean, this guy's cardio is dialed in.
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All right. Well, first off, Jack, thanks for being an awesome guinea pig yesterday. You hit it out of the park as far as your cardio training. So tell me a little bit, like, what are you doing for cardio? How often are you running?
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Interesting. I know that the team talked to you about your left foot. Yes. And did they show you the pictures on the treadmill?
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I think it's very likely that the ankle sprain has changed your gait such that you probably are going to develop an injury over time with your running if your pattern is not corrected. So you're overcompensating on the left. And I assume you noticed the difference in the height of your shoulders and your head and everything while you were running.
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So even though the engine is working insanely well, this test only measures the performance of your engine. Your chassis, which is a subjective assessment to use the car analogy, shows that the chassis is a bit weak.
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That's right. And again, the good news about running is each step is very light. But if you're running 20K, that's a lot of steps. So even something that's a light impact but done thousands of times will produce a problem. Okay. So let's shift from how well the engine is, which is exceptional at both ends, by the way. To be clear, your peak engine output, which is VO2 max, was awesome.
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And your engine efficiency, which was your zone two, your fat oxidation, exceptional. We do have this issue on the chassis that needs to be addressed or you're going to get a repetitive strain injury. So then the next thing that the team did was just a very simple test called the DEXA scan, but we do a more comprehensive one.
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So we're looking at all the bone density, left hip, right hip, lumbar spine, and then total body fat, total muscle mass, and then visceral fat, which is fat around the organs. I think the most surprising aspect of the test was your bone density.
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So a DEXA scan measures bone density very accurately and both sort of across the board in terms of your lumbar spine and your right hip and your left hip, you were in your lumbar spine two standard deviations below the mean. for someone your age. So that means basically you're in the bottom 10 percentile of bone density for a guy your age. And for your hips, you're not much better.
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Both on the left and right hip, you're about 1.5 to 1.7 standard deviations below the mean. So what does that mean? That means that you already have something called osteoporosis. So when your T score, which in your case is almost the same as your Z score because of your age, but the Z score compares you to someone your age, the T score compares you to someone 30 years old.
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And by the way, it's a different reason. I'm going to point this out and I want to come back to your story. Walking down is not about endurance. Walking down is about eccentric strength in the quads to be able to decelerate the body as it's moving down. Very important. Coming up is about concentric strength in the quads and glutes and endurance. Okay. All right, but continue.
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So when your T score is minus one, you have osteopenia. And when it gets below minus 2.5, you have osteoporosis. Those are just technical definitions of bone density. The problem is your risk of bone fracture goes up really significantly. Now, because of how young you are, it's not like I'm worried you're going to walk out of here and something's going to go wrong.
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But the risk of you sustaining an injury in sport is not trivial, right? So if you were out skiing, and Steven was out skiing, assuming he had normal bone density, and you guys both took a tumble, I would be infinitely more worried about your bone density. And we have patients in our practice who do.
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They're young, healthy people, and they get these freakish fractures while skiing or playing sports and things like that. And they have really low bone density. So it's just something we want to address. The bigger concern is that what is the story of this going to be when you're 60 and 65 and 70? And that's the one where we really want to mitigate it.
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So I know that the team talked to you about making sure you follow up with an endocrinologist. You want to make sure that there's nothing here that is medically obvious to be treated such as vitamin D deficiency, anything that has to do with parathyroid hormone or calcium and things that are medically obvious to treat.
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The most important behavioral thing that a person can do with low bone density beyond correcting all the nutritional deficiencies that can lead to it is applying heavy load to the bone. So bones are active pieces of tissue, even though we don't think of them that way, and they respond to deformation. So you have to put strain into a bone for it to respond and strengthen. And it's counterintuitive
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that running is not amazing at doing that. It's not bad. So in general, runners have better bone density than sedentary people, but not by much, believe it or not. Swimmers and cyclists, believe it or not, actually have lower bone density on average. But resistance training with heavy weights is actually kind of what is necessary. Grappling as well, by the way.
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So people who do jiu-jitsu, strength training, resistance training, those are the ways that you're going to increase this. So I would say that was the first finding that is important and worth discussing.
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I mean, I guess, did you have asthma as a child or anything?
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Well, if there's something that was impacting your calcium levels when you were little, that would certainly be a potential risk for it. Our bones are mostly formed for males in the early 20s, for girls typically in the late teens. So anything that disrupted calcium metabolism when you were young could have played a role in this for sure.
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The reason I asked if you had asthma is a lot of the times we see folks that had any medical condition that required corticosteroids. Prolonged use of corticosteroids would be another big risk factor. Of course, there's also genetics, so probably worth knowing if your parents themselves have low bone density.
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But it sounds like there's something going on with calcium metabolism as a kid that might have played a role. The reason it is really important to connect with an endocrinologist now is there are actual medical studies
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treatments that can increase bone density in addition to all of sort of the total optimization of the nutritional stuff, vitamin D, calcium levels, things of that nature, and of course the training.
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No, I mean, I think if you think about the long bones of the body, which are the ones that we're basically measuring here, I mean, the short bones in the spine, but the femurs and hips, anything that puts those things under deformation. So anything from a farmer's carry to a step up to a box squat.
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I mean, you know, it's whatever you can do safely that's loading you and placing these bones in a manner that… forces them to actually undergo deformation. And the other thing I would also make sure of is that someone's checking your blood levels to look at things like testosterone and estrogen. So estrogen, believe it or not, probably the most important hormone besides vitamin D in bone health.
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So you can think of a bone as something with a strain gauge in it. And as the bone is deformed, the strain gauge sends a signal, a chemical signal to cells that build the bone. The chemical signal is estrogen.
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So the reason women are so susceptible to osteopenia and osteoporosis is once they go through menopause, many of them lose their estrogen if they're not placed on, well, they all lose their estrogen, but if they're not placed on hormone replacement therapy, they don't get it back. And so they lose that chemical signal. So women see a rapid drop-off in bone density at menopause.
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Peter, is this graph accurate, roughly? Yes, this would be accurate.
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It's preventing decline. Most of us reach our peak bone mass in our 20s. So the name of the game is prevent it from getting any weaker. The good news is, by the way, I had a woman on my podcast named Belinda Beck who studies osteoporosis. She's from Australia.
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And she did this amazing study there called the Lift More Study where she enrolled a bunch of women with osteoporosis who had never done any resistance training. And half of them were randomized to the usual activities like yoga and things of that nature. And then half of them were randomized to heavy resistance training.
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And the women that did the heavy resistance training actually, first of all, on DEXA saw no change in bone density or saw a very minor reduction in bone density compared to a significant reduction in the women who were not resistance training. But more importantly, on CT scans,
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The women who had done the resistance training actually showed an increase in cortical thickening of bone, suggesting that it might even be that DEXA is not by itself sufficient to fully assess bone health. It assesses bone density, but not necessarily bone health. And her hypothesis is that these women might actually be getting stronger bones, even if the density is going down just a little.
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But either way, even if density were sufficient, the fact that their density went down so much less than the others was amazing. And it's actually, you know, if you can find the video and link to it on YouTube, Belinda Beck's Lift More study. It's just an awesome video to watch these little old ladies walking around picking up, you know, dead lifting their body weight and stuff like that.
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Yeah, calcium, vitamin D, protein. Everything that's going to support muscle mass as well because that's the other thing that we found here. So we looked at your body fat percentage. Again, in absolute terms, not that high, but for your age, pretty high. Because you're young, so you're at the 80th percentile for your age. And your visceral fat was at the 50th percentile for your age.
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So we don't really care that much about total body fat. We care a lot more about visceral fat. So the fact that your visceral fat was at the 50th percentile, visceral fat is the fat that's around your organs. That's the more metabolically deranging, damaging fat. We actually have a very high standard. We want to see that below the 10th percentile. Thank you. Thank you. Thank you. Thank you.
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Think about the scapular stability that's required. Think about the upper body strength you need to lift yourself back into a boat if you fall. I mean, the list goes on and on and on.
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Thank you.
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Thank you.
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Thank you. Thank you. Thank you.
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Thank you. Thank you.
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Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. in an otherwise healthy environment, right?
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So there's muscle mass, muscle strength, but we don't have a single metric that we can measure that better predicts how long they will live than how high their VO2 max is, which is the maximum amount of oxygen you can consume. If you compare somebody who is in the top 2% to someone who is in the bottom 25%, there is a 400% difference in their all-cause mortality over the coming year.
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So if you talk about the individual who comes home and has a glass of wine while he's with his wife and they kind of unwind in the backyard and talk about their day and things like that, there might be benefits from doing that that outweigh the very, very small amount of toxicity that came in that ethanol.
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That's exactly the exercise we do, right? We take people through... give us the 10 most important things you want to be able to do. So like if you start with, I want to be able to go back to Bali and I want to be able to go down those hundred stairs, get in the raft, go down the river, come back up the stairs, that gets broken down into very specific movement patterns.
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Once you reach about 30 grams of ethanol a day, I don't see, and I have not seen, a shred of evidence that there is any amount of pro-social behavior that can offset the toxicity of that ethanol. So while I would not go as far as the World Health Organization, which has condemned ethanol as a carcinogen at every dose, I just don't see the data to make that case for every dose.
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I tell my patients in a very measured, nuanced way, kind of what I just told you. Like, you know, I drink alcohol, but I think about it every time I do. Like, is it worth it? Is it worth it? Is it worth it? Like, I'm not just drinking for the sake of drinking. I have this expression, don't drink on airplanes because the alcohol sucks. Like, I'm not just drinking to numb myself, right?
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Like, if I'm going to drink, there's a reason. It's going to be really freaking good. And that, for me, amounts to probably like four drinks a week.
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Well, first of all, as a disclosure, I'm an investor in a company that sells electrolytes, so LMNT. So I'm an investor in that company, which I always want to disclose stuff like that if it's pertinent. The short answer is it depends. So why did I get interested in electrolytes? Well, I historically never consumed electrolytes when exercising.
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I was pretty much always consuming water and or water plus carbohydrate, depending on the intensity and duration of the exercise. I also tend to have very low blood pressure. And a couple of years ago, I had a really, really bad fall when I woke up in the morning and I was jet lagged. So I had just flown to Brazil. So obviously you get a little bit dehydrated on a plane.
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And then the first, like, you know, you get in whatever that night. And then the next morning I woke up, got out of bed and face planted into a table. You can probably still see the scar on my forehead. And I get back home and, you know, my doc measures my blood pressure. It's like 95 over 60. And he's like, yeah, you're just you're really dehydrated, man. Like we need to get a little more.
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And it's not like I don't eat salt. I make zero effort to restrict sodium in my diet. But clearly I was just exercising too much. You know, I mean, especially living in Texas, like when I'm exercising outdoors, I'm sweating like crazy. So it's like you just got to get more salt, man.
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So I just went, I literally then did a super deep dive on hydration and realized that there's basically two ways to maximize hydration. Either you consume water with a high enough, not just a high enough, with the absolute correct concentration of glucose in it. And the correct concentration is between 5% and 6%.
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So that's 50 to 60 grams of glucose per liter of fluid will maximize water uptake through the sodium water transporter. Or you consume what's called osmotic sodium in water. Those are your two options, with the glucose one being slightly better. And so what I realized is, look, I don't exercise long enough anymore to justify it.
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And the only workout I do a week that is intense enough to justify it is that VO2 max one, where I actually am using glucose in water. But for the rest of my workouts, I don't need it. I just need sodium and water. And then I just went through every product on the market. Like literally went to Amazon, click, click, click, click, click, click, click, click, order every one of them.
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Playing football with the kids out back gets broken down into very specific movement patterns. By the way, they're very different, right? That one comes down much more to foot reactivity, lateral movement, things like that. Being able to pick something up off the floor is yet another set of movement patterns.
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And realized at the end of the day, it's a commodity product. Get the one that tastes the best because that's the one you're going to have to suck down every day.
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Maybe just the idea that it's really tempting in the world I live in to want to find single sources of problems. Right. So there's always a boogeyman. And I think, unfortunately, the entire landscape of health influencing and social media has created a very unhelpful narrative around many of these things. And so-
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There's an effect called the Dunning-Kruger effect, which can be sort of put into a cartoon where it shows experience on the x-axis and confidence on the y-axis. So you've seen this graph, I'm sure, where it starts out like it just skyrockets up.
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to what's called the peak of stupidity and then it kind of comes down into the valley of humility and then as you become more and more of an expert you gradually rise right so it's this idea of like the deeper you go out from shore the further from shore the deeper the water gets and you and most of what you're what what i'm sure your audience is going to be exposed to because we all are if we're on social media or whatever is like people preaching from the peak of mount stupidity
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And so I think maybe the thing to be thinking about is like what are the signs of that, right? And it's usually people that are like there's one thing that is the thing, right? Like it's this additive in food or it's this particular oil or it's this sugar or it's this, that. And it's like the truth of the matter is it isn't one thing.
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Like it's really, really complicated and it's hard to talk about things that are complicated and we tend to – Just want to focus on one thing. And I've been guilty of this myself. If I look at stuff I was writing 15 years ago, I'm like, man, you really oversimplified that too much. Like you over indexed on that and you ignored this thing.
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And so I just think that, you know, try to identify people out there who are talking about things in a nuanced way. And you're generally going to be closer to the direction of reality.
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It turns out there are approximately 27 physical requirements that are necessary to do the sum total of most things people want to do.
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Well, on my podcast, it's easy because, again, the nature of my podcast is super inquisitive. So it's just very easy to push back. And sometimes I don't. Sometimes I'll – you know, I was recently interviewing somebody, and they made a comment, and I just knew it was wrong. But I was like, you know –
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I'll make an editorial comment later about this for the audience to understand that he's confusing cause and effect. And I didn't push back. And afterwards, I thought I probably should have. I probably should have pushed back on what he said a little bit. But again, on my podcast, it's easy. I think the bigger issue is when people send me links to podcasts, like, what do you think of this?
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And I have to go through and explain why what this person said is wrong. Completely wrong. I mean, just completely unfounded in any scientific basis whatsoever. But they're a very compelling speaker. And so I get it. Like, I get why, you know, that you would, you know, as my friend, send that to me with concern.
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I think our website probably, so Peter Attia MD, the website will probably direct people to all the different sort of places where we have unbelievable amounts of free information. So we have a newsletter that comes out every single week. It's free. It's really valuable. People, you know, the open rate on that is through the roof because it's not junk.
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Like it's, we're putting something in your inbox every single Sunday that you're going to want to read about the exact topics you're asking. So.
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Because I've been dealing with that for a long – I've been dealing with something for a couple of weeks that is incredibly frightening. But I think I've finally worked up the courage to do it. But I can't speak about it, unfortunately.
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At least not yet. I will be able to one day. There will be a day when I will be able to tell this story. And it will be one of the most important decisions I've ever made in my life.
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Obviously, I don't agree with that, though I have tremendous empathy for people who might feel that way. When you see something as ubiquitous as the decline of untold numbers of people as they age, it would be very easy and tempting to say that that is the inevitability of our species. Death is inevitable. despite what some biohackers may tell you.
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Decline is inevitable, but the rate of decline is very much up to us. And the preservation of strength, stamina, movement capacity, Those things are largely up to us. In fact, there are actual data that demonstrate quite clearly. In fact, I was just reading a paper yesterday in the journal Cell that looked at the role of exercise in aging individuals to preserve mitochondrial function.
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So this is a study that looked at older individuals, and it randomized one group to a significant amount of exercise, and the other group was just sort of business as usual, being largely sedentary.
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And then using pretty elaborate techniques where you biopsy the muscle, they look at the mitochondria, which are kind of the powerhouse of the cell, in these individuals, and it turned out that in the people who were exercising, there was very little decline in the mitochondrial function compared to what happened in the people who were not exercising.
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Now, just because your mitochondria continue to function well doesn't mean all aspects of aging are offset, but it's a very important one to demonstrate. And this is also true by the way of strength and endurance. There's a big difference in the rate of decline of muscle mass, muscle strength, and cardiopulmonary fitness in people who exercise versus who don't.
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So it's all kind of a long-winded way of saying you have, as an individual, so much more under your control than you realize. But you have to sort of begin to compounding the gains. I'll do it when I'm 50. Well, look, the good news is 50 isn't too old. And I've met many people who don't begin to do this until they're 50. But again, the analogy I would use here is 50.
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But how do I know if it's an issue or not? We'll go into much more detail around that, but the way to avoid this is to train specifically for that marginal decade. And there's so many things that we just do wrong. So the sooner you start, the better. So rule number one.
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comparable to that of investing for retirement. The longer you wait, the less money you're probably going to have at the end.
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The sooner you start, the better. The drawback that young people have is... I mean, you've had a great experience because you're introspective about it and you've been able to observe it in somebody older. So you've been able to gather motivation without having to experience the decline yourself. So that's a wonderful position to be in. For many people, that's not the case.
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They only begin to realize the inevitability of the decline when it besets them. But the way to think about this, again, is another analogy, is that of a glider. So gliders eventually all have to come down, right? Our health span is basically a glider, but we have a lot of control about how long it stays in the air based on how high we can start it.
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So if you think about, you know, would you rather take a glider off a really high cliff or off a low cliff, that's the decision we get to make. And we sort of call that concept physiologic headroom. So the example you gave is a great one, right? So muscle mass, muscle strength provide an enormous amount of physiologic headroom as does cardiopulmonary fitness.
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It wouldn't have been much about exercise. It would have been more about other aspects of life, for sure. Because for whatever reason, I've always gravitated towards exercise. That's always been a very high priority for me. So I think my advice to 32-year-old Peter would be much more about relationships and emotional health.
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But if I could go back and speak to 14-year-old Peter, A, he wouldn't have listened. But I would have begged him to go a little bit easier on his body and back off on certain things that probably have led to injuries I have today that could have been prevented. Can I ask what those certain things are? Sure.
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I think I lifted far too heavy, far too often, and probably without enough coaching on technique. And so, you know, by the time I was 27, I had a devastating back injury. But it's one of those things that happened without any incident, right? Which is often the case, by the way, for a back injury. When you really blow out a disc in your back, it's not necessarily something you did in that moment.
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It's usually something that's been built up from the past. So this injury I had at the age of 27 really was the result of years of... unnecessarily heavy axial loading, loading done with probably insufficient technique, you know, or technique that was at times sloppy and under fatigue, because I used to do a lot under fatigue, you know, I sort of believed in training under a lot of fatigue.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
A second obvious issue as we age is a reduction in bone density and a reduction in muscle mass. And this is the reason why women are more susceptible than men to these injuries, because for obvious reasons, women have less muscle mass on average and have lower bone density on average, in part due to the fact that many women didn't receive hormones after menopause.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
In this conversation, we speak about all of these topics, but with a particular focus around an aging population. So we talk about what longevity really means, not just adding years to life, but life to years.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And as their estrogen levels went down after menopause, their bones got disproportionately weaker relative to men because estrogen turns out to be the most important hormone in preserving bone density. And so all of these things taken together are what mean that falling is something we have to be very mindful of at any age. But boy, does it play a bigger role above the age of 65.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And again, I won't ask for a show of hands, but I would be shocked. if no one in this audience knew somebody, if not personally, who hadn't experienced a significant fall that resulted in a broken hip or a broken femur. And the tragedy of that type of accident is that in many cases, it's not fully recoverable. So you have the proportion of people that will die as a result of that.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
But even the people who live, often about 50% of them never regain the same level of mobility they had before. So all of this to me points back to the idea that we want to be exercising as much as possible.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I'm going to sound like a broken record saying this, but you're going to want to have your body as prepared as possible because that physical piece is so important in preventing these types of injuries.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Is there anything that people of this age can do now to preserve that muscle or strengthen it? Or did it have to be done while it was still like in their 20s?
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Obviously, if you could go back in time and I put you all in a time machine to when you're 20, knowing what you know today, maybe you would exercise more. But that's sort of an irrelevant point. I would say the point is what we do today is what matters. There's a woman named Belinda Beck that I interviewed on my podcast.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
A few months ago, she's a researcher in Australia, and she did a study there that I really was fond of called the Liftmore Study. So this is a study that was done with a group of women, all of whom were over 65 years old and all of whom had a disease condition of very, very low bone density.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
We talk about the four horsemen of chronic disease, talk about why it's never too late to start making changes for better health, talk about the critical role of exercise, especially strength training and maintaining mobility, preventing falls and preserving independence and how to approach exercise later in life.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So there's a group of 65 and plus year old women who had very brittle bones, who didn't exercise beyond yoga and walking. So it's not like they were inactive, but they'd never lifted weights. And these women were randomized into two groups, one that continued with that type of exercise, and then one that engaged in really, really heavy strength training.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And I love that there's a video of this on YouTube that is easily one of my 10 favorite videos of all time, because these women who look so frail by the end of the study are able to, in some cases, pick up their own body weight off the ground, do a deadlift with their own body weight. And they are coached on how to do this safely and they gain strength.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And they really do hardcore powerlifting exercises. Like they're not holding the little two-pound dumbbells doing curls. They're doing squats. They're doing deadlifts, getting to pull-ups, bench press, all sorts of things. By the end of this study, they defied something that we thought was possible, which is we never thought it was possible to increase bone density.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
We thought the best you could do was maintain bone density or maybe slightly prevent the rate of decline. But amazingly, in these women, based on the CT scans of their bones, they actually increased bone density. I find this to be one of the most uplifting and important findings with respect to aging.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And I think it speaks to how the idea that lifting weights is a young person's thing or a male thing. I think both of those are just incorrect. Lifting weights is something every person on this planet should be doing.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Moving from risks into action, do you want to quickly walk through the tactics in your longevity toolkit? And then from there, we can go into detail on each of them.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Broadly speaking, there are five buckets of things that we have control over to impact all of these things we're talking about. So one we just talked about, exercise. And you can probably tell my bias is that that's the single most important one for the most part. So the second in no particular order would be nutrition. So what you eat matters. We'll talk about that, I'm sure, in more detail.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
The third one would be sleep. So the difference between sleeping well and not sleeping well has an enormous impact on your brain, but also on your metabolic health, which then indirectly plays a great role in other diseases. The fourth would be all of the medications and supplements, drugs, anything that your doctor prescribes or that you can buy over the counter.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
talk about the importance of protein intake and nutrition principles for aging, talk about sleep optimization, and we talk about emotional health and social connection purpose and why relationships matter as much as physical health. So without further delay, please enjoy this special episode of The Drive.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And these are of varying degrees of efficacy. Some of them are incredibly dubious. Some of them can be lifesaving. But again, all of those things we'd want to think about. And then the final bucket would be kind of all the tools that we would have at our disposal to improve our emotional health and well-being.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So we've already touched a little bit about why exercise is important, but for people in this audience, how can they start to safely exercise while also managing physical limitations?
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
It's hard to provide a blanket statement on that because everybody's going to be different. But I think it's safe to say that people are less fragile than they believe. And I meet many people, for example, who have back injuries and say, look, I have a back injury. I can't really do anything.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And the reality of it is when you sort of probe a little bit further, what you realize is nothing tends to make their back hurt more than inactivity. I don't remember who made the statement. I loved it and I paraphrased it or plagiarized it many times. Sitting is to lower back pain what bourbon is to alcoholism.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Any of you whose back has hurt will probably think about that and go, you know, he's kind of right. When my back hurts, sitting is the one thing I don't like to do. Or after a long drive, it hurts worse. And for most people, actually being active makes them feel better. Now, let's be clear.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
There are certain activities, like if you have no cartilage left in your knee, more walking won't make you feel better. You're going to have to see an orthopedic surgeon. They might need to do a knee replacement. But boy, I will tell you, in this day and age, in 2025, what can be done with a knee replacement, a hip replacement, even a shoulder replacement?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I mean, these operations have come along so far, and they have restored so much quality of life to individuals. So every one of these cases has to be managed individually.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
But if you have a really good PT or rehab professional who knows what's fixable with more training or more conditioning versus, hey, this actually does need some medical attention, I think the aspiration should be, what can I do to get as active as possible?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Moving from exercise into nutrition, we saw questions come through that different diets are being talked about and they aren't sure which one they should follow. So is there a diet that you think is best or does it depend on the individual?
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I don't think there's a diet that is best. I think there are principles that matter and everyone should find the diet that best allows them to adhere to the principles. So what are the principles? The principles are not to eat too much and not to eat too little. That sounds dumb, but it's just the reality of it. And I think everyone struggles with a different end of that spectrum.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
There are some people who just don't like to eat that much. They're like little birds. And as they get older, that becomes a huge problem. They are too frail. At the other end of the spectrum, you have people like me who like to eat too much, and we will spend most of our life fighting against the urge to eat too much.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And that also becomes a problem as you get older, because the heavier you are, the more weight you're putting on each and every one of those joints. And again, we're thinking about all these things that are working against us as we age, not to mention other complications that come from eating too much.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
But I would say that in an aging population, the most important thing I want to emphasize is getting enough protein. First of all, I just think for many people, it's kind of hard to get enough protein in. Even I have to pay attention to it and I don't have a problem eating. But I need to be mindful of, hey, did I get enough protein? It's really easy for me to get all the carbs in the world.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Welcome, everyone. My name is Olivia Atiyah, and I'm here with my dad, Peter Atiyah. We are here to talk to you today about longevity. So over the summer, I volunteered at a senior living center called Querencia, which is where I met Sally, who unfortunately couldn't be with us today because she's sick.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I don't have to go out of my way to eat more fat. But I do have to be cognizant of getting enough protein. And enough protein is a pretty big number. It's about one gram per pound of body weight. So I would challenge each of you to pay attention to, hey, if you weigh 150 pounds, are you getting 150 grams of protein a day? And I would bet that especially for the women here, that's even harder.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Now, if you fall a little bit short of that, it's okay. But if you're at half of that, you're really not getting the optimal amount of protein.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And as we age, we develop something called anabolic resistance, which means that it is harder and harder for our muscles to synthesize and grow new muscle cells with the given amount of amino acids, which are the building blocks in protein that we get by eating protein. And therefore, we actually need more and more protein to overcome that. So we talk a lot about obesity.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
We talk a lot about osteoporosis and osteopenia. But there's another condition of aging called sarcopenia, which is the condition of muscle loss. And that's a huge problem. And there's really two ways in concert, two ways to address that. One is consuming enough protein, and the other is doing enough resistance training.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So, again, doesn't matter if you're a vegetarian, doesn't matter if you like a Mediterranean diet, doesn't matter if you like steak and potatoes. If you can adhere to those principles, that's going to make your life easier. Is it harder to adhere to those principles if you're a vegan? Yeah, it's a lot harder, but it's not impossible. I know lots of people who have done it.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
But looking at a food tracking app in your phone is a great way to spend a week evaluating how many grams of protein you're getting. And I think you'll be surprised that for many of us, we're probably underdoing it.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Now moving on to sleep. Sleep is something that you've written a lot about. And you said that you didn't used to take it very seriously, but now you do take it very seriously. And that's true. He goes to bed at like eight every night. Why do you think it's so important?
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I think I'm up till nine these days. Sleep is important, and you're right. I used to, probably until 12 years ago, I think my mantra was, I'll sleep when I'm dead, and I just would try to sleep as little as possible. But the evidence are pretty overwhelming, especially for both near-term and long-term function of the brain, that sleep is very important.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Now, I think at your age, a couple of unique challenges emerge. Again, I think most people, once they're over 65 or 70, they're not fighting the will to sleep because they want to be out partying all night. It's more that other things are getting in the way. So we know that as a person ages, they tend to sleep a little bit lighter and their sleep architecture tends to change a little bit.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
But we got to talking and I discovered that she's very interested in my dad's work, as I'm sure all of you are. So we decided that we'll be here today and we'll be doing 45 minutes of conversing between us two to keep it interesting. And then a little bit of time at the end for you guys to ask him things that you're interested about. So with all that being said, are you ready?
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
We also know that other things get in the way, especially for men, which is it gets harder and harder to make it through a night without having to get up to pee. I'm already at that stage where at least two out of the seven nights a week, if I am not mindful about when I had my last glass of water, I'm going to be up at two or three in the morning to pee.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And sometimes that's harder to go back to bed after. So what are the things that we have under our control? Well, one of them is absolutely timing of water. Now, again, water is super important. The older a person gets, the more susceptible they are to dehydration. The older a person gets, the less reliable thirst is as an indicator for fluid status.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So at Olivia's age, you don't really, believe it or not, need to pay attention to how much you're drinking. Thirst will be the guide. But that becomes less and less true as you age. So you're juggling a narrow problem, which is on the one hand, You have to be mindful about drinking enough. But on the other hand, you can't drink too much too close to bed and that's going to keep you awake.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Another thing that makes a huge difference in sleep quality is timing of food. So the longer you can have between when you have dinner and when you go to bed, the better. So we eat dinner really early because we have young kids in our house. That's why I can get away with going to bed at nine because it's still been three and a half hours or three hours since I ate. Another thing is alcohol.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So some of you probably drink alcohol. The less alcohol you have in your system when you sleep, the better you're going to sleep. Having a super dark room, having a super cold room is going to make a big difference. And perhaps the biggest thing to make a point about here is consistency of timing, especially on the wake up. So if you could tether yourself to one time, it's what time do I wake up?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And if you force yourself to wake up at the same time every day and don't allow yourself to take a nap during the day, and this is a big ask because I know naps can be tempting, it's going to regulate when you end up going to bed by building up enough sleep pressure.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So if a person tells me I'm struggling to sleep at night and I find out they're napping during the day, the first thing I want to do is get rid of the nap. I'm going to fix the wake-up time, eliminate the nap, and then actually let them get into a better sleep cycle that way.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Are there any good sleep supplements that you recommend taking and that are not damaging to you?
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Yeah, there are. I mean, and I think one has to be very careful with this stuff. There's certainly evidence to suggest that as we age, melatonin levels go down, and therefore melatonin can aid, at least with sleep initiation. But it's important to know that melatonin really is only the signal to initiate sleep. It's not going to necessarily keep you asleep all night.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So if you're not doing all of the other things correctly, melatonin is going to be limited in its efficacy. So before I go down the route of supplements, I want to get everything we just talked about vis-a-vis the hygiene completely dialed in. And then, yeah, if there's still an issue falling asleep
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I think melatonin can be a viable tool, although I really want to make sure it's the lowest dose you can buy. They tend to sell this stuff in high enough doses to kill horses. It's not necessary. The lowest dose, which is maybe 300 micrograms, is probably all you need. At most, twice that dose, but you don't need anything north of a milligram.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
As I'll ever be.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Okay. I think it'll be helpful to start talking about the actual word longevity because it can mean different things to different people. When you talk about longevity, are you talking about living forever or how are you defining it?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I think one has to experiment a little bit with other things. I find ashwagandha a little bit helpful. For others, maybe not so much.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Okay, and then we'll quickly touch on the last one, which is emotional health. A lot of people think that this is not really something that matters in longevity, but you talked about this in the last chapter of Outlive and how it's really important to you and that you've recently discovered it. So do you want to talk a little bit about that and how it's important as people are aging?
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I think it's actually important at any age. And I think that what I imagine is so appealing about living at a place like this is you have a built-in system of friendship. I would imagine that that's probably a great source of well-being that many of your peers would be missing out on if they were living alone. I think about how little I see my parents because we live in a different country.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So I can imagine that things that we take for granted when we're young, like being close to our children or our grandchildren, aren't guaranteed when we grow older. Now, of course, she's signed a contract that says she can't leave Austin. So this won't be a problem for me.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I think a social support network and some sense of purpose might be the single most important part of the emotional health toolkit as it pertains. to living longer. Every one of us knows the story of the couple that have been married for 70 years. One of them passes away and then the other one dies within a year. I don't think these are just anecdotal.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I really think there's an understanding of why that happens.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So you can do everything right. You can eat the right diet. You can sleep right. You can exercise. But if your emotional health is lacking, then it's like you won't live as long.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
It's possible. I would say even more than that, regardless of how long you live, if it's unhappy, why bother? Let's say you do live a long time, but you're alone or you're miserable. In some ways, that would be the ultimate purgatory.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Is there anything else you want to add before we hop into the Q&A?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
No, let's turn it over to you guys.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Okay. Yes. So why did you decide to start focusing in longevity?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I guess there's sort of two things. The first was when Olivia was born, she's my oldest. I bet all of you can appreciate this, those of you that have kids, which I'm guessing is most of you. Something about your mortality kicks in. There are many stages to mortality, but I think having a kid is one. I think losing a parent is one.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Definitely not living forever. Although understandably, that's probably what some people think of when they think of longevity. I'm talking about it in terms of two things. One of them is called lifespan and the other is called healthspan. And lifespan is the part that I think most people think of. It's the how long you live part. But then there's healthspan, which is the how well you live part.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
As we gain and lose things throughout life, we become aware of its finitude. And her birth was a moment where I was like, huh. This is amazing. I'm not going to be around forever to be a part of her life. So that kind of got me thinking about it.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And that coincided with me also coming to the realization that there are lots of things in my family history that might otherwise suggest a short life for me. And I wanted to get very serious about it. So my own journey into this space was actually very selfish and was strictly geared towards me figuring out things for myself.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Yes.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Awesome. Okay, I'm going to repeat that question. So there were two questions there. The first was an update on clotho, and I'll explain what that is for everybody else. And then the second was on the gram of protein per pound of body weight. Is it ideal body weight if a person is overweight? I'll start with the second question. The short answer is... It depends on how overweight.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So if a person came to me and said, look, I weigh 260 pounds. I probably should weigh 200 pounds. I would tell them if I agreed with that assessment, I'd say being closer to the 200 is probably fine. You don't need to be at the 260. Okay, this gentleman was asking about a podcast I did. So I don't know how many months ago it was, six, nine months ago. I had an amazing scientist on my podcast.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Her name was Dina DuBall. She's a neurologist at University of California, San Francisco, and she studies a protein called clotho. This is a protein that is made by the body. It is made in response to exercise, but it also is just made endogenously and declines with age for reasons we don't understand. So children make six times more of this than adults.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
But of course, any one of us can transiently increase it by exercising. What's special about this protein is it seems to be one of the most important proteins that protects the brain. And so in both mice and monkeys, when you inject this protein, if these are animals that have signs of dementia or cognitive decline, it reverses.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
If these are normal animals, they seem to get superpowers, like supercognitive powers. So that protein is going to be tested over the next three years in humans. And if the results of that look promising, then a larger clinical trial will take place.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So I would say the best case scenario here would be that in seven to 10 years, this could be an actual drug that humans take either to prevent cognitive decline or to treat it.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So what is the best type of protein supplement you recommend to get to your grams?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So I always ask people, if possible, and it's not always possible, whatever you can get from food is great. But I understand that for many people, and again, especially for women, it's really hard to just mash through that much protein. So we turn to supplements. Now, when it comes to foods, the three that stand out the most are dairy products,
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
beef and eggs, because there's a quantitative way that you measure both the type of amino acid and what's called bioavailability of the amino acid. So how complete are the sources of amino acids and how readily can the body access them? So again, if you're thinking about eating, beef, eggs, and dairy are the big ones. You can get lots of amino acids and lots of other proteins.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I'm not saying don't eat chicken or fish or vegetable proteins, but those are big ones. Therefore, when you're supplementing whey protein, which comes from dairy, tends to be the winner. Now, casein is also great because it's also from dairy. So whey or casein probably stand out a little bit above, but so does egg protein supplement.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So what I tell people to do is figure out what works best for you because there's some people that just can't do dairy proteins. Remember, just because you can't tolerate dairy doesn't mean you can't tolerate a dairy protein. Most people who can't tolerate dairy can't tolerate the carbohydrate in the dairy, but they're totally fine with the protein. So give it a try.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Anything else? Yes.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So you're saying a few years ago, he did a genetic test and it did not show a genetic. Okay. So let's assume that the test was correct. What it was screening for was very likely a gene called the APOE4 gene. And this is a gene, the APOE gene that exists in three types. There's the number two, the number three, and the number four.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And both of these things are important. I would argue that they're of equal importance and an extreme of one without the other is not ideal. In other words, I don't think there's anybody sitting here who says, I'd love to live to 100, but I want to spend the last 20 of those years unable to move. I mean, that wouldn't be ideal.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Now, every one of us has two copies of every gene because you got one from your mom and one from your dad. So if there's three types of a gene and there are two copies, there's six combinations. We can go through them all. You could be a 2-2, you could be a 2-3, you could be a 2-4, you could be a 3-3, a 3-4, or a 4-4. Okay, why is that relevant?
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
One of those types is higher risk than the other two, and that's the four. So people who have two copies of the four are at significantly higher risk for Alzheimer's disease, about 10 times higher risk. That doesn't mean that they're guaranteed to get it, but their risk is significantly higher. People who have one copy, typically a three and a four, are at about a two times risk.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And so what that study told you was, what I'm assuming it said was you did not have a copy of the four gene. So you might be a 3-3, which by the way, most of you probably are. 60% of the population is a 3-3. That's the good news. The bad news is it doesn't mean you're free of risk. Because the only people who can't get Alzheimer's disease are people who don't have brains. I mean, I'm being glib.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Everybody with a brain is at risk. And unfortunately, women are at almost twice the risk of men. And we don't have a great understanding of why. There are lots of theories. I won't expand on them now for the sake of time. But this is one of the areas where women are disproportionately affected to men. The other one, by the way, being osteoporosis and falls.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So we've touched on both of the areas where women are at higher risk. Of course, men have a higher risk of cardiovascular disease. So the takeaway for me is I'm a 3-3 as well, but I don't rest on it. I act as though I'm high risk, meaning I take all the steps possible.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Exercising being the single most important thing we can do to preserve brain health, managing nutrition, sleep, all of the things that I can do.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Yes.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Okay. So the question was talking about how your mom had a fall. She broke her hip, had a long protracted recovery, managed to survive, but was never the same again and basically slipped into a state of cognitive decline. And your question was, is there a relationship there? Very good question. My intuition is that there is a relationship there.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
In other words, we don't have the parallel universe experiment where we could see how she would have been had she never had that fall. So what we're trying to understand is, is there any causality between the fall and her cognitive decline? And my intuition is that there is. And it's exactly what you said.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
It's that with the period of profound inactivity, and probably with it, not just the physical inactivity, but also I would suspect some cognitive inactivity, if nothing else, it may have sped up by a period of years, something that may have ultimately happened, but I think probably was happening sooner than it should have. It would be a very difficult thing to prove that.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And similarly, I think the idea of living an amazing, healthy life, but that life being cut short prematurely at 50, nobody would think that that's ideal. So when I think of longevity, what I'm really thinking about is maximizing both the length of life and the quality of life. And again, quality could be further broken down into sort of a physical piece. So am I free of pain most of the time?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
That's what my intuition says. And I think that's just yet another reason to think about all these things we've talked about as far as like, what are the steps we can take to minimize our risk of a fall?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Awesome. Well, I think that's all we have time for. But do you have anything else to add?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I like that I was on the hot seat from you today. So it's pretty fun.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Yeah. Well, thank you guys all so much for coming.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
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The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
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The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Am I able to physically do the things I enjoy doing? And that could range from just the activities of daily living and self-care to recreational activities. If you like to garden, how long do you want to be able to do that? If you play golf, if you like to go for walks and hikes or swim. And then there's a cognitive piece that
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So I don't think anybody would fully expect, even at my age, that my brain is kind of as sharp as hers is, but I still want to believe that my mind is pretty sharp. And I think we all sort of want that for as long as possible. And then the final piece is an emotional piece that deals with happiness, sense of purpose, connection to others.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
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The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And again, you can imagine a scenario where somebody has perfect physical health span, meaning they can do anything they want to do physically. Their brain is sharp, but they have no friends and no relationships. And I think we would all agree that that's not really an ideal life. And I don't think anybody would aspire to that. So that's a lot there.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
But when you put all those things together, to me, that's what longevity is.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
If some people here are wondering, is it too late to start caring about longevity and living longer, what would you say to them?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
I would say that that's not the case. I would say that on the one hand, sure, the earlier a person begins to take steps to increase their longevity, the more opportunity they have. It's sort of like investing. When is the best time to start saving for retirement? Probably the minute you start earning your first paycheck in your teens or 20s.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
But does that mean you shouldn't save money when you're older? No, it doesn't. There's also a lot of data that we have from clinical trials that are done with seniors that demonstrate that, for example, people who have never lifted weights in their life before, who start lifting weights for the first time when they're in their 60s and 70s, have a remarkable benefit.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
This is not just true of weight training. It's true of any sort of exercise. So the short answer, I guess, is that no, it's never too late to really start thinking about this. But obviously, the best time to plant the tree is yesterday, if not today.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Why do they have a benefit if they haven't done it before?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Well, there's an effect of training. So specifically thinking of exercise, the body is really a use it or lose it organ or collection of organs. And the muscles are a great example of that. So it's actually true of young people and old people. The greatest effect of exercise is generally seen in the person who goes from being completely sedentary to even a mild amount of training.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So if you look at somebody like me who exercises all the time or someone like you who exercises all the time, if we added three hours a week to your training or to my training, it actually wouldn't have an enormous impact. If you took an individual who did zero exercise and you took them to three hours a week, which let's be honest, guys, 30 minutes a day, six days a week is not a huge ask.
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
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#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
The impact is enormous.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
That's strange. That's not what you'd think. Can you talk about the importance of adding life to years rather than just years to life and what that means to you?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Yeah, it means a lot to me. I think it will mean a lot to people here because the metric that most people think of is life expectancy. How many times have you heard it? Life expectancy is increasing. Life expectancy is decreasing. And I think the reason for that is, frankly, it's just the easiest thing to measure because it's objective, it's quantitative, and it's a single number.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
It's a number that shows up and it can be measured from a death certificate. We know exactly how many years to the day that a person lived. And if we keep track of that, we certainly know something about them. But my argument would be that it is not the most important thing.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And I would challenge us to find an individual who would, if given the choice, and I don't think one ever has to make this choice, but for the purpose of the thought experiment, if you said, look, you could live to 80 in remarkable and perfect health. And then when your life is over, it ends very quickly and suddenly.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Versus you could live to 100, but you spend that last 20 years in a painful state of decline. I think very few people would choose the latter, even though they're living longer. And I think what most people want is quality of life over quantity. outside of these extreme examples, which are common and tragic where people die and they're young.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
But I think when you really start to think about pushing those things, most people, in my experience, are more interested in quality of life.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
When it comes to someone's risk of dying, you characterize the biggest risks as the four horsemen. Could you explain what those are?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Yeah. You can't have a discussion on this topic without talking about the four horsemen, which might seem a bit grim, but there's no reason to avoid talking about the inevitable, which is every one of us in this room is not going to be alive at some point. And I think to confront the how is important. So statistically speaking...
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
All of us in this room are going to succumb to one of four processes or disease processes. So in rank order, the first of those would be cardiovascular and cerebrovascular disease. That's the leading cause of death in the United States. That's the leading cause of death globally. It's the leading cause of death for men, and it's the leading cause of death for women, full stop.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So that's a heart attack, a stroke. The number two, and it's not that far behind in the United States, is cancer. And of course, cancer isn't just one disease. We lump it all together. But of course, prostate cancer and breast cancer are frankly as different as a pickup truck and a Corolla. They both have four wheels, but that's about where the similarity ends.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Number three would be the diseases of dementia and the neurodegenerative diseases. And there's a lot of things in here. So you have Alzheimer's disease, which is the most common form of dementia, but you also have lots of other types of dementia that are not neurodegenerative, such as vascular dementia. And then the fourth horseman is kind of a spectrum of diseases that we call metabolic diseases.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
The most extreme version of this would be type 2 diabetes. But of course, all along the way, you have conditions like fatty liver disease and insulin resistance. And all of these conditions form a continuum. And the most important thing to know about them is while not that many people will die directly from those diseases,
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
This conversation is a bit different from our usual format, as my daughter, Olivia, trades places with me to take this seat as the interviewer as we visit a senior living center to discuss all things longevity as it relates to an aging population.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
If you have anything along that continuum, it's increasing your risk by about 50% of the other three horsemen. So we really want to think about a strategy at mitigating all four of these conditions and delaying them as long as possible.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
What would you say to someone that may already be navigating these chronic diseases that come with aging? And what advice would you give them on how to manage a high quality of life and keep hope during these times?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
You know, it would matter very specifically on which one we're talking about. I certainly won't ask for a show of hands, but just based on the age of everyone in this room, it's impossible for me to imagine that nobody in this room hasn't already faced some of these diseases.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So if you're sitting in this room and you already had a stent placed in your coronary arteries, that says, look, you've already had a brush with coronary artery disease. Maybe someone in this audience has already had a heart attack and you're fortunate enough to have survived it. Well, the short answer is, look, the fact that you've survived it is great. And that means you get a second chance.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Many people don't. So many people's first brush with heart disease is death. In fact, on average, about 50% of people, one in two people that have a heart attack, it's immediately fatal. So if you're in that group where you've had that heart attack or you know somebody who has and they've lived to tell about it, they're in the lucky camp.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And what they should be doing is everything in their power to not only prevent it from happening again, but to strengthen their body. And so the first thing I do is I ask myself, what were the conditions that I had that led to this heart attack in the first place? Now, some of these conditions you don't have a lot of control over. Genetics play a strong role here.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
But there are many things that can be controlled, such as cholesterol levels. Blood pressure, smoking, those would be the big three. And we have ways to manage all of those things. Also, we know that exercise plays a very important role, as does metabolic health. So I've met many people who have had that near brush with death from that point of a first heart attack. They survive it.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And what do they do? They turn it around and they say, look, I'm going to lose 30 pounds. I'm going to stop smoking or I'm going to manage my blood pressure, cholesterol better. I'm going to take up exercise. And I know people that have gone on to live 30 years after that event that might have happened when they were 60 and they live until they're in their 90s.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
A bit of background, Olivia spent part of her summer last year volunteering at this center where she connected with a number of the residents who had an interest in curiosity about healthspan, lifespan, and strategies for living well as they age. And through that experience, they invited me to speak with their audience and we decided to record it and release it to you as well.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So I guess I would always frame it through the lens of, hey, am I fortunate enough to have survived this thing? And if so, what am I going to do going forward?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So someone here asked, what happens to our balance as we age? Falls seem to be so prevalent here in our senior community. Can we help these problems from increasing as we age?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Yes. If there's a fifth horseman out there, it's accidental death. Now, what constitutes accidental death varies a lot by age. So when we're talking about people that are Olivia's age, the most common cause of accidental death is going to be car accidents and overdoses, drug overdose. When you talk about people my age, the most common cause of accidental death is overdose by far.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
When you talk about people your age, it's a total flip and the prevalence of accidental death goes up by five or six fold and it is virtually all related to falling. So I guess there's two questions. Why are falls so lethal? And maybe more importantly, why do people above the age of 65 fall so much more? And by the way, why do women fall disproportionately more than men?
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And why are women more injured by falls than men? These are the questions that I think we should spend a moment on. So let's start with the why do falls happen? You touched on it a moment ago. As we age, we don't just lose our balance, but we're losing something else that people my age and certainly her age take for granted, which is called reactivity.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So the other day I was in the woods because one of my kids accidentally kicked the soccer ball down into the woods. So I had to go and get it. And as you can imagine, the ground is very uneven and it's covered in leaves and twigs and branches. So you can't even see what you're stepping on. I'm sure you can all picture exactly what this is like. Every step is a sprained ankle waiting to happen.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
And sure enough, at one point I step into something that wasn't as it appeared and I got jolted. And I had to react very quickly with my leg to put it in the right place so I wouldn't fall. And I did. And I'm here sitting here talking about it, and I don't even remember which leg it was. That's how insignificant this was.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
But the type of muscle fiber that was necessary to do that, which if we want to get technical, is called a 2A muscle fiber, is the type of muscle fiber that is responsible for explosive movement. It's the type of muscle fiber that is the most powerful muscle fiber. Well, those muscle fibers start getting weaker and weaker and shrinking at about the age of 25.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
So I'm long past my peak in my early 50s, but I still have enough to hold me on. But at some point, they really, really start to diminish. And by the time someone's your age... You got threads of those things left. So you're losing those things. Now, the good news is you can train these muscle fibers, but the only way to train them is to move very heavy weights.
The Peter Attia Drive
#342 ‒ Aging well: Peter shares strategies for improving longevity with residents at a senior living center
Sounds crazy, counterintuitive, but that's what we have to do. We have to move really heavy weights and we have to train them. in movement patterns like that, which means, for example, bouncing, moving side to side, jumping rope. Things like that are necessary for our feet to have the reactivity that you had when you were young.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
In this conversation, James and I really focus on the four components of what go into forming behavioral habits. We break those apart and we focus on how you can learn new habits or unlearn bad habits. I think you'll enjoy this episode if you've ever wanted to change a behavior or create a behavior, which basically I think is all of us.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I don't know how much you've paid attention to the discussion debate around free will. I have always assumed we have free will. This is one of those things that is kind of an anthem to me to imagine a world under which I'm not completely under control of my own will and my behavior. But my good friend, Sam Harris, who I don't know if you were familiar with Sam's work,
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
You're familiar with the fact that he's written extensively and spoken extensively about the idea that we actually don't have free will, that this is an illusion. There are examples that I can conjure up to make that case.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
For example, he uses a very clever thought experiment, which is if I tell you to think of a movie, the first movie that pops into your head, you have no control over what that's going to be. And conversely, there's a part of me that thinks, okay, but there were lots of things I have free will over my ability to go and do something, take an action, go and exercise or something like that.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
But the deeper I get into this thinking, the more I start to realize, well, wait a minute, that may still be innate. This ability that I have using myself as an example to really have an easy time exercising, it requires virtually no effort to exercise. In fact, it usually requires a lot of effort to sometimes not exercise, but requiring a lot of effort to mind what I eat.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And I know people for whom that's not the case. I know people for whom they just have an easy time eating what's healthy, but maybe they don't like to exercise that much. Before I go any deeper into my question, let me just pause and ask you for your reaction to that overall line of inquiry and how do you think about free will as it pertains to what we're going to talk about today?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So without further delay, please enjoy or re-enjoy my conversation with James Clear, and we hope you all have a wonderful new year. Hey, James. Thanks so much for making time to sit down today. It's been a while. I've wanted to sit down and chat with you.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I guess I would add to that is it might be that free will or the absence of free will is what determines a person's maybe call it genetic propensity to change habits or form habits. There may be some people for whom that is easier than others. But that's probably a spectrum. And it doesn't imply that a person who struggles with a given behavior can't learn to master it.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Again, using an example, I'll never be a Michael Phelps, ever. There is no scenario under which I was going to be as good a swimmer as Michael Phelps. So even if he hadn't started swimming until he was 15 and my parents threw me in the water at two, I was never going to be that good. But it doesn't mean I couldn't learn to swim.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And similarly, had he never been thrown in the pool, we would never have heard his name. So I guess that's how I kind of rationalize it, which is there are going to be people for whom it is easier to go through the exercises that we're going to talk about. And there are people for whom that's just going to be more difficult. And you can't change that part of it.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
That's the part, I guess, that is set.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I'm trying to think when I first read your book, cause I read it twice and like all good books, you get more out of it. I think the second time in part, because I think the deeper you get down the rabbit hole of trying to create habits, whether it's in yourself or helping others form habits, the more you realize how challenging it can be.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Two comments I'd add to that. One completely trite, but amusing, which is not only does Phelps have the perfect chassis and engine for what he does, but just as you described Steffi Graf, I've seen Phelps race at meets that meant nothing. Total throwaway meets. He's not shaved. He's not tapered. He couldn't care less to be there. He's swimming like a 200 IM.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
It doesn't look like he's going to win at all. And yet somehow in the last 15 meters, he out touches everybody. I've seen this on enough occasions that I just think like, this is a guy who hates losing. So even though he's not necessarily in shape at this moment, even though this meet means nothing for him, he's training through it.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And half the people he's competing against, this is their pinnacle. He hates losing so much. So it is, it's really the perfect combination.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
But maybe for folks who haven't read it, because I suspect there's going to be a bunch of people listening to this who have read it, and I want to be able to go deeper for them and think there's going to be some people who haven't read it. Give us a bit of the history as to why this even appealed to you.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I love watching this in the best of the best. Formula One is one of my favorite sports. And historically, my hero is this guy named Ayrton Senna. And
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And you gather from that documentary, I mean, he was a perfectionist even amongst his peers. He took it to a level that exceeded that. It actually cost him his life. I don't think the documentary fully explains how much that need to win killed him because the day he died, he was trying to do something in a car that shouldn't have been done at a time when it shouldn't have been done.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
But it's amazing when in a sport like that, where the stakes are so high for trying to do something at the expense of maybe a mechanical limit or a limit of the car, but yet all drivers will tell you they're going to go for it. If there's a gap, they're going to go for the gap. And there was a debate in the 90s in Formula One.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So Senna's death changed the sport forever because that's really what changed the imposed safety in the sport. But the debate prior to that was, look, we'll just tell the drivers to drive slower. They don't have to drive this fast. They can choose to drive 10% slower. Which of course was nonsense.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
The head of the FIA at the time, who has just recently passed away, made a point which was that that's the dumbest thing you could ever say. They will all choose to have a less safe car if it goes faster. Because you're talking about the 20 most competitive drivers on the planet.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Now, there was another point I was going to make that was, for most of us, we will never know what it's like to be the top thousand in the world of anything. If I think about all the things that I love, driving a race car, shooting my bow and arrow, exercising, blah, blah, blah. I mean, I'm multiple orders of magnitude beneath even the most lowly ranked professional of those things.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And this gets into something else, which is, for me at least, the joy is not in the absolute comparison of myself to others, but the relative comparison of where I was before. Do you think that's a universal thing? Is it universal that people are mostly engaged by how much they are making progress relative to their own performance?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Or do you think that there are some people who are only capable of finding pleasure when being compared to others in an absolute basis?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And how much of it do you think is, for lack of a better term, journey versus destination focused? Because if you talk about your example of weight loss, that is generally a very destination-based metric. I want to lose 10 pounds. I'm not going to be happy until I lose 10 pounds.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
the process of how I go about doing it, changing the way I'm eating, changing my exercise, accepting the fact that you're not going to lose 10 pounds linearly, it's going to look like this. Those are details that I'm willing to tolerate, but I want to lose those 10 pounds or I want to fit into this piece of clothing that I used to fit into. Contrast that with, I want to learn to speak Italian.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I'm enjoying this process of learning a few new words every day and learning how the structure of this grammar works relative to my native tongue. And I'm never going to be perfectly fluent in Italian, but I know that in some point I'm going to be completely functional. This journey of learning this new language or learning how to play this instrument, that's what's giving me the pleasure.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And I don't know if that distinction makes sense.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So let's talk about habits now, because I think that's the thing that, as you said, basically shapes the nature of what we're going to do.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
There's a saying that many people have said, and I won't even try to paraphrase it because at the moment it's escaping me, but the gist of it is like, you don't rise to the level of your training, you fall to the level, or you fall to the level of your training.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Why is it called atomic habits? I remember when I first saw the title, my assumption was atomic must be huge explosion, like big habits, which of course is exactly not what it means.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So you talk about three different types of change, outcome change, the process change. We've touched on a little bit of those, but the one we haven't really touched on is this identity change.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
That was something that when I read your book really resonated because it provided, I think, a very decent explanation, at least for why exercise comes naturally to me, which is it's so hardwired into my identity. and why maybe certain other habits I've tried to create over time don't come easily to me because I haven't fully identified with them yet.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So expand on that, but also how you came to realize that.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Tell me what you think the difference is in identity between the woman you gave the example of and say yourself. So you're both striving to the same objective, which is a healthy weight, but she accomplished it by focusing on what would a healthy person do in this situation. You accomplish it again, just pertaining to nutrition at the moment.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And presumably by saying, I don't know what your macro goals are, but these are the aspirations that I have and I'm going to stick to these. So tell me a little bit about the difference between those approaches and how can a person know which will be better for them outside of just empirically trying them both?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Yeah. I was kind of curious to ask about that because I wonder how that process changes in this person after 10 years. I mean, most people understand that losing weight is actually not that hard, but keeping weight off is exceptionally hard. So what your friend did, yes, losing 110 pounds is remarkable, but the fact that she's kept it off for a decade is actually what's remarkable.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And I'm curious as to what the temporal sequence of events is where, hey, for the first year, it was a daily struggle of what would the healthy person do? What would the healthy person do? What would the healthy person do? And at some point that transitions into, I'm a healthy person. This is what I do. I'm a healthy person. This is what I do.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And then it becomes so autonomic that you can slip up for a day and it feels wrong. Like, oh God, that cotton candy is horrible.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
One of the most common examples that I hear of in my practice for the epiphany behavior change that sticks is the person who quits smoking the day their child is born. And I've always found this interesting, right? Because the day before their child is born, they clearly know how bad smoking is. There's nobody who's smoking who doesn't understand the risks of it.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And by the same token, who doesn't, as you pointed out earlier, enjoy the benefits of it in the short run. Very rewarding in the short run, very damaging in the long run. That's completely understood intellectually. On day X, they have a child and they decide, I'm done with this. I'm not going to have smoke in my household because...
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I also know the benefits of secondhand smoke or the harm rather of secondhand smoke. And I'm not going to expose my child to this. And yet amazingly, I mean, over and over and over again, I hear these stories from patients saying, yep, I grew up in a household where my parents were incredible smokers. And the second I was born, they stopped. They stopped. And that was 40 years ago.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
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The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And they've never had a cigarette since. Is there a transference process here where because it involves the life of another person, it's easier to make this change stick?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I can only think of one dramatic habit I changed that has stuck. And it is the silliest thing, but I always bit my nails growing up, bite them nonstop. Invariably what happens is you'd get a little infection because you bite too close. And it was like, my mom was always like, God, that is such a disgusting habit. Like it just looked horrible.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
The day I decided to change it was the day I got my first interview for med school. You apply to medical school and then all of a sudden the envelopes start coming in and you've got these interviews. Just as I got that first envelope and I realized, oh, I'm actually going to go and be interviewing, at least for me, I didn't interview to go to college.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
This was the first time I had to do an interview. And I don't know, just something came over me. I was like, wait a second, dude, you can't be the guy that's showing up to an interview with these horrible looking nails. You have to cut this out. You are going to get a nail clipper and you are going to start clipping your nails like a civilized human being. And that was, I don't know, 25 years ago.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And today, like when my nails get long, I'm a guy who likes short nails. So I'm always sort of trimming them. I can't imagine that I once bit them. It just seems so strange to me. It's a silly example.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I wonder if part of the cue for me was buying a suit. And it was the first suit I had. That was sort of a, wait a minute, you're wearing a suit. Think of the trouble you're going to get this thing. And then this tie that you're going to wear and blah, blah, blah, all this sort of stuff. But it's interesting.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And then clearly it just became a part of my identity, which is I'm a person who has nice fingernails. I present well from the fingernail standpoint, at least. Hasn't translated to all of my habits, but let's talk about the four laws because these four laws are kind of the central tenets to what we speak about.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And they can be inverted as well, which I think is important as we think about creating, call it adaptive habits versus breaking maladaptive habits. So what's the first law?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I'm guessing there's a lot of probably evolutionary rationale for why we're creatures of habit. Presumably the less energy we had to devote to things that would help us survive and procreate, the better. And obviously that's why we have an autonomic nervous system that allows us to function.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So with that as a primer, before we do that, I think you wrote about this in the book, which was that the dopaminergic surge comes more from the anticipation of the reward than the actual behavior that gives the reward. Did I remember that correctly?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Things like breathing and having your heart go from beating fast or beating slow to be completely out of your voluntary control. I'm curious as to whether or not we have a sense of ancestrally, what types of habits were people ever trying to deliberately change? Maybe it's not an answerable question, but I don't know if you ever contemplated that.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Presumably, again, using your example, there are lots of diversity between individuals, right? So you take 10 people who have never smoked a cigarette. Let's just, to make the math easy, say, well, seven of them have no desire to, so they walk away. Three of them are like, yeah, I'll give it a try. They take a puff.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
One of them starts hacking and says, that is the most disgusting thing I've ever done. I never want to do that again. And they never do. One of them says, you know, I kind of like that. I'm going to do this socially. Anytime I'm going to have a drink, I'm going to have a cigarette. And one of them goes on to become a chain smoker. Now, what explains that distinction?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
How much of that is neurochemical?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I also find it interesting that different people will get that pleasure from different things. When I'm not in a good place, when I'm unhappy about something, it's never my tendency to have a drink. So alcohol would only be associated with something I want to do when I feel good to begin with. I would never want to have a drink when I don't feel good.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
But when I don't feel good, I would happily binge on junk food. That would be the thing that provides comfort. And of course there are people when they're unhappy, they would never want to eat even let alone have junk food.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I find it interesting to at least contemplate how much of that is genetic, how much of that is learned and what else is going on and sort of understanding that because that does sort of factor into falling to the level of our habits because we fall to these levels when things are not going well typically.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
When did this idea of being proactive in either breaking a habit or creating a new habit, do you get the sense that that is a recent luxury of our species?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
All right. I interrupted you before. You were just about to launch into the four laws.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Is there some evidence to suggest, if I remember back to like my psych 101 class, which is obviously pretty elementary, that some of the most addictive behaviors are variably reinforcing? I sort of remember this example of why slot machines are particularly addictive because the pattern with which they produce a win is actually random. And therefore you really don't know when it's going to come.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
You know it's going to come. You have to have belief that you'll see other people win and you've won in the past. But that's somehow even more addictive, whereas the cookie in theory is not variably reinforcing. It's pretty much reinforcing the same way every time. I mean, presumably only subject to the tastiness of the cookie.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
You remember Anchorman? Yeah. I assume you've seen. Yeah. This might actually mean that there is truth to the statement that 50% of the time it works every time.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I think that was Paul Rudd's line, wasn't it? was it? Yeah. When he used black Panther, the colon.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Now, how often is a certain behavior the combination of breaking a habit and creating a habit? Again, it seems like a lot of the ones we default into talking about are the hard ones like nutrition. We all eat. We're all going to eat all the time. It's not something you can opt out of or into. We all eat.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
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The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So presumably if a person says, again, I hate coming back to weight because it's such a stupid example relative to say overall health, but let's say health actually. I want to be a much healthier person. So I need to change the way I eat. That's two things, right? You have to start eating better and stop eating poorer.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Which necessarily displace the old ones. For example, with eating, it is a bit of a zero-sum game. I mean, not entirely. I guess you could just keep eating more and more and more. But generally, if you say I'm going to eat more good things, it kind of drives down the bad things. Is that the way it normally works then?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
The example that we come back to is smoking because smoking doesn't really take that much time. So it's hard to say, I'm just going to introduce a new habit that will force smoking out. Are there other examples though of habits where you really do focus on how to break the bad one?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
The environment seems to be so potent. You know, again, David Foster Wallace writes about in his commencement speech, this is water. He talks about the ubiquity of water and also the fact that you don't even realize it's there. And that's what makes it so profound, right? Is that he referring to certain thoughts. But I think the same is true of these cues.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
For most of us, we're not actually that aware of what it is. It can be pointed out to you and you can say, oh yeah, I come to think of it, I am a fish swimming in water. Or yeah, I come to think of it every time I get in the car, it's the act of getting in the car and driving to work that signals a change in where I'm going and that's what forces me to light up.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
But the example of having the cigarette at 1030 with your coworker is a very powerful one because of the connection in the environment. I remember in my residency when people would come into the hospital with abscesses from IV drug use. So very Baltimore, which is where I did my residency, there was just rampant IV drug use.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
You'd be amazed at how much that habit and that addiction could cause a person to do something that at the surface doesn't seem that logical. Use dirty needles and needles would break in their abscesses. And you'd be down there and you'd be sort of draining a huge baseball size pus filled abscess that's got broken needles in it. And this person is very sick.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I mean, this is a person who's now risking their life. due to this. And they would be back in a month with the same thing in a month and a month later, the same thing over and over again. And tragically, eventually a lot of these people would die.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
But I remember at some point saying to these folks, this was the best advice I could offer, which was not very helpful, was, I don't think you can go back to the same place you live. I think you need new friends. Now, that's not a very helpful thing to offer somebody who probably doesn't have many choices.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
But the point was like, how could you expect this person to go back to the same place that they were living in the same environment? With all of the same people doing the same things and say, well, you just got to resist it. It doesn't make sense. Presumably someone who decides they want to stop drinking alcohol really ought not go into a bar that much anymore.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So one thing I want to park for later, once we get through the laws, is a very specific question around the challenges that some people face and that they don't control their environment. And again, I come back to food because I think for most of my patients and for myself, food is such a struggle because again, it's always around us. You have to do it. It's not a behavior you can just opt out of.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And I think those of us that have kids, not to throw our kids under the bus, but I haven't met too many people whose eating habits get better once they have kids. If they're generally inclined to be healthy people, because at some point you sort of start losing the battle of how much non-crap you can have in the house due to time constraints and the other constraints, which is look...
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Kids are going to eat things that are probably not so bad for them, but I shouldn't be eating. Wheat thins. My kids love wheat thins. I love wheat thins. I think the difference is they can get away with eating a lot more wheat thins than I can. So I've lost the wheat thin battle. We have a pantry that is full of wheat thins.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And I'm never, at least for the foreseeable future, going to get those wheat thins out of there. So now every time I walk in the pantry, I'm staring down the barrel of wheat thins. And I would love to get those wheat thins in the trash. But every time I do, my wife says, understandably, hey, if you want to be in charge of feeding the kids every meal, knock yourself out, chef.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
But if you're not, let me handle food. And our kids eat well, but they're going to eat wheat thins and a few other things that you don't want to eat.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And that's actually something I feel like I've also noticed with my patients and myself, which is It seems that the people who are able to be more self-forgiving when they slip up and get back on course have an easier time than people who approach it through a very perfectionistic lens. And once they make a mistake, they get into the cycle of self-judgment and beating themselves up.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And I say them like it's me too, right? We all do this. And all of a sudden a blown meal turns into, well, forget it. The day's over. I mean, I've screwed this day up, so I'm just going to eat whatever I want. And then you wake up the next day and you probably feel like crap, both physically and emotionally.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And that reduces your drive to continue to do what you set out to do and give the spirals. And you make a point about that in the book, which is if you're going to miss a workout, miss a workout, but don't miss two.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Yeah. This is probably an area where a habit that is probably desirable for many people also becomes a tool to help. And that's mindfulness meditation, which I think is one of the more powerful tools to help people observe the judgment without judging it, which sounds odd to someone who hasn't practiced that, but that becomes very powerful.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Yeah, it seems that the vehicles that we would have used to attain status earlier were much quote unquote simpler. And today we're looking at other ways to do it. Hearing you talk about habits that way makes me compare two activities I like very much. and contrast the challenges of learning each of them. So one is riding a bike and the other is learning to swim.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Made a difference as I've kind of released the need to be perfect. It's really a continuum and there's a spectrum of efficacy here, which is like on Monday, we traveled the whole day. We got back and I really wanted to work out. I just hate ever missing a workout.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
But the reality is once we got home and the kids were exhausted and my wife was tired and it just felt like sort of a schmucky thing to do to go and work out and leave her with decompensating kids and a whole bunch of stuff that needed to be unpacked. Actually, part of the judgment was letting go of that, letting go of the fact that it wasn't going to work out that day. And that was okay.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Now you can do that on anything. I think if you can come to be flexible and say, you're stuck in the airport with your kids, the food sucks. It is what it is today. And you're not horrible because of it. But I think this idea of get back on the horse as quickly as possible is really powerful. Again, anecdotally, I always bring everything back to driving a race car.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
It is so rare that you make a mistake and crash in a car because of what you did at that moment and not because of what happened earlier. If you spin at corner four, the mistake usually started at corner two. And sometimes you don't realize it. And sometimes you do realize it, but you arrogantly think that you don't have to make any adjustment going forward because of it.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
At least for me, that's been an incredibly humbling experience with how mistakes compound.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Yeah. Annie Duke talks about this in a slightly different way. And she refers to it as backcasting. And I find it to be an incredibly powerful tool, again, to be contrasted with forecasting, right? Forecasting is I'm just going to stand here and I'm going to tell you I got to do B and then C and then as opposed to saying, no, this is where I am. That's the desired outcome.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So if you took a 20 year old who had never done both, and admittedly, it's easy to find a 20 year old that's never swum. It's probably hard to find a 20 year old that's never ridden a bike, but I would posit that it's really easy to teach a 20 year old to ride a bike if they haven't done it.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Let's start working the steps backwards. What you've described is slightly different, but I think it preserves this idea of taking stock of where you are and most importantly, understanding where you need to be and not trying to do what I think stochastically is really hard, but predict every step going forward.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Before we leave the first law, what advice do you offer for people if they aren't quite clear what the cues are? Again, in the spirit of trying to even displace a habit that's maladaptive and create new ones. Again, is this something that's just empirical or is it, I hate to use the word, but are there tricks for identifying what the cues are?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And let's assume for a moment, this isn't someone who had never been able to do it before, but found somebody who'd never ridden a bike at 20. And the reason I would argue that is in a bike, the object is balance. It's really about balance and you get your feedback immediately.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Yeah, that's a great exercise. Is there any concern that when a person does that, the Hawthorne effect kicks in and they basically start deviating from the natural behavior because of the observation? In other words, is the act of going through this exercise potentially making it harder for them to transparently see what's happening?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So, you know, the second you're out of balance on a bike, because you're in the environment of the air and the air has a density such that it's not forgiving. You basically are out of balance. You're going to fall. Conversely, although most people don't think of it this way, swimming is also about balance in the water. You're trying to balance yourself this way versus this way.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
These devices here, these continuous glucose monitors, they are a remarkable tool for both insight. When you first put them on, you're sort of learning, oh my God, like I didn't realize eating that thing would have this response in my glucose.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
But once you sort of saturate the insight part of that equation, it can be three months, six months, depending on the complexity of your life, it becomes forever a behavioral tool.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
you don't want to eat a certain thing if it's going to raise your glucose because you've at least bought into the thesis that you don't want to have your glucose skyrocket the way it does when you eat m m's so it's interesting it becomes kind of an accountability partner and i find some of the most interesting and sticky devices do that the wearables that offer an insight that's not obvious but is objective tend to be the things that we really like coming back to
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Whereas the ones that are kind of obvious, like how many steps you take, that's not very sticky because we sort of have an intuitive sense for what that is. Like once they've spent enough time walking 10,000 steps a day, they don't really need a device to tell them that anymore. It becomes easier to do on their own.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Most people would naturally sink feet first and you're trying to balance yourself this way so that you can breathe. And those things are not easy to do because the feedback loop is very long and it's very hard to make the connection that you're out of balance. It also doesn't hurt as much when you fail. So when you fall off your bike, it's very uncomfortable.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Yeah, this idea of what gets measured gets managed is a great tool. About six months ago, I started going to the water meter of our house every Tuesday and recording it. And then I've got a little spreadsheet that... Says, okay, this is how many gallons we've used this week. This is what it would project to for a monthly usage, et cetera, et cetera.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And you just can't believe how much our water usage has come down in six months. Because in Texas, water is not that expensive actually compared to California, but just it became something I was obsessed with, which is like, we're not going to waste any water. I just don't want to waste any water. It's now become a game for me. It drives my family nuts, but it is a game.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Like we are going to have the lowest water bill ever in Austin. No one is going to use less water than us. I'm obsessed with that spreadsheet.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Oh, yeah. When I'm giving my kids a shower, like once I'm lathering them up the water, I got to turn the water off. And they're like, Daddy, why are you turning the water off? I'm like, because we're just putting soap on right now. You don't need the water. It drives everybody nuts. Okay.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
But when you're out of balance and swimming, you just have to work harder, but you don't realize why you're working harder. Anyway, that's why I think it's very hard to learn how to swim and it's not very hard to learn how to ride a bike. And therefore it requires much more deliberate practice to learn to swim than it does to ride a bike, at least at some basic level.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Yeah. You brought up CrossFit earlier, but I always thought that CrossFit was one of the best examples of this. I never did CrossFit myself. There's lots of criticisms of it, et cetera. But the reality of it is it was certainly, it was and is something that really creates a community of people who have a certain belief about who they are and what they do.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
For all the people who not CrossFit, I've seen it take a lot of very inactive people and turn them into some pretty impressive people.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
It's really a great example. I guess we'll go to the third and fourth law, but I want to take a step back and ask you where you put nudging into this. So Richard Thaler's book, Nudge, which was probably the first book I ever read on this subject matter. I mean, it seems so obvious, which is what makes it so interesting and insightful, right?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Sometimes the most brilliant things in retrospect seem so entirely obvious. But it was, I think, reading Richard's book circa, I don't know, call it maybe 2012, it's probably nearly 10 years ago, this idea of the default food environment sort of came to me. And I use that term with our patients is the more you can control your default food environment, the more healthy you can be.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
For this week's episode, as we're nearing a new year, and a lot of you are probably going to be thinking about your New Year's resolutions, we wanted to re-release one of our most popular episodes, my discussion with James Clear from November of 2021.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So if your default food environment sucks, you're going to be relying on willpower a lot. And that's really, really hard. If your default food environment is one extreme end of the spectrum, you can have a perfect default food environment. You can be the healthiest person in the world, even if it's not enjoyable.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
If you were locked in a room and all you had were the best foods to eat, you're going to end up being healthy and you're going to be kind of like, oh, if I eat one more macadamia nut and have one more avocado and salad. But nudging obviously refers to a cue, but it also refers to this environmental change. It doesn't seem to really capture the idea of making it attractive or does it?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So one of the other things you talk about is the idea of accountability. It's come up now several times. And I think everybody would agree that the moment you have somebody else in this thing with you, the better it gets. Is there any evidence about the type of accountability partner? So an example you gave was your wife. Great accountability partner for you guys to work out.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Would that be more or less effective than if you were matched with a person who you didn't know, but who had similar aspirations, where you'd be less comfortable and perhaps more inclined to hold yourself to a higher standard? Again, it kind of comes back to this idea of how we're wired
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And speaking of a coach, just more broadly, how does a coach or how did the best coaches, if you have insight into this, thread the needle of creating accountability, but also creating encouragement when you fall short?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So we could just say basically adaptive or maladaptive.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I think meditation is another great place where that two-minute rule really helps. I think it can be really daunting the first time you decide. For the first time, let's say you buy the idea that, hey, you know what? There's probably real value in this. I'd be better served to go on a silent retreat for seven days or meditate 40 minutes every day.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
It's like that's a real big step for someone who's never done it. How about two minutes every single day you meditate? And maybe in a few weeks, it's three minutes a day. But yeah, you have to sort of lay down that track to say, A, I'm a person who meditates and B, this is the actual muscle memory of what it looks like to sit down.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So how do you make them satisfying? Because that's the fourth law.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Right. Ice cream wouldn't be a great reward for getting in better shape.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Let's take a step back from all of this. When someone picks up your book, presumably there's a selection bias that exists, which is this is a person who either through luck or through some recommendation or friend or whatever has made a decision that they at least want to examine the habits in their lives and or potentially change them.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
What do we know or what can we extract from this about a scenario that's different, which is, I'll use my example. You have a patient who you're trying to help and helping that patient requires some intervention. They're going to have to make a change. Now that change can be at one level really simple. I think the simplest change medicine has to offer is take a pill.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
There's a time and a place for pills. I think it's a bit silly when people assume that everything modern medicine has to offer is bad, pills are bad. Obviously that's not the case. Taking your medicine for your blood pressure, your cholesterol, these things, if it's warranted, that's a really important thing to do.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
And we also know, by the way, that even something as quote unquote simple as taking your medicine is actually really hard for a lot of people. Most people are, I think studies demonstrate, you know, sort of in the neighborhood of 60 to 70% compliant with something as simple as take a pill. But it only gets harder from there. Getting someone who's not sleeping well to sleep well.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
That's a real big set of behavior changes. Getting someone who's not eating well to eat well. Getting someone who's not exercising to exercise. Getting someone who's not taking care of their mental health to take care of their mental health. All of these things require enormous change. If a person says on the surface, yes, I want to be better. I accept that I want this outcome of being healthier.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
but they haven't specifically had the need or desire to change the way they eat or exercise or sleep or whatever, it adds a layer of challenge or friction to this process. What advice would you offer to me in a situation like that for trying to implement your insights into that scenario to a person who hasn't fully selected into wanting to change habits?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
James is an entrepreneur, photographer, and the author of the New York Times bestseller, Atomic Habits, an easy and proven way to build good habits and break bad ones.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
So James, you're working on another book, right?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Well, I can't wait to have you back to discuss that after I read it twice, which I will do, I'm sure. Thanks very much, James. This has been great to sit down with you. And this is almost like reading the book a third time. And I picked up a lot of things that I hope readers or listeners have also. And I look forward to implementing it both personally and professionally.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
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The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
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The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
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The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
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The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
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The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
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The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
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The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
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The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
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The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Actually, I want to come back to that topic because I think therein lies one of the themes of your book, right? Which is that willpower is not a great long-term strategy. But before I get to that, I want to kind of talk a little bit about you personally, at least before you came to these realizations. I know you're an athlete.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
I wanted to interview James after reading his book for the second time, and I realized that it was such an important part of what we try to do in our practice, and of course, what most of us try to do in our own lives, which is change behaviors. And behaviors can easily be distilled into habits.
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
In your book, you write about this horrible accident you had when you were playing baseball. I believe that was high school or was it in college?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
During that period of your life, were you someone that others and your peers would have looked at you and said, oh God, that James, that guy is so disciplined. I mean, he just has what it takes to always get the job done and he never indulges in the wrong things and always does the right things. Like, were you one of those guys that was just a beacon of quote unquote discipliner?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Were you a normal guy or were you someone who had a hard time doing what was right?
The Peter Attia Drive
Building & Changing Habits | James Clear (#183 rebroadcast)
Was there an area that you struggled with from a behavior standpoint?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I wanted to have Sue on this podcast to speak about her extraordinary career spanning medicine, oncology, biotech, and global health leadership, and to really explore her knowledge on how scientific innovation and leadership can drive better healthcare outcomes.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Okay. So we have nothing. And what is the approximate conversion? So for a patient who develops AIDS, what fraction of those will go on to develop KS?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What was the prevalence of HIV AIDS in the population in Uganda?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I mean, worst Russian roulette's one in six if you've only got one bullet in the chamber.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
In this episode, we discuss her early days in medicine, training at UCSF during the start of the AIDS crisis before people even knew what it was, and the lessons that she learned on handling uncertainty, balancing public health messaging, and accelerating treatment breakthroughs.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
These patients weren't necessarily dying from the KS directly. That's a proxy for how weak their immune system was. I assume they were ultimately dying from a pneumonia? Yeah.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What did you know at this point in time about HIV? Because the virus had been identified by this point. What was known and what was unknown?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
This was with Gallo? Was it Gallo?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Going back to these 16-year-old girls, is the reason that the heterosexual transmission was so high because the viral loads were through the roof? Because today, if a male with HIV had unprotected sex with a female, it would not be that high, would it?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So it's a one-two punch. Yeah. Super high viral load.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
The decision that she made to specialize in oncology and how her time treating HIV-related cancers in Uganda reinforced the need for integrating epidemiology patient care and policy to combat global health crises. We spoke about her transition into biotech, helping develop breakthrough cancer drugs like Taxol, Herceptin, and Avastin, and the role of precision medicine in improving outcomes.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And so the government was receptive to this. Yeah. They understood the science. They understood the epidemiology. And they were completely on board with the campaign.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What other countries in Africa were afflicted to this extent?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Can you estimate in a year how many people died from AIDS in Uganda when you were there?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I guess the point is it's a staggering number.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And yet there were so few of you that were on the front lines.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What was the chemo?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
If yes, you're too healthy for me.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
How did you manage the personal toll of the grief and the death of seeing this? I mean, look, I think every doctor to some extent goes through this, where you try to sort of compartmentalize what you're seeing. But the truth of the matter is virtually no doctor can really comprehend what you're describing there. How did you process that?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Does your husband share that? Was there a yin and a yang to the relationship where you supported each other in a way that was helpful in that? I do understand what you're saying and I appreciate that there is a joy that comes from helping people, but I can also at least personally say that there are moments when it breaks down and you feel so overwhelmed by sadness.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Sue talks about her leadership roles at UCSF and at the Gates Foundation, driving innovation in healthcare and global health, and the lessons learned from leading health research institutions and global health initiatives, balancing financial constraints with scientific progress and building culture.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And so you came back to the U.S. after about three years. And did you go back to UCSF?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Taking care of a million people with HIV wasn't enough to justify coming back to UCSF.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
In San Francisco?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Okay.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And you were doing at this point, oncology unrelated to not necessarily focusing on HIV and AIDS related cancer, breast cancer.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
We end this discussion with a perspective on the future of medicine, including AI's role in healthcare, such as the opportunities and challenges in leveraging AI for drug development, diagnostics, and expanding access to high quality care. So without further delay, please enjoy my conversation with Dr. Sue Desmond-Hellman. Sue, thank you so much for making the trip out to Austin.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Is this the Davida Hellman Rosenberg book? Yes. Yeah, yeah, yeah, of course.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
This is unbelievable. So you're sitting in Kentucky practicing garden variety oncology. Talk to me about what that's like. I mean, that's completely orthogonal to what you've been doing for the past couple of years.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
But did they not understand what you had spent the last couple of years doing prior to being in Kentucky? Did they not know what you had done in Uganda?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I always have to remind myself, tell people what Taxol is, how it works. Just give them a quick, what is neutropenia? Why would we care?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And the reason we would give somebody with cancer a microtubule inhibitor is because that prevents cells that are dividing. You can't divide. They need these microtubules when they create new cells, and we want to block that.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Really, really was excited to meet you last year. Just an honor to spend part of a day with you and then realize that I could somehow twist your arm into coming on the podcast.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
It had already been approved.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So now you're doing post-marketing surveillance on safety.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
You've had just an unbelievable career. You are an absolute giant in many ways. I love to always give people a sense of how someone got to where they got. So if I recall, you grew up in Reno, is that right?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What was the pharma landscape like in the early 90s? So you had Bristol-Myers, you had Pfizer, you had Merck.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
How long did it take them to thank your husband for forcing them to bring you along?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
When you pause at where we are in this story to think of everything that would come from this moment forward and to realize there's a scenario under which nobody knows everything that's about to happen, and you're an oncologist in Kentucky right now.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And you went to high school and college and even medical school all the way through, right?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
1976.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Okay. Give folks a little bit of a history of Genentech. Genentech's a storied company, but also a different company in that it was founded on a new technology.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Tell people briefly how this worked. What was recombinant DNA technology? What were they putting the gene into? How did they get the gene to make the protein? We take this all for granted today because we have... It's tricky, yeah. Yeah, but it's so incredible.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
then that you ended up at UCSF for your residency?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Do you have a sense of how many kids that was?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
By this point, it was being used rampantly in sports.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Was it being used by this point also pretty heavily in HIV, right?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Meaning there was no benefit to an HIV patient being on growth hormone?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Okay. So remind me where we were in the AIDS epidemic in San Francisco in 82. What was known?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Did they go after that knowing what they were doing? Or was this a bit of a fishing expedition where they realized in the process of trying to do many things that, oh my God, we can actually make TPA, which you're going to explain in a minute why that changed the game of cardiovascular medicine.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Was Eric at Scripps at that time or where was he?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
You had to make sure it wasn't hemorrhagic or you could make things so much worse.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Why did they out-license insulin?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Got it.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And why did you decide to leave? Bristol-Myers Squibb is just crushing it. You finally earned the respect you deserve. You've got this struggling company, Genentech. Was it the opportunity?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So what was the first thing you worked on?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Who developed EPO? Amgen. Amgen, okay.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Got it.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
When you clone it, if you publish it, that doesn't give you the right, it's a race for everybody.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So let me ask a silly question. Why do you publish the results of the cloning before you've gone and made the recombinant protein yourself?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Okay. So once it's published after the patent, you get to make it.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Was that known only once you started developing and you understood the kinetics of it?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah, so you can't give it prophylactically because you don't know who's going to get thrombocytopenia.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What do you do? You plasmapherese the patients if you've overshot? Or not plasmapherese, platelet-pherese.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
as a result of treating patients. And what were they presenting with at the time? It's hard for anyone of even my generation. You've never seen a drug naive patient. All of my experience with HIV, which was a lot in Baltimore many years later, but everyone was on something. So how would these men present to you as a medicine resident?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Tell folks how that drug worked, what it was for.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Why do you mechanistically, do you think that the overexpression of HER2 was impeding immune clearance? What was the thesis at the time for why overexpression of HER2 was cutting life expectancy down?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Of course, yeah.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah, but I think what I really enjoy about this type of discussion though, Sue, is one, it's the story of your career, but it's also the story of oncology.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
It's the story of modern oncology. So you're one of the few people whose careers takes us through the walk of modern oncology.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What was the biggest failure at that point commercially?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
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The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I almost forgot the BMT stuff. It's so archaic.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah. I mean, we've got to be getting close to Avastin now too, right?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Tell folks why that's so unusual.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
How many cells in the body, how many types of cells in the body express CD20?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
But it's not as specific as CD19, is it?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah, I know CD19 is on the B cell, but I didn't know the, okay.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
We were talking about this earlier. This is chimeric.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah, so tell folks what that implies, because that's another wrinkle in the story.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And the CD20 antibody was just also a straight naked antibody?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And targeted for an immune destruction?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And why do those patients with marrow that's still producing CD20 positive cells not go on in a constant state of lymphoma requiring? In other words, why is it that you can treat this and create a durable remission?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So it's just getting rid of enough of the diseased B cells until you get the load down low enough that the immune system can wipe out the clone.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What was the price of these drugs at the time they came out? Were these the first chemotherapeutic agents, or you kind of want to distinguish them from traditional chemo, but were these the first oncology drugs that came with big price tags?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And about this time, we get the whole anti-VEGF story, right? Yeah.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Tell folks what that is.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
That was... So Judah Folkman over at Boston Children's.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah. I never had the chance to meet him.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I've never met Judah. He wrote a fantastic book that I read in medical school, poured over the book. I'm blanking on the name of it. Do you remember the book? It was his story.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Again, a beautiful story.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
You know, the saying that I love is it's the description of science as a beautiful, compelling hypothesis slayed by an ugly fact.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Mostly human.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
This was the first phase one. So you're going very low dose. We're going to dose- Very low. That's the first time it's going into a human.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And this is also mid-90s. Yeah, yeah. This is all happening when you arrive.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I mean, what a time to be a Genentech.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Wow.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
How are you picking the cancer to study something like this? Herceptin's obvious because you're targeting a receptor.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah, they're easy. You know what you're doing. But here you could be targeting anything.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Why is that? You've got the IL-2 stuff going on where you've got 10% of people will respond to it, but 90% won't.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
These were patients with metastatic breast cancer?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And the standard you're going to hold yourself to in the phase two is 50% shrinkage?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
This is a great time to actually hit pause. I wanted to do this later, but I think this is the right drug to go through two things. One, even though I've done this probably half a dozen times on the podcast, you should never assume somebody remembers it. I want people to understand what the difference is between a phase one, a phase two, a phase three study. Also understand what's preclinical.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
It's not intuitive to people why it costs a billion dollars to get a drug to market and why it can take a decade. And then within that, if you could just embed enough of the details about decisions that you can make that will make or break you, how many times has a drug failed because the experimental design the wrong patient selection, the wrong disease selection.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
You have got to line up four pieces of Swiss cheese just right to get the pen through to hit it. Sorry to interrupt, but let's go back to, you got Judah Folkman talking about VEGF, VEGF, VEGF, that then turns into, well, if we made an antibody to VEGF, okay, so there's your idea. Now start the clock and start the dollars.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Tell folks the difference. How do you think of small molecule versus antibody? Where do we draw the line?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I do this through cardiovascular medicine to explain to people the difference between a statin and a PCSK9 inhibitor. You have these two very common drugs that are used to lower cholesterol, but a statin is a small molecule. I don't say this in an insulting way, but we use the terminology, it's dirty. It does block an enzyme, but it's got all these off-target things.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And your liver function gets whacked. You get insulin resistance. Some people get horrible muscle soreness. So 5% to 10% of people taking this drug are going to have a side effect that prevents them from taking the drug. I've never seen a person yet who couldn't tolerate a PCSK9 inhibitor where you inject an antibody into them that binds to a protein and shuts it off.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Right. Who would take an injection for cholesterol?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And was there ever a sense of fear among the medical staff that we don't know what this is, we don't know how it's transmitted, and therefore we don't know how to protect each other or ourselves or other patients for that matter? Like, it's hard for me to imagine that given how much we take for granted today.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Did you guys have to have somebody in parallel developing a CLIA-certified assay that a pathologist was going to use, or did you do that in-house?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And you could quality control the hell out of it?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So whose responsibility is, like, how do you encourage the world to make that happen?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Now, why didn't you guys do that in parallel? Was the cost too great? And did you want to de-risk the drug before you sunk the cost into that?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I see. Okay. So nowadays we're doing that in parallel. Oh, for sure on parallel.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So how long, just to again, go back to helping people think through the arc of time, from the moment you guys hit a go decision on, we want to do this, we want to pursue this path, how long until you file the IND?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Maybe tell folks what the IND is so they understand why that's an important milestone.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So we're going to do the Peter Sue drug. It's going to be amazing. We're going to set the lab up right over there. But the moment we want to run a clinical trial. And ship it. And get it out of the state.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And there's an art to knowing where to start the dose because it's an escalating dose trial. That's right. But you're extrapolating from what you learned about toxicity in a totally different organism that never translates one-to-one to the organism of choice.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And typical cost given the relatively low numbers of patients?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Tens of millions, yeah.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What's the right outcome? What's the right patient?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So where were you guys with anti-VEGF in phase two? You're at breast cancer and did you do colon?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Five of you and the usual suspects.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
That was a stage four?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
This is a median survival study. You're not doing overall survival, correct?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I feel like it was eight more months of median survival. Does that sound about right?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Now, at this point, I'm in medical school just down the street. I'm at Stanford. And I remember we had a big discussion about this. I'm in my first year of medical school. And the discussion we had in class was, I think at the time Avastin was $100,000 for the treatment. Extends median survival by whatever, but I think it was eight months.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
The UK said, no, the NHS said, we are not paying for this because at the time the NHS had this $100,000 quality adjusted life year hurdle, which is understandable, right? That's how you throttle supply side economics. They said, look, we can't pay for a drug. We can't pay more than $100,000 for an incremental year of quality adjusted life year. This is only giving you eight months.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
That's why I know it was less than 12. And so the NHS flatly said, we're not paying for this. And I do believe people in the UK could pay out of pocket for it.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
That's right. People in Canada could not because you couldn't have private insurance in Canada, though you could come to the US for treatment. So of course, this just became a great topic of discussion for med school freshmen. What was your thought at the time of, have we moved the needle enough? How do we think about the economics of this?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Did you go straight from Genentech to being a chancellor at UCSF? Just because I want to stay with the story, I want to continue the arc of your career. We're at the halfway point, right? We're one third of the way into- Early days. Yeah, yeah, yeah.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
How did you, given you are truly on the cusp of what is happening in oncology and biotechnology, and now the same institution that said- you can't come back here to have a clinical appointment after saving the people of Uganda is now offering you the highest post essentially outside of a provost, I'm guessing, right? I don't even know where the chance- It is the highest post.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
It is the highest post. Okay. So that's kind of remarkable. And does that just speak to what they saw as the vision of that institution, which was few people have learned what Sue has learned in the last 10 years, and we want that type of leadership here?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
That's right. That was 99?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Oh my God. Okay. I'm off by a whole decade. I thought that was sooner.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
It was a- It's a hostile takeover. A hostile takeover.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
No, I don't.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guest this week is Dr. Susan Desmond-Hellman.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And that was starting in the 80s?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Of Nobel fame.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I'm sure that when you're going through that, sorry to interrupt, because you're now interviewing with the Board of Trustees.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah. And so they must be asking you to present a vision. They're not interviewing you to make sure you know how to use PowerPoint. Yeah. Do you remember what the vision is that you presented to them?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
You were the president. What was your title at Genentech before you left? President. Yeah, yeah.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
My kind of guy. Yeah.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Got it. For all intents and purposes, you were acting like this was Ebola without knowing. Absolutely.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
You're really the CEO of the system.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Were you nervous? I mean, when they called you and said, you've got the job, was there a moment where you thought, have I bit off more than I can chew? This is a huge responsibility.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Because you're an outsider, you were an alum, but you weren't coming up through the ranks as the CEO of the hospital or something.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And so you finished your residency in internal medicine. Did you go directly into your fellowship?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So tell me about the budget of UCSF. Because it's a state school, presumably California provides what fraction of it?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So what's the benefit of being a UC?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So in that sense, you and Stanford aren't that far apart.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Show me the P&L on those things there. So NIH is bringing in how much? Oh, gosh. Percentage-wise, roughly.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
A third of the revenue for general operations is coming out of the NIH overhead. And then clinical revenue.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Okay. And then philanthropy is some direct, some into the endowment where you're living off the interest.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And that's basically what your revenue streams are, those four things.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Well, especially because you don't have undergrads, right?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I didn't even apply to UCSF, by the way, because I mean, I was not in California when I was applying to medical school. I was told it was such a great medical school that I was like, there's no way I'm going to get in as a non-Californian. So I didn't even apply.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I did.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Because there's like seven of you, right? There's seven of us.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Americans are, hands down, the most generous people in the world. I think that's a demonstrable fact.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I'm sure that you must deserve some of the credit for that. I don't think it's just that a bunch of people in the Bay Area came into money at that period of time. What was the approach you took towards philanthropy and how did you reach donors that maybe previously hadn't been involved in UCSF? Because again, one of the things that's working against you is you don't have an undergraduate.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And why did you pick oncology?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So Stanford has a big advantage over you in which you've got a lot of people that are coming through doing engineering degrees, doing CS degrees who are going on to create enormous enterprises. Anyone who's an alum of UCSF went to graduate school there. There's no business school. There's no law school. So you're missing out on a lot of this.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yes.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yes.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What percentage of your time was spent externally versus internally?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And what was the internal focus then?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So who were your direct reports, the provost?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
This would be something you did as a scientist, not necessarily as the chancellor. Not as the chancellor. The chancellors weren't doing this all the time.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So then let's get to the next chapter. What all of a sudden in 2013, 2014 leads to the next transition to being the CEO of the Bill and Melinda Gates Foundation?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Was he still there?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I assume that the rationale for that was obviously their focus is on global health. And you have the background in the clinical side, the research side, the epidemiologic side, the management side. So there's kind of those are four legs of a chair. Were there other things that I'm missing that they felt were kind of essential pillars?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
But those points of view don't strike me as mutually exclusive for an organization with enormous resources.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So how did you weigh this decision?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Were they surprised? Did they try to talk you out of this?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Okay. So you head up to Seattle now. Yes. When you show up to the foundation, how many employees are there? What does it look like? It's a not-for-profit, but does it run like Microsoft? I mean, how does it operate?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I can really relate to that. When I was in my third year of medical school, I went to the NCI for three months with Steve Rosenberg. And it was the exact same experience. And I remember learning many lessons from Steve. One of them was that cancer diagnosis, and of course, at the NCI, as you know, nobody's showing up with stage one, two, or three cancer.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What was the most difficult thing for you to impact that you wanted to change? Meaning, was there a global initiative that you wanted to get your hands around that you just couldn't do organizationally or technically? Or what were the challenges?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Say a little bit more on that. Is that because in the not-for-profit space, you have a different talent pool than you do at Genentech?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What did the org chart look like? So I assume Bill and Melinda are co-chairs.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And then as the CEO, who are your direct reports? Is it organized by a bunch of GMs in different programs? Yeah. So there's a TB person, an HIV person, a polio person, a malaria person?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
By definition, every patient there is showing up with metastatic cancer, and they've progressed through all standard treatments. So these are people that have six months to live. And maybe 10% of them you actually come up with a durable remission for. But he said, look, cancer will do one of two things to a family. It will take a strong family and bring them much closer together.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So under global health, you then have sub... Then you have the subs, yeah. Global health is a big job, obviously. It's a very big job. That's the biggest.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I don't even realize. I'm not as familiar with the portfolio.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What's the annual budget?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Wow.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah. So what are things that you could not have done there in that role had you not had the leadership roles at Genentech and UCSF?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Performance was struggling, you mean? Performance was struggling.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Are you basically only able to affect that through your interaction with your direct reports and just hope that that's the infusion of culture that then trickles down? Because it's hard to go two levels below your management, and yet the people who probably need this compassion the most are people you're not even going to meet.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
It will take a fractured family and blow them wide apart. As a doctor, as a nurse, as in anybody in the field of oncology, your ability to kind of be there for that family is as important, potentially more important than it is in any other specialty of medicine.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah. The word culture, it's very misunderstood. When you think about the culture that you wanted to bring to the Gates Foundation, I'd like to understand what that was and how successful you think you were able to be. And I say that because you were in an organization where you also had very powerful other present people whose culture was also a part of the organization.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Which is kind of odd. The person who's the decision maker is sitting in the presence of the two most senior people in the company, leaving it to him to make the decision.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
You were the coach.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So tell me a little bit about the state of oncology in the mid 80s when you're embarking on your medical oncology fellowship. Help people understand what the world of cancer looked like roughly 40 years ago.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So this brings us up to 2020. And were you at the foundation when COVID hit?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah. Interesting. Let's talk a little bit about COVID. So I've talked before about this idea of the difference between science and advocacy, and I still haven't really wrapped my mind fully around it other than kind of a sense of lost opportunity with COVID. What do I mean by that?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Well, on the one level, there was so many pretty incredible things that happened with respect to the speed with which a vaccine could be developed that really made a difference in terms of mortality for a subset of the population. But a lot of that's overshadowed today by the lingering doubts, the lingering suspicions, the mistakes that were frankly made
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And my fear is I'm not convinced we're better off today in terms of preparedness for a pandemic than we were in 2019, which seems like an unimaginable statement given what we've been through. Do you think I'm too pessimistic? How do you feel?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yep. I concur with all of that. And I do wonder what it will take to restore confidence. Look, we could sit here and talk about mistakes. It might be that the medical community and the scientific community need to be more vocal about acknowledging mistakes. And I do think An enormous mistake, though it's understandable to me why it happened, because so much was happening so fast.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
But I believe deep down it was an enormous mistake to be the head of science, to be the head of advocacy. I think having Dr. Fauci as being both of those hats was a cataclysmic error. And it's not about him. No human can do that. A scientist has to be an impartial observer of fact,
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
who is happy to change his or her mind in the presence of new information with no attachment to what has been said in the past. An advocate has to be driving policy and action, and sometimes they have to settle for the best you can do, any port in a storm. When you put those two hats on the same people, I worry that you lose all trust.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I do wish the medical community could have an open and honest discussion about that. I would say that not if, but when. We will have another pandemic. There's zero doubt in my mind.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
We will absolutely have another pandemic. I hope it is decades from now, but we will. I hope somebody will remember that lesson and say, we want our chief communicator of the state of the science to be completely uninvolved in telling the public what to do, simply there to report what we know today. Today, we think masks work. You know what?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
We just did a study and we realize they don't work worth a lick. Today, we believe vaccines prevent transmission. We just did a follow-up survey. They don't prevent transmission. It's okay. It's okay. I think that's a very forgivable position.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I don't have a solution to that. I mean, the great example, which is a very good example, and I don't know the solution, is in May of 2020, if you suggested that this came out of the Wuhan lab, I mean, you were kicked off social media, you were kicked off YouTube, you were in the doghouse. That was misinformation.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Well, I think almost any observer today would agree that that was actually information. But where do you draw the line? I don't have an insight. This is so far above my pay grade.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Actually, I'm glad you brought that up. I wanted to have a discussion about this. Okay, finish your point, and then I want to make a broader point about oncology.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah, I think that's a great point. I'm glad you brought the ivermectin and cancer thing up. So a couple of my patients, which is a statement, I'm going to acknowledge that my patients are educated and affluent people for the most part. A couple of my patients have sent me clips of various people claiming that ivermectin is curing people with stage four cancer.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Now, because they're sending these to me in text and I'm really, really busy, I'm responding in a rather glib way, which is usually using phrases like, this is effing bullshit. But I usually follow it up a few minutes later with a text that says, happy to discuss. And usually they say, no, Peter, I just needed to know that this was nonsense.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
But I also agree that I don't think people should just be taking thing on faith. And I really want to be able to offer. So I think I made a note that actually I wanted to discuss this exact example. And hopefully we'll be able to clip this particular segment so people understand why this is such a idiotic statement.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
To believe that ivermectin cures cancer and to listen to the stories of multiple people with all sorts of different metastatic cancers that are cured, you're almost explaining that cancer is a single disease. So explain why, at face value, the idea that anything could cure multiple forms of cancer is an impossibility.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And when you go even one step further, as you've alluded to, it's not just that colon cancer and breast cancer are as different as kidney disease and heart disease.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
It's that breast cancer with an estrogen receptor that lights up versus a HER2 new receptor that lights up versus no receptors that lights up, those pretty much have nothing in common other than the fact that they originated from the mammary cell of a woman's breast.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
The other issue I have with this type of rhetoric is the next line that follows is the pharma companies all know this works. And the reason they're keeping it from you is so that they can make more money giving ineffective drugs. Now, again, I'm going to offer my point of view on this, but you being the veteran of some of the biggest pharma companies in the world, feel free to correct me.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I think pharma would be happy to have a drug like ivermectin that cured all cancer because the first thing they would do is put a slightly different modification to it to make it more efficacious, basically less side effects, and they would patent it and they would make all the money in the world.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
If they're able to make $100,000 on a drug that extends your life by eight months, I promise you they will be making millions per drug if it's curative. So again, such illogical arguments are put forth and it drives me sort of bananas. But if we want to go back and say, how did we get here? I think... When my friend Joe Rogan took ivermectin for COVID, which when Joe asked me, what do I think?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I said, Joe, I think it's a totally safe drug. I'm pretty sure it has nothing to do with why you're feeling better today. I think you're feeling better today because you have an amazing immune system. You're an insanely healthy human being. You did 10 other things, two of which might have worked. I'm pretty sure the ivermectin had nothing to do with it.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
That said, the medical community didn't say that to him. What they said is you're taking horse dewormer, you idiot. Well, that was a strategic error. That's an awful way to talk to somebody. And ivermectin might be a horse dewormer. It also happens to be, and I look this up, Sue, there is no drug on planet earth that has been taken by more human beings than ivermectin.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And it might have the fewest side effects of any drug out there.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Works beyond, yeah, exactly.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
But again, it's something about the elitist nature in which that was handled that has now created this terminal effect of ivermectin is a cause celeb for, I mean, pretty soon someone's going to say it cures Alzheimer's disease, I'm sure.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah, that's a great way to put it.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
To me, that's heartbreaking because the answer should have been, I talked about this with Joe very openly on his podcast. I said, look, I've looked at all the RCTs of ivermectin and COVID. There's no signal, except my memory could be off on this, but there's a little signal in this Brazilian trial, but the methodology of that trial was horrible. So I have to believe this is not working.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What was the nature of the program? It was a three-year fellowship with a research track on the side, because obviously UCSF is such an academic place.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
It's a good try. All about trying. It was a great idea to take off-the-shelf drugs and see if they worked.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
When they don't, we have to move on. By demonizing it and by demonizing the people that felt it might work, we find ourselves in a situation right now where it's very irrational.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah, I agree with that. Public health has really struggled in some ways. You've had these incredible success stories and then some awful failures.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I want to talk a little bit about AI. A lot of people might not realize you're on the board of OpenAI and you're the only person in medicine on that board. So talk to me a little bit about how that came about. I don't want to obviously talk about the implications of that, what you're excited about and what you're afraid of.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Sue is a physician who is board certified in internal medicine and medical oncology. Her impressive career has spanned multiple fields. She has been a leader in the pharmaceutical industry where she helped develop several groundbreaking drugs, worked as the chancellor of the health science campus of a major university system, UCSF, and served as the CEO of the Bill and Melinda Gates Foundation.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Give me a time and money sense in terms of savings. This is a very important question.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
IND to approval.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And you believe AI can do that right now? Or we're on the path to that?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And you could argue with a regulatory change in the FDA, if we said greater emphasis on safety to approval, greater emphasis on post-market surveillance for efficacy, we shift this thing a little bit. Now you could say at three years we're trending, you get a provisional approval, and now we're going to follow you.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
There's an example like PaxLivid in my mind, you could argue maybe should have been pulled, maybe it wasn't as effective as it looked in the trials. And that doesn't mean they were wrong to approve it because it was any port in a storm. But after the fact, we could have been, oh, you know what? No harm, no foul. It was safe.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And so maybe we do that for oncology.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Exactly. Ongoing.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
This is across the board, not just in clinical trials.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I think that that is absolutely correct. On the nursing front, there's a huge demand, obviously. How much of this do you think of absent robotics? So robots can really change the game. I'm not close enough to that. Are you?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah. So I don't know how long until a robot is doing what a nurse is doing. But when you think of medical and chart reconciliation and things like that, is that where you think the greatest opportunity is?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So the Nobel Prize last year was awarded for protein folding, AI-driven analysis. Explain to people why that is significant. How much do you think that particular achievement is going to advance biotechnology and what remains ahead of it as far as even greater molecule selection?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
This is how you even- This is figuring out what you're going to do.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Do you think this is the most important thing from a promise perspective that AI has brought to medicine since?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And so what do you think would be the next mega unlock? Would it be on the data front? Would it be a predictive model? How could we shorten a clinical trial by 60%?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
You brought up the example of hep B and hepatocellular carcinoma. Was it understood at the time what we now know?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
You need a good biomarker.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah. There undoubtedly are. There probably are.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Sue, what's your level of optimism or pessimism around liquid biopsies? And do you think that AI can help us with these?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And is this on the sensitivity front? Yeah.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Yeah, I was about to say, do you think the problem is tumors don't shed enough DNA?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
I agree with you, by the way. I would add to that PSA in the hands of someone who understands what to do with it. So PSA by itself, pretty bad. PSA density when you know prostate volume and PSA velocity when you have serial measurements starts to become very predictive. So you take a man who has not had a prostate biopsy,
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
and you stratify his PSA according to PSA density, the ability to predict if he has a Gleason 3 plus 3 or 3 plus 4 or 4 plus 3 is really quite high. It's high. And at least you can then stratify those patients more quickly into a PHI or a 4K and ultimately decide do they need a multi-parametric MRI and you go down that path.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
So it's not turnkey and I completely understand why they've said we're going to make no recommendation. I do take comfort in knowing. It's sad to me, but I take comfort in knowing. Too many men are dying of prostate cancer. It should not be the third leading cause of cancer death. It shouldn't. And yet I understand that it's a big ask to get every doctor fully up to speed on the algorithm.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Do you recall what the incidence of Hep B was and Hep C back then?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
When you go through the four leading causes of cancer death, two of them don't need to be on the list. Colon cancer and prostate cancer don't need to be on the list.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Now, lung, I think we can reduce it a lot, but it's going to be awfully tough. And breast is still really tough because it's not Halstedian. It doesn't have that straightforward progression from polyp to cancer. No, it's true.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
What is your level of optimism that we could ever... So instead of just talking about a broad liquid biopsy, let's just talk about breast cancer. What do you think it would take? And do you think it would be a protein? Do you think it would be DNA? Do you think it would be RNA? If you had to guess, what would be the earliest signature in the blood of different breast cancers?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Where would you put your money?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Think about how that would change breast cancer treatment.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
It's funny. I say the following deliberately not acknowledging your gender because I'm sure you hear all the time, Sue, you are the most remarkable example of a woman in medicine. Gender aside, you are just a remarkable inspiration, period, as a physician, as a business leader, as a public health official. I have been a fan of yours for so long.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
When I walked into that room last year and saw you sitting there, I was giddy. So thank you for humoring me and making the trip possible.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Tell me about how you wound up in Uganda.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
For all of my disclosures and the companies I invest in or advise, please visit peteratiamd.com forward slash about where I keep an up-to-date and active list of all disclosures.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
This is Moffitt?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And this was through an epidemiologic contact tracing lens, not necessarily going into the lab and trying to figure this out.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And it was only... And I'm sorry, you, your husband, and who else?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
That's the dream team.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
She also served on numerous boards of both corporations and nonprofit organizations and She co-chaired the National Academy of Science Committee that pioneered precision medicine and currently sits on the board of OpenAI.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
And what about safety?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Was Idi Amin still ruler? No.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Give me a sense of what this meant. So, we're talking late 80s now.
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Is AZT out yet?
The Peter Attia Drive
#346 - Scaling biotech and improving global health: lessons from an extraordinary career in medicine | Susan Desmond-Hellmann, M.D., M.P.H.
Okay.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
I don't like the medical definition of healthspan, which I believe is, quote, the period of time in which an individual is free of disability and disease. I find that to be a very unhelpful definition. It's awful, yeah. But part of the reason it's awful is it's binary. Yeah, exactly. But if we made it analog instead of digital, I'm not saying that makes it easy. It's still very challenging.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
But now it allows us to start talking about things.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
I would only be able to ask you that. So we do this exercise, guys, because I completely agree with you, Steve. We call it the marginal decade exercise. So we say to every one of our patients, and I write about this a lot in the book, everyone will have a marginal decade, which I define as the last decade of your life. So obviously by definition, everyone has a marginal decade.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Most people do not realize the day they enter it, but most people have a pretty good sense when they're in it. Okay. So the exercise we do is we go through with the patient and we say, what are the things that are most important to you to be able to do in your marginal decade? And they generally fall into three buckets with a sub bucket, physical, cognitive, emotional, social.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
The physical bucket, we kind of divide into activities of daily living and recreational activities. So that's where, again, most people obviously intuit that, boy, I would really not be happy if I couldn't take care of myself. If I couldn't get out of bed, get dressed, shave, cook, that would be disappointing to me.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
But then, of course, you have different levels of ambition within the recreational side. I've got patients who say, when the day comes that I can't heli-ski, I'm going to be devastated. And other people are like, I just want to be able to garden. That's going to create a very different standard.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
On the cognitive side, you have people who say, I want to be able to run my hedge fund and still make money and make really important investment decisions. And other people are like, I want to be able to do crossword puzzles and read the newspaper. I agree with you. You can't define it, but it doesn't mean we shouldn't try to personalize it. Okay.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
But I want to come back to you, Matt, with the original question. Why are we at a point where... Why has longevity gone mainstream?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And Matt, of course, is famous for his work in the Dog Aging Project. So in today's roundtable, we discuss a number of things, such as the relationship between healthspan and lifespan. And what does healthspan actually mean? Is it something we should try to define? Can you improve one without improving the other?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Yeah.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
To that point, Matt, what is the collective wisdom of the group on the funding appetite for that? Because I agree with you completely. Like if we could channel this exuberance away from kind of the highly commercial speculative grifting towards the budget increasing legitimate investigative, that would be awesome. What is the appetite right now of NIA with respect to this?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Sorry, just to put numbers in perspective, NIA gets what percent of NIH?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
But I'm saying there are 17 groups of NIH. NIA being one of them gets what fraction of NIH budget, roughly? I think it's roughly 3%. 3% of NIH budget is NIA. Within NIA, how much goes to this type of research?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
What's your level of optimism, Rich? You're obviously very close to this.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Even with this outside attention?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
What has caused a surge in the public interest in longevity science and what major barriers are preventing longevity research from reaching its full potential? This actually was one of my favorite parts of the discussion. How do we evaluate the effectiveness of interventions like rapamycin, senolytics, or calorie restriction in humans, where it's very difficult to study them for obvious reasons?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
You're saying, look, Calico, Altos, other private companies, especially within biotech and pharma that are looking at geroprotective molecules, building on the work of the ITP. Yeah, I think it's safe to say the amount of money that's being spent privately probably outdoes public spending. I mean, in a given year, two to one easily.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Are there reliable biomarkers or aging rate indicators that can measure biologic aging, which of course is a very hot topic? What role do epigenetic changes play in aging? Specifically, are they causal? Are senescent cells a valid target for longevity interventions, or has their role in aging been overstated?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Naive question. I'm embarrassed I don't know the answer because I spent more than two years working there. What's the mission statement of the NIH?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Let's state that again because it is so profound. I want to make sure not a single person missed that statement. The top 10 causes of death in the United States are well enumerated and incredibly predictable, and they increase by category, by decade, 3% to 8% monotonically with no exception. Point being, 90% of and more than 90% on an adjusted basis of what causes death goes up with age.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And yet, a few basis points of federal R&D goes to addressing that.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Are GLP-1 receptor agonists, for example, drugs like terzepatide and semaglutide, potentially geroprotective beyond just their weight loss effects? How do we overcome the funding and political challenges that prioritize disease-specific research over foundational aging science? What would it take to make longevity research more mainstream and gain broader support from the public and policymakers?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
It's very interesting because you don't know which is the tail and which is the dog. I've always assumed that the one leading the charge is the clinical side of things. In other words, the engine, the machine of medicine 2.0 is built around the delivery of care. The delivery of care, as you said, Steve, is built around care. I'm going to wait. I'm going to sit here and hang. We're going to wait.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
When you get the disease, we're ready. You had the heart attack. Fantastic. You've got chest pain, ST elevations. We got a stent for you. Now you have cancer. We're all in. And then the research flows from that mindset. Of course, I don't know, not that it really matters, but it might be that it's flipped, right?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
It might be that the clinical engine behaves in that way because that's how the base of the pyramid has been built. Again, not that it necessarily matters, but if you could be health czar and fix one of them, you might actually start with the research side of things.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And the system would work. You'd get the best and the brightest that would go into that and do that. So this then begs another question that is a tired question, but I can't help but ask it at this point. Is aging a disease?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Anyway, this is a new format, this idea of doing a roundtable. So we really want to hear from you. Is it something you like? If so, what are other topics you would like to see for roundtables? So without further delay, please enjoy this roundtable discussion with Steve Austad, Rich Miller, and Matt Kaberlin. Gentlemen, this is a lot of fun. I am excited to be sitting down with you guys today.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Well, so now let's go one step deeper on that. How do you think about biologic versus chronologic age in concept and in practice?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Where do we want to begin? Let me start by saying the following. The term longevity, someone sent me something the other day that was like list of, I don't know whether it was how many times the word longevity was searched on Google or something like that, but it literally looks like Bitcoin. So we are clearly at peak longevity in terms of public interest.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Yeah. I think for me, the challenge is I kind of land where Rich was, which is if a patient says to me, hey, why aren't you doing this biologic age clock on me? My response is, well, I know your VO2 max. I know your zone two. I know your muscle mass. I know your visceral fat. We did a very complicated movement assessment on you. I understand your balance.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
I understand your lipids, your insulin, like I know these 57 things about you and I can tell you individually on each of them how you're doing. That number doesn't tell me a single new piece of information.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Yeah, tell us about your experience because this was, you did what I wanted to do, but I've been too lazy to do.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Which for all of you who have kind of devoted decades, plural, to this, I just want to kind of get a reaction from you, each of you, on what that means, why you think it's happening, and maybe even extending the metaphor a little bit. Is there a bubble going on? We'll start with you, Steve.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Furthermore, they fail in the one thing that I think they're attempting to do. And I usually use this illustration with patients. So if I have a 40-year-old patient who says, I really want to do one of these tests, I say, if the answer comes back and says you're 20, Is your expectation that you will live another 70 years?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Conversely, if the answer comes back and says 60, is it your expectation that you will live another 30 years? In other words, is this number predictive of future years of life? Because right now we have this thing called chronologic age that is the single best predictor of future years of life.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So do we think biologic age as determined by these tests is better as a predictor of future years of life? Which, by the way, would be very testable. How many people have contacted you to get ITP sample data to say, can we predict how much longer these mice were going to live?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Yeah, MetLife does this really, really, really well.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
To me, that's the gold standard. When life insurance companies start using biologic clocks as the cornerstone of their actuarial algorithms, I'll start to be impressed.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And we should explain to people that there is a difference. So some of these clocks use solely epigenetic measurements. Not all. Most of the direct-to-consumer ones are epigenetic. But some of these tests use a litany of biomarkers inclusive of epigenetics.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So they'll say, we've sampled your methylation pattern, but we also looked at your vitamin D level, your glucose level, your cholesterol level, and a whole bunch of other things. And we compressed all of that into a number as well.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
That's a big statement. I don't know that I'm disagreeing with you. I just want to make sure we understand the statement.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Yeah, so... Let's think about this for a second. I have seen very impressive data where we can look at tissue samples of organs and we can tell, okay, I'm going to show you a sample of nephrons.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And just based on nothing but the methylation pattern, we know that if I just said to you, one of these is a 20-year-old, one of these is a 50-year-old, and one of these is a 70-year-old, it's very easy to predict based on the methylation pattern, which nephron came from which person. Completely agree with that.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So that's the question.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Right. So do you believe that all of the research we're seeing on the epigenetic clocks is going to be the 78th variable that we would include in our gestalt? I don't know.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Yeah, you and I spoke about this very briefly at the end of our last podcast, and I want to come back to it with all of us on this table, because there's so much in what you just said, Matt, that I'm going to lay out a broad question, and then we can start attacking it in different ways. So one of the things I want to address is, do we believe...
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
that it's possible that of the hallmarks of aging, epigenetic change is the most important.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Another topic I want to address, do we believe that the epigenetic changes that we observe over time, which are undeniable, are causal in the arrival of other states, everything from the arrival of senescent cells, the increase in inflammation, the reduced function of the organs, which really is the hallmark of aging,
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And if so, does that mean that reversing the epigenetic phenotype will undo the phenotype of interest? And Rich, where I'm going, that you and I left off was, what about the proteome? What about the metabolome?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Walking around a pond.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
It is extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member-only content and benefits above and beyond what is available for free.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So 30 years ago, you didn't see glimmers of this?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Do any of us want to rattle them off being that I'm the only one that's got the list sitting in front of me?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Would that happen automatically if we could wave that magic wand and increase funding?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Is part of the issue that you're saying, well, what's causing the cause?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So let's use a specific example. When you look at a patient with type 1 diabetes and you look at their beta cells in their pancreas, they look different epigenetically than the beta cells of an age-matched person without type 1 diabetes. And we also know that their beta cells don't function. So they've lost function. So let's ask that question as a specific example.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
What do you believe or what confidence would you assign to the notion that that the epigenetic change on the beta cells of the type 1 diabetic are indeed causal to the loss of function of the beta cells.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
What about something far less impressive, but still worthwhile? So consider if we could get to the point where we could locally deliver vectors that would epigenetically change chondrocytes so that you could take osteoarthritis in the knee and just regenerate cartilage, regenerate cartilage by changing the epigenome.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
I guess it kind of depends on why we think an individual would be experiencing osteoarthritis. How much of that is senescence? How much of that is inflammation?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
My favorite disease. Let's talk about cancer.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
That's been tested. We know that.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
That's a really good point that we all take for granted that I think is worth noting. Rapamycin can be unsuccessful as a chemotherapeutic agent and can yet be very successful as a cancer preventive agent. Absolutely. And it's exactly for that reason.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
This gets to, if I were health czar, this is what I would do. Because it comes back to what Rich said at the outset, which is, why is this a zero-sum game? I mean, you didn't ask it that way, but that's effectively the problem you're dealing with, which is why can't we study cardiology, oncology, and neurology and aging without everybody feeling like they're taking them?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So my way of saying that in Peter terms is we need to have medicine 2.0 and medicine 3.0 in parallel. Because the tools of the medicine 2.0 scientist and physician, which we see on display today, are putting the stent in, giving the chemotherapy, lowering the cholesterol, all of these things. The medicine 3.0 toolkit looks different. Different science. You're going to use rapamycin here.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
You're not going to use it over here because it's too late. Instead of saying one or the other, why isn't it both? Why wouldn't we want both of these running in parallel?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Yeah, I think I misspoke. It will be a portfolio reallocation. But it will be worthwhile because the burden of this disease will be lower. So in other words, it's sort of like saying, right now I spend $100,000 a year on the barrier to my house to prevent anybody from breaking in. And I spend $100 a year patrolling the neighborhood to make sure there aren't too many bad guys in the neighborhood.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
There's a scenario where if your total budget is $100,000 and $100, maybe you could spend $80,000 in total by spending more money patrolling the neighborhood.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
But wouldn't some of those people, as the funding dollars move towards the aging side, also want to move and say, look, I'm going to study this through the aging lens?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
They report to somebody too. Who would that be at this stage? Yeah, no, I mean, come on. Maybe it's because the public doesn't understand this. Those people answer to the public.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Yes, although let's ask the question, what have they done for those patients lately? That's a different question, but I mean, I'm just reinforcing what you said. I think part of this is educating people. If you know somebody who's suffering from Alzheimer's disease, you know very well that the only thing we've got going for us right now is prevention.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
We don't have too many silver bullets in the treatment gun.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
If you took the tools of medicine 2.0 and just applied them 30 years earlier, we wouldn't have ASCVD. That's the one place where it's weird. But again, that's because the mechanism of action is so well understood with ASCVD compared to Alzheimer's and cancer.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
You know, if I were to write my book again, I would add a fifth horseman because I talked about these four horsemen of ASCVD, cancer, neurodegenerative and dementing diseases and metabolic disease. But I would actually add a fifth hallmark. It's not really a hallmark of disease, but it's the fifth thing that brings life to a bad close, which is immune dysfunction.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And I don't think I gave that enough attention in the book because, of course, as you said, it factors in very heavily to oncogenesis. But also, as COVID showed us, what a risk factor it was to be old. And, you know, I'm reminded of this when I see people my age get brutal pneumonias. And like two months later, they're okay.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And you realize, two of my patients actually in the past six months have had really bad pneumonias where you're looking at the CT of their chest and you cannot believe they're alive. But of course they're fine. Three months later, four courses of antibiotics later, they're fine. And you realize you do that to a 75 year old, it's over. And it simply comes down to how their B cells and T cells work.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
That, to me, is an area where I'd love to see more attention, which is, what would it take to rejuvenate the immune system? As a proactive statement.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
You said something a while ago, Rich, that I think is timely now, which is with each generation of these drugs, they get more efficacious and less toxic. Not yet, but that's the hope. Well, no, no, but I'm going to use another example. The GLP-1s are the best example of this, right? So you go back to the very, very first generation of GLP-1 agonists, barely lost any weight, horrible side effects.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Generation 2, about 10 years ago, a little bit better weight loss, side effects so-so. Fast forward to semaglutide, quite a bit better efficacy, still really bad side effects. Next generation, terzepatide, better efficacy, side effects are almost gone. Now, why haven't we been able to do that with these geroprotective drugs?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So we have this one study using Everolimus that gives us a hint that says, hey, this might actually enhance immune function in people in their mid-60s. But we need the follow-up study, the follow-up drug. Imagine what the fourth generation of that drug can do where it's tuned to get better.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. Welcome to a special episode of The Drive. Today, we're introducing a new format to the podcast.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Which is true, by the way, of non-molecular tools as well.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
God, has it been that long? First one I remember was 2017. So yeah, a decade easily, because I probably wasn't paying attention in 2014, 2015.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So there are two places I wanted to go next, and I'm going to let Rich decide, because he's going to have the strongest point of view. Can we talk about senescence, or can we talk about what biomarkers would be necessary to help us study aging in humans as we translate from your work and Matt's work?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Can I just make a point for the listeners so they understand the challenge of what we're talking about? When we study blood pressure drugs or cholesterol drugs, the biomarkers change so rapidly and we know the relationship between the biomarker and the disease state.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So if your blood pressure is 145 over 90 on average, before I give you this ACE inhibitor, and three months later, six months later, nine months later, a year later, your blood pressure is averaging 119 over 74. I know I've done something well. Now, I will still probably in the phase three, in fact, I will in the phase three have to make sure that I also reduce some event in you.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
But generally by the phase two, I know that this drug is not toxic and that it's predictably lowering your blood pressure. That's really, really
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Is it a marker of nicotine or carbon monoxide?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Now, I just want to push on one thing, though. You talked about, obviously, the discoveries of molecules. You've been personally central to that work. But there was still a lag, Rich. I mean, it was 15 years ago the first ITP was published showing the overwhelmingly surprising and positive results of rapamycin. Those results were repeated. Why a decade?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Does it go? up in any of the mice that did not receive a successful drug?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
I've always wondered if in people the easiest way to do it would be to take the most obvious thing that we know is going to reduce the rate of aging. So it'd be an interesting experiment, but you find someone who is overweight, diabetic, and smokes and has hypertension. You get hundreds of these folks.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
You put half of them on a, to be ethical, a plan where you try to get them to stop, and presumably many don't. In the other group, you pull out all the stops and you don't care because you're interested not in testing the hypothesis, does this thing help you? You're interested in getting them to lose weight, not have diabetes, stop smoking, exercise like crazy.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
The greatest division between two groups of individuals where we would, I think, be able to agree that this group is now aging slower, the group that we've reconcile their diabetes, quit the smoking, et cetera, et cetera. And then I'd love to see Rich's 12 line up in that population.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Why do you think that is, Steve? Why is it? Because I was going to ask about parabiosis later on in the discussion. We might as well talk about it now, right? Parabiosis seems to actually kind of work in certain mouse models. Do we have any reason to believe it's going to work in humans? And if not, why not?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Let's be generous and charitable and call it a still decade-long lag from that. And by the way, I'll throw one more thing in there. If you go back to Cynthia Kenyon's work, which may have been the thin end of the wedge into the idea that lifespan was malleable, albeit through a genetic manipulation in a less relevant model, there's still a lag.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Different variants of that, yeah. Yeah. I haven't seen them. I've seen the one that's looking at, it's not really a parabiosis study, but it's looking at plasmapheresis for Alzheimer's. I consider that a little bit different, but fair enough. Okay. Because they're just using albumin, I think, aren't they? Right. But there's also studies going on of young blood.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Okay. I want to come back to this, but my question was why the difference? You're saying, Matt, the difference is probably amplified in disease-specific cases like heart disease, cancer, and Alzheimer's disease, probably less relevant when you're talking about aging because even a flawed mouse model still ages. In fact, it's designed to age in a certain way.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Do you buy Steve's argument that it's a confluence of technology, tech entrepreneurs?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
I would have to take an example in humans that is so egregious that nobody with a straight face could say one group isn't now aging slower than the others. Sure. Would that convince you though? So let's say we do that. Well, it would make me worry. It would only show you the positive signal. It would show you the specificity and not the sensitivity of the test. That's the problem.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
You might miss the signal. If you found a proteomic genomic, like if you found a multimodal signal that detected a difference in rate of aging between those two very extreme sets, you might miss it with a geroprotective drug, which wouldn't be as dramatic as that chain.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Because it's out there. I mean, it's in the literature. I mean, this is not perfect, but it would be one thing I would immediately think of, which is I would take a really good biobank that would have enough samples that I could sample a bunch of human stuff and use an unbiased sample and a biased sample.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So I would determine an algorithm based on one and see how well it predicted on another based on enough samples. That would have to be true at a minimum.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So that exists. And Dunedin-Pace is using something besides epigenetic or is it only epigenetic? I think it uses something else.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Well, but now we're getting into the definition of aging a little bit, which is, would you agree that the approach I'm describing would produce a longer life?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Well, if 80% of people died as a result of trains on train tracks, that might be a worthwhile example. But given that 80% of people die from these four chronic diseases... I'm all in favor of protecting people against chronic diseases.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Don't enough have to change that you increase the length and quality of your life? And if you still get a cataract at the same rate, I'm not sure that should be disqualifying.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And if the dogs did your thing- But we might not have an intervention that does that, to your point, Rich. I'm saying we might not have a non-pharmacologic method that does that. It's not clear that even though exercise clearly extends lifespan, it's not clear that it's doing so by slowing aging.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
I think so. My intuition is I think so, but I can't point to the evidence that tells me so.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Somewhat depends on where you start. I've always found these to be a little bit problematic because I don't think that defining it by the input is as valuable as defining it by the output. In other words, to say you exercise this many minutes a week versus that many minutes a week is a little dirty because intensity matters. What you do matters.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Sometimes the output is what matters more, how strong you are, how high your VO2 max is. Those tend to be more predictive because that's the integral of the work that's been done. But your point is it's well taken. The impact on health span is what I tell my patients. If this amount of exercise didn't make you live one day longer, the quality in which your life would improve would justify it.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Rich, have you done this experiment with an ITP cohort where you run in addition to a drug parallel? Nope. You know what I'm going to ask?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So you haven't done a sedentary versus exercise.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
You haven't done a obesogenic versus fasted.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
We got to get you a budget increase because that will now get to this question because now we could look at the soluble thing.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Do any of you believe that GLP-1 agonists are geroprotective?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
I'm taking the first as a given.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And I think it's impossible at this point because the studies are all done in obese and patients with type 2 diabetes that we can't disentangle them. So we will just say that for that patient population, the caloric restriction appears to be geroprotective. But yes, you're right. I'm technically asking the second question, which is in an individual who is metabolically healthy but overweight,
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
where there's actually no evidence that weight loss per se is necessary outside of maybe some edge cases in orthopedic stuff. Is there a geroprotective nature to this? And where it's most talked about is in dementia prevention right now. That's where it's at least most complicated to tease that out. So what do you guys think?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
I mean, Rich, this is one for you to test. Yeah, why hasn't the ITP tested this yet, Rich? Is it because the oral ones are just not strong enough?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Can you break your protocol and do an ITP with an injection?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
That sounds like an I need more money problem.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
I mean, there is an oral semaglutide formulation that's taken daily.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Could you do three instead of five next year and make that one of them? reallocate some funding?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
I have not seen the data on that. I can tell you anecdotally, having seen patients, it's going to be dose dependent. So as you know, that drug is dosed from as low as two and a half milligrams weekly to as much as 15 milligrams weekly.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Usually people who don't need to lose much weight, someone who says, look, I just want to lose this last 10 pounds and I've done all the exercising and dieting I can do. they typically just lose that 10 pounds and they take a very low dose. Now, to your point, if they took the 15 milligrams, would they become sarcopenic? I don't know.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
We could sit here and come up with 50 amazing questions.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Well, I think what's really frustrating as well is that these are the types of experiments that would allow us to actually start to economically model the impact of these drugs outside of just kind of a disease state. For example, if drugs like these are indeed and people can work three years longer or five years longer because they're healthier. Think of the impact on that over at OMB.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
What does that mean to tax take? What does that mean to delaying Medicare? What does that mean to reduced healthcare spending at the time when it is most expensive?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Wow. Can we just, because I'm in the mood to see you get spicy, can we just talk about senescence for a minute? Senescent cells, he means, Rich.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
What's the mechanism of this drug's action?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Has no action or it had no effect?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Are these the guys at Mayo? Yes. Yeah.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
But what was the phenotypic change in the mice when you did this experiment?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
But the nature mice were treated for how long? They were a long time.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
I mean, is your issue, Rich, that we talk about it like it's one cell, but in reality... Yeah, that's a big part of it.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
It's our inaugural roundtable conversation. For this one, we have gathered three brilliant minds, all former guests of the podcast, to sit down and have a nuanced, funny, sometimes a little heated discussion about one of the most fascinating and rapidly evolving areas of medicine today. also known, I guess, as longevity science. So joining me for this episode are Drs.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Do you think it's possible that a drug such as rapamycin has part of its effect on aging through a broad inhibition of a subset of the SASPs?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Do you think that going back to the meta problem at the beginning of our discussion, do you think that's maybe a better way to think about allocating funds? So for example, the NCI obviously receives the most funding within NIH. Maybe some of the NCI funding goes to the NCI to study cancer prevention through Giro Protection. Right. If the turf war is what matters.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Let's talk a little bit about metformin. Rich, do you think metformin is geroprotective in humans? I know it doesn't appear to be in your mice.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Actually, no, no. You know what? It was a different podcast. I did a very lengthy treatise in a journal club comparing the Bannister paper to the Keyes paper and came to the conclusion that the Bannister paper had too many methodologic flaws to be valid.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And how much of that is a selection for people in diabetes that are progressing much less slowly because they're the ones that stay on a single agent as opposed to the ones that progress into.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Yeah.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
This is a very important point. It came up in a recent podcast that I did with Sam Sutaria talking about healthcare costs. And in that discussion, one of the things that emerged, which I think most people are sadly familiar with this statistic today, is that among the OECD nations, the United States has the lowest life expectancy.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Why is generic sirolimus so expensive still?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Let me push back on that for a second, which is diabetes is an artificial diagnosis in that we just make a cutoff. We say your hemoglobin A1C is 6.5, you have type 2 diabetes. If your hemoglobin A1C is 5.9, you don't.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
But there are data that we've looked at that suggest a monotonic improvement in all-cause mortality as average blood glucose goes down measured by hemoglobin A1C in the non-diabetic range. Meaning, people with an A1C of 5 live longer than people with an A1C of 5.5 live longer than people with an A1C of 6, all of whom are non-diabetic.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Point being, if metformin's geroprotection comes through the regulation of glucose in the patient with diabetes, does it stand to reason that even in patients without diabetes, further attenuation of hepatic glucose output is going to improve all-cause mortality? Maybe.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And I don't want to speak for Nir because it's been a while since we've spoken. But the last time I had Nir on the podcast, his rationale for why metformin was geroprotective had nothing to do with glucose homeostasis in a non-diabetic. It was, and I know you're going to love this. I mean, Rich, you're really going to love this.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
There was a figure of the hallmarks of aging and how metformin acted on each of them. But my point being, not to say that that's incorrect, correct, or anything, it's that there was something much more primal about metformin's actions. Now, here's my pushback on that. Metformin requires an organic cation transporter to get into cells, as I've learned somewhat recently, that muscles don't have.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So if you look at the tracer studies, metformin does not get into muscles. It gets into enterocytes and the liver. It's very concentrated in the liver. gets in the gut, unclear from these tracer studies if it's getting into immune cells. So Nav Chandell tells me that he believes they are getting into immune cells as well.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Which is ironic given that we are spending on average about 80% more and in some cases double what most other developed nations spend on healthcare. So how do you reconcile this? Well, Sam made a very interesting point, which is that's aggregate life expectancy. But why is that the case? That's because the United States has by far the greatest rate of death in middle age.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So the question is, at least I think we need to ask ourselves the question, if it's working, which cells is it working on and how? And so the liver part's easy. Everybody gets big concentration of metformin shows up here. We sort of understand that that reduces hepatic glucose output. After that, I'm sort of scratching my head going, I don't know how it works.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And it makes sense, the glycosylation, the hyper growth factors like insulin, IGF-1, all these things. I mean, there's logic to that.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Let's use canagliflozin as an example. We've demonstrated, and I use we very liberally here, you've demonstrated that it reduces all-cause mortality in your mice, in males. And we know exactly what canagliflozin does in the kidney. And we know that those mice live longer. Do you believe that the longevity benefit came through glycemic control?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Because there was no difference in weight, if I recall.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Was the difference in weight statistically significant between the long-lived males and the normal males?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So the weight loss wasn't necessarily what explained.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So when you look at maternal and infant mortality, we're horrible. When you look at gun violence and suicide and homicide, we're horrible. And most of all, when you look at overdoses, we're horrible. When you kill a whole bunch of people in their 40s and 50s, you cannot have a very high life expectancy. Understood.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So what is your intuition, Steve? Going back to metformin.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Matt, why do you think that the ITP studies for rapamycin always worked, regardless of start young, start old, give it with metformin, do it by itself, always worked, and the mice are taking rapamycin every day?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Is the metabolic rate of the mouse so fast that giving the mouse daily RAPA is not the same as giving the human daily RAPA?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Why did you guys decide? I mean, I guess in 2008 or seven, when you did the first study, maybe it wasn't clear this idea of mTOR1 versus mTOR2 and the constitutive dosing. Maybe we should ask how many people at this table actually believe that model. Yeah, that's kind of where I want to go. I want to understand what we think is true and not true about rapamycin based on this experience.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
But what Sam pointed out was once an American reaches the age of, and I forget the exact age, I think it was about 65, all of a sudden they jumped to the top of the list. That was very interesting to me. In other words, if you look at the blended life expectancy, we're not doing very well.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Mouse liver. What about muscle?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
But if you look at life expectancy, just in measured as years alive, once you escape those big causes of death in middle age, we actually do quite well. And it comes down to what you're saying, which is we get very good at delaying death in chronic disease. That's what I call the medicine 2.0 machine at its absolute finest. We are going to keep you along an extra six months once you have cancer.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Sorry, what model was this? This was mice. Mice. Probably black six.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So what is your belief, Matt, around dosing Rapa in humans then, or even in your dogs?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Yeah, it was a milligram a day, five once a week, 20 once a week. Now, I've had both Lloyd Clickstein and Joan Manick on the podcast. It's been so long that I don't recall if I asked them why they designed the trial with those forearms.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Let's do the closest thing that a group like this could do in terms of a speed round. I'm going to go through a couple of other ideas. I just want to get the, what are you thinking about this? Can we say anything positive about resveratrol? No. Rich?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Why does this thing not die? Why is there still a hundred different resveratrols being sold on Amazon? Why do I still get people asking me, do you take resveratrol? Should I be taking resveratrol?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Yeah, yeah, yeah. Now, we could say that if you were force-fed the highest fat diet in the world, such that your liver encroached on your lungs through your diaphragm, isn't there a chance, Rich, that under that situation, resveratrol might help?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Wasn't that the one and only one experiment that worked?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
All right. Let's have a word on NAD, NR, NMN. Steve, what is your point of view on this?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And is it your view, Steve, that this stuff probably does not extend lifespan? But maybe there is some other healthspan benefit out there that has just not been studied. The right experiment hasn't been done. It hasn't been powered. Pick your favorite excuse.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Do you think if you're going to manipulate it, you would have to do it with really, really high intravenous doses? Or do you think you could achieve those levels using oral precursors? That I don't know. I will express complete ignorance on that. Matt, what is your point of view on all of this?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
We talked briefly about parabiosis and plasmapheresis. Let's come back to it a little bit. Steve, is there gonna be a day when the substance found in the blood of someone much younger than you, when infused into you, whilst some of your old blood is removed, is going to, assuming we figure out at what frequency that has to be done,
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
It is. Steve, if we could design the perfect experiments that would try to ask these questions. Let's just say we started by doing just the one experiment, which was the full parabiosis. So the putting in, the taking out, we didn't try to disentangle the effect. And there was no benefit in humans.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
What would be your best hypothesis as to why it would have failed, assuming it was statistically powered correctly and there was no methodologic error? If this was a biologic result, why would you think, given how favorable this has been in mice, it would not occur in humans?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
I mean, if it does work, this is an opportunity that we had the technology to do this 50 years ago, right?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
In other words, you might start with that, and no one thinks that if you do that experiment where you literally take blood out of an old person and discard it and take blood out of a young person and put it in, and you get a favorable result. Nobody thinks that that's what's going to the FDA. That is the proof of concept.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
But I don't know, would you want to go on that fishing expedition until you at least saw a signal? Yes. People are doing it. I mean, there are companies doing it. And on the basic research side. Of course they are. I'm asking a different question, though, which is...
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So if you could only do one experiment, would you do a plasmapheresis experiment? And if so, would you test... The simplest one is you literally just exchange old plasma for albumin. That's what they're typically doing in these studies.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
So scientifically then the hypothesis is it's the presence of something bad. Well, it's both. That is worse than the absence of something good. Because the albumin is not going to give you the young person. That's the problem with that experiment to me.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Just seems like there's not enough time and not enough money to do the work. Hopefully some of that's changing. If we were to do another longevity round table next year, which is problematic because this table, you guys are going to have to get awfully cozy. Any nominations for folks you'd want to invite to a longevity round table next time? There's so many people we could do this with, right?
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
And I'm guessing nobody wants to give their seat up next year. We have to make this table bigger.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Who's your nominee? I'd need some more time to think about it. All right.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
All right. So we think we'll do another longevity roundtable around the oval table? Sure. Let's do it. Let's see where we are a year from now.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
The derivative is very much positive.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Now, is Morgan at Yale still? She's at Altos. She's at Altos. Yeah. Okay. I wasn't sure if she was there full-time. Got it.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
All right. Well, Rich, you can get back to me on your nominees as well. I will definitely do that. All right.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
All right, guys. Thank you. Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
For all of my disclosures and the companies I invest in or advise, please visit peterottmd.com forward slash about where I keep an up-to-date and active list of all disclosures.
The Peter Attia Drive
#333 ‒ Longevity roundtable — the science of aging, geroprotective molecules, lifestyle interventions, challenges in research, and more | Steven Austad, Matt Kaeberlein, Richard Miller
Steve Ostead, an expert in aging biology and author of groundbreaking research on extending healthspan, Richard Miller, pioneer of the study of anti-aging interventions through the Interventions Testing Program, or ITP, which you hear me reference a lot, and Matt Kaberlin, whose expertise explores the intersection of genetics, aging, and translational research.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Like that's the middle-aged man injury. Oh yeah. Playing soccer with my kid and I'm just waiting for it.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
That's right. Because all I'd been doing in the intervening 25 years was swimming, cycling- Non-impact, non-impact. Hiking, which is fine, but it's still not jumping. It's not reactive.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And so part of what made me start to realize this was as my kids got old enough and I was now playing sports with them, when you play basketball, soccer, and baseball with kids, you realize exactly what you just said. It's not a predictable movement. It's never the same movement exactly twice.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Which actually gets to this idea that people listening to us are probably very familiar with, which is the centenary in decathlon. Give me some of the things on your centenary in decathlon.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Wrestling?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Yeah, yeah, yeah. Not a pile driver.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Discuss a framework for assessing and treating individuals, heightening the importance of understanding from between movement patterns, functional asymmetries, and personalized rehab approaches. Talk about some specific case studies, including Kyler's work with professional athletes and others to demonstrate the benefits of individualized strategies.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
When you're in your marginal decade, how many pounds would be your expectation? Give me some numbers. How many miles, how many pounds?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Okay, I like that goal.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And this is on what kind of terrain?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I agree. I think as much as I think there are probably examples where the wise old grandpa or grandma can sit inside and tell stories to the kids. I mean, there's value in that, but I think there's even more value in going to their world. They typically don't want to come into your world. You typically have to go into their world. So you have to be able to go fishing, hike.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And again, people listening to us who have young kids should not waste the opportunity to observe what young kids do. There'll be different technologies in 25 or 30 years, but I think the principles will be the same. Kids like to play and therefore playing with my kids today is giving me a dry run of what I want to be able to do in 30 years.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
When I first introduced this idea of the Centenary in Decathlon to the first of our patients, this is before, of course, we started 10 Squared. One of the bits of pushback I got a lot was, especially from people who were like in their 30s and 40s, they were like... Peter, I'm not that interested in my 80s and 90s. You keep talking about making me a kick-ass 80-year-old.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
the role of fear in movement and rehabilitation and how overcoming mental barriers is just as crucial as physical recovery, actionable strategies for you to assess your own movement patterns and implement proactive training techniques to build strength and longevity.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I want to be a kick-ass 40-year-old. What's wrong with that? What's the flaw in that logic?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Yeah. The analogy I used with people at the time, because archery is something I enjoy, is that what we're trying to do is train you to be exceptionally accurate at 100 yards. And you're telling me that you don't care about 100 yards, you just want to be accurate at 40 or 50 yards. And I'm telling you, trust me, if you're an ace at 100 yards, it's like shooting fish in a barrel at 40 yards.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And this is where the analogy is actually has a deeper layer of truth, which is that's a very nonlinear thing. 100 isn't just twice as difficult as 50. it's four or five times more difficult. And similarly, to be really fit and healthy in your 90s is a dramatically more demanding feat than just to be a fit 50-year-old.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Let's fast forward a little bit. Basically, as I'm kind of getting better from the shoulder thing and realizing how fortunate I feel to have had this experience where I've known Alton for a while, then I met you. It's this great connection.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I say, hey man, what do you think about this idea of we build this separate little business that just focuses on the training piece that's outside of my practice, outside of your practice, but integrates it with everything that's necessary to train a person for the marginal decade. So you bring in
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Now, in addition to this conversation, Kyler also filmed a short series of videos in the gym demonstrating exercises for common issues like lower back, neck, shoulder, and knee pain. These are designed to help you put some of these concepts from today's episode into action. The videos are only available to subscribers and can be found on the show notes page for this episode.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
All of the cardio training, you bring in all of the strength and conditioning, you bring in the coaches to integrate the whole thing. So, okay, we're doing that now of all the things we do in 10 squared. I still think that your domain is the hardest for people to wrap their heads around. I think people understand, oh yeah, you guys will help me get a high VO two max and you'll boost my zone too.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And you're going to make me stronger and blah, blah, blah. How do clients look at you?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
What are some of the things you see, and I'm not asking this to be critical of what other rehab professionals do, but as a person listening to us who says, look, man, I've been not getting better. I've had fill in the blank injury. So I've had tennis elbow that won't get better. I've had lower back pain that's just not getting better. Shoulder pain that's not getting better.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
How do you help that person think about whether or not there's an underlying structural problem that needs a surgical intervention or a more direct intervention versus You're not being instructed to do the right things and or you're being instructed and you're not doing it. Like, how do you walk somebody through that tree? Obviously, it's a heavy lift with a lot of details.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Are you saying that, it's going to sound like an ignorant question. Are you saying that in some facilities, one PT will work with multiple clients at the same time and put them through the same workouts, even if they're quite different?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So without further delay, please enjoy my conversation with Kyler Brown. Kyler, wonderful to have you. Yeah, thanks for having me.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Now, is this taking the extreme example at the other end, which is professional athletes? You work with a lot of them. You work with golfers, football players, basketball and baseball players typically, right? Is there any other type of athlete I'm missing? You know, I've had some incidental tennis people, a lot of runners too. Yep. Now-
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Some of those athletes come with deeper pockets than others and come from leagues. So when you're talking about the NFL players, for example, is that problem completely solved? No, not at all.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I want to kind of give folks a little bit of a sense of what you and I came up with a few years ago in the throes of my recovery from shoulder surgery and why that gave us this idea to take two things that seemed quite unrelated at the time, my recovery from an injury, coupled with this idea that I'd been
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So how do you guys do that? I didn't ask her in advance if we could do this. So we might have to edit this out of the discussion. Sure. Can we use my wife as an example? My wife is a client at 10 Squared. Great example. So Jill's a runner, like a little deer. Runs, runs, runs, runs, runs.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Yep. I'm very hands-off. Anything that has to do with her, actually, by design. Can you tell us a little bit about her? And what did you learn when you did an assessment of her? And how did that impact how she works with the other members of the team on the cardio side, on the strength and conditioning side?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
There's another detail here that I do recall. Obviously, you recall as well, but it might be worth pointing this out to the listener. So she normally only runs one marathon a year. Last year, she ran two. She ran her Boston qualifying marathon, which I think was Chicago or Houston or something like that.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
and then got into the London Marathon and went and ran that seven weeks later and started to get, for the first time ever, a little bit of knee pain. Yes, the other knee. The other knee. So can you explain why you didn't think that was a coincidence?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
marinating around this idea of a centenary decathlon in a marginal decade and why we decided to kind of put the best ideas or the themes of these together. So how does that sound? Sounds great. All right. So let's see, you and I met four years ago as soon as I moved to Austin. I don't even remember what we worked on because I think it was just like preventative stuff.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And so if the knee is caused by the hamstring, what do you think is the cause of the hamstring injury? And why are women, middle-aged women, so susceptible to this injury?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And the other thing I would add to this, which I suspect any woman listening to us who's had kids will appreciate, is even though Jill is tiny, she said her body never went back to pre-pregnancy. So if she talks about how she used to run before 2008, so our first child was born in 2008. And she ran a bunch of marathons before then. And then she's run a bunch of marathons since.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And she weighs the same. She's been very fortunate in that regard that her body weight hasn't changed in that period of time. But she says she cannot biomechanically do what she used to be able to do. Now, when I hear that, I assume her pelvis was mechanically changed having kids. And she feels it, but she can't articulate it, nor can I necessarily. But she just says there's something different.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
She felt like she used to float. And now she feels like she runs. Yeah, right. She's colliding.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I hope somebody is listening to us, by the way, and is thinking of another type of a 10 squared, which is what are we doing for women immediately post baby? Vaginal and C-section is two totally different operations or two different things. There should be really robust rehab paths to get them back in amazing shape immediately, as opposed to we'll come back to this in 10 years.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I think there's something about the pelvic floor that is absolutely decimated in pregnancy or delivery, more to the point. I deep down believe, no pun intended, that that's a part of what has gone wrong in her hamstring. I see this in many of her friends. This is a very common complaint. It doesn't present as even a hamstring injury. It presents as
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Either a knee injury, like an ischial tuberosity pain, which is like the sit bone. And they say, oh, it's just not comfortable sitting. Yeah, I don't want to sit.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
That's right. You're right. We were probably a couple months in maybe, and it was clear that I was nursing this bad shoulder. Um, And I knew what was going on because I had torn the labrum before. The diagnosis, I remember, was actually made in 2009. I had my first arthrogram in 2009.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Let's talk for a minute about the core. I hate the term because it's so misused, but the way we talk about it is probably most closely aligned with how DNS thinks about it, dynamic neuromuscular stabilization. So maybe just say a moment about it through the lens that we think about the core as a cylinder as opposed to quote unquote abs. Yeah, exactly.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
For folks listening who don't know what that is, an arthrogram is an MRI where prior to you going in the scanner, the radiologist takes a needle about yay long, like four inches long. shoots the needle into the capsule and injects contrast so that it really allows the MRI to show the labrum and how much it's detached from the glenoid fossa.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Yeah, there's so much I want to say on this. I don't want to lose the thread, but I'll sort of say two things that seem unrelated, but they're quite related. The first is, I wish there was another word for stability that didn't imply static. We think of that as things that are not moving. So rigid, stable, et cetera. But the truest way to appreciate stability is kinetic stability.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
That's why in the book, which I know you haven't read, but if you do read it one day, no. I've been too busy. Yeah, I know. The section of the book where I write about stability, the analogy I use much against the desire of my publisher who hated it was that of a race car. Because again, you're thinking like, how does a race car explain stability?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
But if anybody's driven a race car, or if you haven't, if you can take my word for it, one of the fundamental differences between a race car and a street car is that in a race car, you're transferring much more of that horsepower to the tires than you are in a street car. In a street car, a lot of energy seeps out because the chassis is not very stable. And you might say, well, why?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Well, in the case of a car, it's because it's more comfortable. Race cars are not being optimized for comfort, they're being optimized for performance. If you're optimizing for performance, you actually want more stability in the chassis and the suspension so that you're transmitting more force to the tires and the tires to the surface.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And similarly, when you think about an individual who has stability, they are able to transmit force much more directly to the outside world and they are able to receive force more safely from the outside world. And that's why no matter how long you ever gave me, I could never throw a hundred mile an hour fastball. And it's not that I don't have the strength.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I'm sure that if you put a 20 year old version of me next to a pitcher, I could have outdone him in every measure of strength. but I didn't have the stability to be in motion and stabilize the capsule of my shoulder and transmit force like a whip through my arm. You wouldn't look at a picture and think that's stability, but it's remarkable stability.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And so it was patently clear at that time I had a torn labrum. It was significantly torn, but not as torn as it would be 13 years later. But I had largely avoided surgery by doing as much as I could to strengthen the rotator cuff. And frankly, I was afraid to have surgery. That was the bottom line is I didn't want
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So when a client comes in at 10 squared and you do an assessment, how do you gauge how far they are away from being able to do... the dynamic movements? How are you gauging? What are you testing? What are you looking for to say, yeah, this person could start doing plyos.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Like for example, one thing I love doing, I don't have this on my centenary and decathlon list because we're being so strict about that only having 10 things, but I have kind of a side list of things that I want to be able to do. Like I want to know how late in life I can maintain certain metrics. And one of them is how late in life can I still do a broad jump of my height?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So why is that something I enjoy doing? Because it combines two things. It combines the concentric strength and power to be able to leap, but even more importantly, and at least as difficult, is it requires the eccentric strength to land and decelerate really quickly. How do you know when you look at someone if they're ready to do that, for example?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
to trade one problem for another, meaning I didn't want to trade pain and instability for immobility. And I saw that as the trade-off. Folks listening probably recall that I had a podcast. I did a sit-down discussion with Alton, who is the amazing surgeon, Alton Baron, who ultimately did the repair. But what I was most impressed by in that experience, which turned out to be wildly positive, was
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So just to be clear, people understand a wall squat is just level one.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Number one is failure constituted by pain or not doing it for a certain length of time.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
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The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Okay. So let's go back to Jill for a minute. So we have this diagnosis, which is, okay, we've sort of figured out why your knee is hurting. We now have a radiographic diagnosis that completely comports with what's being seen on the physical exam and symptoms. These are stubborn injuries. What was the next step?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
that immediately you and Alton started working as a team. And maybe you could talk a little bit about what you guys decided to do in the six, I think it was eight weeks we knew prior to surgery. We scheduled it such that you could do something before then. What was that discussion like?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I should know this because I live with her, but I don't remember exactly how long she actually had to stop running. I know that it was right after the first and second PRP injections, but does eight weeks sound about right? Yeah.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Right. When you're training for an event that's 30 years from now, you don't have to take shortcuts.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
All right, so let's pick another type of client that you'd see at 10 Squared, which is maybe somebody who comes in who doesn't have a great training history. They've never really been an athlete. But the thesis really resonates. They sort of go, you know what? I get it.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I feel fine now, even though I'm not particularly athletic and I'm not training a lot, but I'm young enough that it hasn't caught up with me yet. I'm in my 40s or whatever. But I now accept that when I do my test, because those people don't typically do very well on the assessment, you can't hide from not having done the work. So how do you think about...
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
where to start when there is so much work to do. So you talked earlier about this is on the second floor, this is on the first floor, this is on the penthouse, this is in the basement. We're going to focus on the basement. Well, what do you do when everything is first floor basement? Number one, we got to build the habit.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And if you were to handicap that, how many years away would he have been from something like that being quite likely? Is this something that's going to happen before he was 60?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Is that difficult to communicate to clients because do they ever feel like, hey, I'm not doing enough?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
That's a bummer. Yeah, this idea about foot reactivity is so important. I've been much more attentive to it in the past couple of years, and I've noticed the number of times when I've lost my footing and regained it. So I've never had a fall. It's never resulted in anything because it's been caught.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
But I keep thinking to myself, this is the type of slip that can be devastating because these are really type two fibers that are doing it. And the type two fibers atrophying as we age are the types of jumping things that we do sufficient to preserve it.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
If you're someone like me and you, who part of our CD involves probably walking on uneven surfaces one day, whether for you it's rucking, for me it's maybe going out and hunting or something like that, you're not walking on pavement. And you're not even just walking on like beautifully manicured grass. Yeah, it's slanted to the side. It's like pebble gravel.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
You're always going to lose your footing somehow and you have to be able to regain it. What are the most important exercises that you need to be doing to maintain all of the characteristics of tissue and nervous system to preserve?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I need to be strong. Basically, I needed to be able to hunt in September. So we backed out of that, said the surgery needs to be no later than March. It was January. And then the question was, should you do the surgery right away or do you use two months to prehab?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And so tell me how you thought about that.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And maybe just to even things out. So Jill doesn't think I'm picking on her injury. Let's talk a little bit about my limitations. So the thing that's probably been my biggest source of nag in the past 12 months has been foot ankle. Let's talk a little bit about those injuries, why they're occurring. And again, they're not debilitating. They don't actually prevent me from doing a single thing.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
But because I'm... sensitive. I just want to know, is this a harbinger of something? What's your assessment of what's going on? And how would you even describe it? Would you describe it as my ankle? Would you describe it as my navicular tailor joint? Where's the actual issue in me?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And thank you for not telling everybody the last cause of injury. I would never. Just for the listener. I don't know why, but I somehow decided two months ago to pick up a pogo stick. Never done it in my life. Somehow decided. Hey, is that in the bonus Centenary Decathlon for you? Yeah, I was like, I'm going to add another activity. Pogo sticking up and down the driveway.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Yeah, that goes in the bucket of you should have called me first. Like what a, I mean, the second I started, I was like, oh, not a good idea.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Just to be clear, we are nine or 10 weeks ago since my pogo sticking debacle. It's no longer as bad, but every single morning when I get up, there is still incredible and sharp pain right at that tendon. Why is this taking so long?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
We'll make a series of videos, of course, to go along with this. But explain that exercise, because it looks ridiculous. Nobody's doing that on Instagram. They are, but they're drinking the Kool-Aid. Yeah, all right. But it's a complex movement. So we've got a plate in front of me.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So we're two and a half, three inches up. Yep. My front foot, just ball of foot and toes are on there. I'm in a split squat. Yep. What am I doing with that front foot? I'm lifting it into plantar flexion. Yeah.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So this is the second time I've had this flare up. The first time I had it was probably a year and a half ago when I really started increasing rucking volume. This was caused by kind of an acute incident, which was the pogo sticking where I clearly over planter flexed or dorsiflexed, I guess, was part of the extreme dorsiflexion that did it. What do you think was driving it on the rucking side?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And more importantly, what does this mean for me? Long-term? Yeah. Because right now, it doesn't matter. If this keeps happening and I'm in my 80s, this is the difference between reacting and not reacting and being able to get around and not. So how do I prevent this from being a lifelong problem?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So I don't want to jinx myself and I hope I'm not doing it by saying this. Is this why, despite all the crazy stuff I've done, all the miles I ran growing up, never really had a knee issue, but boy, do I get these feet issues?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Yeah. Let's talk about something that you touched on a few minutes ago, which is around fear. We see this a lot. We see this in the medical practice where we have patients where we're overseeing all their training. Sounds like you see this at 10 Squared as well, where you have clients that are just coming in for obviously the training piece of this.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So is there any common thread to this or does it come in all walks of life? I've seen it in former athletes. who are injured, but the injury is so bad that they just never quite want to go back down that path, especially if they've had multiple re-injuries. I assume you see this in people who are not necessarily athletes.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So what do you think is going on there and how do you work up the confidence to accept that the pathway back isn't necessarily pain-free or injury-free, but it's more of a trajectory that's going to get better?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So the things that I remember, which are probably fewer details than what you remember, is one, how much rotator cuff work we did ahead of time, particularly around supraspinatus. So we really got that muscle as strong as possible in eight weeks. Anybody who's gone through that type of rehab, which I'm sure many people listening have, it's uncomfortable.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guest this week is Dr. Kyler Brown.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So it's really about empowerment with education. What is it that you would see when somebody comes in that would make you say, actually, we need to immobilize you? Is that something that's only going to be on an exam where you see a motor weakness, for example? Immobilize how? Like put them in a boot? Let's look at the lower back.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So if somebody shows up with a lower back complaint to you, what's going to make you say, no, actually the answer is seeing a surgeon or complete and total rest. What is kind of your algorithm on people presenting with lower back pain?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So this means you're going to do the rectal exam, make sure sphincter tone is there.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I mean, you're burning a little tiny muscle that is not used to working that hard. The second thing that I remember, and hands down the most important thing, was what you and Alton decided to do post-operatively completely shattered everyone's understanding of what we do with these patients. So the traditional view is, especially, this wasn't a slap tear. The entire labrum was hanging by a thread.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Describe for people what that is.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Can people do these by themselves or do they need to be? Yeah, very easy. We can link to where people can go and look at these.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
It's almost always the sign of a great spine surgeon, which is once you rule out the Acute weakness, the thing that is a surgical necessity, the ones that want to wait are generally the better surgeons.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
It must be amazing how often we all encounter, hopefully not personally, but professionally, people with lower back pain. The statistics are, I can't imagine there's too many people listening to us who don't have personal or indirect experience with it, either obviously through themselves or through somebody they know closely.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
There is something about it that I can really relate to being nerve wracking. It can be terrifying and also demoralizing, I think is how I would describe it. Just demoralizing when your lower back hurts in a way that's not the same as if your shoulder, elbow, knee, or hip hurt.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And normally, as you said, a surgeon's primary objective is, hey, I'm going to make sure that this is never unstable again. I'm going to cinch this down really tight and you're going to be in a sling for four to six weeks. And that's going to give it plenty of time to heal. All of that sounds great, but you'll never regain your mobility.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Do you think this is scalable? I feel fortunate that we're able to take care of people where we have the luxury of doing this very bespoke approach. You can integrate your strength and conditioning with your cardio, with your PT rehab and all that stuff, and it's all great.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
But do you see a day when this could all be app and AI driven, where any person out there with any set of lower back symptoms could be provided with the feedback that they would need to take care of themselves? If they execute, absolutely. How would you get the feedback?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
If you have good enough image recognition software, would that be a necessary step that if you were using such a device like an app, you would have to be able to set up your phone on a tripod to be at least able to capture you doing it? Because the advantage of being able to do this the first few times with an actual person like you is the cueing is so important.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
A lot of these exercises are not natural.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
100%.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
100%. Yeah. Image recognition is one thing, but it's knowing what to do with that information.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And why did you gravitate towards this? I mean, we didn't really get into telling people your story, but you went to chiro school, but then you immediately went out and did a sports medicine thing. You worked with the New York Giants.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Why did you just opt into the role you're doing now, which is much more in the PT rehab space than it is what people, I think, assume of traditional chiropractic, which is here's a 40 adjustment schedule. I don't have a point of view on that, but what drew you more towards the side of things you're on now?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
You'll never regain the range of motion you want, the healthy range of motion you had. And frankly, you'll probably atrophy away. And so Alton said, no, we're going to have you out of a sling in 24 hours. And I was like, how is that going to be possible? And yet we did. There's no way he could have done that if you guys weren't partnering on this. How is that even possible?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
What is the role for what most people think of when they hear chiropractic, the adjustments? What does it do? I don't want to ask you to sort of be critical if that's the word of a profession that you remember of it, but the fact that you aren't out there
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
doing it 24-7 suggests either you think it's really, really valuable, but it's just not something you want to do, or you don't think that it's valuable enough. How would you advise somebody that came to you and said, hey, Kyler, I have injury X, my neck, my back, whatever. I got this awesome package of 40 visits for X number of dollars with my local chiropractor.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I see him for eight minutes a week, twice a week, actually. It's really special. Do you think that's a great plan?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And why does that fly in the face of everything we would think of?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So is it safe to say then that whatever the suite of underlying modalities are, from adjustments to taping to cupping to needling to active release to manual, you name it, the goal of all of these, and the more of them you can utilize the better, is to create a window in which the individual is safe and out of pain so that they may do the work to retrain a movement pattern and increase strength?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Okay, so let's kind of put this now all back together, right? We've kind of gone really deep down one of the three pillars. You now have basically two things you're trying to do. You're trying to do everything you're doing in concert with a broader agenda of change.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
creating a precision training program, not an exercise program, not a workout program, a training program for an athlete whose sport happens to be life. And you have to be able to do it with the strength and conditioning coaches, the cardio coaches. And then the other thing you have to be able to do is you have to be able to do this remote because most of the 10 squared clients are remote.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
They come to Austin for two days, they do a whole bunch of assessments, They go away for six months, then they come back. Some of them go away for less, but a lot of them, they go away for a year. It's because they're out of the country and it's just not easy for them to be here. So how are you able to do this remotely? What are the challenges and what enables it to make sense?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
What do they need when they're back home?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I want to tell a story on that vein that is one of the most incredible experiences I ever had. This would have been in 2018 or 2019. And I had the first flare up I'd ever had of my lower back since 2000, when I had my botched surgery and all that nonsense. So I'd gone 18, maybe 19 years, maybe it was early 2019 without a single flare up. And then it happened. I get the flare up.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
At the time I was working with this guy, it was my first person I'd ever met who did DNS. I had already learned about intra-abdominal pressure. We were doing all stuff. In fact, when I went to see him, my back was totally fine. I had tennis elbow. So I had this tennis elbow and he figured out pretty quickly that my tennis elbow was completely due to my scapular instability.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And my chief complaint was when I do a lot of pull-ups, my elbow hurts. I don't even play tennis. So we had fixed all that, but I kind of was like, this is amazing. I want to know what else is going on. And then independent of that, I get this lower back flare up. And so I'm in there seeing him on one day when I'm in, honestly, like about the worst pain I'd been in, in years.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
His training, by the way, is also a chiro. So he's chiro by training who probably hasn't done an adjustment in 20 years, just doing DNS. And I'll never forget the exercise he had me do. Cause I was like, I don't know how this is going to work, dude. So he laid me on my back and he had me get into like an imaginary leg press position.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
You know, those old school leg press machines where you're pressing up. Yeah. Not the one where it's on a slope, but the rack moves vertically. Super old school. Yep. So I'm on my back. I'm in that position. And he is now laying on top of me. So he's got his pecs basically on my feet. And he's cueing me through really good intra-abdominal pressure and isometric contraction, pushing.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And lo and behold, my back is getting better and better. And we're doing sets, 10 second, 20 second, 30 second. At some point, I'm getting so strong, we need more resistance.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So now we go and build a makeshift thing under the squat rack, where I forget if I was on a Smith machine or on a squat rack, where basically now I have infinite resistance, kind of like how you described it with the partial deadlift. I am getting to the point where when I walked in there, I wouldn't have been able to push 10 pounds away from me. That's how much pain I was in. And now-
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
I'm convinced I was pushing 600 pounds of force against that immovable bar, and I've never felt better. And I couldn't understand how that could happen. How is it that I could not walk, but limp into that guy's gym in so much pain and spasm, and an hour later... I feel like a million bucks. How could that happen?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Yeah. I consider that one of the most profound experiences of my life from a physical perspective and also in how much it changed my point of view about what back pain is and isn't. I don't want to suggest for a moment that if you're sitting here listening and you have back pain, that's the answer. Go and find a guy to do that.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
But I'm saying that there's so much more going on than we realize and so much of back pain is not surgical and so much of back pain can be healed with retraining a movement pattern and getting our nervous system to kind of get out of the way.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So speaking of that, I think what we'll do is we'll now pivot over to the gym and kind of work on a few issues. So we identified four areas that we want to highlight for folks. We're going to do neck, lower back, knee, and shoulder. I guess you picked those because that's 80% of what people complain about.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Truth be told, I learned a lot of that the hard way from my first orthopedic surgery back in 2000 when, A, I'm not even convinced I received post-operative instructions. And if I did, I didn't read them. And I was breaking every rule there was. The stakes were higher here in a way, and I think I was very mindful.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So walk us through the framework. I love your framework for how you approach these. So what's the framework?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
For example, people, myself included, when you have surgery, you tend to go on YouTube to learn all about it.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Yeah, so that makes sense. That's basically the thought algorithm on how we do this. What can we show people? We're going to go to the gym and we'll give people a few examples. I'd love people to have some takeaways on, hey, what can we do here? How could I put this into practice on my own?
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And I'm like, okay, I want to see everything. I want to watch the post-operative. I want to watch the rehab process. And so one of the big milestones you see for people with labral surgery is when they basically can dangle the arm and rotate like a lightweight. And Alton was really clear, like, you're not going to be doing that for a while.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Okay, excellent. Kyler, this was really a ton of fun. Enjoyed sitting down with you. It's not normal that I sit this far from you, but at a distance, you look just as great as ever. Devastating as always. Thanks a lot. Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
For all of my disclosures and the companies I invest in or advise, please visit peterottmd.com forward slash about where I keep an up-to-date and active list of all disclosures.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
We're talking about range of motion without stress on the repair. Right.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Kyler is a sports rehab chiropractor who specializes in sports injury pre and post-surgical rehabilitation and bridging the gap from rehab to performance. He is the co-founder, along with myself, of 10 Squared, an Austin-based private member training program focused on building and maintaining exceptional muscle capacities for the marginal decade.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So in parallel to this, I'm continuing to sort of refine my thinking around the idea that we're all going to have this marginal decade one day. And it does come across as sort of a depressing thought. Nobody really wants to think about the idea that there will be a day when you knowingly or unknowingly enter the final decade of your life.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
But at the same time, to act as though it's not true won't make it not so. So I think it occurred to me that the more deliberate we can train for that last decade as though we are athletes, the more we can enjoy it.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Because as I watch people in the final decade of their lives, and I've had the both privilege and curse of seeing a lot of it, I believe that the thing people complain most about is what's taken away from them physically. Now, there are lots of people in the last decade of their life that are lonely because they were miserable sons of bitches and their family, they don't have family or friends.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
All of those things. There are many people whose cognition has failed them long before their body has failed them. And that can be very distressing. But if I'm really thinking about this in terms of large numbers, more than two thirds of people, I would say in the final decade of their life, when they're really thinking about what's impacting the quality of their life,
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
It's this, it's the physical part. That's the thing I've lost that I miss the most. And sometimes it could simply be freedom from pain, but more often it's restriction of activity. Yeah, totally. And that's my biased experience. You see much more of this. Tell me what you think.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Yeah, and I kind of even began to observe that in myself, which was there were a lot of activities that I was doing where I was doing them because I'd historically always done them. We fall in a groove. This is a type of exercise I enjoy doing. This is a type of workout I enjoy doing.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
And then I had to kind of take an honest assessment of some of these and say, okay, for every activity, just like for every investment, there's a risk and there's a reward. And the way you might think about investing in your 20s is probably different from how you maybe should be thinking about investing in your 60s or 70s or beyond. And similarly, the risk and reward changes over time.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
So for example, when you're 20, the risk is just inherently lower because you have better tissue. We could go through all the reasons why, inflammation, senescence, everything that changes as you age reduces tissue quality. And younger people, I'm sure you see this all the time, can just get away with doing things incorrectly.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
In fact, would you agree that sometimes some of the most gifted athletes actually have horrible patterns of movement, but because they're so gifted, it doesn't seem to matter? Yeah.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Originally, this was a conversation that we recorded just for the 10 Squared audience. But once it got out there and we saw how much the clients there appreciated it, we decided to repurpose it as a podcast for all of you. In this episode, we discuss the principles behind injury prevention, recovery, and performance optimization, including how small movement dynamics can lead to chronic issues.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Yeah, the jumping is a great example because if I go back to when I was in my sort of training peak, so basically age 13 to 20, call it those years when I was training a lot, jumping was an enormous part of what I did. There wasn't a day that I wasn't jumping. So for example, I was skipping rope 25 minutes every single day. You know, lots of those are doubles. So you're really up there.
The Peter Attia Drive
#350 ‒ Injury prevention, recovery, and performance optimization for every decade | Kyler Brown, D.C.
Absurd amounts of plyometrics. And then from basically 20 to my mid 40s, didn't jump at all. Not a single jump. That became one of the realizations was, oh, you've lost a lot of tissue pliability. As one example, now something that I do a lot of is low level jumping. You're right. Sometimes I get really worried. I'm like, oh man, I don't want to have an Achilles rupture.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
So how did you start to formulate this understanding about these different types of resources, be it time, be it money, which is the resource I think a lot of people think about, experiences themselves as, for lack of a better word, an asset or a thing, the actual experience, the people you're meeting, all of these different things. When did you start to
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
We start this discussion by talking about Bill's background and his upbringing and the genesis of the philosophies in this book, something that came to Bill throughout the early part of his career. We talk about the overarching philosophy of the book, which is that we all have three important resources, time, health, and experiences.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
coalesce around some of the ideas that ultimately, of course, would go on to become the thesis of this book?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
The idea that- It's also, just to double click on that, Bill, it's also visceral when you start to think of the difference between using money for activities or trips versus things. So I buy a shirt and this shirt basically works out to three hours of what I make per hour. So this is a $3 shirt, I mean a three hour shirt. Yeah. Conversely, I take my daughter out overnight.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And of course, we use money as a tool to trade off these three things. Bill makes the argument that no matter at what level of wealth you are, most people overlook the most valuable asset of all, which is time. We speak about the importance of understanding risk, including the opportunity cost of decisions that we do or don't make, the risk reward matrix, thinking about regret,
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
We do like a daddy-daughter date night, go out to dinner, stay at a nice hotel, have a fancy breakfast the next day. That's five hours of my time in terms of work. But do you see those sort of differently at the time? That one of those is like an experience and one of them is a thing?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Right. Imagine that you have $25 chips. You figure out your hourly after-tax all-in wage is $25 an hour. Every time you flick a chip, it's like I gave an hour of my life. Boom, boom, boom.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Are you having that discussion with other, either people who are your peers who are presumably on the same treadmill or the people who are already rich, but still presumably killing themselves, trading their health for wealth?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
I would argue a little different, Bill. I would argue that at this point, you're 22, 23, 24. I think that's remarkably early to be having that thought, don't you?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Yeah. It's one of the games I often play with my patients. It's anybody. I could play this game with anybody, which is, listen, if right now you always do this with someone who's younger, obviously I say like right now, would you trade places with Warren Buffett or Charlie Munger? And they're like, everybody says, of course not. And I was like, what do you mean of course not?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Like Warren Buffett's worth a hundred billion dollars. How would you not trade places with him? And they're like, I mean, he's 90 years old or whatever. And I say, okay, so would you rather have not a penny to your name and be 20 or have a hundred billion dollars and be 90? No other difference, right? Like I'm not going to stipulate anything else. I've never met a person who wouldn't take being
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
a completely broke 20-year-old. And that I think speaks less to health because look, ostensibly Warren still appears somewhat healthy, right? He's cognitively intact. It's not like he's like a frail 90-year-old or whatever he is, but it's about runway. It's about, yeah, but maybe Warren might have 10 years of life left. That 20-year-old could have 80 years of life left.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
and the dangers of living a life on autopilot when it comes to work and fulfillment. Overall, I have found Bill's insights from this book and my conversations with him, outside of this podcast even, to be valuable in my own life, and I think they are very important for anyone, regardless of age, net worth, or stage of life.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And so when you face it in such stark terms, only then I think does the average person start to realize how precious time is.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Now let's pause for a second, Bill. Is that standard thinking slash teaching within the wealth management community?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
So without further delay, please enjoy, or re-enjoy, my conversation with Bill Perkins. Bill, thanks so much for coming by. I've been looking forward to this for a long time. I have too. I'm really honored to be on your podcast. I don't know.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Let's also pivot and talk about, I remember one of the stats that always stuck with me was during 2008. So a really good friend of mine named Jim Lambright, who was at the time the president of the Ex-Im Bank,
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
When the TARP program kicked on, because he was close with Hank Paulson and had already spent so much time in China and had government clearance, basically Hank brought Jim Lambright and Neil Kashkari, who was with him already at the Treasury, I believe, to run TARP. So basically, Jim and Neil are doing all the deals for TARP. And Jim is getting steeped in how bad is this going to be?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
What is this going to mean for the average person? And I remember one day he called me with a stat that I couldn't believe. And I forget the stat, so this is only directionally it. But it was what fraction of people in the United States could not produce $1,000 with three days notice? meaning they didn't have that excess liquidity of $1,000.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Again, I don't remember the number, but it was in the ballpark of like 30%. It was a high number. I don't know what those stats are today. I've tried to look some of them up and they're not maybe quite as dire as that, but they're not that much better.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
It's not great. So what's the natural history of that person who's 40 years old whose total net worth is $50,000 and their available liquidity is $1,000. They're thinking, I'm going to work till I'm 65 or 70 or whatever, and then I'm going to collect my social security. Does this thinking still apply there?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
A little while ago, I made a video on Instagram where I talked about three books I've read in the last 12 months that I didn't expect to A, have such an impact on how I thought about things, but also B, even though they're completely different books, they strike me as having kind of a unifying theme in this sort of thing about quality of life.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
One of the things about the way you framed it, Bill, that I really like, it's a very nonlinear problem. So let's look at those three variables. At the surface, one might suggest, well, wait a minute. It is a min-max game with one of them. You always want max health. But technically, even that's not true. Because if I told you, Bill, I have the secret for you to have max health.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
I can preserve your healthspan and lifespan indefinitely, but here's what it's going to cost you. Every minute of the day, you have to be working on your health. So from the moment you wake up from sleep, you have to do a two-hour meditation. We then have to go and do this yoga. We then have to go and do this workout.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
When you're done that workout, you have to go and do this, and then you have to go to bed. You'd be like, well, Peter, that sucks because, yeah, I'm going to live for 100 more years and I don't get to spend any of that time doing anything other than improving my health. It's a glib example, but it factors, I think.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
The three books are, one of them was From Strength to Strength. One of them is 4,000 Weeks. And the other one is Die With Zero. Now, what's interesting is I know exactly who suggested I read 4,000 Weeks. And I'm really good friends with the author of From Strength to Strength. So that's why I just read that knowing it was coming out. I still don't remember who recommended Die With Zero to me.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
By the way, Tetris is the only video game I enjoy. I go through periods where I won't play it for a year. And then I go through periods where I'll waste 30 minutes a day, which is a lot of time for me. For me, 30 minutes in a day is an inordinate amount of time. And when I'm sometimes in those phases of playing it a lot, I dream in Tetris.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
I literally dream that everything I'm seeing in the world, I'm trying to optimize the shape and interaction of.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Right. Because they're not going to want me reading to them in college.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Yeah, you're not climbing Kilimanjaro at 80.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
So how do you think... about your own risk tolerance. Now, I guess there's maybe a caveat the listener needs to understand at this point, which is what you do for a living today. So you are an energy trader, among other things. You do many things. But is it safe to say that the majority of the wealth you've created came through your ability to understand how natural gas moves and trade on that?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
John Arnold, who is one of your closest colleagues, someone who I've had on the podcast, nicknamed the king of gas, the greatest gas trader of all time. Do you look at a guy like John and say he has a high risk tolerance?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Do you look at someone like yourself and say you have a high risk tolerance or do you not feel that way at all and feel like, nope, I'm completely in control of calculated risks and that's why they net out to be positive. In other words, I'm less swayed by short-term volatility because my methodology doesn't feel like I'm gambling.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
But I remember... just thinking, okay, well, cool, sounds interesting. Ordered it and then just couldn't put it down. As I think I mentioned in the video, immediately made my wife read it and then immediately just went out and bought many copies of it along with many copies of the other two books. So I basically started handing them out as like a triplet copy.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Tell folks what expected outcomes mean because they want to understand the probabilities and how these work.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Yeah, in trading, if someone is right half the time, they're pretty good.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
So with that said, if someone says to you, you just have a really high tolerance for risk. I don't. I'm very risk averse. I don't like to take big risk. I never want to have the chance of losing something. Loss aversion is a greater motivator for me than gain. How do you talk to that person and how do you help them Think through the difference between fear and risk tolerance.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
One of my patients said something to me once. He was about to do something that I just thought was really risky. Now, it was a very unique opportunity. And he said, Peter, I'm going to go and do this thing. And I said, I think there's a significant risk to you in doing that. It wasn't a financial risk. It would have been a health risk, a physical risk. And he said, you're right, Peter.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
If someone was over and they hadn't read them, boom, they were leaving with all three copies of the book. So that speaks to why I wanted to sit down with you. And let's give people a sense of who you are. So you grew up in Jersey, right? Yeah, I grew up in Jersey City, New Jersey. You're an engineer. We have that in common, right?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
I acknowledge that risk. That is the risk. But I'm optimizing in a risk, pardon me, a regret minimizing framework, not a risk minimizing framework. For me, it's risk reward.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
How variable do you think people are in their stratification of what encompasses net fulfillment? Maybe a better question is... Do you think people are even understanding about and deliberate about what that means? That doesn't strike me as something that the average person could articulate very clearly what it is that will be their fulfillment maximizing function in terms of experiences.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And I want to reiterate a point you made, which is it's not just the experience, it's when they occur. The combination of which experiences and when they occur and who they occur with, do you get the sense that the average person can actually articulate that?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Now, I had a discussion with a patient just yesterday, so runs a hedge fund. And not surprisingly, given the economic climate we're in, hedge funds aren't doing particularly well, especially long hedge funds. And this guy doesn't need to be working.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Even though he's now having a down year, I mean, he could certainly return all the capital to his investors and manage his own capital indefinitely or do nothing, literally do nothing. But he said, what would I do? Yeah. What would I do? I'd sit around for three months and it would feel really nice to have no stress for three months. And then I'd be bored out of my mind.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
So he's like, no, I got to keep going.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Now, how do we differentiate that from people who... And I would put myself in this category, truthfully, where a big part of their work... is their fulfillment and they do feel a sense of purpose in what they do beyond just the making money part of it. And I suspect that like, again, just to make caricatures of things, right?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
So maybe the person who works in the widget factory that makes the widget that they don't even know what the widget plugs into, but they need a job. If they inherited a big lump sum of money tomorrow, they would happily quit the widget job.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
But maybe they'd get bored and they'd want to go back and start volunteering and doing something where they don't actually get paid, but they're really enjoying what they're doing. And then, of course, you have the group of people whose job is doing two things. It's providing money for all the things that you need, both in approximate sense and distally.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
but also it is a sense of purpose and therefore it fits into their fulfillment. But these things can be very slippery. And I would certainly put myself squarely in that category, right? Which is I still work harder than I should. And I absolutely know that I'm failing in the equation, even though I'm fulfilled by this and I wouldn't want to not do this, but I'm doing too much of it as an example.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
You graduate college with a degree in engineering. Maybe you're not first in your class. You decide though, you're going to go and instead of going to grad school or something like that, you're like, I'm going to go to New York. Is that your first job? I love that.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
I think that that's probably the part of the book that most kind of resonates with someone like me, which is, especially when it comes to kids. And I have, I guess the, maybe it's an advantage, maybe it's a disadvantage, but my kids are sort of separated in age by a bit of a gap, right? So my daughter's 14 and then the boys are five and eight.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
In other words, I now know what it's like to have a teenager. I now understand all the things that you kind of give up when your kid's a teenager. Our daughter's an amazing kid, but the reality of it is like she doesn't really want to be around me. No, they don't want to know you when they become teenagers. I didn't want to know my parents when I was a teenager.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Whereas conversely, the boys can't leave us alone. And it's tempting to sort of say, I wish they would just leave us alone. But now knowing that, oh, actually in six years, you'll kill to be back in this situation makes it infinitely more easy to appreciate. That's kind of one thing that I think is helpful for people to understand the seasons, this idea of seasonality.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Like you, I probably think back to things I didn't do for different reasons, right? So when I was in college, I mean, I couldn't have worked harder. I mean, I was out of my mind how hard I worked. My night off, there was one night, which was Friday, when I only worked till 9 p.m. It was my break. And from 9 p.m.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
I would go and do laundry after 9 p.m. on a Friday. That was my way to just take a little time off. But other than that, it was- six hours a day of work outside of class. And I think of all the things I didn't do in college. So first of all, my only memories of college are pure misery. I hated every minute of college. I didn't have- You didn't have the experience. Yeah.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Now, I could say, well, a lot of good came out of that because I did really well and did well. That set me up for the next thing and the next thing and the next thing. But I could have traveled. I Having a college experience didn't mean I had to get drunk every night. It meant that I could have saved all that money I was making by tutoring and done something different.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
It is extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member-only content and benefits above and beyond what is available for free.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And you read it at what age?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Push into the future.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
One of the other things that you talk about, and you've mentioned it already today a couple of times, is philanthropy. So there's a story in the book about a woman who dies and leaves a large gift. Tell that story again.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Well, and this is sort of interesting because think about what our mutual friend John Arnold did 10 years ago, which was before he even hits the age of 40, he decides, I'm no longer going to do this full-time. My full-time job is now giving this money away.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And I think one of the things that John exemplifies is how to give money away thoughtfully. Correct. And what you realize when you spend any, like the time with him, which you've spent more than I have, it is really hard to give money away strategically and thoughtfully, which is why I suspect John and Laura set themselves up with 50 years of a runway to give. Yeah. I don't know.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
There's a pretty good chance they still won't be able to give it all away, right?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
But it takes time. I mean, that's the other point. You have to invest the time to try something out, see if it works. If it does, double down. If it doesn't, learn why it doesn't, pivot. And you can't do that if you say, look, at the end of my life, I'm going to give away a billion dollars. Like it won't be effective. There's a double issue here.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
There's the issue you already said, which is the compounding issue. No, if you give a billion dollars away in 50 years versus giving away half a billion dollars or a hundred million dollars 30 years sooner, that money will do more good.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
But there's another layer to that, which is you have a chance to learn from what that money did and make corrections that themselves allow for more thoughtful giving.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
The other thing that you talked about in the book that really probably, this is probably the reason I had my wife read it right away, was the idea of, we sometimes think that there are people in our lives that we want to give money to at some point. And you sort of think, that's a person that was really important in my life or in our lives.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And maybe we leave them X amount of dollars at some point. And then you sort of realize, well, why don't you finish why that's maybe not necessarily the right strategy?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Or relatives or anybody else.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Correct.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Again, when I read your book and you articulate it that way, I mean, it's such a gut punch of this realization. And one example is kids. My wife and I have people in our lives that we're not related to that we value so much. And we've always said like, yeah, we want to give them X number of dollars at this point in time.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Absolutely. It's right now. Well, especially when you think about exactly what you said, which is that person will do much more with that in applying it to their fulfillment curve in real time.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
How do you help a person do the math? Because we've talked about this quite a bit and you've alluded to it. There is really a curve. This is where both your background primarily as an engineer and a trader come into solving what becomes a mathematical set of equations where you have... certain variables you need to understand.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Let's say we're solving this for me or for you or an arbitrary person who's sitting here who's 50 years old. A 50-year-old person is listening to this or a 30-year-old person. Maybe we do a few different scenarios. Let's start with the 50-year-old who is firmly planted on the treadmill of autopilot. Their kids are in middle school and high school.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
They realize how much money they need for college for their kids. They've got a mortgage payment. They've got a good job. And they have a fuzzy notion that they're going to work another 15 to 20 years. And they come to you and they say, Bill, I read the book. I buy the thesis. I don't know how to implement it for my numbers and for my fulfillment curve. How do you help them think about it?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
So I'm going to say, so Bill, no, I do have interests, but I got to be honest with you, man. I've backed away from them. You know, I've kind of let them go. I've let myself go a little bit. Before my wife and I had kids, we loved traveling. And before our kids were born, we hiked the entire rim of the Grand Canyon. We went down to the Colorado River back up, probably the greatest thing we ever did.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And then once the kids came, we were kind of head down and work. And I just want to make sure that my kids don't have debt when they go to college.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
I was like- It's also so expensive, Bill. I mean, do you understand what it costs now? One of my kids has a friend who did this African safari a year ago. They said it was amazing. To price that trip, Bill, today, $30,000 to go do that African safari now with the airlines, with the safari. That's a lot of money.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
I just want to be safe. I mean, how do I know?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
When you do that with people, Bill, how often are they able to articulate clearly what they're afraid of versus it being kind of just a fuzzy notion of... A lot of it's fuzzy notion and we just keep pushing and pulling it out.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Right. That's very difficult to underwrite.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
To me, that's the interesting distinction. Maybe somebody listening to this says, are you freaking crazy? I'll never take a $30,000 trip ever, ever in my life. Yeah. The bigger point is, is there a trip that you think you will take near the end of your life, and you're holding back on taking it now. I mean, to me, that is one of the big aha insights from this philosophy.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
So how do you get through to somebody when you confront perhaps an even more illogical problem? Because the problem that we just discussed is actually quite logical. Like it's easy to understand why a person would think I have to save for a rainy day. That's been pretty ingrained into a responsible person. To me, there's a far less logical reason that people forego doing things when they're young.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And by young, I mean kind of like middle-aged, like in their work.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Young is right now. Yeah. And it's because they're so busy making money. So this is probably the one. That's the rat in the wheel with no cheese.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
How do you help somebody break that?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Is Chris Rock in town tonight or is he in Houston?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
It is one of the biggest cliches ever, which is the person on their deathbed who says, I wish I didn't work so hard. And yet we all know this cliche, and yet many of us still work too hard. Habits are powerful.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And what do you use to help jar you out of autopilot on these things?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
So each week you do check off a box on the calendar?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. Welcome to a special episode of The Drive.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
This job is down on Wall Street. This firm's on Wall Street.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
How do you help somebody think about when their net worth should peak? Because a clear implication of everything we're talking about is net worth probably needs to peak a lot sooner than it currently does. As you said, I think the default for most working people is that net worth
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
peaks sometime after retirement or certainly around the time of retirement, even if they're thinking about drawing down. But again, for most people, given the age of retirement, there's a mismatch between when they're hitting peak net worth and when they're hitting peak capacity to utilize net worth. That's a massive mismatch.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
How much were you learning the business? Because I imagine one could take a job like that and not actually learn what's happening, like what the machine is doing.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And that, of course, just speaks to the imbalance between the three variables. It's like if you spent a little bit more of your time on your health, you would buy yourself a bigger runway to utilize your wealth on the experiences.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Yeah, say why.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And they're healthier longer.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Let's go back to risk again. What's the mantra of the energy trader or the gas trader? The name of the game is to stay in the game. Sort of like Simon Sinek's book, The Infinite Game. It's not about winning. It's about being able to keep playing over and over and over again. So inherent in that is never making a bet or a trade that can completely wipe you out and take you out of the game.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And how do you think about that in a person's life? I mean, I like the example of skydiving. How do you think about this now in terms of the seasons of the person's life? Are there certain seasons where certain risks make sense, be it financial risks or?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
It has to be now.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
How much did it hurt?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
At the time you spend a lot of money, was it for you enough money that you were like, am I crazy doing this? Did you have second thoughts about it?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
You know, it reminds me of something. When my wife and I got married in 2004, you know, we got married at a golf club. We didn't have two nickels to rub together. So it was like, I think the wedding, the ceremony, the reception were all at the same place. The whole thing cost less than $20,000, obscene amount of money for us at the time.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And it was amazing because everybody we actually cared about in our lives was there. We were really fortunate that, Hey, almost everybody could make it who we invited. You know, there were almost 200 people there. So at one point I grabbed my wife, we kind of walked out onto a balcony and could see everybody. And I said,
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Do you realize that this is one of only two times in our life that we will be surrounded by everyone who's meaningful to us, who's alive, and the only other time it's going to occur, we're going to be dead. We'll be in the casket. We'll be at our funeral. So we got to really take this in. And I realize now there was a huge error in my logic, which was that was totally untrue.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
That didn't have to be true at all. You can create that anytime you want. You can decide for no reason, I want to bring everybody in my life who matters. Throw a birthday party. It could be a birthday party.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Now, let me ask you a question. At that birthday party when you were 45, how many people were there?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And how much time did you get to spend with each person?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
You know, I think after my wife read the book, that was one of her first thoughts, which is I've never had a birthday party. So the last birthday party I had was, I was seven years old. After that, I just decided I never wanted to have a party and I never have.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And she's like, look, I really want, I know how much you are obsessed with your friends and how much you share with them individually, but wouldn't it be great for everybody to be under one roof for your birthday? And I'm resisting it to know. And she'd never throw a surprise party for me. She knows that would just kill me. So she won't do that.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
But she's really negotiating with me to sort of have a party. And my view is... It won't be enjoyable for me because I'll be the center of attention and I'll feel an obligation to give everybody the same amount of attention. Whereas having dinner with five friends is infinitely more enjoyable. So I'm trying to balance her. It's just a different experience.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
I guess what bums me out is like, I feel like I wouldn't even know how to appreciate a party.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
You can enjoy a party as much if you're the host or it's your birthday as if you're at somebody's party?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
What year did you finish writing Die With Zero?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
In the three years-ish since you've written the book, has your thinking changed in anything? Have you evolved? Are you more nuanced in anything that you wrote about?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
117.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
I was throwing a party that night.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And how much will you talk with them about... what you think or don't think they should do with that money. Is that one of those things where you feel it is your responsibility to say absolutely nothing and let them figure it out on their own?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Well, Bill, I want to thank you very much for writing this book because, as I said at the outset, it really is one of a handful of books that has caused me to rethink a lot of what I've been doing, how I've been thinking about the problem of optimizing these variables. I'm really confident that people are going to pick this book up and find similar value, at least in magnitude.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
They might find different things that speak to them more or less than me, but I believe that from a valence and magnitude perspective, people will across the board find this valuable. So thanks so much for writing it and also for coming today.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
I think the example you gave there is a great one. And I would agree with you completely because I too fall in the camp, despite my profession of believing we are all absolutely going to die and in relatively short order. And therefore anything that changes our experiential existence for the better is part of living. Yeah. So thank you.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
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The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
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The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
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The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
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The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
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The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
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The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
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The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
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The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
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The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
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The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
For this week's episode, we want to rebroadcast my conversation with Bill Perkins from January of 2023. Bill is a successful hedge fund manager and entrepreneur and is the author of one of my favorite books, Die With Zero, getting all you can from your money and your life.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
And how much were they understanding your hunger, your drive, your aspirations in this new role? I mean, because presumably they had seen you in high school and college. not achieving at your potential, and now all of a sudden you're hustling, you're working two jobs, you're reading, you're learning, you're doing everything. Were they purviewed to that sort of metamorphosis in you?
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
So you weren't necessarily like advertising to them.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
So let's go back to when you're on the Upper West Side. You write about this in the book. You and your roommate kind of had a slightly different, I don't know, call it a point of view on future earnings and what that allowed you to do with your time. You told a story about something you did that seemed kind of bold.
The Peter Attia Drive
Optimizing life for maximum fulfillment | Bill Perkins (#237 rebroadcast)
Bill's book is one of a handful of books that I keep multiple copies around in my house to give to friends or family or anybody who's over and who I think would benefit from it. This is really a conversation about how to optimize your life by investing in your experiences instead of waiting until the end of your life to do everything.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
In this episode, we focus almost entirely around one area of her expertise, which is cognitive behavioral therapy for insomnia, or CBTI. Ashley gives us a masterclass exploration of CBTI, including various methods, including time in bed restriction, stimulus control, and cognitive restructuring to combat insomnia.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah. I try to be uncomfortably cold when I get into bed. Right, but your hands and your feet? No, generally not. I mean, it's just my body. But again, I'm using a device to cool me as well.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I want to kind of go into many more of these because I know this is the exciting stuff that people are interested to hear about. I do want to take one step back and just make sure we understand what constitutes cognitive behavioral therapy before we even get into cognitive behavioral therapy for insomnia.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So we've had a podcast where we talked about dialectical behavioral therapy, DBT, but we haven't covered CBT. Can you give us a little bit of the tapestry of what defines it and why it, of course, then has this additional subset of treatment for insomnia?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
We speak about how to manage racing thoughts and anxiety, and Ashley shares techniques like scheduled worry time to address stress during the day and prevent sleep disruption at night. We talk about the impact of temperature regulation and the role of warming extremities and optimizing sleep environments for effective sleep onset.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
We discuss behavioral and cognitive interventions and the impact of leveraging small, actionable changes in thoughts, feelings, and behaviors to overcome patterns of insomnia and other mental health challenges. Ashley shares some sleep hygiene fundamentals, addressing blue light exposure, food and alcohol intake, and creating bedtime routines for better sleep.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Is that kind of running the triangle in the other direction? So you change behavior to change thought, you change thought to change feeling?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
And tell me a little bit about the history of CBTI specifically. When did the idea come to existence in a way that's been packaged more or less the way it is today?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
And these men were struggling with anxiety or actual insomnia?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
And to be clear, just going back to this study, was there a belief or were some of these guys studying in bed?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
She provides practical tools for tracking progress, like using sleep diaries and A-B testing to identify and refine effective interventions. And we explore the potential for AI and digital tools to democratize access to CBTI and address the growing demand for sleep therapy. So without further delay, please enjoy my conversation with Dr. Ashley Mason.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah, I want to talk about both of those a little bit more. I want to bracket sleep hygiene and come back to it because I think, again, the temperature and all that light stuff, we shouldn't gloss over that even though it's easy to take for granted. And I know that many people listening to this podcast will have heard other content where we talk about it, but I'd love to have it all in one place.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I think the time in bed restriction is pretty interesting. And in talking with sleep physicians who also implement this, it seems quite draconian at the outset. It can be remarkably difficult. They're giving people five hours in bed max, and they're really trying to force sleep pressure. How do you navigate that? And how do you decide how hard to squeeze the tube of toothpaste?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
It's like a food frequency questionnaire in epidemiology. Totally. Total waste of time. Total.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Hey Ashley, thank you so much for coming to Austin to talk about a lot of interesting things. Let's start with the one that I think everybody listening can probably relate to at least once, which is insomnia. Where did your interest in insomnia arise?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Six hours being the number?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
And just to be clear, let's say five and a half is the floor. Six is typically what you would do. So six and a half in bed.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I see. So when I bring my sleep log to you, you've seen that for the past week, I've been spending 12 hours in bed. But by my recollection, because I'm looking at the clock when I'm not sleeping, I'm only getting six and a half hours of sleep in the 10 or 12 hours I'm laying there. You're going to say, oh, okay, that's your sleep time. Take that, add 30, that's your time in bed. I got it.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yes, yes.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
They're going to bed at one in the morning.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Now, let's say you're doing the sleep log and they're spending eight hours in bed, getting four hours of sleep. Let's say they're getting five hours of sleep, eight hours in bed, and then they're taking an hour nap a day. So they're removing all their sleep pressure during the day by taking that nap, but they kind of need to take the nap because they're not getting enough sleep.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So they're in this vicious cycle. So do you add the hour of nap time back to sleep and say, actually, you're getting six hours of sleep. Let's do the exercise based on five plus one plus a half, 6.5.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Okay, but just to be clear, if you have someone who is using a nap to compensate for their insomnia, step one is just kill the nap. Kill the nap. And then let the cards settle where they may for a week, recalculate actual sleep time, and then go through the exercises described. I've made this point on a podcast before, I think, but just want to get your blessing.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
When we're on bow hunting trips, you are going to bed insanely late and waking up insanely early. It's just the nature of when you get back to camp and eating and then you got to be up super early. So I've never been on one of these trips where I could actually be in bed for more than five and a half, six hours in a night. So the strategy is to get that sleep.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
But then I always try to get a 90 minute nap at around one in the afternoon. And the reason I pick 90 is to get a full sleep cycle. And I tend to function incredibly well under those circumstances. Because remember, you're also very physically active. Like this is demanding time. So would I be better off not doing that nap midday?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Okay. All right. Got it.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
While we're on that topic, what do you say to the legions of people watching who fall asleep watching TV on the couch? Oh, the worst.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
What about just the social dynamic of it, which is when you have a couple, not that I'm saying this from experience at all, and one part of that couple, they want to be together and watch TV, but one member of that team falls asleep immediately while the other does not. And the one that does not tries to tell the one that is to go to bed, but that one wants to be with the other.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I don't know if you can ever imagine a scenario like that.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I'm just making it up.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Doesn't appear to be.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
The problem is sometimes other members of the family who tend to be smaller also tend to be occupying all of the bandwidth during those earlier hours when the member of the family in question is able to be awake.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Obviously, I'm talking about my wife here, so I'll stop double speaking. But if my wife falls asleep every single time on the couch, but then when said Netflix is over and we go up to bed, she falls right back asleep and it doesn't seem to keep her awake. Is it pathologic?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah, it makes sense.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
broadly two to three different archetypes of that. I know there's a circadian rhythm test you can take online that gives you a sense of it. I almost think it's so self-evident if you pay attention to your patterns.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Let's go back to sleep hygiene for a second. We talked about temperature. Nowadays, we have these incredible devices that can cool our mattresses and things of that nature. Obviously, we have air conditioning that can cool the room. Do you have a preference for one or the other? I mean, clearly not everybody needs to buy a mattress cooling device if they can't afford it.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
That shouldn't be an impediment to sleep. Do you have a room temp set? We typically talk about the mid-60s as an ideal room temp. Do you adhere to that? Yes.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Let's talk about light. Do we need to have it so pitch black you can't see your hand in front of your face? Do we need to block the moonlight? How dark do we need it to be?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
You wouldn't just get relief from the eye mask in that situation?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Meaning like you're going to cover the alarm clock or whatever.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
My trick is I unplug alarm clocks because I realize sometimes they're so complicated that they just go off in the middle of the night and I didn't realize it. And yeah.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Well, I mean, no disrespect to the WHO. I don't know what I believe that they say. I know that there's an association between night shift work and cancer, but do we really know that it's causal?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
How do we get around the confounding effects of the obvious dietary shifts that occur in people when they're working under those conditions? I mean, if I think back to how I ate in residency or how I eat after a night of poor sleep, I mean, to me, that would be more the cause. I'd put more of that on kind of the metabolic ill health that might result. But carry on.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
But going back to the cancer thing, what would be the believed mechanism of action?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah. So the one that I use, just by full disclosure, I'm an advisor to that company. The one that I use, you change how cold it is throughout the night. So I think I run it as, I think the settings go from zero to minus 10. Minus 10 is the absolute coldest. Zero is no temperature change.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
No, it's a point scale. Okay. Yeah, yeah, yeah. Yeah. So I think I get in and I have it at minus five and then I run it down to minus 10 and then I bring it up to minus five in the morning, something to that effect. So I'm taking it from cold to really cold up to cold.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Before we dive into what CBTI is and how it works and how profound it can be, let's maybe help folks understand a little bit about insomnia and maybe go through some of the definitions around the different types of insomnia and maybe some of the different causes for it and maybe even what some of the other treatments are, pharmacologic and otherwise.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah. But that gets to the point which we know we don't want to be warm. We don't want the duvet.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
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The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
The good news is if you can keep your room at 65, none of this matters. And the biggest challenge, honestly, is hotels for most people. It's where you have the hardest time. hotels are the worst.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
What about blue light before bed? I've looked at these data quite a bit. And I would say that six years ago, I was in the camp of Every light had to be red. So, you know, I had to have my phone shifted into a red light phase. My computer shifted into a red light phase. I had all of these apps that managed all of this stuff.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So as soon as the sun went down, blue light was being removed from my electronics. And I have to say, I sleep subjectively and objectively better today. I say objectively, if you can believe what a sleep tracker tells you, but we can bracket that and come back to it. We should. never taking blue light out of my devices, but instead paying attention to what I'm consuming.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
In other words, my new hypothesis has become, it's not the blue light that is the problem, it's the stimulus that often comes with the blue light. In other words, not looking at social media regardless of light color, is a far greater positive impact on my sleep than looking at those things, but just making sure that there's no blue light coming through. So let's talk about that.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
What is the role of minimizing blue light when it comes to preparing for sleep?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Not doing anything stressful or stimulating. No.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
The beauty of these interventions is if you can isolate them to one change at a time, you can be empirical about it. And something like wearing glasses is benign. I mean, you're only out the money you spend on them. And if it works, great. And if you really want to test it, take them off and see if your symptoms return. And if they don't, Maybe it fixed you.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Maybe it wasn't that who cares if they return and you can fix it. Yeah. Like I try not to be terribly dogmatic about this stuff, but I also think that when people go to great lengths to remove blue light without removing stimulus, they're missing the boat a little bit. And for me, social media is not much of a stimulus actually, because I don't pay that much attention to it, but work is.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So for me, the single worst thing I can do right before bed is look at email. Whereas watching TV, it's a total beautiful way for me to be distracted by watching something mindless on Netflix for an hour. And as long as I don't go and check my email and see what got sent to me in the last hour, it'll be great. It doesn't matter that I just finished watching a big, bright screen of Netflix.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
It doesn't seem to impact me.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
By the way, do you have a nice template? We have one that we give our patients. Again, it's super low-tech. It's a piece of paper. So low-tech. Do you have one on your UCSF website?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah, yeah. Okay, maybe we'll link to it in the show notes. Yeah, easy to do. We could link ours as well, but yours is probably better. Ours is like boxes you color in. Oh, yeah. And it's like you put C when you had caffeine, A when you had alcohol, E when you exercise.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So we're documenting when did you exercise, when did you have food, alcohol, caffeine, and when were you in bed and when were you sleeping by the shading.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
It's so easy to do. To be clear, is there a particular brand?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
What fraction of people are such rapid caffeine metabolizers that they seem immune to caffeine and sleep?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Okay. Low hanging fruit. Just stop it at 11. Stop it. Do the experiment at a minimum. Okay. So those are three.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Any other really obvious things to AB test for two weeks?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Including this one, right?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah. This is an easy one to fall asleep too, but- I don't know.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
One of the things I want to talk about is on the relaxation techniques. Where does mindfulness-based practice come into it? So anyone who's done mindfulness-based meditation probably appreciates how difficult it is. It's not like transcendental meditation where you're focusing on a mantra. You're instead focusing on a sensation, typically breathing.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
But body awareness is a thing that you want to focus on. Is that counterproductive or is it productive as you're laying there awake?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So you mentioned 50 to 60% of people are going to have a remission.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
70% will have a meaningful clinical improvement. Of the 30% that do not, why? When does the treatment fail?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So in other words, we're really saying 30% of people are not able to adhere to the treatment.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
There's an amazing treatment for that. Can I see the wearable device?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Here's my vice grips.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I made a note to ask you this question. When do you tell people, because we do this with our patients, which is take the tracker off. We're doing a six month tracker holiday, done with the tracker. Done. So is that mainstay part of your treatment is like, let's get all that anxiety out of there?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Maybe they shouldn't be helped. Maybe there's nothing to fix. Correct. Yeah. Correct.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
And the space between them is a week?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Given that people are waiting a year and a half to see you tells me that there's a mismatch on the supply demand curve. Yeah. Why is that the case?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yes.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
We use it ourselves. The Society of Behavioral Sleep Medicine thing? Yeah.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So what will it take for AI to replicate what you're doing to scale this much more? Because a lot of this, a lot of the work I do can be done by an AI. How much of the art and science of this is teachable to LLMs and at least as another offering? I'm not saying it should ever displace what you're doing or what a therapist is doing.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
And just to be clear, Ashley, when you say that a point estimate of 5% to 10% of the population would have insomnia at any point in time, you mean according to that definition where it's been going on for months, it's causing distress, and it's impacting life?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
But if we have a backlog of people for years, shouldn't we have an alternative which might say, look, there's an online course that you can do that will give you 70% of the value of what you might get sitting in the group with Ashley.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Or just come up with an alternative to scale.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yes, exactly.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So it's low-end 1 in 20, high-end 1 in 10 people, adults? Adults, yes.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
By the way, when you're giving them that bootcamp speech, is the time in bed restriction typically the thing that causes the most distress?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
That's huge. And are people able to, with a high enough fidelity, report awake time in bed? For example, like if I were doing this, let's assume I've got a clock next to my bed that I can look at because you have to do that for this purpose. You have to have some device to keep track of time. So I get in bed because my time in bed tonight is 11 and my wake up time tomorrow is 530.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So that's a higher estimate than I would have guessed, given your definition. If the definition was three nights of bad sleep, I would say, yeah, that makes sense.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Okay, so I get in bed. It's 11. Check. Okay. How do I know what time I fell asleep? Let's just say I didn't have an issue falling asleep. How do I know if it's 1115 versus 1130?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
That's exactly what you should be doing in the middle of the night. So person wakes up at two in the morning and they can't go back to sleep, get up, go and do something that is not productive, not rewarding in the way that, hey, this is, I'm building a pattern around getting up and doing something I like. Right. So I wouldn't be able to get up and play chess.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I wouldn't be able to do the online chess thing that I love.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Okay.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I couldn't check email.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
What about scrolling social media?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Read for pleasure?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Okay.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Stock trading? Not if it's stressful. I wouldn't do that. Okay. So there's a narrow subset of activities that you are going to get out of bed to do.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yep.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yep. One obvious thing we haven't talked about, and maybe it's so obvious we don't need to, but just to close the loop on it is food and alcohol and how they pertain to this. What's the checklist you run through with the clients?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guest this week is Ashley Mason.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So they just don't enroll until they're... No, no, no.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Are there any specific cognitive techniques that people are instructed to be working on when they first wake up?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Nothing. There's nothing, no mind game to play. It's all behavior, behavior, behavior.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Let's talk about sleep supplements. So do you do a purge of supplements when people come to you and they say, hey, I'm taking a pound of melatonin every night. I'm on an ashwagandha drip. Just rattle them off. We could go through the list.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yes, I think we wrote a newsletter on one of them.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Let's assume that they're taking melatonin because they're getting it from one of the companies that submits to third party testing. And so now they know they're doing it. And again, let's further posit that they're not taking a dose that is deemed too high.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So if you look at some of the sleep literature, there seems to be most people would agree anything north of a milligram is probably just too much. Whereas kind of in the 300 to 600 microgram, there might be some benefit. And more importantly, not just benefit, but actually safety. You're not downregulating melatonin receptors. You're offsetting the natural decline in melatonin levels over time.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I can tell from your face you don't agree with any of this.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah, interesting.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So what about sleep medications? And let's talk about as many as you want. We can talk about benzos. We can talk about trazodone. We can talk about Ambien. We can talk about the orexin-based drugs. How many of the patients who come to see you are regularly taking one of these prescription-based drugs for sleep?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Why couldn't they get them here in that situation?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
They couldn't get a prescription while they were here.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
And what about Trazodone?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
No, in fact, I've seen data that it does the opposite, that it's slightly positive.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Now I'm trying to remember something that I wrote probably three years ago. I believe the study looked at sleep duration as the primary outcome and a secondary outcome may have been staging.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Although with the dose people take it, it tends to not have that effect. I mean, most people are typically taking it at 25, 50, typically no more than 100. Maybe at 100, depending on the size of an individual, they're getting some of that benefit.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
If folks are showing up on... 20 milligrams of Valium or Xanax or pick your favorite Benzo. Do you have them go and do a taper detox with their physician before they come into the CBTI program?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So you will manage the medical withdrawal on that?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
And this has to be one of your colleagues at UCSF or whoever they're prescribing.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I don't particularly like them myself, but let's take Valium. Okay. Long acting.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah, sure.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I like the party dose.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
You're limited to 10 a night and you've got to take it before bed.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
How are you even making that increment?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Can you say more about the predisposing factors? Are those genetic?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
If they're only doing a seven-week program with you.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Before they enter the program. No. This is a separate issue.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Why?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I would have never even thought of that.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Sinister.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So vodka on Monday and then tequila on Tuesday, red wine on Wednesday, and then Chardonnay Thursday. And this way I'll never become an alcoholic.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
And just to be clear, This is psychological. There can't possibly be a physiologic difference between 4.75 and 5 milligrams of Ambien. In fact, the medicine isn't even homogeneously enough compounded within the capsule. So as long as everybody understands that.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah, because the binder and the active ingredient.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
And do you think that this methodology of the incredibly slow taper with incredibly high precision, do you think it works for opioids?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Oh, I don't mean for sleep. I just mean in general. Or is the problem so grave that you have to be a little more aggressive and switch them to a completely different class of drugs?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yep.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I mean, I think we've covered a lot on CBTI and let's now revisit the idea of the types of things that people should be on the lookout for that need to be addressed first. So we haven't talked about sleep apnea. We haven't talked about restless leg syndrome. What are the other things where you just want to have...
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Some sort of sign off that says, hey, we've also confirmed that these things aren't present or what gets your suspicion roused that says, hey, we got to look at something else because you're presumably not doing polysomnography on everybody on the way in. How do you navigate that?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
They can't be self-referred?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah. What degree of social jet lag do you tolerate? Just for folks listening, social jet lag, meaning the experience of changing your sleep time during weekends, which could be akin to jet lag if it differs by hours. In an ideal world, it would be zero, right? In an ideal world, I wake up at seven o'clock in the morning every single day of the week.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
For an individual who says, oh, but God, on the weekends, it's just so nice to not have to get up at seven. Do you say, look, give yourself a 30 minute grace and that would still be considered perfectly healthy?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
That's all of them. Yeah. That's during treatment. I had to check.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So basically force the suffering into the narrowest place possible.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
We're recording this on a Tuesday. Sunday, two days ago, I was flying back to Austin from LA and the flight got delayed over and over and over and over and over again for reasons that are so asinine they're not even worth describing. And then we finally got on the plane and taxied and then the water was leaking out of the coffee machine. So we had to go back to get another plane.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I'm not making this up, but I can only tell you how ridiculous this is. The punchline of the story is we didn't get home until two in the morning, which is long past my bedtime. So what would your strategy have been getting home at two in the morning prior to Monday, a work day where you do have some leeway? I don't have to get up at six, which would be my normal wake up time.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Would you have said, just get up at six, stick with it and make it up by going to bed a lot earlier Monday night? Or would you say sleep until eight? You'll probably feel better than if you woke up at six. How would you handle that situation?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Let's say I said Tuesday because I'm sitting down with you.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
That's actually what I did. So having not thought about this, I just slept in till, I think my wife tried to get me out of bed at seven and I said, can you let me sleep till eight? So I didn't get up till eight. But last night, you're right. I had a very hard time going to bed. It was like 11 o'clock and I was still up meandering around. Yeah.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Absolutely.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
And this is just adenosine building up?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Oh, hundreds. Yeah, I would need scientific notation to count them. It's so pathetic.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Your adrenal glands still make cortisol.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Any rules about exercising? Do you have people that are showing up and you're going through your intake and you realize, based on their schedule, based on work, based on kids or other obligations, the only time they're going to get their workout in is in the evening? And is that counterproductive? Put it this way. If it is an issue, how do you adjust?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Ashley is an associate professor at UCSF, where she leads the Sleep, Eating, and Affect Laboratory. Her research focuses on non-pharmacologic interventions for mental health, particularly exploring how treatments like whole body, hyperthermia, mindfulness-based approaches can improve mood disorders, sleep, and eating behaviors.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah. My brother-in-law plays in a men's hockey league and you only get ice time late at night. So I think they literally play Sundays at 11 PM or something. And he's always fried Monday because pretty hard to play a game of ice hockey and then fall asleep after that. So- I want to understand more what the spectrum of CBTI looks like.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
I mean, your process sounds super dialed in, but also it's quite bespoke. You've brought a lot of your own expertise to it and you've created a system where you've got, we're going to do the intake. We're going to do these five sessions, which I think are group sessions, the way you described them. Then we do kind of the exit. you bring so much rigor to it.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Is that the way it is always done or are there CBTI therapists out there who function like psychotherapists and they say, yeah, we're just going to engage with each other until your problem is fixed and we'll see each other once a week or maybe once every other week. Everything you're doing sounds formulaic and I'd say that not in a bad way. I think that's probably a big part of its efficacy.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Is that something people should expect when they are going to a CBTI therapist?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
What type of scores are you getting on the PSQI?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Okay.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
The book, Quiet Your Mind and Get to Sleep, you mentioned that that's something that people could do in therapy, but you also mentioned that it's something people could just do on their own.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So if somebody is listening to this and they're thinking, A, I can't afford CBTI, or B, every practitioner I've called said the soonest I can get in is nine months from now, if my choice is continue to suffer or do something proactively, you would recommend that as a great strategy to start? Yeah.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yeah, that makes a lot of sense. So the focus is much more on the coping strategy and the behavior that came out of the predisposing factor or the precipitating event actually is really- Used to respond to the precipitating effect.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Any concerns with extreme temperature changes before bed? So people using sauna, people using cold plunge, taking hot showers, hot baths. Subjectively, from my experience, a sauna before bed really seems to help. Maybe it creates a bigger gradient in temperature drop as I go from high body temp to low when I get into that super cold bed.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
But what is your experience with that and how do you manage it through the process?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
It might be the same problem as the exercise issue. It might be the same problem as the exercise. Yeah, if they don't have the rapid recovery.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
And in fairness, I don't actually go straight from sauna to bed. It's usually sauna to 30 minutes of Netflix to bed.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Yes.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Okay. Can we talk a little bit about Is there a difference, for example, between the individual who can't fall asleep, this initiation of sleep insomnia, versus the person that I hear much more about, frankly, I experience more, which is, it's not that hard for me to fall asleep, but boy, I will jolt up at
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Ashley, someone listening to us for the last two and a half hours might assume that the only thing you know about is CBTI, but it turns out that we've only scratched the surface of your area of expertise. And there are other clinical areas that you have a lot of interest in that I think our listeners would have interest in as well.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
The good news is we've, when I say we, I mean you, you've delivered kind of a masterclass on a topic that I've wanted to know much more about. You know, it's interesting. It's a bit of a black box because we send a number of our patients to CBTI therapy around the country. And I would concur with what you said, which is based on their ability to comply. The efficacy has been unparalleled.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Simply stated, as far as regular old doctors, I think we're pretty good at helping people with sleep given the nature of our practice and how much attention we can pay. And therefore, I think by ourselves, we do pretty well. But when we can't and we refer to CBTI, I would have to think if there's been a patient who hasn't been helped. So that's great.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
But truthfully, you've filled in all the gaps for me. And I think more importantly, I think you've really helped listeners understand this and I hope given people a lot of confidence. Because what I also take away from this is there's really nobody who should be suffering from insomnia. It's really not a necessary thing to suffer.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
There's things we might have to suffer with in life, but this isn't one.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
The drawback is we have kind of run out of time to talk about a few other things that are really interesting, which is not uncommon on this podcast, which means we're going to have to do a part two at some point to talk about eating behaviors, thermal regulation, the impact that that has on depression or other things like that. So apologies that maybe we spent more time on CBTi.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
than we intended to. But as I kind of warned you before we started, we love to just meander where the discussion goes. So is there anything else you want to talk about on the CBTI front? I have a lot of notes on where I wanted to go, but I also realized there's probably something I've forgotten or there's an area you want to double click on.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
one in the morning with some thought or anxiety that I can't get out of my mind and my mind starts running and I can't go back to sleep or I get up because I got to pee. But when I come back, I erroneously just do something with my mind where I get thinking about the day's problem or whatever, whatever. Do you think of those as difference or the different side, same coin, I guess?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Are you under the impression that obviously people are waiting a long time to see you? That probably speaks to how good you are and the resources that UCSF provides maybe in combination. But if a person's listening to this and they're like, yeah, I wish I could work with Ashley, but I just want to work with somebody.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Do you have a sense of how large the CBTI community is and how long a person should expect to wait? And do these therapists ever work via telemedicine so that you have more opportunity to work with folks?
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Oh, so you're eight people per bracket don't all physically come to San Francisco.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Although we have to hope that the providers, if you live in Iowa, we want to make sure they have license in Iowa because you wouldn't be able to see somebody.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Well, Ashley, this was awesome. I learned a lot and I'm pretty sure everybody listening did. So thanks for sharing and look forward to round two at some point next year.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
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The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
She's also the director of UCSF's Center for Obesity Assessment, Study, and Treatment, known as COAST. Her work integrates clinical psychology with integrative medicine, aiming to develop accessible treatments that address the biological and behavioral aspects of health.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
Make time for them.
The Peter Attia Drive
#341 - Overcoming insomnia: improving sleep hygiene and treating disordered sleep with cognitive behavioral therapy for insomnia | Ashley Mason, Ph.D.
So this could be a valuable technique even absent insomnia. Totally. Totally.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
With over five decades of research in the field, Dr. DeFranco has received numerous prestigious accolades, including the Banting and Claude Bernard Awards, the highest honors that can be given to a diabetologist. This episode with Ralph is really a masterclass in the organ-specific aspects, the pharmacology, the diagnosis of type 2 diabetes, and it draws from his vast experience.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
I just want to make sure people understand that. I was going to come back to that. I wanted you to finish that point. So let's make sure we go back to the test, because it's very counterintuitive. I've got a catheter in each arm. I walk in off the street. I've been fasting. My blood sugar is 80 or 90, whatever milligrams per deciliter it is.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
You are going to have to infuse both insulin and glucose into each of my arms. The reason is, when you said a moment ago, you're going to steadily increase my insulin and take it to a steady state of 100... IU per ml. That's a staggeringly high insulin level. Not so high. In your eye, after a meal, it would be maybe 60. Obese people very commonly get to 100.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
For a healthy person, would never see an insulin level that high. And if you were not simultaneously running glucose into them, you would kill them within minutes. Yeah. Hopefully not. Yeah, but to get to the point, they would become so profoundly hypoglycemic that they would cease to exist.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Sorry to interrupt, but just to make sure that people are following us, the reason you wanted to use tritiated glucose there was not to quantify the total amount of glucose disposal. You could do that on mass balance. You wanted to determine the ultimate fate of glucose. How much became hepatic glycogen, if any? It sounds like the answer is none. How much became muscle glycogen?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Sounds like you said about 90%. And how much ultimately got converted through de novo lipogenesis into adipocyte or free fatty acid? Sounds like that's about 10% under the euglycemic condition.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Is that correct?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
I mean, presumably you're doing this test and a person is sedentary. Yes. Is muscle that metabolically active at rest? I guess it is. Yes. Yeah. So that's really interesting. Does that mean you're increasing energy expenditure under these conditions?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And Ralph, just for a sense of amount, if you're doing this in, say, somebody my size who's insulin sensitive, how many actual grams of glucose would you be able to get into the person within the hour whilst keeping insulin clamped?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Let's just reflect on that for a second. People who listen to this podcast are probably sick of me saying this, but I'm sorry. I just can't stop saying it. The liver never ceases to amaze me. It's an incredible organ. It's an unbelievable organ. And again, I come back to this idea. It's the only major organ for which we don't have extracorporeal support.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Now, if you listened to my conversation with Jerry Schulman a few years ago on insulin resistance, what amazed me was how little overlap there was, not because the information is not congruent, but because of how much we were able to go into different topics.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
If your heart, if you went into cardiogenic shock and we felt we could reverse it in time, we could put an intra-aortic balloon pump in you. We could put an IABP in you. We could put a left ventricular device in you to stem you over until we get you out of there. If your kidneys are destroyed, we can transiently dialyze you.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Even if your brain is experiencing swelling, we can, you know, put enough steroids in you or decompress your skull to give you the time to recover and keep you alive otherwise. Go through all the major organs. If your spleen is dinged, take it out. Even if you lost your small bowel, we could at least transiently keep you alive with TPN or something like that. None of this is true with the liver.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Yeah, baboons. Yeah. So the fact that the liver can titrate this amount is remarkable. So two milligrams per kilogram per minute. So you take an individual who weighs 100 kilograms, you're putting 200 milligrams per minute of glucose into circulation. Then you can multiply that by however many minutes you want to look. So that's a gram every five minutes.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
That's 12 grams of glucose every hour that the liver is putting out.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Sorry, and the fat, you had to get how high? 10, a rise of 10. Tell me, these people, when they come in unhealthy, they're what, they're at 5 to 10 faster?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So the discussion with Jerry Shulman, which I would encourage everyone to listen to if they have not, really focused on one of the areas that insulin resistance manifests itself, which is in the muscle. What we talk about here is about all of the other organs. Spoiler alert, there are seven that are impacted by this condition.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
You have now maximized muscle glucose uptake. In reality... Even in an insulin sensitive person? Yes. Just to make sure I understand what you're saying, you're saying that if you took an insulin sensitive individual at 100... units of insulin versus 200, you will actually drive more glucose uptake. You haven't saturated the GLUT4 transporter at 100.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And therefore we go into much greater detail there in addition to the pharmacologic interventions. And I just have to say, I learned more in this podcast than I do in most podcasts. It's one of the few that I had to immediately go back and listen to, and my notes from this podcast are so voluminous that they even provided substrate for internal meetings with our team in the practice.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And sorry, Ralph, do you think that that is a result of the hyperinsulinemia or the untreated or poorly treated hyperglycemia?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
But we have really good drugs. Yes, yes, yes. But if you were only doing this with insulin, it's an awful trade-off. You're going to die very quickly from hyperglycemia if you're left untreated. But if we overdo it with insulin to maintain normal glycemia, we're going to kill you slowly. It's a quagma.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
This is something, Ralph, I don't think that has been necessarily appreciated by the medical community. Absolutely not. There has generally been an ethos of, when I've talked to patients with type 2 diabetes, what they've been told is, I'm told to cover with as much insulin as is necessary to maintain my glucose levels in this range. And it means I can eat whatever I want.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
It's okay if I have all the pasta and bread and sugar in the world, because as long as I'm covering it with insulin, I'm okay. And then you find out. wow, you're taking 150 units of insulin a day in all of its forms, the short acting, the long acting, et cetera. But I didn't actually realize that what we would consider physiologic is 35.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
I may have known that at one point and I've since forgotten, but that's a great reference. So basically, if there's a person with type two diabetes listening to us today, And they're taking 75 units of insulin.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
One of the takeaways should be what do I need to do with my nutrition and other pharmacologic activities plus exercise plus everything that's under my control to maybe get that down to 35 where I would be at a physiologic level.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
In short, there are many things that I've taken away from this that will directly impact my patients. Just as far as some of the other things we discuss, we get into details about how insulin resistance impacts liver. We do talk about muscle, but we talk more about fat cells.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
You have to explain that to me again, Ralph. That is mind-boggling. I would never have predicted that. So let me say it back to you because I feel like I missed it when I was writing something down. Yeah. You took normal volunteers who had a fasting insulin of eight. Yep. And they're lean, healthy. Okay. And simply infused insulin in them, presumably with glucose. Oh yes, of course.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
On the clinical research center, we can monitor, keep the glucose perfectly constant. We're not letting the glucose change. Person shows up, insulin eight, glucose is 90. You do a euglycemic clamp where you bring insulin up only by one and a half per, one and a half X. Much less than would be when you eat a meal. Exactly.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Not even a postprandial bump, but now it's constitutively sitting there at 20. And you've obviously had to bring glucose. You had to infuse glucose to maintain euglycemia. Correct. Did you say that in four days? 48 to 72 hours. These people are as insulin resistant as type 2 diabetics.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Okay, again, very, very counterintuitive because if our model is that insulin resistance, which is the hallmark factor contributing to type 2 diabetes in the combination of beta cell fatigue, is driven by lipotoxicity, which we're going to come to. It's an important one. Yes. These people didn't have any of that.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
We talk about his development of the euglycemic clamp, something that some of you have probably heard of as the gold standard for measuring insulin resistance. Again, we talk about the pharmacology, not just the SCLT2 inhibitors, but the GLP-1, agonists, metformin, and another class of drug that we don't talk about that often. that, frankly, for me was a real eye-opener.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
These people didn't have any of the intramyocellular lipid that we talked about with your colleague, Jerry Riven, as a predisposing factor.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So then when you turn the clamps off, Let's just say we ran this for 72 hours. We've made them functionally diabetic. Turn the clamps off. How many hours or days?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
What would you predict?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
I've seen even data that says it was 1% as recent as 1970. It's very low. Yeah.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And you think, Ralph, that the greater genetic effect is on the insulin resistance side or on the beta cell fatigue side? Both. Okay. So let's tackle each. Since you started with insulin resistance, let's go there. Let's talk about what we know about the genetics of insulin resistance. That's easy. Nothing.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
There's a lot more I can say, but I think at the end of the day, you just kind of got to listen to this one, maybe twice. So without further delay, please enjoy my conversation with Dr. Ralph DeFranco. Dr. Ralph DeFranco Ralph, thank you so much for coming down to, I guess, up to Austin from San Antonio.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Even if you took the subset of people with type 2 diabetes who were lean and you compared them to people who were lean and non-diabetic versus obese and diabetic, a GWAS was not able to identify a signal in those three cohorts?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
That's the answer. I've taken care of a couple of patients with type 2 diabetes who are very lean. Including one patient whose body fat by DEXA was about 8%. For people listening, that is insanely lean. Very lean. So you take an individual whose body fat is 8%. and yet they have type 2 diabetes. The first thing that comes to my mind is a lipodystrophy.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Is this an individual whose adipose tissue is the problem? In other words, they're not able to assimilate enough excess nutrient, i.e. glucose, into the fat cell, and so they're undergoing the toxicity associated with an insufficient reservoir. Is that what could be the causal, not that I can tell you what's causing the lipodystrophy, but is the lipodystrophy the issue that's driving the diabetes?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Very excited to sit down with you and talk about potentially one of the most important subject matters in all of health. People who listen to me all the time here and are familiar with me talking about these four horsemen, cardiovascular disease and cerebrovascular disease, cancer, neurodegenerative and dementing diseases.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And then there's this fourth horseman that I talk about, and it's in many ways the squishiest because it's not the one that shows up on the most death certificates. But in many ways, it's the foundational one that is amplifying the risk of all of those other causes of death.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Let's just pause there for a second, Ralph. I want to make sure everybody's following what you're saying. You're saying, look, one of the challenges of having a disease that isn't perfectly, perfectly clearly defined where every single member of the class that has the disease looks exactly the same. The word for that is heterogeneous.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So let's take an example where the disease is very heterogeneous. Sickle cell anemia. Correct. Everybody who has sickle cell anemia from a pathophysiology standpoint is identical. Correct. And guess what? There's a single mutation that defines the disease.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Because you have a single gene that defines the disease, one gene mutated produces one change in one base pair that changes one amino acid that changes the property of the hemoglobin molecule and everybody looks the same. But you're saying, Peter, it's totally different.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
With type 2 diabetes, we have some people that are thin, some people that are fat, some people that have lots of insulin resistance in the muscle, some people that don't seem to have much, but it's all in the liver. I want to make sure we define the octet, the ominous octet. But if that's the case, why would you ever expect to find a simple genetic answer? By definition, it's going to be a mess.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Absolutely. And so if you don't have a very definitive phenotype, It's going to be difficult. But the implication, by the way, is any physician who approaches a patient with type 2 diabetes as a single entity is going to be providing suboptimal care.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
We're going to talk about the therapies in detail. But yes, you have to take a precision medicine approach to type 2 diabetes, which begins by trying to identify which phenotype your patient is.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And I refer to it as metabolic disease spanning the spectrum from hyperinsulinemia to insulin resistance to fatty liver disease all the way out to type 2 diabetes. So given how much I speak about that, it seems very important that we should have a really thorough discussion of that foundational metabolic disease and no one better than you to have that discussion.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Let's go back to the ominous octet, make sure I have that defined and all our listeners do.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Very counterintuitive.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Not that we should mire ourselves in teleologic things. Do you have a sense of why?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
I always thought that the reason we saw high free fatty acids in people with type 2 diabetes was not because the fat cells were undergoing more lipolysis, but because the fat cells were themselves becoming resistant to insulin and not able to take up fat. So same net effect, but I was kind of drawing the arrow of causality in the other direction.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Let's say that again, Ralph. I want to make sure people understand this. And the reason it's important is obviously everybody listening to us right now is very familiar with drugs like semaglutide and trisepatide. But I want people to understand why those drugs were developed. And of course, semaglutide's already probably what, the third generation of it anyway.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So let's start a little bit with just telling folks briefly about what you're doing at UT San Antonio and why you've spent the last 40 plus, almost 50 years now working on this problem.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So when we go back in time, we'll understand why people try to develop these drugs. But just say that again. So you eat your meal, GIP, GLP-1 are increased. And they come out normally. Yep. That's not the problem. And they're telling the beta cell, hey, make more insulin. Beta cell's deaf, not listening. It's resistant to the GLP-1 and GIP.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And he should be responding to 70% of his input should come from that signal.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And tell me, why is it mechanistically that the beta cell becomes deaf to GLP-1 and GIP? I don't know that we know the answer to that. So it's just another horrible piece of this puzzle where everything starts to work against the patient.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
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The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And sorry, just to make sure, I'm embarrassed to say I forget this from biochemistry. Is it driving the liver to make glucose out of, for example, glycerol, amino acids or other things?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And does it also drive hepatic glucose output?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Or does it just drive the creation of gluconeogenesis? No, no, no, in absolute terms. It increases hepatic glucose output as well as gluconeogenesis. Yes.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Yes, absolutely. Absolutely. And this is really Roger Unger and Dallas's. And again, why is it overproducing it? Why is it doing something that doesn't make any sense in the context of what's happening?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
It's counterintuitive. Usually when things go wrong, they get attenuated, right? Like it makes sense that the beta cell eventually fatigues because that's an attenuation of doing something that it's getting tired of doing. The alpha cell ramping up is a little less intuitive.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Which is the first SGLT2 inhibitor. That's correct, yes. Brand name on that one?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Forsiga, all right.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
This again, this is so counterintuitive. I know. Okay. This does not make any sense. I want to just bring it back to people listening so they understand what we're talking about here. The kidney is this massive filtration, another remarkable organ.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
No offense to the nephrologist, not as remarkable as the liver, but every bit is remarkable in terms of- I think it's more remarkable than the liver, guys, but that's okay. Everything that's floating through our plasma, our kidneys, by the way, they take 25% of our cardiac output. Huge. Yes. So it's massive. This organ weighs 2% of our weight and takes 25% of our cardiac output. Why?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Because we have to take everything that is in our circulation and dump it out. And then the kidney has to selectively bring back in what's normal. This was explained to me. I still remember in medical school. as a brilliant trick of evolution.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Evolution was never going to be able to predict every toxic thing we might encounter, and therefore teaching the kidney how to spot toxic things and get rid of them would have been a failed mission. Rather, it was better to teach the kidney what was absolutely necessary and to discard all other things. Pretty simple way. Yep.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So it's the take everything out of your drawer and dump it out and only bring back the socks and underwear that you need. So glucose, potassium, sodium, you name it, chloride, phosphate, all of these things get dumped along with everything else. And then it knows I need this much glucose. I need this much sodium. I need this much potassium. Yeah. So SGLT2 does the lion's share of this.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
It takes back 90% of the glucose.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So my point was SGLT2, if it had a brain, would say, oh, you have too much glucose. Turn off. Turn it off. How about we just stop reabsorbing all this glucose? But you said it's the opposite. I told you earlier, it's going to get worse. It ramps up SGLT2.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
People who are listening who are particularly astute might recall, I've referenced a number of Cahill's papers, but one of the more interesting studies he did, which it's possible he did while you were even a student there, was the 40-day starvation study. Now, you might have not been quite at Harvard yet because this was, if I recall, in the mid-60s, maybe 66, 67.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
How many grams of glucose can be differentially or extra secreted, basically, in the presence of an SGLT2 inhibitor today?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Good for the heart, yeah. I want to come back to that because I'm making notes of other things I want to come back to. And so I want to come back to, just so you can hear me say it now and we remember, I want to come back to combined inhibitors, the SGLT2, SGLT1 inhibitor. I think it was a new drug. Sotagliflozin. Yeah, that does both. We'll just touch on that.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And then I want to also come back to the broader geroprotective nature of the SGLT2s as documented by the ITP in mice and then also in the human studies for cardioprotection. But before we do that- We need to finish the- Exactly. Let's go back to number eight.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And it was probably a group of medical students that actually volunteered, if not medical students, undergrads. They did a water-only fast for 40 days. And the study basically just followed all of the metabolites, what happened to glucose levels, obviously insulin, beta-hydroxybutyrate, acetoacetate. Anyway, it was very fascinating stuff.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
I'm sorry. You're saying that these are the few areas in my brain and your brain that are actually default insulin insensitive. Yes. Don't take up glucose. Correct. If I do an insulin clamp.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Now, of course, if you take people with mild cognitive impairment, there have been some experiments that actually suggest in these people, insulin infusion can transiently improve glucose uptake, but presumably that's because they're insufficiently getting glucose in the disease state. Yes, this has been postulated.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
One of the things that was most interesting to me in that study was even under a period of such extreme starvation, the brain never gave up its dependency on glucose. So even though ketone bodies began to service the brain by about day seven to 10 as the majority of the fuel,
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And we've done this. Does it result in any meaningful clinical increase in adiposity, or is it so subtle that you don't notice it?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Is there anything that improves mitochondrial function more than aerobic exercise training?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Even at three and four weeks of starvation, glucose was, if my memory serves me correctly, still providing about a third of the brain's energy. Your memory is very good.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Why don't people use this drug today?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
It's incredible. We kind of glossed over this. We're going to spare people the details, but it's probably worth just reminding people. Insulin binds to the insulin receptor that's outside the cell. That's a kinase receptor, correct?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And if I recall, isn't this where Jerry argued that the intramyocellular lipid was creating the defect in that pathway, the accumulation of intramyocellular lipid?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And so given that that's both a very important and very common pathway towards insulin resistance, bringing it back to PPAR gamma, PPAR gamma is part of the pathway. It's part of the IRS1, PPAR gamma, PI3K, GLUT4, bring the glucose in the cell.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guest this week is Dr. Ralph DeFranco.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
In other words, if people don't want to get mired down in this, which is totally understandable, insulin hits a receptor, that receptor kicks off a cascade. That ultimately results in a little tube, like a little straw that goes into the cell surface that allows glucose to freely flow in, in its gradient. Remember that same pathway also activates nitric oxide synthase. That's right.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Generates nitric oxide. And that's why we see in patients with insulin resistance, even if glucose is controlled, cardiovascular disease is still up. A very important. Yeah, very important point. So back to Actos.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
It's a victim of maybe not so nuanced thinking about the drug. Now, the critic would push back and say, Okay, Ralph, but don't we have better drugs?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So let's talk about metformin. Everybody wants to know if metformin is geroprotective. But let's just remind people, metformin inhibits complex one of the electron transport chain. Is that a given? Yes.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Is the belief that metformin's efficacy in diabetes is through reducing hepatic glucose output? That is 100% true. Okay. And what's the mechanism by which it reduces hepatic glucose output?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Does it get into muscle mitochondria? No, it doesn't get into muscle at all. Why does lactate go up when people are taking metformin? Level of the liver.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
There's a block. This is very important. I have erroneously always believed, so I'm really happy to be corrected. I love being proved wrong. I have always believed that the reason we saw an increase in fasting lactate, even in healthy people, if they took metformin, was because of the inhibition of the ECT in skeletal muscle. No, no. And you're saying, Peter, that's not possible.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
It can't get into skeletal muscle?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And when you say high dose, I mean, is two grams a day of metformin?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
That's the normal dose? That's the normal dose. Okay. So metformin has the following going for it. It's free. Yes, it's basically free. Yeah, it's free. And it does a pretty good job at reducing hepatic glucose output. Yeah. And it has no myotoxicity, frankly, any toxicity. GI. Yeah, the GI, but you can usually overcome that with a slow ramp up.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Let's maybe talk a little bit about what insulin resistance is. We'll get into what causes it, but let's just maybe define for people this term that gets thrown around constantly. And let's explain what it is from a technical standpoint.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Do you think many people, I feel like I'm asking you this question a lot and it's getting a little old, but do you get the sense that most people are still thinking what I think? Yes. Metformin gets into the muscle.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Metformin's an insulin sensitizer. Absolutely. And it's an insulin sensitizer by getting into the muscle and inhibiting complex one. Absolutely. People have done PET studies.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Is there a downside to using metformin in combination with the other three drugs? No.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
But you have to start somewhere, right? Yeah. Let's pay it its dues as being the Gen 1 OG version of that drug, without which we might not have, we wouldn't have semaglutide or trisepatite.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Ralph, why the disconnect between what you're seeing in the EDIC study and what the ADA is promoting? You have to ask the ADA. What's their answer? If I'm a patient or if I'm a physician who's treating these patients and I'm saying, guys, I'm confused. I'm looking at the literature. I'm seeing this. I'm looking at your, and by the way, I see this with the AHA and cardiovascular guidance.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So I'm not singling out you, but is this simply a question of the pace at which medicine moves is so glacial? That's part of it.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And why has there not been political pressure? Because the cost of insulin is enormous. Your approach is going to be less expensive.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
You had to have failed on metformin to get into this study. Okay, so you failed in metformin, then you enter the study, then we go single agent.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Well, they stop working. Yeah. I mean, basically, they kick the can down the road without addressing the pathophysiology. I like that way.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And let's just go back. Metformin is free. The Gen 1- Exenatide, basically free. Is basically free now. Pioglitazone is $5 a month. Okay, so we have three free drugs that work better. Correct. Now, it's interesting. When you talk about today's triple therapy, which is way more efficacious, two of those three drugs are very expensive. Yes. The SGLT2 inhibitors are very expensive.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
In the modern day, Gen 3, Gen 4, and soon we'll have a Gen 5, GLP-1, they're very pricey. $1,000 a month. Now, are they great drugs? Of course. I guess the question is, do you need to be on those drugs if your old version of triple therapy...
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And the reason is patients are frustrated with the fact that they're retaining water? No, gain weight. How much weight do they gain typically?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
If you give PO plus a modern-day GLP-1, don't you offset the weight gain?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So if a patient is willing to go down the path of a modern-day GLP-1, doesn't that completely eliminate?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
I think I go for being a little bit chubby. But now that's not even a necessary comparison. You don't even need to make that trade off with a modern day GLP-1 agonist.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Yeah, that's never going to happen. But I also don't think it needs to happen in the same way that... I agree with you. In the same way that we saw, for example, PCSK9 inhibitors reduced MACE in people with secondary prevention. Take people who had already suffered MACE, put them on a PCSK9 inhibitor, you secondary prevention, reduce subsequent.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Well, of course, everybody's using these for primary prevention now. That's effectively what you're saying. We already know the SGLT2 works for secondary prevention. That may never get approval for primary prevention, but it probably justifies its use. I agree with you 100%.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So just to make sure I'm synthesizing what you're saying, Ralph, if you only get one drug and you're price agnostic, GLP-1 agonist. Yeah. If you get to add a second drug, you're going to add PO. Yeah. If you get a third drug, especially if you care about your heart, SGLT2. Yeah, SGLT2. And what's amazing is metformin didn't even make the top three in your list. But it's number four.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So here's my question. Given that metformin is free, should we just be adding it the second we put on the GLP-1? I don't have any problem with that.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Yeah. I want to ask you about that. So just again for the listeners, right? Semiglutide's Gen 3. Trezepatide is Gen 4. Retatrutide is coming out, assuming the Phase 3 goes according to plan. And Cargisema is the new Nova 1. Yeah. Let's go back to Retatrutide. GLP-1, GIP. And glucagon. glucagon. Can you explain that in the context of the octet where glucagon is going up?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Yeah, I would be surprised if they're going to see a clinically meaningful increase in involuntary energy expenditure.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So you're saying if a person shows up with hemoglobin A1c of nine and a half percent, this is a person who hasn't come to medical attention soon enough. And I'm going to give you the answer definitively, but I'm going to let you ask the question. You're happy if they only go from 9.5% to 7%? If they only had a 2.5% drop, you wouldn't try to get them down to 6%? I would, and we've done the study.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
I can send you all the papers. It's all published. I hope every single family medicine internist, everyone who ever takes care of somebody with diabetes is listening. I hope so too. Because you're basically saying we can take these two old cheap drugs and take someone from the most brittle type two diabetes. I mean, a hemoglobin A1C of 12. Pretty bad. You're knocking on death's door. Correct.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
You're going to go blind. You're going to have your toes amputated. You're not ever going to have an erection again. And you're going to die of cardiovascular disease or kidney disease or Alzheimer's disease quickly. These numbers that I'm telling you, they're right from the paper and it's a large, over 200 people. And in a couple of years on two old cheap drugs, you're normal. Yep.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So the only pushback is those patients are going to have to gain a couple of kilograms. But of course, if you're willing to now spend a bit more money and switch them from Gen 1 to Gen 3 or Gen 4, GLP-1 agonist and GIP, then all of a sudden you ameliorate that and you get all the benefits. This becomes a non-issue. Put cost aside.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
I would wonder if you add metformin, you almost cancel out the weight gain a little bit because you might get a little bit of the GI improvement and you get the two to three kilos of weight loss there.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Which was that study?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Can we at least assume that the Gulf states are paying attention to this? A, the study was done in Qatar. B, the Gulf states are disproportionately ravaged by type 2 diabetes. Yep. Is it at least being heated there?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Does that translate not just to structural proteins such as enzymes or cellular structural proteins, but also macro structural proteins such as muscle?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
We'll link to all of these in our show notes for folks. Just simply phenomenal. Let me ask you a question. If you take an individual with type 2 diabetes or insulin resistance, and you presumably collecting urinary C-peptide for 24 hours is the best surrogate for total insulin secretion? No, it's an index.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
If you could quantify total area under the curve of insulin for a person, and then you gave them a GLP-1 agonist, is total insulin going up or down? Depends. Yeah.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Maybe just tell folks, I threw out C-peptide as though everybody knew what it is. That's a mistake. Tell people what C-peptide is and what its relationship is to insulin.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Ralph is a distinguished diabetes researcher and clinician known for his pivotal work in advancing the understanding and treatment of type 2 diabetes. He's widely recognized for his groundbreaking contribution to the concept of insulin resistance, which has reshaped the understanding of type 2 diabetes and its progression.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Do you have any concerns with long term safety or anything other than simply the economics of the GLP ones in this current generation? Again, huge, huge leap forward between liraglutide and semaglutide. And I've discussed briefly elsewhere on the podcast what the roadmap looks like for how many of these drugs are in the pipeline. Oh, yeah. There seems to be no end in sight.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And we're going to look back at semaglutide and say, God, that thing was pedestrian. That's what's going to happen. Give us the bear case. What should we be concerned with? What should we be at least looking out for?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Why is that so bad? How much did it come down? Because if total body mass came down by 33%, but three quarters of that mass was fat, and only one quarter of that was lean, we would consider that acceptable.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So one of the challenges with the term insulin resistance is, as you said, it's a vague term and it's nonspecific because the actions of insulin are so many.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Were these patients exercising during the period of their weight loss? No, no, no, no, no, no.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Yeah, of course, which is heavily dependent on weight as well. Yeah, it all got better. But in absolute terms, did VO2 max get better? Not necessarily. Yeah. The total VO2, not normalized per kilogram. No, everything got better. Okay. That's counterintuitive, by the way. Normally, when you lose weight, VO2 max in liters per minute does not improve because you have less metabolic tissue.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
It has an action in the liver, it has an action in the muscles, it has an action with response to glucose, it has an action with response to amino acids, and it has an action with response to fat, both in the liberation of fat, lipolysis, and presumably in response to oxidation. Absolutely. We'll go through all of these, but let's maybe start with how the euglycemic clamp test is done.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Where are myostatin inhibitors in their development? Phase two. Of course, I think we've talked about myostatin before on the podcast. When you inhibit myostatin, you increase the expression of striated muscle, of which cardiac is striated. It works through the eventin 2A and 2B system. Do you think that's a more promising pathway than the phallostatin pathway where phallostatin... Yes, I do.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Increasing phallostatin inhibits myostatin, but this is a more direct way to go about it.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And we think that this can still be effective in a fully developed and mature adult. I mean, clearly this would be effective during development. And we see that in the animal work. How effective is it? A lot of the animal work is sort of a caricature stuff. It's knockouts, right? They take myostatin knockouts and they look like bodybuilders.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
But if you take a mature chicken or a mouse that's two years old and you give it a myostatin antibody, how robust is the response? Even more so, what about in a human? We don't know the answer to that. So what the phase two studies, obviously the toxicity passed in phase one. Yes.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Didn't increase it, but just prevented it. But that would be ridiculous. I mean, if you took a 200-pound individual who's 30% body fat... They've got 60 pounds of adipose tissue on them. If you took 25% of their body weight off, you take them down to 150 pounds, but you're telling me potentially we prevent any deterioration of lean mass.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
That means they're down to 10 pounds of fat mass on 150 pound frame. I'm making an assumption. Okay.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
I think the FDA would ask that you've also improved function in some way. And the function would have to be determined through absolute strength, not relative strength, would be my guess. I don't know the answer to this question. Because the way I think about these drugs is less about that situation. It's more in the sarcopenic adult. This is the lean, particularly the older person. That's right.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Let's assume that I'm a healthy enough individual that we can use me as a proxy. I come into your clinic. What are we going to do? How do you run this test?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
That's right. This is the elderly individual who's sarcopenic and whose fall risk is enormous. And their risk of fall and morbidity and mortality is very high. And in that individual, I don't think the FDA will be satisfied with simply an increase in lean body mass unless it is accompanied by strength. Now, I think that some of the tests that are used here are silly.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
I think the six-minute walk test should be folded up, discarded, put in the wastebasket, and never discussed again. It is such a stupid test. They do it all the time. I know they do, and it just makes me want to scream. Yeah. We need much more rigorous tests than a six-minute walk test. We need a test that is actually more of a submaximal test.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So if we're testing cardiorespiratory fitness or some sort of peak aerobic fitness, we have to do more than walking. And if we're testing strength, I much prefer grip strength, leg extension, bench press. Again, these can be done with machines. They can be done very safely, but we really need to test strength.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
There could be other functional benefits that exceed strength. For example, glucose disposal could be a functional benefit.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Yeah. But I think that, again, it's harder to tease out because there's more moving pieces and they might argue there are easier ways to increase insulin sensitivity and glucose disposal. But one way to think about this is to go back to what if you did it the old fashioned way? What if you got in the gym and lifted a bunch of weights? That's been done. Yeah.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And it increases insulin sensitivity and functional strength. And so the question is, can we replicate that pharmacologically?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And your life expectancy will be significantly shorter. And your quality of life will be significantly reduced.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
What is the prevalence of type 2 diabetes in under 18?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
You could say potentially in San Antonio, one out of 20 teenagers. It's going to be very high.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Just clinically, if you're in the clinic and you're using the best drugs you have available.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Why?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Is this really a selection bias where for someone to develop type 2 diabetes as a 16-year-old, the underlying genetics and pathology are so severe that the current crop of drugs are the problem, as opposed to when you take the current crop of drugs and you apply them to people who are young, they don't work?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
What do you think? I mean, yes, we're going to argue that these kids are, this is due to what they're eating, but what is it in the environment that is so obesogenic to these kids?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
If you take that 16-year-old with a hemoglobin A1C of nine and you give them Manjaro, where are they in a year?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
What fraction of insured patients will have coverage on Manjaro if their A1C is 9? I can't answer that. Does CMS cover it? Does Medicaid cover that?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Yeah, of course, this begs the question, will the next generation of weight loss drugs be true uncoupling agents where you can basically eat as much as you want and they're going to create so much mitochondrial uncoupling and thermogenesis that you're truly going to see this increase in non-voluntary energy expenditure and, of course, not have the GI side effects.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
But before we go on to the next thing I want to chat about, and I just kind of bring it back to this question, which everybody wants to understand this, which is what has changed so much in the last 30 years that has created this epidemic? And everybody has their favorite pet theory for what it is.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
It's the sugar, it's the carbs, it's the plastics, it's the video games, it's the internet, it's the whatever. Perhaps suggesting that it's many, many things. What is your best explanation for what's going on?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Just to be clear, Ralph, I mean, unfortunately... We as clinicians are not able to do euglycemic clamps. Correct. We are still looking at oral glycemic tolerance tests. We are still giving people oral glucose and sampling glucose and insulin every 30 minutes and trying to impute what we can, which I'd love to come back and talk about interpretation, but carry on with the limitation.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Yeah, yeah. So you've been in San Antonio since the late 80s. When did you really start to notice this was a problem, at least in your community? Almost instantaneously. Even in kids? Even in kids. We can't blame video games. We can't blame social media because that wasn't going on in the late 80s.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Believe me, I see them. What did your colleagues at San Antonio tell you as far as when they started to notice that in the Hispanic kids? I don't know that I can give you a specific time that they told me, except they knew it. So, okay, what about in non-Hispanic kids?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Because if the Hispanic kids are genetically predisposed to this, then the question becomes, when did you begin to see this in African-American kids and Caucasian kids?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And do you think this is mostly an energy balance issue and therefore it's mostly a food environment issue? No, I think it's both.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Yeah. Oh, so it's not just one enzyme then?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Okay, so it starts at IRS-1.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Let's just make sure people understand this. We're kind of getting into some biochemistry here. When glucose enters the cell passively through the GLUT4 transporter. It gets free glucose in the cell. Yes. Then to metabolize it. Yeah, the first step to that is hexokinase, which takes a phosphate off ATP and puts it on the sixth position, if I'm not mistaken.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And it's a specific type of hexokinase, so it's hexokinase 2.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Remind me what Jerry believes is wrong with the GLUT4 transporter? That it doesn't work normally. I thought it worked fine. It's just not getting the signal to work because of IRS-1. That's where the controversy is.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So you're saying it's possible that just having the IRS-1 problem is enough. It's also possible that even if IRS-1 is functioning reasonably, if GLUT4 is not getting up, that's the problem. There is evidence to support that. And then it's also possible that even if all those things work, if you don't get hexakinase to phosphorylate glucose, you back up the whole system. Yes.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Ralph, I want to close by bringing it back to something that people can do to help understand if they're at risk, either lean or otherwise. We talked about it at the outset, but didn't go into it in detail, which is the OGTT, the oral glucose tolerance test.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Now, again, none of us have the privilege of being able to use a euglycemic clamp, both clinically as physicians or as experienced as patients. So we're going to have to kind of rely on other things. We're going to have to rely on body fat. We're going to have to rely on triglycerides. We're going to have to rely on hemoglobin A1C, although I find that to be a particularly useless metric.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Not that useless. At the individual level, I find it very unhelpful. I think at the population level, it's great. And in deltas, it's great, but boy. The correlation between a hemoglobin A1C and realized glucose levels is pretty weak. But let's talk about the OGTT because this is not a test that is done frequently. I believe it should be.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And I'd love to have you walk us through the interpretation of the following. I'm going to give you a couple scenarios. So case one. I'm making this up as we go. You got a person who starts out, all of these people are going to start out normal. They're going to start out with a glucose of 90 and an insulin of six. At 30 minutes, this is after 75 grams of oral glucose, the insulin rises to 90.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
I'm nervous. Yep. The glucose rises to 130. At 60 minutes, the glucose is down to 100. The insulin is down to 60. And we'll just do one more check at two hours. The glucose at this point is 60 and the insulin is 20.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
He played a very important role in bringing metformin to the United States as a standard treatment for the disease nearly 40 years ago, along with the discovery and development of SGLT2 inhibitor, a class of drugs you have no doubt heard me discuss many times before.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Yeah. Agree. with you completely. And we see this all the time. This is a person, by the way, with a perfectly normal hemoglobin A1c. And this is a person who gets passed all the time as totally normal. They're severely insulin resistant. The beta cells are doing a good job. Your hemoglobin A1c is normal and your insulin is six, even if the doctor is checking insulin.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
But as you point out, the thing that trips you off is not their glucose. 90 to 130 to 100 is amazing. It's 90 was how high the insulin was at 30 seconds. And of course they overshot, which is why they become hypoglycemic. Yes. Okay. Well known. Yep. Let's go another one. This person also starts at 90 and six. At 30 minutes, they go to 180. Insulin goes to 30. At 60 minutes, they go to 200.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Insulin is 40. They're diabetic. But just to be clear, these are almost real cases, by the way. This is a person whose hemoglobin A1c is 5.6. Got it.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So if one hour glucose is more than 155- You're in trouble. And that's a great predictor of type 2 diabetes, regardless of all the other metrics.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Next case, I'm not even going to give you the numbers. I'll just describe it. This is a person who has a delayed onset of insulin. So in other words, they start out normal at 90.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Yes. So what's going on in this person where 30-minute insulin does nothing, glucose rises. Yeah. And then at an hour and 90 minutes, the pancreas kicks on and starts to dispose of glucose. What's happening in that person?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
We use the following numbers in our practice as what we consider what we want to see. Do you think we're being too aggressive? At time zero, we want to see you less than 90 and less than six. At time 30 minutes, we want to see you less than 140 and less than 40. At time 60 minutes, we want to see you less than 130. 90 minutes, we want to see you less than 110 and less than 20.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Do you think we're being too hard?
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Okay. Ralph, I don't know where the time went today, but it went. And this was a fascinating discussion. I could talk about this stuff all day long. It's interesting because someone listening to this podcast who heard the podcast with Jerry Schulman from probably three years ago will be pleased because the overlap is virtually zero.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
I mean, that's what's amazing about a topic as rich as this, is you can talk to two of the world's experts and and have two completely different conversations. Conversation with Jerry focused so much on the pathophysiology of insulin resistance. Here, we focused much more on the actual organ-specific aspect of type 2 diabetes.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
We got a masterclass in the pharmacology of it, and then I think kind of brought it back to ways to diagnose it if you're slumming it with those of us in the clinic who don't have clamps. So maybe we should, in the future, we do one with both Jerry and I. I will 100% agree that in a few years we come back and we do a double version of this and that would be fantastic.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Ralph, thank you so much. Not just obviously for this, but for your contribution to this field. Okay. I appreciate it. This was wonderful. Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
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The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
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The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
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The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
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The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
Let's summarize those again. We're talking about this in an insulin sensitive person, right out of the gate, insulin is going to shut down hepatic glucose output. Absolutely. Which again, all of this kind of makes sense if you think through the pathway. Our liver is constantly putting glucose into circulation because the muscles can't put glucose into circulation.
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
So something has to feed the brain. if insulin is high it suggests glucose is already sufficiently high so let's not create more glucose toxicity let's shut that second thing it's going to do is it's going to take that excess glucose and put it in the place where we have the largest capacity to store it which is muscle so point two is we increase muscle uptake of glucose
The Peter Attia Drive
#337 - Insulin resistance masterclass: The full body impact of metabolic dysfunction and prevention, diagnosis, and treatment | Ralph DeFronzo, M.D.
And then point three, you said, was it's going to shut down lipolysis. It's going to shut down the release of triglycerides and or free fatty acids from the adipose tissue.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
For all of my disclosures and the companies I invest in or advise, please visit peterottmd.com forward slash about where I keep an up-to-date and active list of all disclosures.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
The anesthesiologist still had to give typically a narcotic. They were still typically giving something like fentanyl, even though the patient was unconscious. They were also often giving an amnesiac so that they wouldn't have any recollection of what was going on. But of course, we all hear the horror stories of the patient. And a paralytic on top of all that, right?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So you hear these horrible stories of the patient who is paralyzed, but somehow conscious. You can miss on this state sort of thing. But just to make sure I understand, in theory, a paralytic and an inhaled anesthetic should be sufficient to eliminate the perception of pain in a patient who is being cut. Yeah.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Got it. So in other words, you give the inhaled anesthetic just to get unconsciousness, but not to fully suppress the nociceptic system. Instead, you bring on the opioid to do the remainder of that work.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
We talk about the different types of pain, such as nociceptive pain, visceral pain, neuropathic pain, etc. We talk about why pain perception varies so widely from person to person, even in the face of an identical stimulus, how psychological and emotional factors play a role into this. We talk about various approaches to pain management, including NSAIDs, opioids, and antineuropathic medications.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So does that mean we are seeing a cortisol surge? We're seeing whatever one would expect a conscious person to experience with epinephrine, norepinephrine, cortisol, all those things still surging out in response to pain.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Arguably more than you would ever experience. Think about what we do in surgery. My God. Take a scalpel and then take an electrocautery and start burning tissue. I mean, there's no level of nociception you could ever experience like that while being awake, unless you're in a burning car. Absolutely.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So let's go back to something you said at the outset from an evolutionary perspective, which is pain and pleasure have been the driving factors that have been the engine of natural selection. But clearly those things have had to work in pre-conscious models. So that means that whatever we're defining as pain there did not include a perception of pain.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Right. Does a goldfish experience pain?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
We talk about the effectiveness of neuromodulation techniques like TENS and how sleep deprivation affects pain sensitivity, as well as why chronic pain often leads to disrupted sleep cycles. We talk about this and many other things. Again, I share a very personal experience with my own pain and how Sean came to my rescue 25 years ago.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So how does everything you just said differ or overlap with neuropathic pain or that sort of burning pain that I'm sure some people are familiar with? Certainly I was familiar with it for several years. Yeah. Is that simply a subset of this? Are there various different types of pain that don't have a clear cause-effect relation to tissue damage?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So without further delay, please enjoy my conversation with Dr. Sean Mackey. Oh, it's my pleasure. It's really good to see you again after a rather long time. Yeah, I was thinking about it. So this morning, my wife said, oh, what's the topic of the podcast today? And I said, it's going to be pain. And I said, she said, oh, who you have? And I said, Sean Mackey.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And by the way, on visceral pain, what is the response to treatments with respect to the way we saw in noceptive pain where, hey, great response to these NSAIDs or opioids or whatever?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
She goes, her face lit up and she doesn't know you. She's never met you, but she knows your name because she's heard me tell a story. She's heard me tell a story about my own experience through this. I then realized something, which is I haven't seen you since I was in medical school. Which is kind of weird.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yeah, I was about to say, before you gave your examples, I was going to say nociplastic pain must be a huge bucket because it's everything for which we don't understand. It's sort of the all else bucket, which is enormous, especially for chronic pain, right?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Now, there's no objective way to measure pain, correct?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So I'm sure we will get to how you and I met 25 years ago, exactly 25 years ago, and how you played an unbelievable role in bringing me back from arguably the brink of what could have been the end of my life, truthfully. But I want to start with some broader topics around pain. So There's nobody listening to us right now who doesn't know what pain is.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Sorry, you're capturing these through what modality?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Let's just start with standard understanding. If you put me into an fMRI machine and I said to you, hey guys, I'm not feeling any pain right now, I feel great. And then you scan me and then someone came out and took a hammer to my thumb and I went through the classic response that you described earlier, what would my fMRI show?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And to be clear, this is distinct from the part of my cortex that is the homunculus for my thumb.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yeah. Okay. So let's go back to the story of these four branches of pain, or at least the first three, and then how the sensory component is impacting the perception.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
There's nobody listening to us right now who hasn't experienced pain. Yet, if you ask for a definition of pain, I think you'd get a lot of using the word to describe the thing, which isn't truly a definition. So if you were trying to explain to a Martian from another planet who doesn't experience pain what it is, what would you say?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Give me a little bit more.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Okay. So we go back to nociceptive pain. So tissue injury occurs. I think where I derailed us was in classifying all the different types of pain, but you had signal comes up, two signals coming up, the C fiber, the A delta fiber. The immediate response is to get you out of pain. There's an evolutionary logic to that. The C fiber is not there to get you out of pain because the A delta did that.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Is the C fiber there to remind you not to go back and do that again? Perfect. Perfect.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
By the way, do we have any evidence, Sean, that there was enough genetic heterogeneity around this that there were 200,000 years ago, there were members of our tribe who simply didn't feel pain and therefore did not pass on their genes because they made poor decisions?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I find it amazing to just sit around and dream about how little convergence must have existed a quarter of a million years ago in terms of things that ended up not being good for our species, like people who didn't experience pain the same way or didn't have certain filters within themselves. There'd been lots of talk about people who couldn't socialize. You couldn't evolve alone.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So if you didn't have the right set of genes that allowed you to at least be part of some sort of social tribe. And of course, we still probably have people today that have escaped. We clearly have some antisocial folks among us, but they're the exception and not the rule.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So anyway, I just wondered if today we're much more homogeneous in terms of what a human's response to pain is versus what it might have been. Probably.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And I also think about certain things like childbirth prior to any anesthetic was obviously brutal, both in terms of the pain and the mortality. And yet there's no evidence that people were deciding, yeah, maybe we ought not to do this. In other words, the drive for procreation somehow overcame what must have been brutal.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Those are the two things that I joke about with my friends, which is I still don't really understand how our species is here for two reasons. One, women had to continually go back to the well. Because remember, if your reproductive rate isn't in excess of two, the species collapse. So on average, every woman must be able to do this. And back then it had to be reproductive rate of north of three.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Right. Every woman had to do this three times. How she did it the second two times after how bad the first was blows my mind. The second thing is just looking at how stupid adolescent males are. I'm sure you can relate to this. I was one. Yes, as was I. And I look at my boys. I don't understand why males all didn't die from just doing stupid.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
stupid, stupid things before the age of 20 or even before the age of like 15. Those two things are a miracle to our species, that all the males didn't die and that all the females were willing to have at least three kids.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
We'll link to them in the show notes, some of my favorites.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Sometimes trying to create a distraction. Okay. Okay. Sometimes, though, probably illogical trying to keep whatever humor is in there that's hurting isolated like a tourniquet. Right. Right. Obviously, if I'm using cold, especially if it's one of my kids that hurt themselves, we'll put cold on hoping to anesthetize the area, presumably slow the circulation, take down the swelling.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And how do you predict patient comes to you and they're experiencing some pain? What are the clues that would tell you, I think TENS is going to be successful here? In other words, I think that activating A-beta fibers is going to be a tool that will reduce your perception of pain because that's what we're doing. Everything that you do is, how do I reduce your perception of pain?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I can't necessarily take away. I mean, if they have an injury that needs to be resolved, they shouldn't be seeing you. They should be seeing the surgeon or whoever fixes the physical injury, right? In short, yes.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So who is the, I hate to use the word poster child, but who's the patient that when you see them, your intuition says TENS is going to really work for this person?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Can I put a bow on the gait control thing to make sure I understood it? Yeah. It seems like a very important idea, but I also think I might be missing the juice. Is the idea that 10 people could experience the exact same peripheral injury, if you could map the action potentials, they would look identical.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
You could even see identical perceptions, but they could have 10 different gating channels within the spinal cord and therefore perceive pain differently. I just want to make sure I've captured what the gating theory states. You are right.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
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The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yep.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So here's another experiment that you won't be able to do unless you get to teach this class on multiple days, but it's to go one step further, which is to do the same thing every day and see how they compare their score from day to day. I'll tell you my experience with that. I do love to use a cold plunge. So my cold plunge is at 42 degrees with circulating water.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So I don't know what that makes it feel like, but it feels like it's somewhere in the 30s. There are days when I can spend 10 minutes in there and feel like nothing is wrong. There are days when, I'm not kidding, 30 seconds in, my ankles hurt so bad I want to scream. And I think, what's different? It can't be the circulation in my ankles is better one day to the next.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
They're a relatively avascular part of my body. Why is it that one day I can spend 10 minutes and not know I'm in this water? I mean, I know that I'm cold, but it's more like my core temp, but my joints don't hurt. And on another day, the throbbing in my joints feels like somebody's hitting them with a hammer. And I'm the same person.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So in other words, your point is well taken, but I would say there's a second dimension to it, which is even as individuals, we can experience things differently from day to day.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
There seems to be kind of, I guess I should ask this. I'm not asserting this is the case. Is there kind of a moral judgment that comes to this at some level? Like, don't we as a society just tend to look more favorably at people that have a very high pain tolerance?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So when you go through that experiment you just did with the medical students, if everybody's being brutally honest, aren't they kind of looking at the people who score 0, 1, 2 more favorably than those that score 8, 9, and 10? Absolutely. Why do you think that is? If I'm being truthful, I do it.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I just think it's like a compatibility thing. Like I know when I do that type of an exercise compared to others, I tend to just feel less pain. I also know my wife does as well. And so I almost wonder if that's a compatibility. We both just have a high threshold for that when we're exercising, when we're doing anything, even recreationally, that doesn't matter.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So what is the consequence of this? So we're acknowledging that it is an attractive trait to have a high tolerance of pain. Society rewards it. And yet by definition, a significant subset of the population, call it a third, call it a quarter if it's a normally distributed function, are going to be a standard deviation on the other side.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
They're going to be on the side relative to people who have a high tolerance for pain. These are people who are going to really perceive pain And if we just did this through the lens of the responsibility of the medical community, there's a pretty significant consequence to that. Indeed.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So just because you have a high threshold for cold, you could completely flip it on hot or pressure or pinprick or whatever the other modality is.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I was going to say, is there any way to put together a set of experimental lab versions of this to basically generate predictive models of how people will respond to real world pain? I think where you're going with chronic pain is even more relevant.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So for example, why do some people have a disc herniation that leads to manageable pain, whereas for others, the exact same injury by every metric available to us produces a totally different set of consequences? And what do we do about that?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
What about other things? You talked about sleep deprivation. Any other physical things, exercising, not exercising, insulin resistance, non-insulin resistance? What are the other things that might factor into this?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
How much sleep deprivation does one need for there to be an increase in pain perception?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I mean, I felt awful. You felt worse between 5 a.m. and 8 a.m., and then you get this second wind, usually about the time you're operating, and then you usually feel pretty good. But overall, I mean, it's a haze.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yeah, for sure.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Well, look, there's so much going on. I'm happy to tell my story because it's a great introduction to the work you've done. So for folks that haven't heard it, I've shared this before and we were talking before the podcast. I don't remember how much of this is in the book because at one point I wrote all of this out. I'm pretty sure much of it got cut out.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
But when I was in my third year of medical student, I was having just a great old day, rode my bike to the gym, was just about to go in the gym and I get off the bike and I feel a pain in my back like I've never felt before. And it was enough that I decided not to work out, which says something because I would have worked out through any amount of discomfort.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I limped home, laid down and said, you know what, I'm just going to sleep this off and tomorrow will be fine. Tomorrow it wasn't fine. I was in so much pain I couldn't get out of bed, had to actually call my roommates. we had separate phones in the same house, to come and get me up and out of bed. And the next two weeks proceeded to be a really unbearable episode where I was doing an ICU rotation.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
This is back in the Wild West, where I think the nurses and the residents were just shooting me up with Toradol every day, nonstop, getting me through the day. But the nights were brutal. And what I now realized happened was I'd had a really significant herniation. A piece of that L5-S1 disc broke off.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I would later find out it was a five centimeter piece and it had extruded, broken off, was sitting on the S1 nerve root. Every night now I was going to bed feeling as though the skin on the bottom of my foot was being ripped off. The only way I could sleep was to put my foot into a bag of ice. and take some amount of Benadryl that was enough to knock me out.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
This went on for about another week until the dean of students saw me limping along and said, hey, Peter, what's going on? I told him. This was a Sunday afternoon I was studying. He took me directly to the ER, got an MRI, showed all of this mess. The next day I had surgery. As I've talked about in the past, everything went wrong in a series of surgeries. And fast forward three months,
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
three trips to the operating room, multiple discectomies, laminotomies, multiple levels. In theory, my back should be fine. I'm anything but fine. I now have a new pain, but this is unlike anything that was related to my back. This is where you come in. I now have a pain that is so significant and it sounds grotesque to explain it, but this is all it was.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
It felt like someone was reaching in my body from my kidneys into my groin and tearing my testicles out from the inside of my body. So needless to say, I was out of commission. I did not move. I laid on a floor 24-7. And to your point, how did I feel? Well, it wasn't just that I was in so much pain that I couldn't do anything. It was I watched my life disappear.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So it went from, you're not going to graduate from medical school on time, to I'm You're not going to get to do a sub-internship in surgery to you're not going to be a surgeon to you're never going to walk again. So by that point, the overlap was how were the opioids that I was being prescribed to control the pain tripping into these are a tool to numb me to this entire experience.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So at this point, I've talked about this in the past. At this point, I was taking, I think I was up to maybe 320 milligrams of Oxycontin a day. Which is kind of amazing, because if you and I took that today, if you and I split that right now, we would die. that I'm mainlining 320 milligrams of Oxycontin a day just to blunt the emotional pain of this, I think says what we need to know.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
We can come back to the story of how I met you and how my life turned around from that point. And it's still a miracle for me to believe I actually graduated from medical school on time, despite that all happening now into my fourth year, because this was my third year bleeding into my fourth year of medical school when all this was going on. It's kind of amazing. A difficult time.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Third year is tough. So we'll come back to the what happened, but that's a long answer to a question, which is at some point, it wasn't even about the pain. The pain was unbearable, but it wasn't the most unbearable part. It was the expectation of what that pain meant for the rest of my life that became much more unbearable.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I call it the best worst experience of my life. Yeah. more best today. The gratitude I have for that is, I mean, again, I wouldn't want to do it again, but it has been such a positive impact on my life.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Before we go into the ins and outs of what pain doctors can do, let's just talk about some of the bread and butter stuff on pharmacology. How can we navigate our way through what NSAIDs do, what opioids do, what COX-2 inhibitors do? What should people be aware of in using these things? Obviously, opioids are a remarkably controversial topic.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
But there's probably a nuance to it that's missing from the broader discussion. But why don't we start with a softball like NSAIDs? How do they work? Everybody's heard of Advil, Aleve, Naproxen, all of these things.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Now, are you talking about this through the lens of acute pain or only through the lens of chronic pain at this point?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I did too. And I still remember the day in, oh God, it must've been December, 2001 when the FDA came down and said, no more Vioxx. And I looked at my last bottle and I was like, oh God, no.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I mean, in the world's most susceptible individuals at a relatively small, absolute rate. I've already had this discussion with Eric Topol, which was like mistake, net negative. Oh, is that right? Absolutely, net negative. Yeah, because I've always wondered- Merck's is faulted. They should have been much more transparent about this.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Put a black box label on it and we should all still have access to Merck's.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
The baby got thrown out with the bathwater on that one.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Why do you think there hasn't been any drug that's come close to that? Like Celebrex is a joke. Like none of the drugs that are in the...
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Do you have a version on dose? I mean, do you say 800 milligrams of ibuprofen TID three times a day, 2400 milligrams would be, you would tolerate that for how many days if a person needed it? Week to two weeks on that.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
You're eating. Yeah.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yeah, it is interesting that we can buy acetaminophen and ibuprofen over the counter, and yet they can cause a ton of damage if not taken correctly.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Liver failure. Let's talk about acetaminophen for a while. When I last tried to understand it, there was no clue as to how it worked. To this day, do we understand how it works?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
But there's a nice synergy with acetaminophen and ibuprofen because different mechanism of action, different organ systems are impacted. So you can take less of each when you combine them. What's your take on that?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. I guess this week is Dr. Sean Mackey. Sean is a professor of pain medicine at Stanford University.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yeah. My go-to stack, if I am actually in pain, a year ago, I had to get a crown put on a tooth that had an old filling that broke. And it's the funniest thing because of how remarkable the teeth are at sensation, but the crown was a little too high. Okay, so what's the impact of that? That meant every time I took a bite, that one tooth was bearing the brunt of it.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
It was the last tooth I had right in front of my wisdom tooth. And I'm talking to my dentist and he's like, yeah, Peter, it's just too high. Just come in and let me shave a little bit of it off. Well, I didn't have the time to go in. So for two months, I did not go in to get this thing shaved off. The pain was, this is how stupid I am.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Like I couldn't spare the two hours to go to the dentist and he was willing to see me nights and weekends. This is the most accommodating dentist in the world. Everybody should have that kind of dentist. Tony Pacheco. I can't say enough about him. And yet I couldn't make the time. So for two months, the pain got so bad that eventually couldn't chew on that side at all.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So my point is I had to be taking something to get through the day. And the stack that worked was 400 of Advil, 500 of Tylenol, three times a day. Okay. Took care of me.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I don't know, but the reason I prefer it is that I can line up the dosing with the acetaminophen because I believe naproxen you only take once a day, right? Twice a day. Twice a day. Okay. You're right.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I wanted something where I could do it TID instead of BID.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Okay.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Are there types of pains people should be thinking of where these things work especially well and other areas where, yeah, that's just not going to have much efficacy?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So you're saying maybe we should be empirical. In other words, try the naproxen, try the ibuprofen, figure out which one works. Obviously, don't take them together.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Do you have a concern with people taking acetaminophen and consuming alcohol? Do you tell people to refrain from alcohol when they're taking Tylenol?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I typically, when I'm taking acetaminophen, I don't drink much anyway. I'm probably going to have four drinks in a week. So meaning four days a week, I will have a drink or three days a week. But if I am taking Tylenol, I'm just going to refrain. Again, I don't have any evidence to suggest that that's necessary. Probably the safest. It's the precautionary principle at its finest.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Okay, I want to talk about muscle relaxants. So the other thing that has been a real favorite tool of mine is baclofen. Now, it's not a particularly potent muscle relaxant, but it seems to, for me and for the patients of mine in whom it works, offer something really potent like Valium. Doesn't bring all the baggage of a benzo. or even a Flexeril where you can kind of get the drowsiness.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And frankly, a lot of people just, I mean, I used to even get nauseous on Flexeril. But something about Baclofen, I don't even know it's in me at 20 milligrams twice a day, but it actually takes the edge off. And where I typically find this beneficial is is if I slept wrong and I get a kink in my trap, or I've been on a super long drive and my QLs sort of flare a little bit.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And I know that if I had all the time in the world, I could go and stretch my way out of that. But sometimes I just don't have that time and I need to kind of get right back to doing something awful like sitting. And just two or three days of 20 milligrams of baclofen BID with a little NSAID and like, I'm as good as new and I save myself the real flare up.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
What are your experience with muscle relaxants?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So how many days are you comfortable with a person?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
What doses typically, or is it just individual?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And what dose are you comfortable up to 20 milligrams three times a day?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Okay. You alluded to Neurontin earlier, and you alluded to the fact that it played a role in my recovery because once we got the big stuff out of the way, I still had a couple of years of peripheral nerve injury. And the only way to put the fire out in my foot was Neurontin. And unfortunately, initially it required four grams a day. I was taking a gram four times a day or something like that.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And Sean, just to interrupt for a second, thinking through the history of medicine a little bit, the latter part of the 19th century brought a couple of other tools to pain. So between local anesthetics, cocaine down to lidocaine, and general anesthetics in the form of ether, which finally allowed surgeons to cut people without having to hold them down while they screamed.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And the good news is it worked. The bad news is you're pretty much always tired. So I was very happy over time to get that dose down. And I think within 18 months, I was completely off the Neurontin and lo and behold, never experienced. Although interestingly, maybe once every year, I get like an enormous surge of fire into that same foot.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
literally one shot of flame that lasts seconds and it's gone, but essentially never again. Is Neurontin still a very powerful tool in the use of neuropathic pain? You alluded to other drugs like antidepressants as well, in addition to a rather impotent anti-seizure med, but what else do you have at your disposal for this type of pain?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
You could fall asleep driving.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Now, pregabalin can also lead to weight gain. Doesn't it also increase appetite? Both.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And they also both enhance sleep, especially pregabalin. And so there's a little bit of an added benefit to patients who were using these to also put the pain out at night when it can be most noticeable.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
There was actually a study, I don't know if I'll ever be able to find it, it was sent to me that actually suggested pregabalin didn't just make you drowsy, which was obvious, but also promoted appropriate sleep architecture.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I could be totally wrong on that, but it could be your experience.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
It sounds like that didn't shed any new light. That was viewed in the one hand as just a blunting instrument, but it didn't change the model. Didn't change the model.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And again, you're using these for the most recalcitrant neuropathic pain typically?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
We didn't even do this, I'm sorry. We didn't define chronic pain, but how would you put a definition on that?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Antidepressants and their role in pain management?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Sorry, how much lidocaine? I hope it wasn't toxic. I'll come back to the story. It's pretty funny. I'm looking forward to it. Which TCAs are the popular ones? Everybody... I think there's about nine. What are your top two or three?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Oh, amitriptyline. Yep, yep.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Is it offset by GLP-1 agonists in the modern era?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Because we think you're depressed. You're depressed.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Not FDA approved drug. Approved for pain is what you meant. Yeah. Thank you. Thank you for that correction. FDA approved for something else. You're absolutely right. Okay. Well, this brings us to opioids, which I saved for last because of, well, there's actually more drugs I want to talk about, but in terms of the off the shelf, typical stuff that people think about.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So a lot of hay has been made over this. There's no question that opioids have been overused and abused. And there's no question that illicit use of these things has had a devastating impact on our society. But it would be difficult to say that the field of medicine would be better off having never had an opioid. We just talked about surgery, for example.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Very challenging to deliver medical care in a hospital without opioids. So the question becomes, what is the most responsible case for oral opioids, which by definition are meant to be used outside of a hospital, not inside a hospital? And as a pain specialist, I would imagine few people are better equipped to navigate the nuance of that question.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Okay.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
By the way, the perfect analogy to this is the mortgage crisis in 2006 to 2008. If you took a zeroth order view, it would be really easy to blame one of the entities, but it is actually a perfect storm.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Just one thing, you are not taking care of somebody in the acute phase of expected pain typically, is that correct? In other words, that guy that just had a knee replacement, he's being managed by his surgeon, correct?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
When is the big gun of your team's expertise being brought in for a post-surgical routine case versus not?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
You know, when we brought pain in for every case when I was in residency, anytime we did a thoracotomy, It was a non-negotiable. Pain was consulted before the case, just for people listening, a thoracotomy. We didn't do these often because a lot of times by the time I was in residency, we did minimally invasive surgery in the chest.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
But sometimes you had to actually make a huge incision under the ribs. And that's a very painful, you just know this from experience, that that's such a painful experience. You cut this huge incision in the intercostal muscles, you put rib spreaders in, you crank these things open so you can do this big operation.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
We just know those patients are going to need an epidural catheter and we want that in before surgery, not after. And it makes all the difference in the world. So pain was a part of that response. I don't remember us routinely bringing pain in regularly. otherwise, but things have changed, I'm sure, in 20 years.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So today, for a general abdominal case or a general orthopedic case, are you brought in preoperatively?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
If someone's listening to us and they're going to have elective surgery at some point, I want to plant a seed in their head for someone who's going to have the knee replacement, the hip replacement, the cholecystectomy, the API, whatever. Should they be requesting this of their surgeon? Should they say, hey, I want to be diligent about my recovery. I want to minimize my use of narcotics.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Do you mind calling in a pain consult so that I can just have a team of docs who are exclusively thinking about my pain? Because let's be honest, the surgeon, I got enough to worry about. I got to make sure you didn't leak, that that anastomosis is fine, that you're not getting a wound infection.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Your pain is literally like third or fourth on the list of my concerns for you to have the best outcome.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
How ubiquitous is the patient-controlled analgesic device, the PCA that we use?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Okay. So people are still typically getting fentanyl through a PCA in the immediate post-operative phase?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And the goal is we want to get you off an opioid, even oral, before you go home. Is that generally the stated objective of the medical system now is whatever opioids you're going to need, let's try to deliver that to you in the hospital?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So how are you thinking about that? How are you thinking about extracting the value of the opioid and minimizing the risk of long-term dependence?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So if you have someone who just suffers from, not that anhedonia is anything but unpleasant, but if they're only experiencing anhedonia but no self-loathing, you would say, well, the risk isn't as high.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yeah, especially with that randomization, because what you really would like to be able to see is you take a whole bunch of people in, you get their incoming metrics of anhedonia, dysthymia, self-loathing, you categorize all the arms and tentacles of depression, and then you randomize within each of those to with and without opioid strategies.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I mean, this is a very complicated thing to do, but if you want to know the answer, that's kind of the way you want to do it.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Even in the world we live in today, where we understand that for a non-zero, potentially non-trivial segment of the population, the introduction to opioids that ultimately destroys people's lives is delivered by the medical system.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
This is a little unrelated, but I remember this when I was in residency. There was one of the attendings, and I don't even remember who it was, But he had this belief, he used to quote this study, and I don't remember it, but it said that if you injected bupivacaine into the injection site, sorry, the incision site. So I'm going to make a midline incision, draw my little line, inject bupivacaine.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So for the listener, this is a long acting sodium channel blocker. Wait for... Some long period of time, like 10 minutes, then make the incision, go about, do your surgery, and then immediately give that patient acetaminophen and ibuprofen immediately post-operatively and keep them on it around the clock. You could eliminate opioid use.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And he was convinced that the only reason surgeons didn't want to do this was because nobody wants to inject and stand there for 10 minutes with your thumb up your ass waiting for the bupivacaine to seep into the tissues. And maybe it's anecdotal, but it really seemed to work.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Like it really seemed to work that you would do this inguinal hernia repair or at the time some small laparotomy or whatever it was, anything. And if you were willing to put that bupivacaine in and sit there and wait And I'm trying to think, we might've used epi with lidocaine as well. So it might've been a little epi with lidocaine plus bupivacaine or something like that.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And you had to be super due diligent about keeping the acetaminophen and ibuprofen levels up. Have you ever heard of anything like that?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Which means you have to use less BOVI, which means less tissue damage. Yes. Maybe he was using epi with bupivacaine. I don't remember. But there's something there.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yeah. But look, a 50% reduction in opioid requirement postoperatively would be enormous. Huge.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Do patients receive that well? That's a hard discussion to have with a patient, I would imagine.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yeah, that makes sense.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So let's talk about a couple other things that are related to this, but distinct. Let's talk about acupuncture. What do you know about it? Well, let's talk about through the lens of chronic pain. Yeah, yeah, yeah. All right. Clinically.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And you say wallet biopsy because the insurance doesn't typically cover it?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So Medicare is covering something commercial payers are not? Well, it's possible. Okay.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So notwithstanding, I like the idea of a wallet biopsy. I hadn't heard that before. In your experience, where do you see it being most successful? What type of pain? What type of clinical presentation?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Puncture, but not in the appropriate spot?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
How do we think of acupuncture differing from dry needling?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
In California, I think it's not legal to dry needle, but you can acupuncture. I even understand the difference.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Maybe. I see acupuncture refers to just going after a nerve specifically.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Okay. Next question on chronic pain. What is the role of cannabis in your experience here? Is it friend or foe? And again, I'm sure there's a nuanced answer.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
He also serves as the director of the Stanford Systems Neuroscience and Pain Lab. His research focuses on the neural mechanisms of pain and the development of innovative treatments for chronic pain conditions. In this episode, I talk a little bit about how Sean and I go way back and why it is that I really wanted to have Sean on this episode.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
That's interesting. So you can't study it. I would assume you couldn't study it with federal dollars because of the federal DEA restriction. I would have assumed because it's legal in California, if you were using non-federal dollars, you could study it in a state like California.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I see. Because it's Schedule 1, the laboratory. It's actually more demanding than how you would study cocaine.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
If for no other reason to study it with less friction. Which you said. Perfect. Okay, there's a condition you've already alluded to today that I am sure everyone has heard of, and yet if you asked most people to define it, they wouldn't be able to define it. And so we're going to start with what it is, why someone might have it, what is the prevalence, are there false positives?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I'm talking about none other than fibromyalgia.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
What's the prevalence according to the current definition?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
But by the way, this is a boy-only thing. I can't imagine girls did this. But yes, of course, this is what little boys do.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
The A-delta is doing two things, if I'm understanding this correctly. Is it creating the spinal reflex where I hit my thumb with the hammer, the signal goes into the spinal cord out through a motor neuron to pull back without me having to think about it?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Is there a high overlap with depression, anxiety, and fibromyalgia? And if so, which is the arrow of causality?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So what is the management for these patients? Is this a curable syndrome or is it a syndrome that is meant to be managed like HIV?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
That's caused by what?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Silly question. Why not five? Like 4.5 has a lot of specificity to it. Was there some reason why it came in at such a dose?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
But am I also feeling the pain? Am I perceiving the pain? If you could do a thought experiment where you could eliminate the C-fiber in an individual, would they still feel pain? Yes.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
70 kilo person.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
What are the other areas where LDN is just captivating the world?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Thalamic pain.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
He's tried everything. Let's try low-dose naltrexone. Why does he come to a pain doc? Because he's got terrible pain. Okay, so he wasn't coming to you for the speech issue.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So there's still a central component to what the A fiber is doing.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Somehow, if that model makes sense, which it at least teleologically does, something about that inflammatory zone in the middle between what was clearly gone and not is poisoning the part that's still okay. What is the downside of this? Meaning, what would one need to be mindful of in trying an approach like this? The beauty of this
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Here's a silly question. Yeah. What's the scenario in which inflammation of the glia is a good thing?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I guess where I'm going with this is we think that at least a subset of people with neurodegenerative diseases, and you mentioned multiple sclerosis, but we think this is true in at least some cases of Alzheimer's disease, that neuroinflammation is a part of the pathology.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So would there be any efficacy to a trial there in either an individual with MCI, mild cognitive impairment, or as crazy as this sounds, is there a reason to consider it prophylactically in high-risk individuals? With the caveat that, hey, by the way, if you happen to get an infection, this would be a good time to stop it and ride it out and get better.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
At 10x the dose. How long are they typically on that drug? Lifetime. So meaning for a subset of individuals, just putting them on the party dose of 50 milligrams of naltrexone keeps them free of alcohol and opioids for life because it so blunts the pleasure center.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
You have to want to be off.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Can't get low-dose naltrexone there. You mean it has to be compounded at 4.5, you're saying? You're right.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So it's basically a free drug.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yeah. I'm very curious to see if anybody has looked at LDN in any of the neuroinflammation stuff. We see the relationship between herpes simplex virus and Alzheimer's disease, between shingles, especially ocular variants of it and Alzheimer's disease. We know that there is some relationship between inflammation and this disease. And we know that that's obviously not all paths cross through that.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
There are lipid mediated paths, metabolic paths, vascular paths. I think it would be very difficult to make the case there's not an inflammatory path towards that condition. And so interesting to think about.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
What's the evidence for the inhibition of the toll-like receptor? Is that in vitro? Yeah, it is in vitro.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Why do you think you see? I mean, that's an interesting one.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yeah. So when we met 25 years ago, how big was the department at Stanford in pain?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I'll finish the story of how we met. So I'm in this state of total hell. In addition to all the stuff I mentioned about this incredible pain, I couldn't even stand up, literally couldn't stand. And if I did, I had to be hunched over. And so at the time I was dating an anesthesiology resident and she was the one that said, hey, we just need to get you in this pain clinic.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
We got to break some stuff. This is going nowhere. You're circling the drain here, kid. I think she was in her last year of anesthesiology. So I think she was doing a rotation through pain, maybe. That's probably how she weaseled me in there. So I come and see you in clinic. By the way, at this point, my mom had flown down from Toronto to take care of me.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
It's not like I could drive or do anything. So my mom drives me into the hospital. Come in and see you. You hear the story. We'd ruled out anything that required any more surgical intervention. In other words, I'd undergone another MRI. I'd had a flexion extension film. I wasn't surgically unstable. And in fact, where the original injury was didn't even seem to be what was driving the pain now.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So you said, look, the first thing we're going to do is we're going to give you an IV lidocaine drip to see if we can just calm these sodium channels down.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So you said, well, how much do you weigh? I said, I weigh 80 kilos. You said, okay, we're going to give you 400 milligrams of lidocaine intravenously. And I said, Dr. Mackey, I just took my boards a year ago. That's a toxic dose. You said, don't worry, we're going to do it in a cardiac monitored room. You will be on an EKG and we will be able to defibrillate you if you have an arrhythmia.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So I said, go for it. So in 20 minutes, I got 400 milligrams of lidocaine, didn't touch the pain. Tried something else, didn't touch the pain. By now it was eight o'clock at night. Oh, wow.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And you said, okay, the only thing left to do at this point is to go in there and do a series of injections at every single facet joint, every single dorsal root, every nerve root, every dorsal root ganglia, the entire length of your spine. I will not be able to diagnose what is wrong because I'm basically going to stop all the pain, but then we will chip away at this over the coming months.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And I said, great. Can we do it now? You said, no, it's eight o'clock at night. We don't have an anesthesiologist. I'm the only one here. I said, you're an anesthesiologist. You said, yes, but I'm the one that's doing the procedure. So I said, well, why can't we do that? And then you said, well, we won't be able to give you any sedation. And I'm about to stick 45 needles in your back.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And I said, I don't care. That's how much pain I am in right now. So we go into the OR and you proceeded to put, I think, hydrocortisone, bupivacaine, and you lit me up, up and down the back. And two hours later, I stood up for the first time in three months. I was completely pain-free. This was remarkable. So we get home, it's midnight. I say to my mom, I'm not going to bed.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I'm going to go for a walk because like I hadn't walked in three months. And you know the campus loop of Stanford? Yes. Yeah. I walked it until the morning. It's a four mile loop.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I just walked around and around and around till nine o'clock in the morning, came back home, went on to develop plantar fasciitis because when you don't walk for three months and then you don't stop walking, but put that aside. And you told me, look, you're going to probably feel okay for a few days and then the pain is going to come back.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Well, it actually turned out to be two weeks that I was pain-free. And then the pain came back. And over the next three or four months, you repeated comparable procedures repeatedly. but with more and more precision, i.e. narrowing in at what the problem was. And if my memory serves me correctly, it was mostly in the T12 L1 area.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And I think the ultimate diagnosis was, look, you lost so much disc space at L5 S1 through the multiple surgeries. If you look at my MRI today, I basically don't have a disc at L5 S1. that you've now developed this facet arthropathy that far up. And that's where those nerve roots are going into kidneys and testes.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Just thinking about this from an evolutionary lens, lots of debate about this in the animal kingdom. Like, does a goldfish feel pain? Do we have a clear sense as to how far from humans and or mammals you go where you still clearly have C-fibers and A-delta fibers?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
But what was amazing was these injections allowed me to go and do rehab, which I took on like a vengeance and basically rebuilt the strength in the musculature of my back. And so within nine months, nine months of meeting you, a year of the injury, I was functional. Within two years, I could get to the point where I forgot about it for days at a time. I'll give you an example.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I could actually sneeze without bracing. That was something I couldn't do. For a year, I couldn't lean over the sink to brush my teeth. That's how weak I'd become. Just the moment arm of your torso leaning over, I couldn't do that. I had to fully brace and support myself to just brush my teeth. So you asked, what was the lasting impact of that?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Well, and I've told this story many times, and of course my kids know it well. One of the lasting impacts was my absolute love for parking as far as possible from wherever I'm going. Because when I was going through this, they wanted to give me a wheelchair parking thing. And I was like, I don't want it. Just a psychological thing. I was like, I don't want it. I don't care how far I have to walk.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And so now my kids know you celebrate your legs by parking far. And in many ways, that became part of this idea, this thesis I had of the centenary in decathlon, this idea of like, what are you training for? You're training for life. Life is your sport. And that can be something as mundane as being able to walk to the grocery store if there's no spot near where you need to go.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And can you push the cart to the car and all that kind of stuff? So the net net for me is it has been incredibly positive. Again, I'm incredibly grateful, Sean, to you, because again, had I not been at Stanford, had I not had that girlfriend who I won't name her to embarrass her, although I think she's still on the faculty at Stanford, by the way.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I just think there's a lot of ways that story could have gone sideways. So I feel incredibly grateful. And the final part of the gratitude is that I would go on to Hopkins for my residency in an emergency room that serviced some of the most opioid addicted people on the planet. And based on my own experience with that, I can say I always had a sense of humility about what they were going through.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I always looked at it as... Oh God, I feel your pain. That is awful. And I could have been there. Wow. But by the grace. So that's been my experience with it, which is 90% good.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Put the fire out.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
So let me ask you a question, Sean. How common or uncommon is my story? Because when you meet a person like me, is there a part of you that thinks we're never going to fix this guy? Like this guy's life is over. He's on 320 milligrams of Oxy, hasn't walked in months. He's in so much pain. The lethal dose of lidocaine did nothing. Is there a part of you that thinks this is a chronic pain patient?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
This is a guy who's going to be in chronic pain the rest of his life. Or do you look at a guy like that and say, no, no, we can fix this?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Like my case.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I got nothing.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
In this episode, we discuss the definition of pain as both a sensory and an emotional experience and why it's fundamental as a survival mechanism and the evolutionary purpose of pain, which obviously has been highly conserved across multiple species. We talk about how pain is transmitted through the nervous system, including the different types of fibers that are involved.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
This is where I was actually going to go, if I can just give you that window. Please. What I was really going to ask is a question about consciousness.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
That's the very important point that I think shouldn't be lost on this. Breaking the cycle isn't the cure. It sets you up to go after the cure. I mean, I had to go through two hours a day of rehab for six months. Yeah, wow. I mean, I had to learn how to move again correctly. I had to strengthen the muscles that were going to make up for doing what my spine would no longer do.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
But you couldn't do that if you were in pain. So you had to learn to do that and you had to be at least pain-free enough to do it, but not push yourself too hard that you would reactivate the injury. Like there was a balancing act and you'd be able to sleep, all these things. And you had to be able to clear your mind and get out of that catastrophizing loop.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Is consciousness necessary for the internalization of this full gamut of pain?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Can't golf, can't garden, can't do anything.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Actually, I was going to say that I was somewhere recently where I was asked to define health span. And health span is squishy to define because there's like a medical definition that I've repeatedly said I think is insufficient. So the medical definition of health span is the period of time in which you're free of disability and disease. So not very helpful.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And I prefer a more functional version of health span. And unfortunately, it's too long for me to rattle off. But one of the lines is freedom from pain. Yeah. Just as it's important to have strength, stability, aerobic efficiency, peak aerobic output, explosiveness. I mean, all of these things are going to reduce as you age, but the longer you preserve them, the better.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
One of them is freedom from pain.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yeah, the listeners of this podcast are not strangers to those statistics.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
But that particular one, it's so tragic.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yeah, and it's actually been yet another benefit of this experience is the ability I now have to help my patients. If you just look at the population and understand the ubiquity and frequency of lower back pain and you realize I don't remember the numbers, but let's say a third of people are going to go through some bout of lower back pain in their life.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
A number of my patients have also been in the loop of chronic lower back pain. For these patients, one of the most powerful messages I can deliver to them is learning that a setback is not permanent. So part of the journey, because remember, it's not like in the nine months after this injury got better, I never had another setback.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
No, within that period of time, I would have days where I felt bad again. Now, fortunately, I never went back to laying on the floor for days. I never experienced that level of discomfort again. But there were many days when I was very uncomfortable, and it would wax and wane. But over time, and with every time that I would recover from one of those cycles, my confidence would go up.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
The ability to know that this is going to pass, and I'm going to have to make some adjustments... and I'm going to have to not sit, and I'm going to have to change the way I lay, and I'm going to have to do these exercises a little bit more, that's okay. This will pass. I actually just got an email from a former patient. He's not even my patient anymore.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
He said to me, hey, Peter, just want to let you know, man, I have never forgotten what you said about this. I just had a big setback last week, and this would have normally taken me down the spiral to hell And I hear your words telling me, it's okay. This will pass. And he's like, you know what? It's a week later. I'm already on the mend. So there's no difference. It's not impacting physiology.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
It's impacting the psychology. And the psychology is what goes on to impact the physiology. So again, I think of that as I tell patients, this is not going to be a monotonic improvement. it's going to look more like the S&P 500, where if you step back 30 years, yes, it's monotonically going up. Look at it for a given week, not at all. It can go down. It's quite volatile.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Now, the volatility will decrease over time, but it never goes to zero.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
How are they treated now?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
How many people get these? What percent of the population?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
But less prevalent than migraines?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Yes. And I just want to point out, and this shows you how long I haven't been in surgery, but 20 years ago, my recollection is an anesthesiologist was giving not just one medication, but several. Yes. So they were giving something like halothane, which to my understanding, we didn't know how it worked then. Do we have any idea how it works today? Better.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And that'll rescue it now?
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Well, Sean, this has been a great discussion. I think we're certainly better off today as a species having a medical discipline that is devoted to pain. We have the luxury of caring about this now. There was a time when just not dying was the highest priority. And now we need more than that. It's not just that we don't want to die. It's that we want to be able to live pain-free.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Not to be confused with discomfort-free. I'm still a big proponent of discomfort, as I'm sure are you. We should be out there working out hard, experiencing discomfort. But chronic pain can be inflammatory to the psyche. And it's not something I would wish on anybody. So it's great to know that since my time as a patient there, that department has increased log fold.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
And I hope that's true and trust that it's true around the country. So thanks for the work you're doing.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I've mellowed.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
I've mellowed since then.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
Thanks, Sean. Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#345 ‒ Chronic pain: pathways, treatment, and the path to physical and psychological recovery | Sean Mackey, M.D., Ph.D.
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The Peter Attia Drive
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Hey everyone, welcome to a sneak peek, Ask Me Anything, or AMA episode of The Drive Podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com forward slash subscribe.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
It's difficult to know, but I think we can probably put some brackets around it. So first, there's a huge amount of variability based on a lot of factors. So where you live, what type of food you eat, and what your source of drinking water is would probably be the three biggest determinants of your exposure to MNPs. That's worth noting again, and I think it's worth stating.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Your geography, your source of food, your source of water plays the biggest role. If you aggregate the data from all of the studies, it would suggest that humans are consuming, and this is a broad range, so that's just unfortunately the nature of this stuff, somewhere between 10 and 300 micrograms a week. This is 10 to 300 thousandths of a gram per week.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
So without further delay, I hope you enjoy AMA 67.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Now, a study that was published in 2021 estimated that on average we consume about four micrograms per week from fish and other sea things like crustaceans, mollusks, tap water, bottled water, beer, etc., etc., The study simulated the expected exposure to amounts that agreed with measured quantities in microplastics and stool.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
So I think this is probably an underestimate given that it didn't look at some of the other areas that have already been found to contain some MMPs, such as fruits, meat, vegetables, potentially plastic off cutting boards, utensils, plastics that may come from things we'll talk about like reheating food and things like that. So
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
The point is that the mass of these things is pretty small and that might not be the right way to think about it. And we can talk about some of the misinterpretations of that stuff. There was a recent study published in 2023. It was in Korea, and it estimated that the population was consuming somewhere between 140 and 310 micrograms per week. That's a nice narrower band.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
It also ports with largely the upper limit of the US-based study as well. I think that's probably the ballpark of where people are consuming.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Not even in the same zip code. So that soundbite that humans consume a credit card worth of plastic refers to a report that estimated weekly consumption was five grams of MMPs. That has been largely debunked, despite what you've said, which is the prevalence in popular media.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
But, and I don't remember who famously stated that a lie will travel around the world or halfway around the world before the truth has a chance to pull its boots on. I don't even need to go into that. We'll link in the show notes to both the original analysis, which came out of the University of Newcastle, commissioned by the WWF, was released, I think, in 2019.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
And then obviously the rebuttals to that. But yeah, the long and short of it is I don't think any serious person believes that we're consuming five grams of plastic a week.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
The main way that these things are eliminated is largely through coughing and sneezing them out. So anything that's coming into our lungs, we can get it out by a cough or a sneeze, as well as urine and stool. So the largest particles, those that are greater than 10 microns, will generally be removed with relatively high efficiency, regardless of how they enter the body.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
It's really the smaller particles that are eventually going to make their way to the immune system. If you were going to do a mass balance on this stuff, the majority to the tune of 99% of ingested microplastics are going to be eliminated through stool. And this is a relatively short transit time. We're talking about 24 to 72 hours. Plastics have a very difficult time crossing the GI epithelium.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
So when you look at animal studies... we would see that it's about 0.3%, maybe with a ceiling of about 1.7% of microplastics have the capacity to be absorbed across the GI epithelium. And of course, it's heavily, heavily size dependent. So it's the particles that are going to be less than 10 microns, which remember that's four times larger than what is required for to get into the lung.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
So again, just think in the lung, we're anchoring to 2.5 microns or less in the gut, even though in theory, the gut could absorb something close to maybe a hundred. I think that's more theoretical and in practical terms, we tend to see it as 10 micron or four times that size.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
So the bottom line is this, if you're encountering a microplastic that's less than 2.5 microns, you could absorb it both in your gut or via your lungs. Now, when we go through this type of analysis in urine, we again see that we also excrete microplastics through the urine, but this is less than what we do through the gut.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
I think there's actually a lot I need to say before we dive into this for context. So I'll preface maybe by saying the following. Obviously, people who are regular listeners of the AMA can appreciate that these are not off the cuff remarks that we make here. And we put a lot of work into doing this.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
When I sit up here and do these AMAs, I'm doing them based on the work that me and a team of analysts have done for usually about a month in preparation for them. I think it would be safe to say that in the six years we've been doing this, or is it seven or eight now? I've lost track. To date, at least, this will go down as the AMA that has required the most work.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
that has probably generated the most swear words and probably resulted in the secretion of the most adrenergic compounds from the adrenal glands. In other words, this has been a royal pain in the ass to prepare for. And as recently as last night at 10 o'clock, I was emailing you saying, what the F? Why are we doing this? It's a never ending morass of information, most of which is incomplete.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
There's so much I could say on this. And then the most wonderful thing happened, which always happens. Anyone has experienced this if they think back to being in college, even the night before the exam, you're like, I don't know what the hell is going on. And the best advice is usually just go to bed, get a good night's sleep, get up nice and early, fresh cup of coffee,
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
And I think that sort of happened this morning. Me and a couple of the other analysts went to bed, got up this morning, and all of a sudden I just had more clarity about, in my words, how to land the plane. And I took to writing a couple of pages out, and I think I've got kind of a sensible way to make sense of something that is incredibly noisy. So what I'm going to say at the outset is,
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
if you are listening to this thinking that there is a punch line and a one word answer i'm going to spare you the disappointment this is a very nuanced topic if i could answer this in a word i promise you i would and i would never try to go through the 75 pages of notes that our team has assembled to help me think about this topic.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
So without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to Ask Me Anything AMA episode 67. For today's AMA, we're going to focus on something that's gotten a lot of attention lately in the news, online, social media. And as a result, we've received an endless stream of questions, not only from our audience, but also from our patients.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
I swear to you, there are a hundred things I'd rather be doing right now than going through this. However, it is important in an area where there is so much uncertainty, so much asymmetry and such complete and incomplete information that we have to understand the boundary conditions so that we can each make a reasonably informed decision.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
So with that as my preamble, let's do our best to guide people on a journey that we've been on and acknowledge our shortcomings, acknowledge where we wish we knew more, where maybe others do know more, but leave people with a framework such that at the end of this AMA, which will hopefully be sometime today and not tomorrow, everyone can sort of make a risk-based decision for themselves, for their families.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
It was actually in a metal Yeti camping coffee cup. That's sort of my favorite way to drink coffee.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Part of this is you just have to suck it up through the semantics. And part of the challenge is that some of the definitions are not very helpful. So starting with microplastics, they're typically defined as any particles of plastic that are smaller than five millimeters.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Now, again, I realize that not everybody is facile with the metric system, but anybody who is will realize five millimeters is huge. You can see five millimeters. That's half a centimeter. So we're not really talking about that. I think most current studies would really classify microplastics as those smaller than one millimeter, one-tenth of a centimeter, about one-twenty-fifth of an inch.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
And then, of course, we talk about what are called nanoplastics, which are particles that are smaller than one micrometer or micrometer, so one-one-thousandth of a meter. So we abbreviate these as MNPs, or micro-nanoparticles. And we should just acknowledge that these things are completely ubiquitous.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
They're found anywhere that we have looked for them, which is to say we find them in water, we find them in food, we find them in fruit, on fruit, in vegetables, on vegetables, in meat, in the air, and therefore micro nanoplasticals or MNPs are completely ubiquitous. Okay, you asked about BPA.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Now, there are lots of these bisphenol chemicals, but bisphenol A or BPA is the one that most people are familiar with. Ironically, the presence of BPA, at least being used actively, has been reduced quite a bit over the past 15 years. But just understand that there's a whole family of these bisphenols, and typically we substitute one for the other. But what are they?
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
They're chemicals that are used to make polycarbonate plastic. Polycarbonate plastic is the hard plastics we have in our world. So if you think about all the places where you use plastic and it's hard, I think of the Nalgene type water bottles, epoxies, resins, things like that. That's where you're going to have historically found a lot of BPA.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Of course, today, this is less the case, but the truth of the matter is they're now replaced by other bisphenols, so BPS and BPF. And the truth of the matter is not clear that we know if those are any better than BPA. So when I say BPA, I think it's just easiest to sort of think of the broad category of these families.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
And that topic is microplastics and all other accompanying chemicals, such as BPAs, PFASs, and phthalates. Given the interest, we decided to dedicate an AMA to this topic.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Another thing that we're going to talk a bit about, and I've talked quite a bit about this in the past, is actually particulate matters of the 2.5 or smaller variant. These are abbreviated PM2.5. And again, it refers to particulate matters in the air that are smaller than 2.5 micrometers. So why is that important?
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Well, there's something relevant about a particle that's that small, which is that if inhaled, it has the potential at least to become systemic. And the reason for that has to do with the anatomy of the lung and the size of both the alveolar air sacs and the epithelial linings of them, which again, it's not necessarily that intuitive that you could breathe something
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
but that it is small enough that it could actually get across a cell barrier at the innermost part of the lungs and enter the systemic circulation just as though it had been injected into you. A PM 2.5 refers to any particulate matter that is inhaled in the air that is of that size or smaller. Now, Are there some microplastics or micro nanoplastics that fit that description?
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Yes, but most are not. So most PM2.5s are not microplastics. I forget the exact number. I know it's somewhere. We did look it up. It's on the order of a few percent. I would say that the greatest contribution to PM2.5s probably come from air pollution. So anything that has to do with when there's a fire, burning wood, obviously burning fossil fuels, but coal being... hands down the leader of this.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
I mean, natural gas combustion produces much less of this. And then we'll talk about phthalates, which are another class of chemicals that are kind of like, I think of them as sort of the opposite of the BPAs. So these are the things that are used in plastics to make plastic more flexible, to have more bend in it.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
In this conversation, we dive deeply into what we know and what we don't know about these chemicals, why they seem to appear all of a sudden everywhere, how we're exposed to them, how much exposure we have, and how dangerous they may or may not be to our health.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
They're also found in products that we use like shampoos, lotions, laundry detergents. It makes fragrances last longer. Now, there's been a constant regulatory shuffling around all of these things, and I'm not going to get into it because I could just put everybody to sleep right now.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
We're going to leave a ton of this in the show notes section where we're going to kind of go through the regulatory machinations on this and which of these products were banned and when and what got substituted in. But the bottom line is that the use of phthalates are still currently allowed in food content application, but many companies have undergone voluntary reductions in this.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
There doesn't appear to be any restriction in the use of phthalates for personal care products, and I think this is probably where people are going to see their greatest exposure to them. So I guess I'll stop there, Nick, but that's the whirlwind tour of what all these different compounds are.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Yeah, I think there's two things going on. So the first is that obviously plastics are relatively new, didn't really exist much prior to the 1950s. And if you think about it, I mean, they were pretty remarkable. So incredibly lightweight plastics. remarkable strength to weight ratio resistant to rotting and corrosion and shattering. I mean, there are lots of reasons we use plastic.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
So when you combine the fact that they've been increasing in their proliferation over the past 70 years, that would certainly explain why we might be seeing more of them. But there's also a little bit of what is the expression, the drunk under the streetlight problem. People are also looking at this more and more and more.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
In fact, if you don't mind, if you could pull up, there's a figure we've got that shows the number of scientific publications focusing on microplastics in the last 20 years. So if you go back, it's showing basically 2000 to 2020. It's a linear scale, but it's still pretty remarkable. It still looks like you're basically watching Bitcoin from 2010 to 2020. That's effectively what's been going on.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
So I don't doubt that there are more and more microplastics accumulating in the environment. That's likely, but we can't lose sight of the fact that we're also looking for it nonstop. So one of the questions that I didn't come up with a satisfactory answer to was, if you just look at the last five years, are we seeing a true increase? I wouldn't doubt that there's more 2020 versus 1980.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Ultimately, and perhaps most importantly, I think, we propose a framework for how someone can think about avoiding and mitigating exposure to these chemicals. If you are a subscriber and you want to watch the full video of this podcast, you can find it on the show notes page. If you're not a subscriber, you can watch a sneak peek of the video on our YouTube page.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
That strikes me as, hey, over that 40-year period, I could really see it going up. But 2020 to 2025, is that a real increase or is that an artifact of observation?
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
We should always be thinking about this through the lens of relevant versus not so relevant exposure. But again, we're going to always try to focus on a relevant exposure, which is an exposure that has the potential to accumulate. So the most common route of human exposure is from inhaling plastic dust and fibers and from consuming food and beverages that contain dust. These micro nanoplastics.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
And again, that's why I prefer to talk about NMPs rather than just micro plastics. Why? Because my concern about consuming a five millimeter piece of plastic is nil because it can't be absorbed. It's going to come right out my body the next day. This is not the thing that we need to be afraid of. So what are the foods and beverages we need to be concerned with?
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
The highest places we tend to see these are in seafood, salts, water, both tap water and bottled water, but also in fruits, vegetables, meats, even beverages like milk, beer, and wine, which obviously contain water as well. Nanoplastics in soil can accumulate within plants, and obviously the exposure gets magnified as you go up the food chain.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
This again explains why we would see it in seafood, given that we understand the role of plastics in the oceans. And that's why obviously you can see seafood and land animals accumulating these as well. The epithelial barrier is the first line of defense.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
Remember, there's an epithelial layer on the outside of your body that we can see, but there's also an epithelial layer on the inside of your body. Everything between your mouth and your anus is also an epithelial layer. And that's why generally micro nanoparticles don't enter the body through the skin or through the gut unless they are small enough. We've already talked about it.
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#332 - AMA #67: Microplastics, PFAS, and phthalates: understanding health risks and a framework for minimizing exposure and mitigating risk
The pulmonary epithelium requires them to be smaller than 2.5 microns. And in the lining of the gut, it could probably be as big as 150 microns to be absorbed.
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#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
Hey everyone, welcome to a sneak peek, Ask Me Anything, or AMA episode of The Drive Podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com forward slash subscribe.
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#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
We talk about how someone can build muscle mass and strength effectively, covering progressive overload, rep ranges, training intensity, with a focus on maximizing results safely. We speak about the importance of power training, why explosive movements matter, especially as we age. and how to integrate them into a routine.
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#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
We talk about the nutrition that's necessary to support muscle growth, breaking down protein intake, timing, the role of supplements like creatine. We talk about different training strategies for various individuals, whether you're new to lifting, someone who's older, younger, looking to maintain strength, seasoned lifter, et cetera.
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#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
We end the discussion talking about balancing recovery and avoiding injury, how to train effectively while minimizing risk, managing fatigue, and ensuring long-term consistency. If you're a subscriber and you want to watch the full video of this podcast, you can find it on the show notes page. And if you're not a subscriber, you can watch a sneak peek of this video on our YouTube page.
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#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
So without further delay, I hope you enjoy AMA 71.
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#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
Thank you for that incredible introduction. I'm doing well, and I appreciate you having me back.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
Well, you're always learning, Nick. That's the thing. At least I think we should all try to be learning at all times. Today, I had a particularly fun day. I went to my son's school to take him lunch. This is something that I like to do once in a while is take lunch and eat with my kids. He wasn't really in the mood to have lunch with me today, which happens from time to time with seven-year-olds.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
So I ended up just in the cafeteria sitting at a table all by myself eating lunch, which in and of itself was pretty funny because I really got a kick out of watching all the kids doing their thing.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
But eventually a bunch of kids in his class I think felt bad for me and they came up and just sat around me and they started asking me a bunch of questions, which of course turned into me asking them more questions like what are they doing in PE, what are they learning in science, that kind of stuff. But the kid sitting right across from me noticed I was drinking a diet soda.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
And truthfully, I don't really drink that many. I'm mostly a Topo Chico, Waterloo guy. But this was the first thing I grabbed. And he said, huh, I noticed you're drinking whatever it was I was drinking. A Fresca, actually. You know that that has a sweetener in it that is 500 times sweeter than sugar? And I said, oh yeah, I think that's how they get away with making it have no calories.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
He goes, you know that causes cancer, right? I just decided at that moment, probably not a good time to argue the abundance of the human literature and the animal literature and all that. I let that one go, but I appreciated the conviction and his concern for my health.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
He also pointed out afterwards that it wasn't going to kill you quickly because you were only ingesting so little of it, which I thought was a very astute comment for a seven-year-old. But anyway, needless to say, I had a lot of fun doing second grade lunch today and I would be interested in going back.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
So without further delay, here's today's sneak peek of the Ask Me Anything episode. Hey everyone. Welcome to Ask Me Anything, AMA episode 71. For today's AMA, we're focusing on a topic that is central to both lifespan and healthspan, which is muscle mass and muscle strength. This is one of the most frequently asked about topics I encounter.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
Honestly, if our audience wants to hear the seven-year-old roundtable, I am totally game to get a group of three or four seven-year-olds around the table and really go deep on the health issues that mean most to them. It's probably quite insightful.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
It's a fair question and one that we internally kicked around. And I think two things put us in the situation we're in. So one is we continue to get asked more questions about this than almost anything. I would say it's among the three most asked about topics. But I think the second thing is because we have so much content out there,
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
If you want to get the TLDR on this, you're going to be spending hours and hours and hours, 20 hours worth of digging. And so what we thought we could do was organize the content in a way that would make it much easier for a person in what will undoubtedly be a much smaller aliquot of time.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
to get everything that they need to get out of this at the zeroth order and maybe first order level and then really through the show notes and supplemental material go as deep as they want if they need more content i think we're going to deliver on this one we've put a lot of work into it thank you for listening to today's sneak peek ama episode of the drive if you're interested in hearing the complete version of this ama you'll want to become a premium member
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
It's extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members. And in return, we offer exclusive member-only content and benefits above and beyond what is available for free.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
So if you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription. Premium membership includes several benefits. First, comprehensive podcast show notes that detail every topic, paper, person, and thing that we discuss in each episode. And the word on the street is nobody's show notes rival ours.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
And while we've covered aspects of it in the past on episodes with guests like Lane Norton, Andy Galpin, Mike Isratel, this AMA is designed to bring all of that knowledge into one streamlined discussion. Again, we've got tens of hours on this topic, probably in the ballpark of 30 hours.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
Second, monthly Ask Me Anything or AMA episodes. These episodes are comprised of detailed responses to subscriber questions, typically focused on a single topic, and are designed to offer a great deal of clarity and detail on topics of special interest to our members. You'll also get access to the show notes for these episodes, of course.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
Third, delivery of our premium newsletter, which is put together by our dedicated team of research analysts. This newsletter covers a wide range of topics related to longevity and provides much more detail than our free weekly newsletter.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
Fourth, access to our private podcast feed that provides you with access to every episode, including AMA's Sans the Spiel you're listening to now and in your regular podcast feed. Fifth, The Qualies, an additional member-only podcast we put together that serves as a highlight reel featuring the best excerpts from previous episodes of The Drive.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
This is a great way to catch up on previous episodes without having to go back and listen to each one of them. And finally, other benefits that are added along the way. If you want to learn more and access these member-only benefits, you can head over to peteratiamd.com forward slash subscribe. You can also find me on YouTube, Instagram, and Twitter, all with the handle peteratiamd.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
You can also leave us a review on Apple Podcasts or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
For all of my disclosures and the companies I invest in or advise, please visit peteratiamd.com forward slash about where I keep an up-to-date and active list of all disclosures.
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
And we realize that for somebody who kind of needs the TLDR, it would be helpful to have it all in one spot and also updated by the most recent insights and information. So in this AMA, we discuss why muscle mass
The Peter Attia Drive
#349 - AMA #71: Building strength and muscle mass: how to optimize training, nutrition, and more for longevity
and strength matter specifically exploring their role in longevity metabolic health and injury prevention talk about the differences between muscle mass and strength which one is actually more critical for longevity and how they each relate to overall health we look at various metrics such as grip strength to predict mortality and why they might be predictive
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
Hey everyone, welcome to a sneak peek, Ask Me Anything, or AMA episode of The Drive Podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com forward slash subscribe.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
If you're not a subscriber, you can watch a sneak peek of the video on our YouTube page. So without further delay, I hope you enjoy AMA number 65.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
Two unrelated things. I notice you have a little visitor for the podcast today hanging out with you there. Hopefully he's interested and this is something he'll like. And secondly, I would add that my wife is specifically asking me these questions. So she's very keen to buy a whole bunch of red light things.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
And I asked her to just hold off until we did the research for this episode so that we could at least have a sense of if there's value there, where it is. I don't know if she's a subscriber though. So if she's not, this might be the one that she subscribes for.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
You can't do this without at least having some understanding of the physics and the principles that define light and waves come up over and over and over again as you try to evaluate the plausibility of the claims that are made here. So when we're sitting here looking out at the world, we're looking at light and there's visible colors of light. Maybe I should take a step back.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
Light exists as waves and they're very short waves to be clear. So sound waves are really, really long. Light waves are really, really short. And then obviously waves can get much, much shorter and you can get into UV, which we've talked about in detail. on a previous podcast, and then even shorter than that would be x-rays, and then even shorter than that are gamma rays.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
So as wavelengths get shorter, the energy gets more powerful. But if we just focus on light, visible light runs the gamut from about 380 nanometers, which would be purple-ish, and then all the way at the longest end, about twice that, 780 nanometers, is where red light is. So when people talk about red light therapy, they're mostly talking about light that is in that very narrow band.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
So without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to Ask Me Anything, episode 65. I'm once again joined by my co-host, Nick Stenson. In today's episode, we cover red light therapy as a topic we get asked about all the time. In fact, my wife asks me about it all the time. So it was clear that it was time for an AMA.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
So for example, again, a white light is giving you all mixed across that entire range. Red light would be more narrowly focused. It's also important to understand that, and we'll talk about this a little bit today, phototherapy in general involves wavelengths across that entire band of visible light, but it also includes something called near infrared.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
So that basically runs the gamut from about... 400 to 1100 nanometers. So I think the easiest way to think about this is red light therapy, which runs about 620 to 780 nanometers, and then near infrared, which is right adjacent to that, the next thing up in terms of length, which is about 790 to 1400. So again, if you forget everything else, just remember,
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
When people talk about red light therapy, they're talking about wavelengths that are just in that red visible area of 620 to 780. And then often they talk about near infrared as well, which is not visible. To be clear, you don't see it, but it's just a little bit longer, 790 to 1400 nanometers.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
We'll come back to this over and over again because there are some instances where the fact that you can't see it might actually make it a little more dangerous.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
People who listened to our podcast on ultraviolet light may recall a distinction I made between UVA and UVB, which came down to the degree of penetration. And so similarly, when you think about red light therapy, And you remember that the longer a wavelength, the more it can penetrate, albeit with less energy.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
What makes red light interesting is it is sort of at this sweet spot where it has some capacity to penetrate more so than other forms of visible light. That's sort of part of what makes this interesting. Now, the exact depth that's reached by the red light or the near infrared is kind of a function of how the light beams are organized.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
So what is the amount of coherence, which is how much do the wavelengths line up with each other? So if the wavelengths are all coherent, the peaks and valleys are in the same place. It's going to have more penetrance. And then what's the extent to which they're all aligned in the exact same direction? That's called collimation.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
So in other words, the light isn't spreading, but rather it's all pointed in the exact same direction. And then finally, you have the intensity.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
And we'll talk a little bit about the difference between watts and joules, because if people are looking at these devices, sometimes they give you information in watts and sometimes they give you information in joules, which of course, there's a very clear relationship between them. And of course, broadly speaking, energy matters as well. So
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
When you take all of that into account, though, the really important principle that I think gets perhaps missed when people evaluate these things is that, for the most part, red light can't penetrate nearly as much as people think it can. Okay.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
If red light is being delivered by LEDs, which is the most common way that it is, it's going to be able to penetrate about two to three millimeters into skin. Now, infrared light can go a little bit deeper, because remember, it's a longer wavelength, and it can reach probably 5 to 10 millimeters.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
Now, if red light is delivered by a laser, because again, you now have a more focused form of light energy, it could penetrate significantly higher than that. It could go from 1 to 4 centimeters. So again, keep in mind, the way that the light is organized plays a significant role in the depth that it can penetrate.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
Now, if you start to think about some of the applications we're going to talk about, when you start to think about red light therapy, just keep in the back of your mind, if something can only penetrate one to three millimeters, it's going to be difficult for it to have some of the profound effects that are sometimes claimed.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
In this conversation, we lay the foundation for what red light therapy is and why there is such an emphasis on it. We then break down the various forms of red light therapy and their various treatments into whether or not I think they are beneficial. In other words, we go through each application and review the data for them.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
Even if something can penetrate 10 millimeters or a centimeter, which would be quite deep, it's not clear that that's going to be able to have a significant effect. As a general rule of thumb, the more superficial the application, the more plausible I think it's going to be as we go through these.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
This is an important and, as you said, foundational question. So to have any biologic effect, the light needs to be absorbed by some photosensitive molecule within the cell or tissue that it's hitting. And so the absorption of light by these photosensitive molecules, which are called chromophores, cause a localized chemical change or a photochemical reaction.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
Now, the most interesting of these is probably something called cytochrome C oxidase or CCO. It's a component of the electron transport chain within mitochondria. And generally speaking, most people who are proponents of red light therapy point to cytochrome C oxidase or CCO as the main target and therefore the mediating effect of the biologic impact of red light.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
So red light and near-infrared wavelengths do seem to excite cytochrome C oxidase, and its activity then increases subsequent ATP production. Conversely, blue and green wavelengths, remember these are shorter, less penetrant but more powerful, seem to decrease the activity of CCO and subsequently decrease ATP production.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
Thank you for listening to today's sneak peek AMA episode of The Drive. If you're interested in hearing the complete version of this AMA, you'll want to become a premium member. It's extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
And in return, we offer exclusive member only content and benefits above and beyond what is available for free. So if you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription. Premium membership includes several benefits.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
So these include red light therapy for aging in general, skin health and acne, wound healing, hair loss, eye health, exercise performance and recovery, metabolic health, general weight loss, spot fat loss, inflammation, injury rehab, and menstrual cramps for women. So in other words, we go through each of these and do a detailed analysis of the literature.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
First, comprehensive podcast show notes that detail every topic, paper, person, and thing that we discuss in each episode. And the word on the street is nobody's show notes rival ours. Second, monthly Ask Me Anything or AMA episodes.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
These episodes are comprised of detailed responses to subscriber questions, typically focused on a single topic and are designed to offer a great deal of clarity and detail on topics of special interest to our members. You'll also get access to the show notes for these episodes, of course. Third, delivery of our premium newsletter, which is put together by our dedicated team of research analysts.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
This newsletter covers a wide range of topics related to longevity and provides much more detail than our free weekly newsletter. Fourth, access to our private podcast feed that provides you with access to every episode, including AMA's sans the spiel you're listening to now and in your regular podcast feed.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
Fifth, The Qualies, an additional member-only podcast we put together that serves as a highlight reel featuring the best excerpts from previous episodes of The Drive. This is a great way to catch up on previous episodes without having to go back and listen to each one of them. And finally, other benefits that are added along the way.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
If you want to learn more and access these member-only benefits, you can head over to peteratiamd.com forward slash subscribe. You can also find me on YouTube, Instagram, and Twitter, all with the handle peteratiamd. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
For all of my disclosures and the companies I invest in or advise, please visit peteratiamd.com forward slash about where I keep an up-to-date and active list of all disclosures.
The Peter Attia Drive
#326 - AMA #65: Red light therapy: promising applications, mixed evidence, and impact on health and aging
We close this conversation by summarizing my overall takeaways for each use case and explain via a summary table that we created that breaks down everything you might want to know to understand this. If you're a subscriber and you want to watch the full video of this podcast, you can find it on the show notes page.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Again, you always could argue, well, maybe it's because they were really well-trained and their mitochondria were well-honed. But it's possible that there's a study where you took completely untrained athletes, had them do an aerobic task with and without creatine, and you might indeed see a benefit there. So again, I think we're still kind of in early days on some of this stuff.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
There was a 2017 review that got quite a bit of attention that we'll link to that concluded that creatine may help with the prevention and recovery from injury. And there have been a number of meta-analyses, looking at cognition. The most recent one, which was this year, looked at 16 RCTs and found that creatine had a positive effect on memory.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
I would say long and short of it is a lot of this stuff looks very promising. There's also some evidence that women in particular might benefit more than even men. Women have lower stores because muscle mass is the predominant store. Women have less muscle, therefore less stores. But there might also be less consumption through diet.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
If you're a subscriber and you want to watch the full video of this podcast, you can find it on the show notes page. If you're not a subscriber, you can watch the sneak peek on our YouTube page. So without further delay, I hope you'll enjoy AMA 69.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
So it, again, at least leads to the hypothesis that women may benefit even disproportionately to men. There's some, I think, rather weak data that suggests that it may help reduce depression in women. And there's some evidence to suggest that it may be helpful during periods of rapid hormonal change.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
And that could be within the monthly period of a menstrual cycle, pregnancy, perimenopause, and menopause. So you might ask, why is that the case? Well, the creatine and phosphocreatine pathways are impacted by hormonal changes. And of course, during all of those periods that I just mentioned, you're seeing rapid hormonal changes.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Hey everyone, welcome to a sneak peek, Ask Me Anything, or AMA episode of The Drive Podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com forward slash subscribe.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
So it's not really that surprising that supplementing to supernormal levels of creatine could offset some of those impacts. pregnancy is a question I get asked about a lot, Nick. I would say I remain a little bit unclear and would probably suggest that it's probably safe during pregnancy, but we just don't have enough human data to form a strong point of view.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
So in my mind, the wise thing to do is to avoid anything that is not absolutely necessary during pregnancy. So just to give an example, when we have women in our practice that are preparing for pregnancy or pregnant themselves, I mean, No matter what they're taking, if they're taking medication for something that they can live without for nine months, we would absolutely stop it.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
So yeah, I would say women should probably dose it at about the same doses as men. But of course, they'll get more bang for that buck because they're on average smaller.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
I would put this in the low risk, modest reward category. We do have, I think, really robust safety data here, and it looks good. If the muscle stores are already full, the liver is probably going to metabolize the delta. The kidneys will clear the excess. There is one thing to keep in mind.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
If you're a person who doesn't have perfect kidney function, you do probably want to talk with your doctor before you take it. And this is very important. You want to make sure that they know you're taking it before they do any blood tests to measure your creatinine.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
because high doses of creatine can impact serum doses of creatinine, which we would use as one of the metrics to determine kidney function. So in our patients that have anything but perfect kidney function, if they're taking creatine, we typically have them stop for a couple of weeks before we do a blood test. Creatine monohydrate really is the version to take.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
I don't even know if they sell anything else. They used to sell a creatine phosphate a long time ago. I don't think that there's anybody selling that anymore. I don't think it matters. But there's just no evidence that you need to be taking anything other than creatine monohydrate. It's wildly inexpensive, and you should be looking for the purest product only that has nothing in it.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
The only ingredient should be creatine monohydrate. No fillers, no extra ingredients, unless there's some flavoring agent that you want. But I just mix this in with an electrolyte drink, so I want nothing other than the creatine monohydrate in the sample.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Thank you for listening to today's sneak peek AMA episode of The Drive. If you're interested in hearing the complete version of this AMA, you'll want to become a premium member. It's extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
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#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
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The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
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The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
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The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
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The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
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The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
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The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
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The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
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The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Obviously, any patients coming into the practice, we're trying to gather as much information about them as we can through their medical history. And an important component of that is understanding all medications, supplements, hormones, anything they take. I call this the bucket of exogenous molecules. So generally, we know this on the way in, and there's a ton of variety.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
There's people who come in who are taking nothing. They don't take any medicine by prescription. They don't take any supplements. Conversely, there are patients who come in on no medications, but a list of supplements that might be two pages long and everything in between.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Our view is generally to approach this the way the kidney approaches the filtration of glucose, sodium and potassium, which is you dump everything out and then ask the question, what should be added back in? And I don't mean we literally stop everything, but I'm saying that's kind of the mental model for how we go about thinking about it.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Because a lot of times when we ask patients, why are you taking this or why are you taking that? They don't know. They just say, oh, you know, I started this a couple of years ago because I saw somebody on Instagram talking about it. Or, you know, I saw this doctor a few years ago who told me to take this, but I have no idea why.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
So there's just a couple of things worth acknowledging before we jump into this. And it comes from discussions that I've had many times, which go something like this. Hey, I don't believe in taking any medicine, just so you know, only natural supplements. Now, my response to that is, tell me the difference.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
There is a difference, but I just want to make sure you as the consumer of this understand the difference. And it's really a question of regulation. So supplements are not regulated. By definition, the FDA has tacitly referred to them as generally regarded as safe supplements. But the process by which that's determined is not entirely that rigorous.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
So without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to Ask Me Anything AMA episode number 69. In today's episode, we cover supplements.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
And pharmaceutical products, while far from perfect, do have more in the way of regulation and oversight. There are places where these overlap. I'll encounter a patient who says, listen, I will never take a statin to lower my ApoB, but I will definitely happily take red rice yeast.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
at which point you have to sort of explain to them that a very high dose of red rice yeast is effectively a modest dose of pravastatin.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
So I think it's just helpful for patients not to get ideologically wrapped up in the idea of over-the-counter supplement versus pharmaceutical agent, and instead to just analyze any molecule you put in your body through the framework we're going to talk about today. Today, we're going to limit it to over-the-counter supplements because these are the things we get asked the most questions about.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
And frankly, it's the area in which it's harder to do the type of analysis we're doing today. So the type of analysis we're doing today is so much easier to do in the pharma space because of the regulatory hurdles that must be cleared by a drug to be approved. So it's almost like shooting fish in a barrel.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Still a great exercise to do, but doing it the way we're going to do it today is really how you develop the muscle for doing this type of work.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
I think this is the single most important thing I'm hopefully transmitting throughout this episode. I mean, the heavy lifting is actually showing you how we go through this, but this is the punchline. Anytime you're considering taking a supplement or someone is suggesting a supplement, you should ask the following questions or something that approximates them.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
So the first question I'm asking is, are you taking this to correct a deficiency or are you trying to achieve supernormal levels of fill in the blank? Second question, are you taking this molecule because you believe that it's going to improve your lifespan or your health span or potentially both?
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
The third question is, if it is lifespan, is it because this molecule is targeting a specific disease and presumably reducing your risk of that disease, or do we believe it's more broadly geroprotective?
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
As this is a very complex topic, we wanted to approach it first by proposing a framework that you can use to evaluate supplements that we can't make blanket recommendations on since everyone has their own individual health circumstances.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
In the supplement landscape, that's pretty rare to find, but obviously you can see examples in the pharma space where we might see certain drugs that we think have geroprotective benefits versus those that have lifespan benefits, but only on one disease.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Of course, the other question that is the corollary of that is if you're taking it for healthspan, can you speak to which apparatus of healthspan? Do you think this is something that is improving physical performance, cognitive performance, or emotional health?
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
The fourth question is, is there a biomarker that you can track to suggest that you are getting the appropriate amount of the supplement or that you might be in the therapeutic window? The fifth question is, do you understand the mechanism of action? Now, again, I want to be clear. You don't have to answer every one of these questions in the affirmative. for it to make sense.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
For example, there are countless things that we use for which we might not fully understand the mechanism of action, but we might feel confident enough on some of these other dimensions to move forward. The final question is, what is the balance of risk to reward? Including potential side effects, the magnitude of the effect,
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
the confidence we have in the data that speak to its safety, and the quality of the supplement itself. And this last point is especially important here. We know from previous podcasts that I've done, including the one with Catherine Eban, that even in the pharma world, the quality of the drug is not to be taken as a given.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
That episode, which is several years old and we'll link to it, really called into question the quality of some of the pharmacologic agents out there, especially generic brands. But whatever amount of nefarious behavior exists over there, I think you're safe multiplying that by 10 or 100 to understand the magnitude by which that's happening in the supplement space.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
So I guess before we jump into this, Nick, I just want to make sure we've pulled together a lot of information on the six supplements you mentioned. For the sake of time flow, making this conversational, I'm not going to go deep into each study that we talk about. Rather, I'm going to try to cover the important details.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
But we will heavily cite, link to, and explain the details of the studies in the show notes. So if you're listening to this because you just want to see how the framework works, great. But if you're like, actually, for those supplements, I want to go deeper, the show notes is where to go.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
To me, the framework is very important here because if I were to just dive into this podcast and give you my point of view on a random collection of supplements, it would be akin to giving you a bunch of fish when in reality, what I want to do is make sure you, of course, know how to fish. But not just giving you the framework, we also want to give you a few fish.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
With creatine, it's clearly the latter. I'm sure there's somebody walking around out there with a creatine deficiency, but that's not really the use case. So when people like myself, and I do take creatine, it's because we believe that supraphysiologic levels are preferential. We take this primarily to improve athletic performance, potentially increasing lean mass slightly.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
There are some emerging studies that suggest that it may also ameliorate cognitive decline. Basically, research shows that once muscle stores are fully maximized, which can be achieved with three to five grams per day, you've flattened out that curve. In other words, you don't need to go much beyond that.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Although, as we've talked about on this podcast, there was a day, for those of us that are old enough to remember, when the zeitgeist was to do a period of loading at much, much higher doses in the neighborhood of 20 grams per day before falling to a maintenance dose of five. But today, people that are taking it are usually just taking three to five grams per day.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Well, we certainly see no direct evidence on lifespan. I think most people who would take this, if being confronted with the granularity of this question in this way, would say, look, I'm taking this for healthspan. I'm maximizing the benefits of my exercise, especially with respect to resistance training and maybe potentially warding off cognitive impairment.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Now, of course, indirectly, I would say that those are also benefits on lifespan, but I would say that that's probably the way to think about this.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
No, there's not a biomarker for this. And again, what do I mean by a biomarker? Well, if you're taking a medication to lower your blood pressure, measuring your blood pressure actually becomes a biomarker for the thing you're taking. Am I taking enough or too much? If you're taking a drug that lowers your ApoB, the ApoB itself serves as the biomarker.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
We don't have a way outside of a lab commercially to measure tissue creatine levels. So we do not have a biomarker for this. And that's why people who take it are just sort of adhering to a protocol.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
On the physical side, meaning on the muscle performance side, it's certainly pretty clear. People will recall how energy currency is delivered. ATP, adenosine triphosphate, is the richest form of energy currency, and it liberates energy. It's spent by liberating a phosphate. ATP becomes adenosine diphosphate, ADP. Of course, that process works in reverse.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
And so we want to use the framework to cover a handful of studies for some popular supplements. We covered creatine, fish oil, vitamin D, vitamin B, or many of the vitamin Bs, and ashwagandha. We also talk about how to look at supplement quality, and we hope that this episode gives you an ability to take said framework and apply it to any supplement you encounter in the future.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
So as we want to build up and replenish our ATP stores, we need a phosphate donor. And this is where phosphocreatine comes in. So we do naturally have phosphocreatine. In fact, when you start to think about the various energy systems, if I asked you, Nick, to do something that was an all-out effort for 10 seconds... That would not require oxygen.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
You're not tapping into your VO2 max or your oxygen delivery system. It's frankly not even an anaerobic activity, meaning you're not actually turning glucose into pyruvate, into lactate, etc., If you're doing something that is such a short burst of activity, you are really relying on the phosphocreatine system to generate the ATP for that activity.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
So if you're doing a 40-yard dash, you're relying on phosphocreatine. But of course, phosphocreatine itself is a phosphate donor, and therefore... Anything that boosts the supply of phosphocreatine boosts the supply of ATP.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
And it's our belief that that's effectively what it is doing, and therefore that it's helpful with anything that requires bursts of activity, but even beyond just the super short extending into the anaerobic. I don't know that there are really any proven benefits that this augments aerobic performance.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Once you get into the purely oxidative phosphorylation pathway, maybe someone will correct us, but I'm not really aware that there are benefits of creatine in that regard. I think it's more in the first two energy systems, the phosphocreatine system and the anaerobic system.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
On the cognitive side, we know that a small amount of creatine is synthesized in the brain and that creatine can cross the blood-brain barrier. But the brain certainly does not take up creatine to the same extent as the muscles do.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
So while we have, again, some evidence to suggest that creatine is efficacious for cognitive function, it might turn out to be the case that you need higher doses of it. I think that's still an open question as far as I'm concerned.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
This is a supplement that has been quite readily studied. There's reasonable evidence to suggest, and again, we'll link to lots of it, that creatine does help improve various parameters of muscle performance. And it's not that subtle. I mean, it's typically in the range of 5%, 10%, maybe even 15%. So these include things like power and hypertrophy.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
Again, the power shouldn't be that surprising when you understand the mechanism of action. The hypertrophy seems to be due to not just the increase in the myofibril thickness, but also in the retention of water within the muscle. And of course, that's still considered lean mass.
The Peter Attia Drive
#340 - AMA #69: Scrutinizing supplements: creatine, fish oil, vitamin D, and more—a framework for understanding effectiveness, quality, and individual need
As I alluded to, kind of physical performance in short, intense burst activities and potentially some benefits in slowing down the aging phenotype of muscle mass. Again, like I said, it's really probably best suited for high intensity and anaerobic activities. But the one meta-analysis we'll cite to found that creatine did not really improve endurance events in trained athletes.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Hey everyone, welcome to a sneak peek, Ask Me Anything, or AMA episode of The Drive Podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com forward slash subscribe.
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#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
So I just want to kind of give the top level stuff. So when you're doing these studies, one of the things you quickly come to realize is people who abstain from alcohol for a reason, which is often where people are abstaining from alcohol, they're either former drinkers or they have health reasons that prevent them from drinking. There's often this paradoxical increase in mortality that we see.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
So if you kind of look at some of the larger studies here, and the largest one that I've seen is the recent one that came out in JAMA last year. It included 107 cohort studies and nearly 5 million lives were studied. And it compared a bunch of different entities to lifelong abstainers.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
So usually these are people who often have religious affiliations or other reasons to have never consumed alcohol. Now, when you compare former drinkers, so people who do not drink at all, but who used to drink, they have about a 26% increase in all-cause mortality compared to lifetime abstainers. And again, that's kind of in keeping with what I said earlier, right?
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Which is these are people who used to drink. They don't drink now. There's usually a reason for that. Now, interestingly, when you look at the occasional, the low volume and the medium volume drinkers, they actually didn't have an increase in all-cause mortality. And just to put some numbers to that, occasional drinkers basically don't drink at all.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
These are people that are averaging less than a drink a week. The low-volume drinkers are going to be up to a drink and a half per day. I wouldn't call that low volume, but that's how they were classified in that study. And the medium-volume drinkers we're up to three drinks per day. If that's medium volume, I need to recalibrate.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
But once you start to get into the high volume drinkers, these are people that are drinking three to four drinks per day. And then the highest volume drinkers are over four drinks per day. These people start to see an uptick in their all cause mortality at 20 and 35% respectively relative to the people who abstain.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Now if you look at these data and divide them by sex, you see another thing emerge, which is that across the board, women fare worse with respect to alcohol than men. So the first and most obvious explanation for this is simply body weight. So if you said like women who consume 45 grams of ethanol per day versus men who consume 45 grams of ethanol per day, of course the women should do worse.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
And I do think that body weight and in particular lean mass, because remember lean mass is where we see water and that's going to aid with the metabolism of ethanol. That's a part of it. But we also know that women contain less alcohol dehydrogenase, which is an enzyme that's responsible for the metabolism of alcohol.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
And the thinking at least is that if women have less alcohol dehydrogenase, just genetically, then they're going to be more susceptible to the downsides of alcohol.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
So I think there's a lot more we could say about this, but the truth of the matter is when you look across the board, alcohol is associated with at least three disease states, cardiovascular disease, dementia, and cancer, in addition to what I just talked about, which is all-cause mortality. Now, I want to point out one thing before we put this topic to bed.
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#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
which is the Mendelian randomizations typically come up with a slightly different answer than the epidemiology. So the epidemiology usually shows kind of a flat curve for low levels of alcohol and then a ramp up of mortality as alcohol creeps up. Different studies and different cohorts are going to find different places. I generally tell patients that I think conservatively one drink a day
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
is, at least according to the epi, a minimal increase in risk, whereas that JAMA study found you could get up to two drinks a day, maybe even three. It was only at three when you started to see the uptick. But the Mendelian randomization, which again is a technique where we look at genes that control a trait.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
So you might look at genes that control cholesterol or genes that control, in this case, alcohol consumption, because again, we know that there are certain genes that make it very difficult for people to drink alcohol. So if you believe that possessing those genes can speak to the phenotype of drinking, and I think this is a decent example of where Mendelian randomizations work.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
There are some where it doesn't. The MRs show that at any increase in the consumption of alcohol, there is indeed an increase in mortality. So they show an increasing level. So we say that that means that the first and second derivative are positive. So any standard deviation increase in the consumption of alcohol
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
leads to a greater increase in the risk of everything from hypertension to dementia to cardiovascular disease to cancer to all-cause mortality. So how do we reconcile these two things? Well, I think it's kind of tough, right?
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Because neither technique is perfect, but I think we sort of have to suggest that the precautionary principle here would be to obviously not consume alcohol at all because it's not an essential nutrient. There's nothing that it's doing that's good for you. And therefore, after that, you just have to be kind of judicious in your use.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
And you have to ask the question like, is this being maladaptive for my life in any other way? Does it, for example, impair my sleep? With the ubiquity of sleep trackers out there, I think most people will observe that if you drink a little bit too close to bed, your sleep is going to be disrupted. Does it change the way you eat?
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
For example, if you have a drink or two in you, are you more likely to raid the pantry or the freezer and get ice cream? And then, of course, there's the much more destructive stuff like driving and things of that nature. So I think overall, we can say that alcohol is under no dose helpful, under low doses, probably not terribly bad, but under escalating doses, it's actually quite negative.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
I don't want to dismiss the importance and the benefit of social interaction and the joy that comes from that. I think it just comes down to the dose, truthfully. So if that person says to me, look, twice a month, I like to meet my buddies and we like to play poker or we like to watch football and we have a few drinks, at the surface, there doesn't seem anything wrong with that.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
But look, if the answer is twice a month, I'm just going to drink 12 beers, I have a hard time understanding how the pro-social benefit of hanging out with your buddies that day justified having 12 beers. If the answer is, I like to kick back three or four beers a couple times a month, then I would say, yeah, it's probably not that bad.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
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The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
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The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
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#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
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#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
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#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
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The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
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#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
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The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
The only thing I would add is we talked about maybe if this format, which is more questions, less depth, more of how I would sort of answer questions if I were at a party and people were asking me if people want more of this, but on a personal level. we've talked about accommodating that. Maybe we just do a quarterly episode where I take very specific questions from individuals.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
If they want to be acknowledged, do so and do that. Anyway, I think there's just a lot we can play with in this format. Let's just see if folks find this helpful.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
So fortunately, if somebody wants to assess their risk of cardiovascular disease, we have a lot of tools to do it. We always start with the obvious, which is often neglected, but we should really know our family history. It's not enough to just know my grandparents lived till such and such an age or my aunt and uncles lived to such and such an age.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Whenever possible, you really want to understand how grandparents, parents, aunts and uncles lived and died. And sometimes it's easier to ask questions like, hey, did they take medication or do they take medication for cholesterol, for blood pressure and understanding those things?
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Again, some of the patterns that tend to show up here when you see people perishing really young from cardiovascular disease or when you see them requiring procedures. such as revascularization, stents, cabbage, things of that nature, especially at a young age, you have to be thinking about heritable causes of ASCVD.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
And again, the two most common are going to be LP little a and some form of familial hypercholesterolemia. Now, the latter is a lot easier to spot because these people have sky high cholesterol levels. The former is much more difficult because virtually nobody is getting their LP little a tested.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
So without further delay, here's today's sneak peek of the Ask Me Anything episode. Hey everyone. Welcome to Ask Me Anything, episode number 68. I'm once again joined by my co-host, Nick Stenson. In today's AMA, we're going to go through many of the questions you've submitted to us through the website and summarized as a way to answer some of the most common questions that have come through.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
And so that's sometimes the individual who themselves is kind of interested in assessing their own risk is the first to figure it out. And then it explains what has happened over generations. So family history, very important. Then you can sort of think about understanding, hey, has there been any damage done to date? And here's where a calcium scan or a CAC can be a very helpful test.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Now, it's not a foolproof test. It has its limitations. But if you think about the process by which damage occurs inside an artery, one of the final stages of that is the calcification of the artery, which actually is a protective mechanism. So the calcification of the artery per se isn't necessarily the thing that's going to kill a person. but it's indicative of very advanced disease.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
And if you see calcification in one part of an artery, it's quite likely that you have less remodeled plaque elsewhere in the coronary artery system. And in fact, those could be the ones that are at higher risk. So again, a calcium score in an ideal world is zero, but it's always important to remember that there's about a 15% false negative.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
meaning somebody ends up with a negative CAC, calcium score zero. But in fact, if you were to put them into a CT angiogram, which uses finer cuts of a CT and uses contrast after it does the initial calcium score, you'll see in 15% of those cases that there is indeed some calcification and or some soft plaque. So Again, that's one more piece of information.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
And again, if you want to go to a level above the CAC, then the CTA is valuable. But now you're experiencing more radiation and you also run the risk of requiring intravenous dye or contrast, which again, it's not a major risk, but it's non-zero. The other things I really think a person can do to assess their risk of cardiovascular disease is obviously look at the lipid profile.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
So the two things we care most about here are ApoB and LpA. And the reason for that, of course, is ApoB is the aggregate marker of all of the atherogenic proteins. Because LpA is so disproportionately atherogenic, you have to look at it separately because even an elevated LpA won't show up elevating an ApoB.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
The good news is that you don't have to concern yourselves with LDL cholesterol, non-HDL cholesterol, HDL cholesterol.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
None of those things actually matter once you know the ApoB and the LP little a. In fact, the triglyceride level itself doesn't matter unless it's dramatically elevated sort of north of about 400 milligrams per deciliter, at which point you would actually need to manage that as well. Another thing that I think gets so overlooked but is so important is blood pressure.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
And it's just too easy to sort of go to the doctor once every two years, get your blood pressure checked, have it come back slightly elevated, have it be attributed to white coat hypertension, and then just sort of walk away from it. But the truth of the matter is...
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
We know pretty unambiguously at this point that having a blood pressure below 120 over 80 is absolutely the lowest risk and is the best way to reduce one's risk. And to be clear, that means that a blood pressure 130 over 85, which historically would have been considered normal, is anything but normal.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Now, the challenge with measuring blood pressure in the doctor's office is it's almost rarely done correctly. Correctly means sitting there for five minutes, doing nothing, resting before the blood pressure is checked. It also means having a cuff that fits correctly, having the arm at the level of the right atrium, so about mid-chest here, not having your legs crossed when it's checked.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
And I always like to check it in duplicate or triplicate. And if a person can do that twice a day for a couple of weeks, once a year, again, not a huge inconvenience in my view, then they can have a real assessment of their blood pressure. The other thing, of course, that's worth stating just for completeness, though I think everybody understands it, is smoking.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Through this, we'll cover a wide range of topics and frameworks. We cover topics such as how to assess cardiovascular health, including what markers to pay attention to, Talk about intermittent fasting, including prolonged and time-restricted fasting methods, as well as alcohol consumption and its impact on health, as well as the association with certain diseases.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
If you're a smoker, you're at enormous increased risk of CVD. And of course, the same is true if you're metabolically unhealthy. This can be anything from hyperinsulinemia all the way to insulin resistance and type 2 diabetes. So those are really the big ones. There's a couple of things I didn't include there. I don't really look at CIMTs. I don't find them to be helpful enough.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
And I think the data would agree with that. So I think that's probably 80% of risk assessment for cardiovascular disease is captured in what I just said.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Yeah, I think the terms fasting and intermittent fasting get used interchangeably. I'm not going to represent that I'm the authority on any of this stuff. So I'm just going to tell you that whatever you are talking about, just make sure the semantics are clear so that you can normalize to what other people are saying. I typically don't use the term intermittent fasting.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
I use the term fasting and I use the term time restricted feeding or time restricted eating to describe what I think most people think of when they say intermittent fasting. But as a general rule, intermittent fasting or time restricted feeding or time restricted eating refers to periods of not eating during the course of a day. So when you hear people say, I do 16-8 or 18-6 intermittent fasting.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Of course, what they mean is I'll go 16 hours a day without eating, eight hours a day of eating, or 18 hours without and six hours with. Fasting is a term I kind of reserve for prolonged fasts, anything that's more than a day, and this'll easily be two, three days, up to really, really long fasts, seven, 10, or even 14 days. Then again, the term fasting implies that it's water only.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
It's non-caloric. So whatever liquids you're getting during that period of time don't contain any calories. Okay, so now let's answer the question, how can you use fasting or time-restricted feeding or intermittent fasting to improve metabolic health? Well, I think the data here are not particularly clear.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
So I'll start with the least clear of them all, which is the use of daily restrictions or intermittent fasting time restricted feeding. The data here suggests that this type of feeding pattern is no better than straight caloric restriction. In other words, when you normalize a person
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
for the number of calories they consume during a day, whether they consume those calories across the course of the day or whether they consume those calories in kind of a small feeding window doesn't appear to have a material difference. What does matter if a person is interested in improving their metabolic health, is that they restrict calories.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Talk about nutrition, outlining the principles of a well-balanced diet and answering some of your questions about protein intake. We also speak about the benefits and downsides of ketogenic diets and low-carb diets. talk about exercise, including how to create effective fitness routines, the importance of recovery, and we explore the topic of wearables. Lastly, we touch on emotional health.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
And if you recall, I kind of talk about this always through the lens of three tools that we have to reduce calories. The first is the direct way that you go about doing it. You literally just go about counting and reducing the number of calories you consume. Again, this is the most precise way to do it. This is why bodybuilders do it.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
You're not going to find a person on this planet that is more attuned to exactly what they put in their body and how that fuel gets partitioned. If you want an exact science, you go about counting every calorie and macro that goes in and you try to create that offset in that way. Again, for many people, this brings a lot of overhead with it. This brings a huge cognitive tax.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
And so we have two other techniques that can work quite well indirectly. So the first is what we've just been talking about, intermittent fasting or time-restricted feeding, where you just say, look, I don't really want to pay attention to what I eat or even how much I eat, but if I just make the feeding window narrow enough, that has got to reduce the calories. And indeed, it can. Not always.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
There's always the story of that person who in four hours a day of eating still manages to eat 3000 calories. But for the most part, as you restrict your feeding window, you're going to also reduce total calories. And then the third way to go about doing this is something called dietary restriction, which says, hey, I'm not going to concern myself with necessarily how much I eat.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
I'm not going to concern myself with when I eat. But I'm going to put in some pretty significant restrictions around what I eat. And again, the more restrictive you are, the more you're going to end up reducing calories. So I think the most important point to remember here is it's the calorie restriction that provides the greatest benefit.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
How you go about achieving it is really a function of your style. I actually recommend people try all of these techniques and we've covered them in so much detail elsewhere and the ins and outs of what the pros and cons of each are because there are many pros and cons of each. I think I dedicate a pretty significant section of one of the chapters in Outlive to covering this.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
There's no denying that alcohol affects our health. Alcohol is a nutrient like any other, but it comes with some particular issues that are a little bit unique to alcohol in a way that we wouldn't say are unique to carbohydrates, fats, and proteins. And that basically is the following.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Alcohol, in addition to being a dense source of energy, carbohydrates and proteins come with four kilocalories approximately per gram, and fats are at about nine kilocalories per gram. Well, alcohol is actually much closer to fats. It's at about seven kilocalories per gram.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
But when we're really talking about the impact of alcohol on health, we're not even really talking about it from its caloric standpoint. Although I can tell you, having done more food logs with more patients than I can count, it is always amazing to see a patient's face when they recognize that 25% of their total calories come from alcohol if they're a moderate to heavy drinker.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Needless to say, this is an episode that has something for everyone. If you're a subscriber, you can watch the video on the show notes page. And if you're not a subscriber, you can watch a sneak peek of the video on our YouTube page. Without further delay, I hope you enjoy AMA number 68.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
So you don't want to be dismissive of the calories. But I think for this question, Nick, I'm going to just put aside the caloric load of alcohol. So what we're really talking about is the toxicity that comes from the molecule itself, nominally through its metabolism in the liver and sort of its metabolic byproducts.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Now, we have a bit of a problem when trying to study this, which is we have to rely very, very heavily on epidemiology. Epidemiology is, of course, one of many tools we have to understand the impact of environmental, in this case, potentially toxins on health, but it just comes with so much baggage.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
Now, again, when you're talking about an environmental toxin that is really, really toxic, like tobacco, epidemiology turns out to be an awesome tool because the hazard ratios are so big that it's impossible for there to be other explanations. The problem is when you're dealing with alcohol, the hazard ratios are quite small. This is basically true of all food.
The Peter Attia Drive
#336 - AMA #68: Fasting, well-balanced diets, alcohol, exercise for busy people, wearables, emotional health, assessing cardiovascular health, and more
And this is why epidemiology just doesn't serve as a great substitute for randomized control trials when it comes to understanding these things. The problem is we don't really have great RCTs around alcohol, and the ones that we have are very short-lived. Now, we did an entire AMA on alcohol. We have an entire premium newsletter on alcohol. So I'm not going to try to rehash all of that.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Hey everyone, welcome to a sneak peek, Ask Me Anything, or AMA episode of The Drive Podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com forward slash subscribe.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
I could do rear foot elevated split squats, regular split squats. There's a lot you can do with a modest amount of dumbbells and a bench. And then of course, most gyms have much more than that. That to me is sort of step one. Step two is when traveling, you have to sort of be mindful of what jet lag is going to do to you.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
So because I'm in central time zone and when I travel west, it's really easy for me to work out early in the morning. A 5 a.m. workout is easy when I go to California for three days. So I can start my meetings actually quite early on those days because I know I'm going to get the workout done early. Conversely, if I go to New York, I have to keep in mind like I'm going to be a little bit tired.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
I am not going to want to work out at six because six feels like five and I don't like working. I mean, even though I'm comfortable getting up at five, I don't want to work out first thing at five o'clock. So then I have to adjust the timing of the meetings.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
So I think those are basically the two big things is make sure that your schedule has the time for you to do the workout and budget according to what jet lag is going to do to you and pick a place to go so that you can get the workout in time. the hotel. That's always going to be easier than if you have to leave the hotel to go to the gym. You can do that.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
And of course, there's been many times in my life when my training was so elaborate that I had to go into a commercial gym, but it was the same playbook. I would just book a hotel near the commercial gym.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
The goal of exercising when you're traveling is not to maybe make the most incredible gains. It's just to prevent the losses.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Yeah, there are two big reasons for this. The first is that women naturally have less muscle mass and are not as strong as men. And yet they still live in the same environment as men do, which is to say they're going to be subject to all the same forces. And this is one of the reasons why we see women fall more than men.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
It's not just that women are more injured by falls, which they are, and we'll discuss that in a moment. It's that women actually fall more than men. And one of the reasons for that is a disparate exchange in strength. So that's reason number one.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Reason number two is, of course, strength training is one of the most important exercises that we have, one of the most important behaviors that we have to stabilize bone density. And because women tend to have a lower genetic ceiling and more importantly, because women lose estrogen during the middle of their lives, they begin to experience a disproportionate drop in bone density as they age.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
And so the gap between men and women that's always there really begins to widen in the fifth or sixth decade of a woman's life. And that's all the more reason why she needs to be strength training. Because there really is no substitute for the type of strain that is placed on bones during strength training.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
It can't be replicated by running, certainly can't be replicated by cycling or swimming or other endurance sports, yoga. All of those things are simply not going to do it, and therefore they've got to be able to put this kind of external load on.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Well, I overall don't think exercise is a phenomenal strategy for weight loss, which is not to say that it doesn't play a role in maintaining a healthy weight. I think it does. But I think if you look at the experimental evidence, exercise, i.e. calorie expenditure, does not appear to be a very viable tool for weight loss. And by weight loss, we're obviously talking about fat loss.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
The majority of the work on that front really has to be done through caloric restriction. So if you just want to simplify and think of a machine with inputs and outputs, it's really reduction of the inputs that seems to play the greater role in weight loss. That said, we think that exercise is a very important part of health. and that health is the single most important thing.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
It's more important than weight loss per se. Furthermore, exercise does indeed make a difference for body composition, and body composition should probably be thought of as more important than weight per se. I don't think a BMI is an especially valuable tool at the individual level. I think it's a reasonable tool at the population level, but for any one individual, BMI is not really that helpful.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
I don't know my BMI, but I would bet that it's in the overweight. I know it's in the overweight category. My BMI is probably 27 or 28, which again, overweight is once you're above 25, but below 30, 30 is obese. I'm not quite there. So if my BMI is overweight, is that a bad thing? Well, not necessarily. It depends on my body composition. And so here's an area where exercise makes a huge difference.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
I think indirectly, there are other areas where exercise is very important for weight maintenance. And I think, for example, exercise maintains insulin sensitivity. And the more insulin sensitive a person is, I think the easier it is for them to respond to appetite signals. And so while just doing the accounting of calories burned versus calories in exercise generally falls short there.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Just a few things.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
In other words, whatever calories you expend doing the workout, you're generally going to pay them back. The goal, I think, is to be sensitive to the appropriate appetite signal so that one doesn't overeat in that state.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
I tried to say that in a Steve Carell voice, like I like lamp. I love lamp.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
No, but I did wake up to an awesome text message today. I've got this car that I'm trying to do something to the stereo system. And the guy who really, really knows what he's doing has been working on it for six weeks. He cannot figure out what's wrong with this thing. And it's super complicated. And he sent me this video this morning and it was like a video of him moving through the car.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Thank you for listening to today's sneak peek AMA episode of The Drive. If you're interested in hearing the complete version of this AMA, you'll want to become a premium member. It's extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
And in return, we offer exclusive member only content and benefits above and beyond what is available for free. So if you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription. Premium membership includes several benefits.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
First, comprehensive podcast show notes that detail every topic, paper, person, and thing that we discuss in each episode. And the word on the street is nobody's show notes rival ours. Second, monthly Ask Me Anything or AMA episodes.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
These episodes are comprised of detailed responses to subscriber questions, typically focused on a single topic and are designed to offer a great deal of clarity and detail on topics of special interest to our members. You'll also get access to the show notes for these episodes, of course. Third, delivery of our premium newsletter, which is put together by our dedicated team of research analysts.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
This newsletter covers a wide range of topics related to longevity and provides much more detail than our free weekly newsletter. Fourth, access to our private podcast feed that provides you with access to every episode, including AMA's sans the spiel you're listening to now and in your regular podcast feed.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Fifth, The Qualies, an additional member-only podcast we put together that serves as a highlight reel featuring the best excerpts from previous episodes of The Drive. This is a great way to catch up on previous episodes without having to go back and listen to each one of them. And finally, other benefits that are added along the way.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
If you want to learn more and access these member-only benefits, you can head over to peteratiamd.com forward slash subscribe. You can also find me on YouTube, Instagram, and Twitter, all with the handle peteratiamd. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
For all of my disclosures and the companies I invest in or advise, please visit peteratiamd.com forward slash about where I keep an up-to-date and active list of all disclosures.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
And he says, I figured it out. And he hits the stereo. And all you hear is the beginning of ACDCs back in black, like full beans. And I was like, that is an awesome video to wake up to.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Believe it or not, I didn't actually own my first car until I was in med school. I kind of rode my bike and took the bus everywhere.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
That was residency.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Yeah.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Yeah, so grip strength is important probably for a little bit of the reasons that we understand the drunk under the streetlight problem, which means the old adage of the drunk guy standing under the streetlight and someone asks him what he's doing and he says he's looking for his keys and they ask him if
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
this is where he dropped him and he says no but this is where the light is right so sometimes where it's brightest is where you end up looking so i don't want to of course minimize grip strength but i also want to just point out that in the literature when you are interested in studying the relationship between strength and outcomes everything from onset of dementia all-cause mortality cardiovascular disease all of these things which has been studied are
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
So without further delay, here's today's sneak peek of the Ask Me Anything episode. Hey everyone. Welcome to a special rapid-fire Ask Me Anything episode. I'm once again joined by my co-host, Nick Stenson.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
You need objective measurements of strength to test. If your hypothesis is strength is positively associated with, correlates with, or even causal towards these things, you have to be able to test it. And so the question then becomes, well, how do you test strength? Should we have people deadlift things?
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
And I think if you go through that exercise, you pretty quickly realize that's probably not a good idea. because most people don't deadlift and technique is pretty important in deadlifting and it's pretty easy for somebody to hurt themselves.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
So what scientists have done instead over the years is they've tended to study things that anybody can do, even if they don't do the particular exercise that's being tested. You shouldn't be testing squat strength or deadlift strength if a person doesn't deadlift or squat. So the things that have typically emerged as strength tests are grip strength, wall sits.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
So that's a test of, you know, at least isometric quad strength. Bench press. If you don't bench press, that's a bit of a stretch. Leg extension. Those tend to be the big ones. Sometimes leg press as well. So I just want to caveat it by saying I don't think there's something super, super magical about grip strength.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
We just have such an abundance of data on it because it's such an easy thing to test. So the next question then would be, is there something magical about having a strong grip? And here I think the answer is partly yes. A strong grip in isolation doesn't really exist.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
So there's really no example I can think of where a person has a very strong grip in their hand, but their forearm, deltoids, scapula, triceps, all of these other things are weak. So a strong grip is sort of a way to test that. Very strong, very stable control through the upper extremity all the way down to the outside world. And again, it's a very practical thing.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Just talk to any person who's reached an age where they can't open a new jar of pickles or they struggle to unlock a door or they struggle to carry a heavy plate. So when your grip strength goes, your quality of life absolutely goes. But again, I think it's just a proxy for people who are strong. And that kind of leads into your question, which is how should you train it?
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
So what's undeniable is the strength of the association. So I'm not even going to go into that because the data are overwhelming. The strength of the association between grip strength and any and everything positive warrants no further discussion. The more important question is, is it causal? If grip strength is just a proxy for health.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
In today's AMA episode, we thought it would be fun to do an end-of-year bonus AMA in a more rapid-style manner to answer many questions that are commonly asked that have come through over the past year across a wide range of topics and frameworks.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
and increasing grip strength does nothing to increase health, then we really shouldn't be talking about this. I don't believe that that's the case. I make an argument for that in Outlive, which is going through sort of the Bradford Hill criteria and explaining why I think there is causality in the association.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
In other words, why is it that increasing metrics of strength and endurance also improves lifespan and healthspan, not that they are just markers of healthy people who go on to have a better lifespan and healthspan? So how would you train it?
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Well, I can't tell you the number of times I give a talk or I just run into somebody in the airport and they tell me that they went out and bought a little grip squeezer on Amazon. And they said, Peter, you've got me convinced I got to strengthen my grip. So now I sit around and I squeeze these little things all day. And I said, well, that's great.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
I don't think there's anything wrong with that, but I don't think that's the optimal way to train grip strength. I think what you really want to do is do all of the other things that rely on strong grip. And the most obvious example of these things are exercises that involve carrying and pulling and hanging. That's really where we put our grip to the test.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
So I'm giving you a very long-winded answer, Nick, but the point is you want to train your grip strength by doing the things that rely on grip. So when you pick things up, when you carry things, when you pull things, if you're doing a seated cable pull, if you're doing a pull down, if you're doing a pull up, if you're doing a farmer's carry, if you're doing a deadlift,
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Those are the way we train grip. So I don't do very many things that are quote unquote deliberate grip strength exercises. I suppose that when I do farmer's carries, I'm almost exclusively doing that to push the limits of my grip.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
We discuss questions on exercise such as grip strength, exercise while traveling, the importance of strength training, and why I don't believe exercise is an ideal strategy for weight loss. We talk about labs, including the quote, top five most important biomarkers, unquote, that everyone should know for themselves. Spoiler alert, I hate that question.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Well, lots of people have weighed in on this question. And I think the question just becomes like, how extreme do you want to go? There's a standard out there that basically says the definition of exceptional strength is being able to walk with twice your body weight for 30 seconds.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
So if you weigh 175 pounds, you should be able to do a trap bar deadlift with 350 pounds and then carry it, walk with it for 30 seconds. Obviously, that's a very high standard, but I would say a more reasonable standard for maybe sub-elite athletes. I think for a male in his 40s, to be able to carry his body weight for one minute is good, and for two minutes is very good, just your body weight.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Again, if you weighed 175 pounds, you'd put 175 pounds on a trap bar. you'd pick it up and march with that for one to two minutes. And I think for a woman, I would probably consider 75% of her body weight to be also an excellent achievement. Of course, you might discount that by 10% per decade. I don't think a person should be discouraged if the first time they try to do that, they can't do it.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
In fact, if you haven't been doing that sort of thing, and if you're not used to deadlifting and doing a lot of pull-ups and hangs, I would not expect anybody to be able to do that. And so you do want to work up to that. And I really believe in the principle of working up to that without going to maximal effort.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
I know that there's a lot to be said from doing maximal efforts, but I think this is an area where I prefer to see people build resilience slowly. For example, if an individual tried that test, so let's just say you take 175 pound person, they put 175 pounds on a hex bar. They say, look, I want to carry this for at least a minute and 30 seconds and they drop it. I'd say, great. Okay.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
What I want you to do is drop the weight on that bar to call it 150 pounds, so 25 pounds below that 175, and I'd like you to do 30-second sets. I'd like you to do 10 sets at 30 seconds. And then I want you to advance weight and or time accordingly, but I want you to be able to get through those 10 sets such that at the end of the 10, you're really completely gassed.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
That's the way I kind of like to see people build strength there. Another test that we've talked about is the dead hang. So as its name suggests, you just sort of put your hands up on the bar. You can do it over any configuration of bars, but I kind of like to just do it over a straight bar and you hang. Now, again, there's Two big things to be thinking about here.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Do you do it with the scapula engaged or not engaged? And I like to do it with the scapula engaged. So the scapula are down. And so the lats are under a lot of stress, but they're not being stretched. If the scapula go up, if the scapula go up, you're going to put a little bit more stress on the elbows. That doesn't necessarily cause problems. By the way, I can dead hang both.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
And my dead hang record was actually an attempt to where my scapula were up. So sometimes I will go back and forth between the two techniques and I didn't suffer any permanent injury from doing that or anything like that.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
So again, I think here a standard would be a very strong 40-year-old male should be able to dead hang for at least two minutes and a very strong 40-year-old female should be able to dead hang for at least 90 seconds. And again, you would discount that as time goes by decade and probably subtract about 10 seconds per decade And again, a lot of people don't succeed in that at their first time.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
We talk about new research on longevity that has come out and that has been particularly exciting. And I answer the question if I have changed my mind on anything recently as it relates to longevity. We speak about some of the frameworks that I use and the importance of using the objective strategy tactics model as an approach versus a one size fits all approach.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
That's fine. But again, you can do that either by adding bands. So you use a band, a resistance band that you are sinking into, right? You put your feet into it. So it's removing some of the weight. Alternatively, I just like to have people go for much shorter periods of time, maybe do 30 second hangs and repeat those.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Sure, you can mix and match, but I think for this, I like to be palms out. So I'm palms out, both hands the same, over. And remind me, what was your record? Four minutes, 35 seconds. And that was with full scapula up, not engaged scaps. Wow. And my wife's record is three minutes and 10 seconds, which I think is actually more impressive.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
It was literally the second time she ever did a dead hang. And she literally just did it to, she was like, why do you keep doing this? Let me try.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Yeah, exactly.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Yeah, there are standards and I apologize. They're not tip of tongue for me. I want to say two minutes is considered a pretty good wall sit for anybody. I don't tend to do wall sits like that. There's another exercise I prefer to do, which is I'll do an air bike. I'll ride on the air bike for a minute hard, and then I'll hold a kettlebell and wall sit for 30 seconds to a minute.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
So it's a shorter sit, but I come in pre-fatigued. Plus I'm adding some stress to it by holding a weight. But if you just do a straight up wall sit, I apologize. We'll put it in the show notes for what a good standard is. I want to say it's two minutes, but it might be five minutes. I honestly don't remember.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Yeah, I do get asked this question a lot. And honestly, like my answer is you have to be deliberate. And that sounds like maybe not what people want to hear. I think people are looking for a quick fix. But when I travel, you can ask my assistant, what's the first thing I'm asking? What's question number one? It's show me the gym. I want to know exactly what the gym looks like.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
And if the website doesn't have good pictures, please have somebody who works at the front desk go down with their phone, film the gym, send us the video so we can evaluate. Yeah, I know. That sounds ridiculous. I get it. But unless you're going to the middle of nowhere where you have no choice in hotel, you have a choice in where you stay. Now, you'll have to make a concession.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
We close the conversation by talking about building good habits and my recent reading list. If you're a subscriber and want to watch the full video of this podcast, you can find it on the show notes page. If you're not a subscriber, you can watch the sneak peek of the video on our YouTube page. So without further delay, I hope you enjoy this bonus AMA rapid fire.
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
Maybe you have to be a little bit further from the place you want to be at. Maybe you're going to add 10 minutes or 15 minutes of driving time. Maybe the hotel is going to be a little bit more expensive. There will be a trade-off, and everyone has to make that trade-off. But I start with that question, which is, how can I make sure that whatever hotel I'm at has a good enough gym?
The Peter Attia Drive
#329 ‒ Special AMA: Peter on exercise, important labs, building good habits, promising longevity research, and more
It's not going to be the gym I have at home. It's not going to allow me to do everything I would do at home. but that's okay. Basically, I've never been to a hotel where I can't do something. Even if they just have a bench and dumbbells and I can do presses and I can do rows and I could do pushups and hopefully the bench incline. So maybe I can do an incline bench as well as a flat bench.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
Hey everyone, welcome to a sneak peek, Ask Me Anything, or AMA episode of The Drive Podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com forward slash subscribe.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
And what the authors of this study postulated was people who are faster nicotine metabolizers are going to have lower levels of circulating nicotine and therefore less nicotine exposure. Now, technically, you could also argue that maybe someone who's a faster nicotine metabolizer would smoke more or consume more nicotine. So put that aside for the moment.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
But nevertheless, the authors used these genetic variants associated with nicotine metabolism to adjust for basically smoking heaviness. And again, we're not interested in the role of smoking. We're interested in the role of nicotine. Okay. Disease risk was increased with slower nicotine metabolism, but the added risk was abolished when adjusted for smoking heaviness.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
Because of course, if you do this, you have to adjust for smoking. indicating that the main drivers of the outcomes are the non-nicotinic components of cigarette smoke. Let me state that again. This is a complicated MR, but it is the closest thing I think we have to looking at humans.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
And it's looking at how much people smoked, how quickly they metabolized nicotine, trying to do an overlay of that to appreciate the nicotine exposure. And it came away basically saying that the harm of smoking is due to the tobacco and tobacco-related products, not due to the nicotine. I want to be clear, this is way, way far away from what you would want to be able to say is level one evidence.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
If you're a subscriber and you want to watch the full video of this podcast, you can find it on the show notes page. And if you're not a subscriber, you can watch the sneak peek of this video on our YouTube page. So without further delay, I hope you enjoy AMA number 70.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
If you wanted to do this in a level one fashion, you would actually have to randomize people to a whole bunch of different tobacco-free nicotine products and study the outcomes of interest. Now, of course, nobody's going to do that for hard outcomes like mortality, but I certainly think people could do that for softer outcomes. And my hope is that somewhere along there, people do that.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
Thank you for listening to today's sneak peek AMA episode of The Drive. If you're interested in hearing the complete version of this AMA, you'll want to become a premium member. It's extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
And in return, we offer exclusive member only content and benefits above and beyond what is available for free. So if you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription. Premium membership includes several benefits.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
First, comprehensive podcast show notes that detail every topic, paper, person, and thing that we discuss in each episode. And the word on the street is nobody's show notes rival ours. Second, monthly Ask Me Anything or AMA episodes.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
These episodes are comprised of detailed responses to subscriber questions, typically focused on a single topic and are designed to offer a great deal of clarity and detail on topics of special interest to our members. You'll also get access to the show notes for these episodes, of course. Third, delivery of our premium newsletter, which is put together by our dedicated team of research analysts.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
This newsletter covers a wide range of topics related to longevity and provides much more detail than our free weekly newsletter. Fourth, access to our private podcast feed that provides you with access to every episode, including AMA's sans the spiel you're listening to now and in your regular podcast feed.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
Fifth, The Qualies, an additional member-only podcast we put together that serves as a highlight reel featuring the best excerpts from previous episodes of The Drive. This is a great way to catch up on previous episodes without having to go back and listen to each one of them. And finally, other benefits that are added along the way.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
If you want to learn more and access these member-only benefits, you can head over to peteratiamd.com forward slash subscribe. You can also find me on YouTube, Instagram, and Twitter, all with the handle peteratiamd. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
For all of my disclosures and the companies I invest in or advise, please visit peterottmd.com forward slash about where I keep an up-to-date and active list of all disclosures.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
You know, I'm actually drinking it in a glass.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
Nick, I have made several changes following the AMA on microplastics. I believe that they are all in the spirit of 80-20. So I'm really low on the sigmoidal curve of cost and energy with one exception. And yeah, I think I'm just taking what I think are the relatively easy steps to hopefully mitigate 80% of my exposure.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
And I'm going to spend no more time worrying about the last 20%, which A, I have no idea if it matters. And even if it does, I don't think I could live my life and be concerned with it.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
I am looking forward to the day when someone else hosts an AMA for me.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
So without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to Ask Me Anything AMA episode number 70. For today's AMA, we're discussing a topic that has been gaining significant attention in both the scientific community and among the public, and that is nicotine.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
One of the things that we appreciated, meaning the team and I as we were preparing for this, was trying to appreciate how much of the research on nicotine is based on tobacco and its first application through, obviously, cigarettes.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
But then also the idea of using tobacco to extract nicotine for non-smoke, but tobacco derived nicotine versus synthetic nicotine, which is honestly what a lot of people are thinking about in that context. And so I think that's important to understand that it is not always easy to tease out the impact of nicotine.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
And I'll foreshadow one example that we're going to talk about, which is infertility. You would think we would have legions of data that would explain the effect of nicotine on fertility, both for males and females. It turns out that if you want to talk about it through the lens of smoking, that's true.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
But if you want to talk about it through the lens of vaping or nicotine pouches, that's not true. And so I think that's one of the issues that I think makes this difficult to talk about with complete clarity. So anyway, I guess that's the first thing I would say. I think the second thing I would say is, and you alluded to this four years ago, we did an AMA on nicotine.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
Don't worry, those of you that listened to that, there's very little overlap. I spent way more time talking about how nicotine worked, mechanisms of action. Today, we're probably going to, I think, answer a lot more of the practical questions that people have. And I will also say that four years later, there's frankly more research on some of the benefits of nicotine.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
And to be sure, we're going to talk about both the risks and benefits of nicotine today. So anyway, I would say that's probably a good place to start.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
Yeah, this is something I think I, maybe I didn't do a good job of this four years ago, or maybe I did. And at the end of the day, people just don't appreciate nuance. But I remember being very surprised at how, A, people thought that the takeaway from the podcast four years ago was we should all be using nicotine. And B, people were like, how can you advocate for this as a doctor?
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
So my hope is to untangle all of that for people. Nicotine is one of many compounds found within the leaves of the tobacco plant. As such, it is in tobacco-based products. But the major health concerns that are associated with tobacco, which are primarily cancer and cardiovascular disease, for reasons we can talk about another time and we're not going to talk about today...
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
are not caused by nicotine per se, but instead they are caused by several other components of tobacco itself and tobacco smoke, such as everything from toxic metals, formaldehyde, things called polycyclic aromatic hydrocarbons. These are actually the things that are causing the harm. Now, There are byproducts of nicotine that are produced in processing tobacco, and they can be carcinogenic.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
This is a topic that we get a lot of questions about, not only from our audience, but also from my patients. In this episode, we discuss the distinction between nicotine and tobacco, understanding why nicotine itself is not the primary driver of the major health risks associated with smoking.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
So that means, and this is a very important point, I want to make sure if you're trying to pay attention to the key points, this is one of them. This means that any tobacco-derived nicotine product may contain carcinogens. This was actually something I did not appreciate prior. I thought that you could extract nicotine from tobacco and be completely free and clear of carcinogens.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
That is not the case. I want to be clear. It might be that, and it likely is, in fact, it almost undoubtedly is, that smoking tobacco is a much higher level of risk. But I want to make sure people understand that if your nicotine is tobacco derived as opposed to synthetic, you are still probably assuming risk.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
So the level of these compounds depends on the processing technique and the tobacco variety, of course. So they're found in the highest concentrations in products that actually still look like tobacco. So I think that's kind of a nice way to think about it. Everybody can imagine what a cigarette looks like. If you take tobacco chewing leaves, people chew tobacco,
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
that's going to have a lot of the negative properties. So the more closely you are to tobacco, the worse things are. So obviously if you're sticking it in a cigarette or a cigar or a pipe, yep, you're getting plenty of it there. If you're chewing it or taking it in snooze, also a big problem. So this is why I don't think I fully appreciated this four years ago.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
When you take nicotine out of tobacco directly, you're still assuming some of that risk that comes in curing and fermentation of the tobacco itself.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
We discuss the risks of nicotine use, including addiction, sleep disturbances, cardiovascular effects, and its impact on mood and anxiety. We talk about the various delivery methods of nicotine, from traditional cigarettes, which I think everybody would agree are bad, to pouches, gums, and synthetic options, ranking them from least to most harmful.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
Yeah, boy, that's okay. This is a philosophical issue. But as some people listening to this podcast know, I am an enormous fan of Formula One. And that goes way back for a long period of time. And up until 2005, tobacco was a major sponsor of Formula One. In fact, the largest sponsor would have been Marlboro. And they were in the early 2000s all over the Ferraris.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
And in the era that is my favorite era of Formula One in the 1980s and the early 90s, they were all over the McLaren car. And so you are correct. From time to time, you will see me wearing something or memorabilia that I have that is a throwback to that era of Formula One. And I believe in the original livery of those vehicles.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
In other words, I believe in era appropriate nods to things that we pay attention to. And so, yes, if you're looking at a hat or a shirt or a car that is a replica or pays homage to something of that era, you're going to see the livery of the sponsors of the time. And that would have been Hugo Boss, Nacional, Marlboro.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
Anyway, there's nothing else I can say about it other than it has nothing to do with a tacit or otherwise approval of these products. I want to be unambiguously clear. I think smoking is an absolute error, arguably the single biggest unforced error you can make with respect to your health. And fortunately, Big Tobacco does not sponsor motorsport anymore, and I think they're better for it. Perfect.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
Well, we're going to go into this in some detail, but I would say that clearly the biggest risk of pure nicotine, and now I'm just talking about it through the lens of synthetically acquired nicotine, so you're getting rid of all the tobacco-related processing, is in its addictive nature. And make no mistake about it, nicotine is highly addictive.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
There are some other areas where, depending on the dose, there may actually be a harm. Again, I think this is very important to understand. There are some mechanistic insights that suggest a negative impact on the endothelium. And it's certainly plausible that anything that negatively impacts the endothelium could increase the risk of cardiovascular disease. But these are not large studies.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
These are not studies that have been done in humans. And these are extrapolations typically from other animal models. So I guess we should probably just maybe spend a minute kind of talking about nicotine again. If people want more detail on this, I think it's covered four years ago.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
But nicotine activates, so nicotine is a molecule, and it activates something called the nicotinic acetylcholine receptor. Now, these receptors are not just in the brain where we most frequently talk about them, but they can actually exist throughout the body.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
And if you look at certain mouse models and rodent models, such as other rodents like rats, it's been demonstrated that high doses of nicotine can actually increase tumor growth and even foster metastases, in addition to increasing atherosclerotic plaques. Now, that sounds pretty devastating.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
the role of nicotine in physical performance, cognitive enhancement, fertility, and its interaction with other stimulants such as caffeine. We touch on the guidance for those interested in minimizing the risks while still using nicotine. And we end this podcast by looking at smoking cessation and considerations for those trying to quit smoking, which often involves using nicotine replacements.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
I just want to always point out, whenever we're talking about these rodent models, there's lots of daylight typically between what happens in that model and what happens in humans. And I think it's important to look at other ways to triangulate upon the answer. So we'll link to those studies in the show notes. But the closest thing that we could find in humans was a 2024 Mendelian randomization.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
I know we talk about these a lot, but I always think it's worth explaining what an MR is. So a Mendelian randomization says, let's look at genes in the population, which we can assume are randomly assorted. That's the randomization part. And let's ask the question, will these genes be a proxy
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
for a behavior that I want to study or something that I want to study where I can now use effectively observational tools to see if there's a difference. One example is Mendelian randomization consistently shows that LDL cholesterol is causally associated with heart disease. Why?
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
Because LDL cholesterol is highly genetic, and you can look across a population and see different levels of LDL, even in people who are otherwise healthy, and you can examine the cardiovascular outcomes of these people, which would be the dependent variable, and that's how you can infer causality. By extension, by the way, HDL cholesterol turns out to be not causally related in the inverse.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
So if you look at this Mendelian randomization, they wanted to look at the relationship of nicotine by itself on compromised lung function, lung cancer, COPD, CH, ASCVD, etc. Okay, I want to be clear. I don't think this was the world's best MR. I think it was clever, though. What did they look at?
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
Because like what genes would you try to parse out to understand how much tobacco someone is consuming, which is what you actually want to be able to do? So what they looked at was they looked at genes that spoke to nicotine metabolism. And so just as caffeine, we've talked about this in the past, caffeine metabolism is highly genetic.
The Peter Attia Drive
#344 - AMA #70: Nicotine: impact on cognitive function, performance, and mood, health risks, delivery modalities, and smoking cessation strategies
So people like me are wickedly fast at metabolizing caffeine, and therefore I seem to be able to drink it later in the day without a negative impact. Someone who's a very slow metabolizer is going to feel it more. Similarly with nicotine, you have high and low levels of nicotine metabolism.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
We usually saw them a little bit higher than that. Actually, I didn't really differentiate between LT1 and LT2. I kind of looked at the single inflection point just using a two line. Usually people were kind of in the three to four range was where that inflection point. You're saying that corresponds to LT2? Yes. So, and this also comes back to a little bit what kind of athlete you are.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
We talk about and define various performance metrics like FTP, functional threshold power, critical power, anaerobic threshold, lactate threshold, VO2 max, and the importance of consistent protocols when testing these performance metrics and how they can vary depending on an athlete's training.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Yeah, this was mostly swimming that we were doing. I found swimmers, by the way, had the highest lactate capacity.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
How much lactate they would produce and tolerate. And tolerate, yeah. Any idea? I mean, it could be just a small sample size. Very often, it depends on what kind of swimmers. If you look at a 100-meter swimmer, for example. So call it 200 to 400 breaststroke butterfly individual medley. I never saw higher numbers of lactate in myself or other swimmers than in those.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
I always assumed it was two things. It was individual medley. You're using every muscle in the body. It's not like cycling or running. You're hemorrhaging lactate into the system. And then secondly, at that distance, two to 400, I mean, you're really in the pain train of, you're clearly not able to do this fully anaerobically. So you're sort of maximizing aerobic and then topping up anaerobic.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
But that was sort of why I sort of assumed, I mean, literally I measured on several elite swimmers, lactates over 20 millimole.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
We discuss differences in training methodologies across sports and how different sports and activities influence power, pace, and endurance. We look at the significance of nutrition in endurance sports, how athletes train to properly fuel themselves for races, and why this is so different from what has been done historically. In fact, we really got into this difference in carbohydrate metabolism.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Let's just translate that into English for people. One of the challenges of talking with you is I enjoy it so much. And I sometimes forget that there are other people listening who might not care nearly as much as you and I do about some of this minutia. But it's just, I can't get enough of this stuff. So let's make sure people understand what you just said.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
You just said that when you look at the most elite endurance athletes, these people have either some combination of such low lactate production and or such high lactate clearance that frankly, the need to buffer it becomes secondary. they're producing such a high degree of power.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
They're generating so much work with so much aerobic efficiency that their steady state lactate doesn't even need to hit 2 millimole, which of course you can sit at 2 millimole all day long and not notice it from an acid-base standpoint. Is that a fair assessment of what you said? Or implication of what you said maybe?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Yes.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Let me just make sure we get people to understand that because that is, as you know, now that I have a VO2 master, I'm testing my VO2 max all the time and I'm also testing my VO2 at sub max levels all the time as well and looking at how that corresponds to lactate levels. Yes.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So why don't you define VO2 max and then we're going to come back to this point because I want to make sure people can internalize and maybe even one day experience what you just described.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Just like the first time Olav and I spoke, this is a discussion that can be quite complex at some points. We do get a little bit into the weeds, but the truth of it is because of the nature of what we're talking about, it's very difficult to talk about these things meaningfully and superficially. Patience is always appreciated and the rewards are always there if you're able to stick with it.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
That's been the case for me. You know, I've shared my data with you. So I like to do it on my bike on a hill. Take a hill that's going to be not too steep, 6% grade. You're in the saddle the whole time and you're in the big chain ring and it is go for broke and make sure you're dead at the top. four minutes of climbing, and that produces a VO2 max.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
There's going to be a level usually near the very top of the hill in the last minute where I reach the maximum volume of oxygen that I'm consuming. Now indoors, I for some reason hate doing it on a stationary bike. So instead I do it on a Stairmaster. So now I'm just sprinting upstairs doing the same thing. I get a comparable number, but it's a little bit lower.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Now what I haven't done yet, and I was going to try to do it before we met today, but I ran out of time. I was traveling last weekend. I have a prediction, which is I think I would have a higher VO2 max running on a treadmill, even though I'm very inefficient running, because my heart rate is always higher when I run than when I cycle. Do you think that would be the case?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
But having looked at that telemetry very closely, a lot of that is driven by the G-forces. I mean, the first time I looked at an F1 driver's telemetry, I was like, there's a mistake. These are just errors. Like these aren't real numbers because I had never seen such rapid changes from low to high to high to low.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
And then I realized they were all corresponding to either very, very strong break points or very, very fast corners. Obviously, the only thing that's common to that is something about 5G on the body is dramatically doing that. Now, it would be very interesting if we could do it. I don't know how you would do it, would be to measure VO2 and see if it has a commensurate change.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
What would you hypothesize?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
I would imagine that's even more pronounced for them. And we could actually measure that because they're already in a mask.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
But there's a slight difference, which maybe you're about to get to, so apologize if you are. There's got to be also a part of that heart rate that is coming from the compromised venous return to the heart due to either the valsalva or the actual impeding of the inferior vena cava.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So without further delay, please enjoy my conversation with Olav Alexander-Boo. Ola, thank you very much for coming to Austin on your way. I guess you're on your way to Arizona. Yes, on my way to Flagstaff. So also thank you very much for having me again. Yeah. Well, as I mentioned last time we spoke, I had a lot of notes. We got through, I think, one eighth of them.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
I would think at a high enough G-force, part of that high heart rate is stroke volume has gone way down because preload is way down. Again, sorry, I should make sure everyone understands what we're saying. When you fill the heart less with blood, you don't stretch the muscles out. That's called preload. So the heart needs to be preloaded with lots of blood volume so it can get a good squeeze.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
And anything that prevents that, either dehydration or literally dehydration,
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
You should never experience that on a bike, right? Because in theory... It's hard to imagine you could ever come close to 30% of a 1RM force on a pedal stroke, could you? That's true. Maybe there's an extreme moment you're at a 16% grade or something like that, I guess. It's possible, huh?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So when you test Christian or Gustav, if you were to have them fresh on two separate days and on one day you put them on the bike and on one day you put them on the treadmill and you have them do a VO2 max test, what would be the approximate difference you would see in them?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
This is the VO2 max hack for everybody watching this. How do I boost my, because my, my, my hack for boosting VO2 max is weight loss. Just figure out a way to lose five pounds in the week leading up to the test. And you're goes, I've been obviously knowing how to train for it.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
I mean, if you train in those intervals, so you're saying if you restrict breathing, as you get close to that failure point, each breath you take becomes that much more of an oxygen explosion.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
But for those listening to this who have a bet with their friends about who's going to have the highest VO2 max, this becomes their little trick. Yes, then definitely you can do this and you will get some really nice numbers. How much of a boost would you get? Like, let's say you're a person who just doing the protocol normally is 60 with no other change other than this breathing trick.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So there's kind of a lot to cover today. And of course, as we've been sitting here for the last 15 minutes or so, we've already kind of started the podcast, unfortunately. And I want to go right to where we just left off, but I'm going to resist the urge. Last time we spoke really about sort of the most nuanced ins and outs of cardiorespiratory fitness.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
What would you take that to?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So obviously losing weight. Yeah. So let's say it's five liters. Yes. Based on the weight that comes out to 60. Yeah.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
I thought you were going to say 64, 65. No, no.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
But wait a minute, though. Doesn't that sort of fly in the face of our definition of EO2 max, which is it's the highest oxygen consumption you sustain for one minute? Because I know when I do my test, I think I'm always checking for 60 second average and I'm not ever just looking at the peak. It's very noisy data.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So in this breathing technique, don't you just get a really big spike that is otherwise noise in the one minute best effort?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
I remember this from our last discussion. It's a completely different... We're not limited at the cell.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
There will be some differences. What are some of the mistakes you want people to look out for? Because again, people listening to this podcast are no stranger to VO2max. We talk about it as If you were going to sort of say, I need to know 10 parameters of my body for optimal health, VO2 max is on that list every day of the week.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Maybe just for the person who didn't catch that episode, can you give the one minute version of what you do and why you're certainly one of the few people that would be poised to talk about what we're going to talk about today?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So even if you are listening to this and you don't care about triathlons or cycling or swimming, but you just have the desire to live as long as you can and as well as you can, you have to know your VO2 max and you need to optimize it and make it frankly as high as you can with whatever time you're willing to devote to training.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
That said, most people aren't going to go out and buy a VO2 master and they're not going to geek out and do this stuff on their own. They're going to rely on going to a place where the VO2 max is measured in a stationary fashion, either on a treadmill or on a bike. What are some things that those folks need to be aware of when they go to a center to test this as far as mistakes that people make?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So for example, I've seen many people go and do a test and I talk to them after and I go, how exhausted were you at the end of the test? And they say, no. It was okay. I could have kept going and I'm realizing, okay, you didn't do a maximal test. Other mistakes I've seen are people who don't have a long enough warmup time.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
The total test took five minutes and I'm like, well, you didn't come close to sufficiently warming up. So are there any other things that you would just have people have in the back of their mind when they call a place up to say, hey, I want to come into a VO2 max test, but before I give you my hundred bucks, I want to understand the protocol.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So what should folks look for? If you were sending somebody to a public place where they could go and do this, they're not coming into your lab where you're going to administer the test, what would you want them to be looking for?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Reasonably well rested, not trained the day before, would you say, or like training the day before?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
That's important. How long do you think that should be for a person who's like modestly trained? Let's assume we're not doing this on someone completely untrained, but someone who's recreationally trained versus relatively elite.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Yeah, it can influence the RQ.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
We tend to do these separately now. So we don't use the day of the VO2 max test to do the fuel partitioning test. So we want to measure fat oxidation on a totally different day. We'll usually separate by a day even. So you'll do your VO2 max test on Monday and we'll do it this kind of way where we can agree completely like you should have all the carbs in the world.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
We actually like to standardize the fat oxidation test to a fasting test. That way it's just always the same. You're going to do it in the morning. You're fasted. It's a submaximal effort. We're not pushing you to maximum because we're just pushing to see what your maximum fat oxidation is.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
What's your preferred in-lab test? Do you use Parvo?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So obviously modality will influence this quite a bit as well. Which is why I was surprised when you said the guys were lower in swimming than cycling and running. Even though I realize that their efficiency in swimming is relative to the world's best less than it is in cycling and running where they would be closer to the world's elite.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
But I would have just thought more muscles would have meant higher O2 consumption.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Yeah. So in many ways, you're kind of an applied scientist. Yes. And your laboratory is both a CPET lab and then a racing environment where most of the athletes you work with are triathletes, correct?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Of course. I think anybody who's done this type of testing and done this kind of work, they'll have an appreciation for what those numbers mean, which is to say, I'm trying to come up with an analogy for another sport to explain what that would be. That would sort of be like, I don't know how to compare it to non-endurance sports.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
It's like saying in an NBA basketball game, occasionally they score 100 points. It doesn't compute. It doesn't really compute that they could utilize that much oxygen.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
But the training at that time was presumably geared specifically towards VO2 maximization. It was short distance. It was interval based.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Over what duration. We don't get into capacity. Exactly.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Yeah. I feel like we're going to use a lot of terms today. We're going to probably throw out the word anaerobic threshold, lactate threshold, VO2 max, FTP threshold. So I just want to make sure everybody kind of understands those things. So let's just take them one at a time. Can you define FTP or functional threshold power for folks?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
5%?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Something measurable?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
These are not people that are out there literally eating endless beetroots you could buy as a supplement. Yeah, concentrate.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
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The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Meaning you have 10% more production of CO2 than consumption of oxygen.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Suggesting efficiency is going down.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
It's not useful oxygen. It's actually the worst thing you could possibly have because you're also utilizing more fuel. So now you've created a scenario where for the same amount of power, not just you need more oxygen, oxygen is free. You're going to need more glucose.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Oh, that's interesting. Yeah. So you're saying because the RQ came in the same, you're going to hold carbohydrate metabolism constant and you're actually increasing fat oxidation. Yes. And that works out perfectly in the stoichiometry? Pretty close. It's counterintuitive.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
We'll delve very gently for the four people that are still listening to us.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
But you have to know plasma volume pretty well to make that calculation, right?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Very interesting. Sorry, one other question there. What RQ are you typically seeing for maximum fat oxidation? Not obviously percent of fat oxidation, which is low, but in absolute grams per minute, max fat oxidation at an elite athlete who's on a high carb diet, you're typically seeing that at what RQ?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Because I would have to imagine that that corresponds very closely to their race pace
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Yeah. We used to sometimes do 20 minutes and subtract 10%. So we would do a gentle warmup for an hour, then do 20 minutes and then subtract 10%. So yes, But I guess the spirit of FTP, which is maybe what we want people to think about and not get mired in the details, is it really approximates an energy zone that is more than just an all out, but clearly less than what you could hold indefinitely.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
This is hilarious. It was about an hour ago that we got off onto this tangent in response to what you said, which was at the most elite level, their race pace is... above 90% of their VO2 max. For elite marathoners, yes.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Again, this is just impossible for me to wrap my head around. This means that someone whose VO2 max is five liters per minute, if they're elite, which means they're obviously pretty light, they're going to spend an entire Ironman at 4.5 liters per minute.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
The VO2 max is declining and therefore it's, okay, that's what I wanted to make sure of. Because I was like, how in the hell can they hold 4.5 liters per minute? Or in their case, 7.2 liters per minute. So this is the difference.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So let's talk about that now in the context of the Olympics. So... You talk about an athlete like Christian or Gustav where, in theory, they want to be able to go between three distances, in theory. Olympic distance, half Ironman, Ironman. Yes. Let's remind people what the distance is. Olympic is 1.5 kilometer swim, 40 kilometer bike, 10 kilometer run. Elites are doing this in an hour 45-ish.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
7.21. Seven and a half to eight hours. And then a half Ironman is you take one of those last distances and you cut it in half. So just under two kilometers swim, 90K bike and call it a 21K run. So roughly twice the Olympic distance in some regards, less in others. And again, they're doing this in three and a half hours. So these are three very different events.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Is it possible to be elite in all of them?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
And it's directionally about the highest output you could have for an hour. And there's different ways to approximate it, of course.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
The efficiency is unbelievable.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
virtually laminar flow that goes through so it's a big canal which is circulating the water on the outside and it goes back in the front and you have even honeycomb structures in the front and the back so it truly replicates swimming stationary so it's the closest thing we have to an aero tunnel for swimming same yeah does it allow you to use dye in the water or anything like that bubbles I assume you use to you can yeah yeah
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
He is well-trained still. All things equal, he should be much higher in his VO2 at that moment in time. He's simply supporting more muscle. Much more muscles involved and bigger proportions involved.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
In absolute terms, yeah. On a relative basis, a third less oxygen. Yeah, which is still crazy, yeah. Here's my thesis on swimming. Of all the three big endurance sports, I feel like swimming has the most potential for radical change in performance based on drag avoidance. All of these sports, but especially swimming and cycling, come down to propulsion versus drag.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Running is less so because these speeds aren't high enough relative to air. Obviously swimming, just so people listening understand why I would say that, swimming is much slower than running, but the density of water is, what is it, 1300 times that of air. So you don't need a high V squared to get a lot of drag just based on the density of the medium you're in, which is water.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So in that sense, cycling and especially swimming really come down to this ability to avoid drag. And that's why in a time trial, position matters so much on a bike. And how can you generate power even if you have to compromise your power there?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So I feel like in swimming, there could be like a massive breakthrough if a technique emerged that reduced output or power or forward propulsion by 10%, but reduced drag by 20%. You know what I mean? Like, again, I'm so far from the sport, I don't know. But like, to me, I would really be curious as to that.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Because again, remember, this happened in cycling in the 80s, where prior to that, nobody was paying attention to bike position. And then Francesco Moser comes along in 1984, smashes the one hour record. With all this crazy aero equipment.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
And then, of course, you got into Borman and all these guys getting into more and more crazy aero positions where their actual power went down relative to what they could have been in a less kinked position. But, of course, their speed went up because the CDA goes down. And I just wonder, like, do you ever think about that in swimming?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Is there some major disruption where we just have this dramatic change in technique to have a bigger positive impact on frontal surface area than the negative effect it might have on propulsion?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Speed and power, perfectly.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
And then how does that differ from another term that is used interchangeably, but I believe erroneously, which is critical power?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So it's a force plate. Yes.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So you can directly measure this with a force plate insole or you could indirectly do it with motion capture. But I assume the motion capture only works on a treadmill.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
First of all, do you have any idea how much you just ruined my wife's life? Do you have any, so how many minutes do you think after this podcast, am I going to be on my computer ordering these devices, jamming them on her shoes? You know, she's running the Boston marathon next year and I'm convinced she's actually going to run it faster than she did her first Boston marathon 20 years ago.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Cause she actually now works with a running coach and her qualifying time this year was only one minute slower than her qualifying time 19 years earlier. And again, it's just because she's more structured in her training, not because she listens to a word I say. She doesn't. But she's like finally at least agreeing to use heart rate and velocity for tempo training.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
She's not listening to this podcast, obviously. One of her friends will probably hear this and tell her to listen. But we're going to implement power training for her running. And she's going to curse me all day long because she doesn't want data. But how is every runner not doing this?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So when running, you have more degrees of freedom. There's more inefficiency. There's probably a lower relationship, a more strained relationship between gross and net power.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Could you imagine seeing this? Have they put these in Olympic sprinters?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
If you had that force plate chip in their insole, you could at least capture force normalized to weight with each step, right? Yeah.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guest this week is Olav Alexander Bu.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
If you're looking at a cyclist, for example, can you make a statement using something so simple? So if you had 10 different cyclists and you did a VO2 max test on all of them and each of them, you end up getting a number, which is going to be, let's normalize it to weight. So you line them up in rank order from the lowest to the highest in milliliters per minute per kilogram.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
And then you look at what power they were at when they achieved that VO2 max, and you normalize that to weight to watts per kilogram. It's not going to be a one-to-one match.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Just to make sure I understand that, are you saying that the rank order will be identical for VO2 max and watts per kilo at VO2 max in cycling?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
But I feel like my personal power at VO2 max is lower than many other people's at a comparable VO2 max. Like I just feel like I'm very inefficient. I have a higher VO2 max than a PVO2 max, if that makes sense. Yeah.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Oh, you're saying I'm anaerobically not trained enough and that's why my power. Yeah. I'm too aerobic, not anaerobic enough. Great point. That's a very interesting point.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
In cycling... One could ask the question. So when the guys are on the bike, are they paying more attention? So let's just talk about them doing a four hour ride in an Ironman. Are they more concerned because you're triangulating between RPE heart rate and power? How are they prioritizing those things? How they feel? what the heart rate is, and what the power meter says.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
How are they regulating effort based on those things in a race? In training or racing? Race.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
And where does critical power typically lie in relation to FTP?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
But also his heart rate might be different there too. When you throw him on for a minute at 21 kph and he says RPE6, his heart rate's probably a lot lower than it would be two hours later at that pace, right?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
What's the mitochondrial density of cardiac muscle versus skeletal muscle? I mean, they're both similar in some ways. They're striated muscles. I should know that. I mean, your intuition would be it has to be very rich in mitochondria, right? Yes.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Yeah, yeah, yeah. Yeah, yeah. And I learned recently in the podcast with George Brooks that we can actually shuttle lactate into the mitochondria for oxidative phosphorylation. I was completely unaware of that. That would explain, of course, why the heart could richly use lactate. Yes.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So you could use it as a buffer. Yeah. Let's make sure folks understand the chemistry there. So I was going to actually ask you about this and then we got off onto another topic. I want to come back to that exact question, but We'll preface it with this question. People ask me all the time, hey, I understand, Peter, that as my workload increases, my production of lactate increases.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
And as my production of lactate increases, my capacity starts to fall off because as lactate goes up, it's buffered by a hydrogen ion or it's married to a hydrogen ion. And that's what creates the acid part of lactic acid. And it's that hydrogen ion that's causing all the trouble. It's not the lactate. We can tolerate endless amounts of lactate. And lactate is crucial in metabolism. Yeah.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
We just can't tolerate the hydrogen that comes with it. And it's that hydrogen that actually paralyzes the actin, myosin filaments, prevents them from disengaging. And that's what leads to that seizing up that you feel, the rigidity you feel when you exceed your lactate threshold. So the question then becomes, well, can I buffer this?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
And everybody and their brother talks about, hey, what if we took lots of Tums, anything that we could get sodium bicarbonate into our systems? Looking at that literature, which I haven't done in a while, this strategy didn't really pan out. There wasn't really a great way to orally ingest enough bicarb to make a difference. Obviously, intravenously, you could, but that's probably illegal anyway.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
I mean, I don't think water would permit that. But even if you weren't concerned with that and just asking the theoretical question, unless you're on a stationary bike, it's not practical to have an IV drip of bicarbonate to buffer your hydrogen. So what is the state of buffering agents to reduce and lessen the impact of lactic acidosis? This is a little bit of a complicated domain.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Unlike all the other simple domains we've been discussing today.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Oh, so you get rid of the gastric, you would bypass the gastric pH and you get it into the intestine.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
What have you seen is the difference in his lactate tolerance with and without this buffering?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
We'll define those in a second. So many of these metrics, FTP, critical power, are easiest to think about in terms of cycling because we use power meters. Do the same concepts still apply in swimming and running? Yes, I would say.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Yes, yeah.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Here's just a crazy idea. Have you ever done a muscle biopsy on the two of them to see the relative differences in monocarboxylate transport density on their muscles? No.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Think about this as, I mean, just for the listeners to understand what we're talking about, the MCT transporter on the muscle cell must play a significant role in determining the relationship between intracellular lactate and intraplasma lactate.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
it would be in an athlete's best interest through training to increase the density of those because the more you can get lactate out of the cell, the more presumably you're going to get the hydrogen with it out of the cell, we probably have a greater capacity to buffer acid in the plasma because we have the respiratory drive to adjust bicarb than we do in the cell where that hydrogen is really poisonous.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So it just makes me wonder, as a hypothesis, maybe Christian has more MCT density. And that's why he is less impacted by this buffering strategy. I don't know. Could be the other way around. I wonder if all things equal, that would be, it's just so hard to believe that two world-class athletes could be that different in their response.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Yeah.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Let's go back and say one thing about temperature. There's some reasonable data suggesting that a relatively high dose of acetaminophen can certainly improve heat performance, so tolerance, race-paced tolerance in warm temperatures. that it may even perform output. And again, nobody knows why. Is it improving performance, i.e.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
absolute output, because it's actually reducing and blunting body temperature, and the temperature itself becomes a bit of a governing mechanism on output? Or if it's just blunting pain, and pain is part of the wall that we face. But curious if you have any experience with high doses, 1 to 1.5 grams of acetaminophen in any of these athletes.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
I'll share two with you. I'm curious to your thoughts. We're going to talk about nutrition in a minute. You already alluded to the fact that your athletes are routinely able to consume 160 grams of carbohydrate per hour on the bike during competition. A hundred years ago, when I was competing in anything, we were stuck at 60. Like it was really hard to get past 60 grams per hour.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So for ultra distance things like I did, it really became a bit of an energetics problem. You had to start figuring out ways to get fat in the substance that you were consuming just to get the additional calories, even though you didn't really need fat because you have enough of it. It's glucose you're limited by.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
I very recently, literally the other day, asked Lance Armstrong, we were talking about something unrelated, and I said, by the way, Lance, back in the tour, how many grams of glucose were you consuming per hour? You know what he said? He said, we didn't even pay attention to it. We just ate when we were hungry.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So this is not saying that the only reason those guys were exceptional is because they were using blood products. No, they were using blood products and they were exceptional and they trained really hard, but their knowledge of nutrition was very pedestrian to what it is today. As you know, if you wait till you're hungry to start fueling, you're not fueling in an optimal strategy at all.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So that to me is one enormous advantage in the Peloton today. I think that nutrition science has evolved so much. What these guys can do, I've heard rumors that they can put down 200 grams per hour, that they've trained themselves up to that level.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
I think a second interesting difference in the Tour today, and I'd love your point of view on this as well, I think people forget how big cyclists were 20 years ago relative to today. If you look at the GC contenders in the era of Lance Armstrong, if you look at Jan Ulrich, Ivan Basso, Lance himself, I mean, these were guys that weighed... 70 kilos. Lance raced it.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
He'd start the tour at 74 and finish at 72 kilos. These are normal sized human beings. If you look at the GC contenders today, these guys are 58 kilos. I mean, they're very small. So in cycling, if we think about it as watts per kilo, it's not that they've gone up that much on watts. Their absolute wattage is significantly lower than what it was 20 years ago.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
They've just gone down so much on weight. So I'm wondering what you think about those two factors that are clearly stark differences between the world's best cyclist today and the world's best cyclist 20 years ago as a way to bridge the gap between the use of drugs then versus not today.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Do we see this in triathletes? I mean, cycling's an interesting sport because you don't really get a benefit from weight reduction if you're a time trialist, for example. In fact, it's the opposite. It's watts more than watts per kilo that matters. But obviously, if you're in the Grand Tours, all three of which are... basically built around climbing, watts per kilo is ultimately the metric.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Now we can debate whether you can get a more optimal watts per kilo at a slightly higher weight than a slightly lower weight, but clearly you're not going to see people winning a grand tour at 80 kilos or 75 kilos. I think those days are probably gone. But in triathlon, how much of an effort do these guys put into their weight?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
What would be his average power in an Ironman for four hours? So for four hours, typically there, they would be around. Let me see if I can guess. You said before we started the podcast, you mentioned they were holding 44 to 45 KPH. Or even slightly above, yeah. In the most extreme cases. So he's got to be at 360 to 370 watts to do that.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Is it lowering mechanical power? Because I think the argument of the acetaminophen literature is that the body is bumping up against a couple of set points that are acting as governors to output. One of them is pain. One of them is temperature. The body does not want to let you get too hot and obviously doesn't want you to tolerate too much pain. Acetaminophen potentially blunts both of those.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
You're arguing, yeah, but if part of the way it's blunting energy output or temperature is by reducing mechanical work... gross mechanical work, then you're going to probably pay a net mechanical work price. Yes. And also capacity price, you could say, in some regards. I have no idea what the answer is. I would just want to test it in training.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Literally alternate weeks with, without as a placebo test, with acetaminophen, without acetaminophen, with acetaminophen, without. Because again, at your level, you get a 1% difference. It matters.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
That is so... Can you tell people what 240 grams of carbohydrates looks like if it were food? Do it in pasta or something like that. How much pasta is 240 grams of carbohydrate? To make it simple, it would be probably as you took pure gel and you filled this glass and you drank it. Take those pure little nasty, disgusting energy gels and fill your 16 ounce glass there with it. And drink it.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
And what form are they consuming the carbohydrate in? Normally they would do it in the form of drink mix. So how do they get that much liquid in their body?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Which again, that also... completely flies in the face of traditional nutrition science, which says 5% to 6% is the limit for gastric tolerability and is the sweet spot for absorption. At 5% to 6%, your max, now again, that's a different problem. That's optimizing for water absorption into the cell, not your primary point.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
You're probably overdoing it on liquid and you're trying to maximize glucose into the cell.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
It's not done on these trained athletes. Okay. First question, how long did it take you to train the athletes to be able to tolerate that? Because if someone's listening to us today, And they're saying, oh, I heard these guys talking about the 12% carbohydrate concentration, which again, just means for people listening, that means 120 grams of glucose per liter.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
That's twice the standard what you'd see in an energy drink. And then I'm going to drink two liters of that every hour. I think within two hours, a normal person is going to be puking their guts out. They simply can't get that volume of glucose out of the upper gastrointestinal tract. So Is this just like any other muscle where you can train yourself to exceed capacity? Seems like it.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Yes. This is where it's going to make a bigger difference. It's not going to make a big difference at the beginning of the race, but it could make a huge difference at the end. Talk to me about formulations. Back when I was swimming great distances, one of the challenges I had over a 12 hour event was literally fatigue of the same flavor. So part of the challenge was how do you just mix things up?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
And after a while, sweet becomes horrible and you actually want something salty, but then salty becomes horrible. Like How are you managing the actual practical implication of this?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Olav was a guest in March of 2024, and at the time of that conversation, I realized we hadn't got through the majority of what I wanted to speak about, so it was inevitable that I would have him back. Olav is an endurance coach, exercise scientist, engineer, and physiologist.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Okay, you mentioned two other terms there, anaerobic threshold. Let's start with that. How do we define it?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Wait, sorry, this Morton gel is a significant driver of their calories as well as the bicarb?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Silly question. The bicarb capsule, they're swallowing a capsule while they're on a bike drinking?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
What is the base of the carbohydrate in that brand that they seem to like? Is it straight dextrose, maltodextrin? No, mainly fructose and glucose.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Yes, exactly.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
If you want to get to 160, you need the technology. Yes, exactly. No fat and no protein, any amino acids throughout that whole race?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Okay. So the Gibbs free energy, if you're making the BHB yourself, much more complicated. But if you take it purely exogenously and consider it an additional substrate above and beyond glucose, do we have reason to believe that we're going to get more ATP per mole of oxygen?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
And then you have also the issue with the salt, if you're bringing in more of the salt versus an ester. Okay, a couple of things I want to chat about. So one, we talked a little bit about this before, but let's kind of go back to it. So remind me, did Christian and Gustav both compete in Tokyo Olympics? Yeah, both did compete in Tokyo Olympics, yes. And how did they do in Tokyo?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Where does anaerobic threshold typically, if we're just limiting this to make the discussion easier and talking about, say, cyclists with a power meter, where does anaerobic threshold tend to sit relative to FTP?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
After that Olympics, they went back to Ironman distance for the next three years, and then Gustav did not compete in Paris. He had an injury. Christian did, and I think you said he was 12th. Yes. How much of that was the mismatch in distance? Again, he's much more optimized for Ironman Olympic distances. That's like asking a marathon runner to go and run a 5K. Very unusual.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
What was the process like to get ready for that? And what was the difference in his personal performance between 2024 and 2021? We went there for two reasons.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Rio to Tokyo or Tokyo to Paris?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Four minutes would be between them and me.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So 40 seconds he lost on the run.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
A lot of people heard about how disgusting the river was. How did that create more separation between the excellent and the good swimmers?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Usually that closes the gap between people when the current is strong.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So at the lower power. So if we're keeping track, we've got critical power, FTP, AT.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Last thing I want to just chat with you about is where you are using AI today or where you see AI going to make your insights better and your efficacy better.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Basically extract patterns you might not otherwise be able to direct your own statistical analysis towards? Yes.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
As you think about 2028, if you think about the next four years, if you had to just sort of speculate wildly, what percentage improvement do you think this will bring? Not to the insights, but to the actual performance.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Yes.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Is there an area in particular that you see the biggest gap between where your insights are, your coaching insights are today versus where you hope AI is going to close a gap?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Well, and you're going to have training data. You're going to have great training data. Yes, yeah, yeah.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Well, it's been a fascinating discussion. Thank you again for making the time to swing by on the way to Flagstaff. And as always, just enjoy talking about this stuff. And hopefully folks enjoyed this as well, even though admittedly it was a little technical at times. Thank you the same. Thank you for listening to this week's episode of The Drive.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
For all of my disclosures and the companies I invest in or advise, please visit peterottmd.com forward slash about where I keep an up-to-date and active list of all disclosures.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
He is the head of performance for Norway Triathlon and is best known for coaching two of the world's top triathletes, Christian Blumenfeld and Gustav Iden. In this episode, we review his work and his approach to coaching and the way that he relies very heavily on data.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
And so if we did a lactate protocol, a speed or power escalation, right? I think we talked about this on the last podcast, which was kind of the way we used to do it in swimming is you'd think we would do 200 yard swims. So you do a 200 yard swim at a very modest pace, come back, check the lactate, rest, do it again, five seconds faster per 200, go and do it again. lactate, and you get a plot.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
So pace on the x-axis, lactate on the y-axis, and the curve is very distinct. It is very, very flat, and then it is not. And we would draw these tangent lines between the two, and then that point was the lactate threshold. Where would that typically lie? Assuming we did it on a bicycle, so it was really easy to do the power checks.
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
First of all, how long a duration would you have an athlete do this if you were doing it on an ergometer? Would you say we're going to do three minute efforts or something like that? Is that appropriate to generate the lactate performance curve?
The Peter Attia Drive
#331 ‒ Optimizing endurance performance: metrics, nutrition, lactate, and more insights from elite performers | Olav Aleksander Bu (Pt. 2)
Even taking into account that there's some lag between what's happening in the muscle and what's happening in the blood?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Okay, so we've established now what's happening. We've established that during the period of perimenopause, the one consistent thing that's happening is inconsistency. At some point, we get to the place where the consistency returns, but now it's a new norm. And that new norm is you don't make estrogen. You don't make progesterone.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The signal from your pituitary FSH and LH begin monotonically rising, rising, rising. And so if you were to do the blood work of a woman in her 60s who had never been placed on HRT, you would see a very high FSH, a very high LH, usually above the lab's cutoff for measurements, and then estradiol and progesterone non-existent.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Let's talk about all the reasons why that woman that I just described in her 60s, who is now 10 years out of any hormones, what are the risks to her physical health, mental health, emotional health, the whole picture of her health, cognitive health, everything? What is she worse off for at that period of time?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
the risks of menopause beyond just symptoms like hot flashes, including the risk of osteoporosis, cardiovascular disease, dementia, and recurrent UTIs, the long-standing controversy around HRT, and how a single study, the Women's Health Initiative study, led to decades of fear-based medicine and an entire generation of women, by my calculation more than 20 million, deprived of the benefits of HRT.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We talked about obviously the risk of dementia. We talked about the risk of osteoporosis, cardiovascular disease, colon cancer. All of these are risks that are pretty clearly going up in the absence of hormones. So do you want to talk about the history of HRT? I mean, it was a largely normal practice in the 1960s. They certainly had some fits and starts.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
They initially were just replacing estrogen. figured out pretty quickly, i.e. within a few years, that if you only gave a woman estrogen, you were going to run the risk of endometrial cancer going up because the endometrial lining just continued to get bigger and bigger and bigger, and you eventually developed hyperplasia, which presumably became metaplasia and ultimately cancer.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We figured out pretty quickly how to combat that. If you just oppose the estrogen with progesterone, keep the endometrial lining in check, And this largely became the standard of care through the 1980s and into the 1990s. And this was largely validated by epidemiologic observations, which showed that women who took hormones did significantly better.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Now, people who listen to this podcast are well aware of how critical I am of epidemiology, and it's certainly very easy to make the case that in the 1980s, women who were taking hormones had a healthy user bias.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
These are women that probably had better access to healthcare, they were probably more health conscious, and as a result, they were probably doing many more things to improve the quality of their health. The NIH did something that I think made a lot of sense. It was the right thing to do, which was they said, look, we can't rely on this epidemiology. We need to do a randomized control trial.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And they did it through something called the Women's Health Initiative, which had two components, a nutritional component that was asking a question about low-fat diets, and then a component that was looking at the HRT.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Would you like to pick up the story as to how the study was designed, maybe talk about some of the potential pitfalls of it, and ultimately how the results of that have been misunderstood and misinterpreted for so long?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
How to use estrogen, progesterone, and testosterone therapy for women, including dosing, delivery method, such as oral transdermal vaginal, and why personalized care is essential. The overlooked role of testosterone in women's health, both before and after menopause.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The benefits of local vaginal hormonal therapy, a safe, inexpensive, and underutilized treatment that prevents urinary tract infections, improves sexual function, and dramatically enhances quality of life in postmenopausal women.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So, Rachel, I don't know how good you are at sensing a person's blood pressure from across the room, but if you were able to sort of project your vision into my carotid artery... I see it bulging. Yeah, you'd notice that my blood pressure is up. I'm probably at 180 over 120 right now. First off, I think that was a remarkable, succinct summation of the WHI.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I'm only going to repeat a few things, not because I didn't think you did a great job. You did. But because sometimes hearing it twice highlights the egregiousness of this study.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Truthfully, I have friends, female friends, and I have patients who to this day are paranoid about hormones, and I just want to offer yet another opportunity for them to sort of understand what's going on. So this was a study that had two parallel arms, one where women without a uterus were just randomized to either this synthetic or equine-based estrogen or
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
This is a podcast in which I learned a lot, even though I like to think I know quite a bit about this already, but Rachel's expertise here is second to none, and I was feverishly taking notes throughout and obviously can't wait to implement many of the things I learned into my own clinical practice. So without further delay, please enjoy my conversation with Dr. Rachel Rubin.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
versus a placebo, and then one where if you had a uterus, you got MPA, a synthetic progesterone, and the estrogen. As you pointed out, the elephant in the room here, the one finding that got all of the attention was that in the women with uterus group, If you got the synthetic progestin and estrogen, you had an increase in your incidence of breast cancer.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It turned out it didn't actually lead to any change in mortality from breast cancer, but there was an increase in the incidence. The number is really scary if it's given in relative terms. It was a 24% increase in the incidence. Incidence, for the listener, meaning getting breast cancer. You had a 24% higher chance of getting breast cancer if you took the two hormones.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
On the surface, that sounds devastating, but again, as people who listen to this podcast know, we always need to think in terms of absolute risk. And relative risk doesn't mean that much if you don't understand absolute risk.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So if I said to you, Rachel, I have a treatment for you that is going to fix a hundred problems, but it increases your risk by 100% of getting hit by an asteroid, would you take the medicine or not? Well, you'd have to know what your base level risk of getting hit by an asteroid is. And given that it's almost zero, doubling it doesn't mean anything.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So the absolute risk increase for these women was 0.1%. So to put that in less technical terms, it meant even if you believe the results of that study, and you've offered a great explanation for why the actual results should be questioned, but even if you take them at face value, for every 1,000 women who were put on HRT, an additional 1%
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
got breast cancer, though she didn't die from it at any increased rate to the women who didn't get the hormone. This to me, and I'd like you to push back on this, although I'm worried you won't be able to because you share my bias. This is the greatest injustice imposed by the modern medical system in our lifetime.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah, it's really interesting to hear you say that because you're highlighting something that's as dramatic and potentially more dramatic than the thing I've tended to focus on. I've focused more so, maybe I just take for granted that I got lucky and I had amazing mentors and they taught me how to do this stuff, but it's also the nature of my personality to just
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Rachel, thank you so much for making the trip out to Austin. I have been looking forward to this episode for a while, and I'm willing to go on record predicting that this will be a very popular episode given the nature of our discussion.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
be endlessly curious and show up in somebody's clinic for two weeks and do this. I've tended to focus on the lost generation of women. So I had my analysts do this analysis two years ago, and I don't remember the exact numbers, but the analysis was
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Calculate for me or estimate for me the number of women who were deprived of HRT because of the WHI and calculate the excess mortality that was achieved through that injustice, through hip fractures, cardiovascular disease. We just went through the entire list.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
calculate the number of lives that were lost, the amount of disability that was incurred, because to your point, even if you don't die from a hip fracture, 50% of survivors never regain the same level of function. And I didn't even know how to quantify all of the sexual side effects that women unnecessarily endured, all of the vasomotor side effects that they unnecessarily endured.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I didn't even try to quantify that because I don't know how to. But that's the thing that I focus on. And again, it's personal to someone my age because my mother and my mother-in-law are in that category. They're the ones that got absolutely screwed by this system.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You're highlighting something equally catastrophic with potentially a greater impact, which is we failed to train a generation of doctors to do anything about it. And if that's not reversed, the problem doesn't get much better.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I did learn that hormones were bad.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I almost don't know where to begin, but it might not be a bad idea to just give people a little bit of a sense of your background. You are a urologist by training, and maybe help us understand how your training in urology led you to what you're doing today, because most urologists wouldn't be doing exactly what you're doing.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Let's talk a little bit about how we go about doing things. So there are two hormones we've talked a lot about, but there's a third that we haven't yet talked about that is very linked to these two hormones, doesn't get enough attention in women, and of course that's testosterone.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So before we get into how one should think about replacing hormones, can you talk about the relationship of testosterone to women's sexual health and what's happening to testosterone levels during this transition from peri to menopause? Because of course, I want to bring this into the HRT discussion.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You've probably heard me make this point before because you alluded to it a few minutes ago. We measure testosterone in nanograms per deciliter. We measure estradiol in picograms per milliliter. If you normalize those to the same level, Women are shocked to learn that they have 10 times the amount of testosterone in their body that they do estradiol, at peak estradiol.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
When we think of urology, we think about prostates, we think about kidneys, we think about bladders.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I think this is an area where women sometimes are also a bit concerned about what happens if I take testosterone because testosterone, understandably, conjures up images of all sorts of things from large muscles, big mustaches, lots of other things. So how do you talk to women about this? We enjoy having these discussions and also acknowledging side effects from
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The most common side effect we see in women is acne. I don't think I've ever gotten to the point where I've seen any of the really dramatic side effects, but I do tell women, I say, look, there's a decent chance if you were shaving your legs every five days, you're going to be shaving them every three days. That's a chance.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
If you were kind of susceptible to acne growing up, you might get a little bit more of it and we'll have to back off. How do you talk about the risks of testosterone therapy?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So let's just finish the swing on testosterone. Do you prefer then to rely on the topical version, which would be like an Androgel-type product, and just dose it at a much smaller dose?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Hmm. That's an interesting question. I mean, I definitely agree that that's true for some people. That said, I've also seen people who within weeks report feeling better. Now, the challenge here, of course, is the only way you could understand this is through blinding. We just don't know how significant the placebo effect is. And therefore, it's hard for me to discount or know.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I want to ask you another question about Natesto. So Natesto, for the listener, is a nasal formulation. It's an FDA-approved formulation. In theory, it seems like a great idea. In practice, it has not really panned out just based on its messiness. It's a gel, a nasal gel. We've had women use it vaginally, nasally. What's your experience been with it?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Why isn't a female formulation being made?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Men, six months- And this was a real goalpost move.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Why do you think this is happening? If you try to steel man the case for the other side, where are they in their thinking on this?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But is this a paternalistic, I mean, I hate to put sociology on top of this. As you know, I've spoken with one of the PIs from the WHI, and I think she is by far the most honest broker of that group. And I don't have good things to say about that group. I really don't. But I also can't even wrap my head around their thinking. Like I can't steel man their case.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I usually do not subscribe to theories like that. I usually find myself thinking there are alternative explanations and we're just pointing to the most sensational ones. But it gets hard to dismiss an argument as follows, which is if the tables were turned and the WHI was really the MHI, the Men's Health Initiative, and it produced equally idiotic results,
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Would we be in the same place we are today, or would men have said, oh, hell no?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And by the way, the Traverse Trial is not even a great trial. I've been so critical of the Traverse Trial. I think you could have come to the same conclusion of the Traverse Trial if you knew how to read all of the data before it. I actually don't think the Traverse Trial added much, but anyway.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I mean, I do believe this is going to change. And I don't know who said this, but it's a great quote that said, funeral by funeral, science makes progress. That's not a great explanation for what's about to happen temporarily, because it's going to be a while before everybody who held that belief in their soul is no longer around.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
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The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But it does give me hope that a new generation of women will come along and take ownership over their health. And look, I've seen a change in 10 years. 10 years ago, when I was prescribing hormones to women, you cannot believe the fights I would have with their other doctors. And I don't mean like we weren't fist fighting, but they were scolding me like, how dare you?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But it came with an arrogance, a lack of willingness to even look at the data. which I found ironic. If you want to scold me, you better know as much as me and hopefully more. But this arrogance of I'm going to scold you, but I know nothing.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And I'm not actually willing to have a discussion with you because I'd be like, great, turn to figure two in the JAMA paper and let's look at this and look at the appendix and look at the supplemental data. Like, are you seeing the same thing I'm seeing? Can we at least agree on the fact?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Now, let's talk about the flip side, because the unfortunate nature of everything we've just described is you create a fringe movement. And unfortunately, I've seen a lot of dock on a box hormone practices that are, I believe, putting women at risk and I believe are doing bad things to women in the name of doing good. And I don't believe that these are inherently bad individuals.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I think they're ill-informed. I think they're just not that bright. And maybe some of them are just actually charlatans and they're seeing an enormous opportunity here. As a general rule, I tell patients be very, very suspicious of a doctor that is selling you hormones. Be incredibly suspicious of any physician
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
who has their own compounding pharmacy within the practice and is giving you compounded formulations and also making money on it. Talk a little bit about, I don't want to call it the dark side, but just the fringe side of this world.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah, and I really mostly want to talk about it from a female standpoint today, truthfully, because I think this is where there's just a dearth of great information out there, where I think there's an abundance of garbage information out there.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah, the number of online testosterone clinics is mind-boggling. And a lot of them are prescribing, I think, second-tier drugs.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
4% of women who would theoretically be required.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
That's worse than I would have guessed.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Every doctor who sees a woman of that age.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah. Let's talk a little bit about the playbook. I want to tell you how we do it. I'm not saying we do it right because I don't think there's a right way to do it, but I mostly want to hear how you do it because I bet you're way better than we are. Maybe we take a step back and explain. We've already alluded to it twice, but I just want to make sure people are understanding this.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So while I appreciate that your breadth of knowledge will cover both sexes, you'll probably notice kind of a bias in what I want to talk about vis-a-vis women specifically. So let's start with perhaps the biggest and most obvious difference between men and women.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
If a woman has a uterus, you have to protect that endometrial lining. Even if she's in the camp of women who don't notice being on progesterone, you have to be on progesterone. We'll come back to IUDs and progesterone-coded devices and things like that. Let's just talk about the way you get progesterone. Progesterone is the easiest of the lot.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Is there any reason when giving oral progesterone to use anything other than micronized FDA approved progesterone orally?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But you're going to start orally.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You're going to start at 100 milligrams, 50 milligrams.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Do we believe that 100 systemically is sufficient to oppose estrogen?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So the only thing that we do I would say different there is while we start women at 50 to 100, we will generally take them to 200 if tolerated, and if not, keep them where they are at 100. But we find women who are in that one-third to one-half group who are very positively selected towards progesterone, they feel fantastic at 200. The most notable improvement is sleep.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So would you agree with that? Totally agree. Most women are just over the moon with how well they sleep.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Hair gets thicker and mood improves. So now let's talk about the other subset of women. And this is a real subset.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And that is from an endocrine perspective, women go through this period called menopause, which is a rather sudden and abrupt loss of their sex hormones. And that's to be contrasted with the way men's sex hormones decline over time a little more slowly.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's, I would say in our population, it's about 10 to 20% for whom if you bring progesterone in the room, something goes wrong. their mood really changes. Now, it can in some cases become depressive, but more commonly what they tell me is, and I'm quoting them, this is not me saying it, I become a raging bitch. I'm worried I might kill my husband.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So for those women, we think progesterone's a bad idea. And we then use a progesterone-coated IUD. So are you doing that or are you using a suppository at that point?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Are you referring women who are on what potentially might be a low dose of progesterone to their GYN for endometrial ultrasounds on some regular interval just to look for hyperplasia or anything like that?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So again, the listeners of this podcast are highly erudite and they won't need the lengthy dissertation, but just give us a quick overview of what the heck is happening in menopause. Why is it happening? And then we can get into maybe what some of the symptoms are before women might really notice them.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Okay. Anything else you want to say about progesterone? Do you start it concomitantly with the estrogen? Do you like to start one before the other?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I agree.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I'm really happy to hear. We're following your playbook already. So yes, we almost always start with estradiol and we muck around for a while till we get it right. That's why I saved it for last, by the way, because it's the hardest, in my opinion, in my experience to get right. Then we fiddle with progesterone and then testosterone if they're not already on it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But to your point, some women are coming into perimenopause already on testosterone. Okay, let's talk about estradiol. There are two other estrogens. Estradiol is E2, but there's estrone, E1, and there's estriol, E3. Now the FDA only has a battery of approved products around the second estrogen, which is the dominant estrogen.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
There's no FDA-approved product for estrone, and there's no FDA-approved product for estriol, but there are plenty of compounded opportunities around that. In fact, the most common of them is referred to as biest, biestrogen, which is an 80-20 mix of estriol and estradiol. What is your take on why that product exists? Do you view that as a reaction to the WHI? I mean, how do you think about it?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We don't use it at all. I have used it occasionally in the past, probably about 10 years ago, largely in women who were terrified of HRT. And to your point, it was viewed as, look, if you buy the argument, and this is a biochemical argument, there's no human data that demonstrate what I'm about to assert.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And again, I say this because one can look at a whole bunch of biochemical charts and tables and talk themselves into anything being true. But there are biochemical arguments to be made that estrone, and in particular one of the metabolites of estrone, and I think it's 4-hydroxyestrone, is the estrogen that is driving breast cancer.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So in an estrogen-sensitive breast cancer, given that you have so many estrogens, is it more likely that one is responsible than another? And so the answer is, oh, some of the data suggests it's 4-hydroxyestrone. Well, estriol has no biochemical path to even get there. In other words, there are no series of enzymes that can convert estriol into 4-hydroxyestrone.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And of course, there are pathways that will turn estriol weakly into estradiol. So maybe you get a little bit more. So there's a long-winded way of saying no reason at all from an evidence perspective to use it. We don't use it, have not used it in a decade, but that was my half-baked argument in certain situations. And in fact, I did use it once in a woman who had breast cancer.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
was adamant that she needed hormones. Symptomatically, she really seemed to. Wanted it very badly. And I felt that this was a reasonable compromise. For what it's worth, she got insanely better on the biased. How much of that was from the estriol? How much of that was from the estradiol? I have no idea.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah. And you mentioned this earlier. I think this is one of the biggest limitations of how I talk about this thing, medicine 2.0, which is very few people are conditioned to ask the question, what is the risk of not acting? We have a reasonable idea of what is the risk of doing X? What is the risk of doing Y? Although in this particular example, we seem to get that patently wrong.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But what's the risk of not doing something is very significant. So let's talk about all of the different ways in which a woman can get estradiol through an approved, tested, chemically sound means.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Let's start with systemic. Let's come back to that as we talk about genitourinary syndrome.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Let's start with the oral. So we have an oral formulated estrogen. We don't use it that much. I'm trying to think. Used to use it a bit more than we did now. Honestly, sometimes I would use it for women who we were struggling to get the dose right on something else and I just needed something to get them through the weekend.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And it was like, OK, I want you to just take a milligram of this estradiol tablet tonight while we readjust your cream or your patch or whatever. When are you using oral estradiol?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's no more increase in risk of blood clot than a birth control pill.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah. So given the ubiquity with which women are on birth control pills- It shouldn't scare you. We tend to blow this out of proportion. Yeah. So what is your patient selection criteria on that? In other words, who are the women that you would say I don't want you on oral. Is this just factor five laden? Is this women who are obese? Where do you say, ah, the risk is a little too high?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And it doesn't drive up SHBG, presumably?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guest this week is Dr. Rachel Rubin.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Does that mean you can get away with a lower dose?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You must, right?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Because of that first pass effect. So how do you dose it?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Did you ask this guy?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
How does he dose it?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I love that analogy. I've never heard it before, but it absolutely replicates what, of course, we see clinically, which is in perimenopause, why do we sometimes, when we're measuring a woman's labs, say every three months, see periods where estradiol is through the roof, FSH and LH are low, and three months later it's completely flipped, and of course with it go symptoms.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Okay. Let's talk about the panoply of topical ways you can do this. Creams, patches. What are the challenges of using these things? How do they limit women's activity levels? I mean, I used to have this whole talk I would give women about what I thought was the best way to maximize the absorption of the cream and what I wanted them to do before they put it on.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And I wanted them to have a shower and I wanted them to exfoliate their inner thigh. And I just had this whole routine that was probably so elaborate that it decreased compliance because like.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
All right. Talk to me about it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We also notice women who use the sauna, who are very, very athletic and exercising like crazy. You just have an adherence, physically an adherence problem.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
What's the case for not just using the ring all the time?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And it's sitting right up against the cervix?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And it's just dose is the only difference between the two.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So can you explain why there's this, if we have hormones running like this during pre-menopause, They're like this during menopause, but this transition is nothing linear.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah, yeah, yeah.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But you change them at the same frequency?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Okay, I thought you changed the East ring more frequently, but good to know.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Why not just swap it every two months?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I'm sure there are a couple of my patients that would actually volunteer to do this where we just do twice a week levels for three months while they're on a product, while they're on a ring and just watch the curve.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
That can get expensive.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Very low maintenance and complete solution.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Two things I want to talk about on the lab front. We've talked a lot about labs, so I'm not sure if you share our view on this. We are really fastidious about using LC-MS for estradiol. We do not want to use the ELISA-based assays at all. Are you pretty meticulous about that, or do you find that you're just happy checking any estradiol?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So let's maybe make that a PSA for people, both physicians who are out there and patients. We have seen that if you do not use the LCMS assay, which is the very sensitive, the liquid chromatography assays, the results can be meaningless. And I mean truly meaningless. And the reason is that the ELISA-based assays are so susceptible to interference from other molecules.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And there are some really known obvious supplements that completely obscure the findings. So biotin, which is in a lot of things, will render a non-LCMS test irrelevant. But I think there are other things that we're just not fully aware of. So it is worth splurging and paying the extra. Maybe it's $5 or $10. It would be the cash price difference on that test.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But absolutely make sure when testosterone and estradiol are being measured, if you're the physician, you actually have to go through the hoops and make sure you're ordering the LCMS test. And if you're a patient, you should be asking for it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I'm actually surprised, but you have to understand, I don't spend any time paying attention to the buffoons in the periphery on this topic. I don't like the whole terminology around functional medicine. I don't buy into the idea that you need to be spending an inordinate amount of money on esoteric, non-validated labs.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You can go to LabCorp, you can go to Quest, you can go like any CLIA approved lab that knows how to do an assay correctly is all you need. Our view and what we tell patients is the symptoms are the most important things, but the numbers help direct my thinking. This is how we manage thyroid. This is how we manage sex hormones.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And to be clear, there's a caricature of the Dunning-Kruger curve that I just find so helpful. So for the folks who aren't familiar, on the x-axis, you have experience. And on the y-axis, you have confidence. In the sort of character version of the representation of this curve, you initially have a huge spike, which then falls into a valley and then a slow rise.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And of course, the huge spike is referred to as the peak of Mount Stupid, followed by the Valley of Despair and the Slope of Enlightenment. It's just important for people to understand that when you are on Instagram and YouTube, disproportionately, you are seeing people at the peak of Mount Stupid, which is to say they have very low experience, insanely high confidence.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
These are the ones that are telling you that TSH, I'm making this up as one example, TSH must be between 0.4 and 1.9. And if it is any bit above 1.9, you have hypothyroidism and you need to be on armor thyroid or naturethroid or whatever. And it's sort of like, no, none of that is correct.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And you just have to take care of enough patients for enough years to get humbled enough to know that whatever you think you know with rigidity is probably wrong.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah. So here's what we do. We focus relentlessly on the symptoms and we care what the estradiol level is. We also think the FSH is a very helpful marker. So if a woman's FSH is 78 and her estradiol is 40, I'm inclined to believe she needs more estrogen, especially if she's saying, I think I feel a bit better. I'm just not sure. Like to me, that says I'm going to go more.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And by the way, with the labs being where they are, I'm more inclined to push a little bit. But again, nothing tells me I've given her too much estrogen more than her saying her breasts hurt. And that's the advantage of doing it with these short-term estrogens because I can pull it back really quickly.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So I don't know if that answers your question, but I would consider myself an essentialist on labs. kind of a minimalist essentialist, but not an absolutist in either direction.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Anything else you want to say about systemic therapy before we go and talk about local therapy in the context of genitourinary symptoms of menopause?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We are going to milk the heck out of this, and I love it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Irritability, very common one. One that I was going to ask you about is brain fog and depression. This is one where I think this is a very unique one because it's one that gets easily dismissed as something unrelated. Say more about those.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
My reading of that was estrogen is so important in the brain that it has to upregulate the receptors as the estrogen level goes down and down and down.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
In other words, it's a lot like the way the brain is treated for glucose. The body will, if you are fasting, the muscles will within days become completely insulin resistant. It's their way of saying every molecule of glucose that that liver spits out better not go into the muscle. It better go to the brain. And so you look like you have diabetes in an effort to save glucose for the brain.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And I think that's what's happening with estrogen.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The volatility of hormone gets less, yeah.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The other one that we didn't talk about was the urinary symptoms. So both urinary incontinence and then the higher prevalence of UTIs. You've alluded to it a little bit, but just maybe finish the swing on that.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I don't even understand what that means.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I totally missed that.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I love that analogy. So you're saying if by the time a man became 50, his penis became a shriveled up useless organ, you're saying that the medical system would have probably done something about this?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You might be onto something, Rachel.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And that was with topical estriol.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Interesting.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I was not aware of that. And yet there is no FDA-approved estriol formulation despite that fact?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Just say that again, please, because I know there are people... that are in the Medicare system who are going to be interested to understand that?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And what I'd like to do now is make sure that anybody listening who wants a more nuanced overview of this, we're going to link to a video that I made a couple of years ago where I walk through the ovulatory cycle and I draw the graph of estrogen. progesterone, FSH, and LH, according to the nomenclature you're using by days.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I mean, again, I always try to come up with the steel man and say, is it that they don't care or is it that they're unaware or is it that they feel that it just needs to fall on the shoulders of somebody other than themselves?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Okay, let me push back. Not because I don't agree with you, but I'm just going to put my hat on that says the opposite. So maybe I am too attuned to this, but I feel like there is nothing more talked about right now. I mean, look at what Halle Berry is doing. Look what Oprah is doing. Look what Gwyneth is doing.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I mean, there are so many very powerful, very influential women that are talking about this. Is this not in the zeitgeist right now?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So you're saying there's not enough physicians talking about this.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
If it really comes down to prescription.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
What does that mean?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Wait a minute, wait a minute. This is impossible for me to fathom. A woman went to her gynecologist and said, I'm having pain with intercourse.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Any idea how old this woman is?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Okay. And you think this gynecologist doesn't know about estrogen?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I did in medical school.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And you're saying that the reason that this price has come down is, I know Mark is a very hard liner against the PBMs. Did Mark basically take a sledgehammer to that?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But let's also have you do an explanation now of the role of FSH and LH on the brain, because you've already referred to that, and what the feedback cycle looks like with estrogen. I just want to make sure people are following the physiology you're describing.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Well, I'm very sorry to hear that story, both at the personal level, but also at the meta level of what is implied. I want to clarify one thing, Rachel. If a woman is on a high enough systemic dose of estradiol, does she also need later in life local estradiol?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Has that study been done? That would be a super interesting study. Think of how easy it would be to do a study where you took a group of women that were all at systemic target of estradiol, and you randomized them to a placebo vaginal cream versus an estradiol vaginal cream.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
You could follow these women for a year if they were in a susceptible enough population, and you would get a very clear answer as to whether or not you're getting additional UTI protection. And if the answer to that is yes, just imagine the implications there. At that point, it becomes malpractice.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Why is DHEA doing it?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We've just started using it, so I don't have a lot of experience with it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Do you think it gives you the same UTI protection?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Rachel is a board-certified urologist and one of the nation's leading experts in sexual health. She is among a select group of physicians with fellowship training in sexual health for both men and women, bringing a rare and deeply informed perspective to her clinical work. In our conversation today, we focus on women's sexual health.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Well, I know what the vulva is and I know what a vestibule is. I don't think I know what the vulvar vestibule is.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And again, just to make the obvious statement, it's because most of the time when a woman ovulates, she does not get pregnant.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Oh, well, it must be the vestibule.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I don't know.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Okay.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Sorry, tell me again, 0.1% T and what was the percent?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And no DHEA in that?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And what's the base?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
This is super interesting.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
There are three other questions that I want to ask you going back to hormones post-menopause. I'm saving the three most contentious questions for last on this topic. Question one, someone's posing this question to you, not me. I buy your argument that hormones are safe, but I am now 56 years old. I finished menopause at 49. Isn't it too late to do anything about it?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Or the window idea.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Throughout life.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Okay. Now I'm going to ask another question that is the extension of that question, but I think your logic is going to hold the same, which is the hedging strategy, which says not only use as little as possible for as short a duration as possible, says you really need to stop this after 10 years.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So even if you were lucky enough to catch a woman through perimenopause, you got her on hormones by the age of 49. Now that she's 69, you got to stop it, right?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
By the way, that was the argument put forth to me with one of the authors of the WHI, who is by far the most willing to concede that mistakes were made, which was, okay, yes, I will concede that the estradiol is doing amazing things for the woman's bones. But remember, they're going to go away when you stop the hormones. As though that was a necessary thing to do.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yes, and it actually dovetails perfectly into my third critical situation, which is how do we manage hormones in women who are at risk of breast cancer from a familial standpoint, who have been diagnosed with DCIS, which is not cancer, but increases the risk of cancer. So that's kind of a subset of the first group.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And then in women who actually have breast cancer or have a history of treated breast cancer. So I would imagine you see women that fit into all four of those buckets. How do you handle it?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
It's insanely helpful. And of course, it echoes exactly what Ted Schaefer said when we spoke about this after discussing the Traverse trial, which was, I think, to me, the most telling thing that Ted said was, look, if I have a man who's got a Gleason 3 plus 3, means he has prostate cancer and we are going to follow this.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And if it becomes a three plus four, we're going to actually have to take this thing out. We'd put him on TRT if he needed it. And his argument was exactly your argument on the pregnancy side, which is the reason we would happily give him TRT is let's just assume he's a man replete with testosterone. Would we castrate him during that period of time of observation? Of course not.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So why would I not give him testosterone if he needs it, even though he actually has prostate cancer?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
because I don't pay any attention to social media, there are people out there saying they're anti-HRT, but they- Use HRT. What's their argument? What are they talking about?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
What do women need to be aware of? Not every woman can come and see you. Not every woman has access to a doctor who has the breadth of knowledge that a select few do in this space. So, A, how can women find... practitioners near them, and what do they need to be aware of?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
What are the exploitative practices out there that they need to be mindful of and not get duped into either dangerous therapies or overly extractive therapies?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
What are some of your favorites?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah, a lot of my patients don't read the book about what their physiology is supposed to do. It's very disappointing.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And what's the website?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Do you feel that there are too many women that are still getting their hormone therapy in the dark alley with highly sus individuals? And if so, what would be a clue that you're in that camp? Because there's nobody that's in that camp that knows it.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
I want a woman who's watching this who's not getting great medical care, but thinks she is to maybe get a bit of a hint as to what that might look like.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Rachel, as expected, this was a fantastic discussion. And I think it adds to what we're trying to do in this podcast, which is really have nuanced and deep discussions about important topics. Not every podcast I do gets to impact that many people. Some of them impact nobody. They're just really esoteric, but they fit into my curiosity window.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
But this is kind of a topic that really impacts almost 100% of the population. Because 50% of the population is who we just talked about. But the other 50% of the population would be hard pressed to say that they don't care about at least one person in that other group. So 100% of people are heavily impacted by what we just discussed.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Rachel, thank you very much for the work you're doing. And thanks for coming today.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So let's talk about why. So why is it that in perimenopause, the fluctuations in estradiol level are so dramatic?
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
For all of my disclosures and the companies I invest in or advise, please visit peteratiamd.com forward slash about where I keep an up-to-date and active list of all disclosures.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So maybe to extend the analogy, part of the reason why a woman during this period of time can experience these enormous surges of estradiol is if you think that there's, say, a kink in the gas line and you really, really want to squeeze the lever to get as much gasoline as you can in the car, sometimes you overshoot and just you get a whole bunch extra in there because there's volatility in the follicle release.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
We discuss why sexual medicine, particularly for women, remains so neglected in traditional healthcare. The critical difference in how men and women experience hormone decline with age, the physiology of the menstrual cycle, including the role of estrogen, progesterone, FSH, and LH and Y perimenopause is characterized by extreme hormone fluctuations.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
Yeah, no, I love it. The one other thing I want to talk about, because it's going to come up later when we get to HRT, is do you buy the argument, which is the argument I have found most appealing, as to why women have varying degrees of sensitivity to the dramatic reduction in progesterone that they experience in the last quarter? quarter of the cycle once the lining sheds.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
So we talked about how, of course, during the luteal phase, we're building up. Progesterone levels are rising. We're building up the endometrial lining in preparation for pregnancy. Most of the times that's not going to happen. Lining sheds, progesterone crashes. This is what's referred to as PMS. And some women are somewhat unfazed by that. And other women, that's a big deal.
The Peter Attia Drive
#348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.
And so the question is, is this about central receptors of progesterone and varying degrees of sensitivity?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Jeff shares insights from his experience as a trauma therapist, diving into how moments of perceived helplessness shape our behaviors and how those adaptive strategies can become maladaptive behaviors over time. We explore the concept of the trauma tree, examining its roots and and its branches.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I really think that's a powerful bucket because it has enough breadth to include things that don't easily pathologize. Maybe for the sake of completeness, we could just go back and talk about the codependencies, addictions, and attachment issues. I think everybody's familiar with the terminology, but just as within abuse, there are things that people don't quite think.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
This is a great framework that they use at the Bridge to Recovery that I still find to be probably the most helpful in explaining what trauma is and how it manifests. Jeff reflects on the transformative power of group therapy, in particular at the Bridge to Recovery, and we discuss briefly some of the challenges and breakthroughs that can occur in that sort of a setting.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Everybody thinks of sexual and physical abuse. Very few people think of emotional abuse or religious abuse, those kinds of things. So similarly, maybe talk through the breadth of what we think of as addiction, codependency, and attachment disorders.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
We speak about the role of vulnerability in fostering connection and the challenges in letting go of control, the path from understanding to action in trauma integration. Jeff offers advice on how to find a great trauma therapist, balancing personal growth within relationships and recognizing when it's time to seek help.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Jeff, when we examine ourselves or we examine or witness others where one or more of the branches of the tree, i.e. the manifestations of trauma are present, is it your belief that that automatically implies there is at least one tie to a root? In other words, is there a scenario whereby these manifestations exist minus the injuring events?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
This is kind of a heartfelt and deeply insightful conversation for anyone grappling with disconnection or seeking to better understand the complexities of their own experience and their own journey of healing. So without further delay, please enjoy my conversation with Jeff English. Jeff. Peter. Kind of hard to believe we're sitting here, huh? Yeah, it is hard to believe. It's amazing.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Gosh, Jeff, I don't even know where to start. I think there are so many huge hurdles for people to get over when they at least begin to entertain the idea that this is something they should look at. So that's the first one. So the first one is there's something wrong.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Unfortunately, as a species, I suppose we have so many remarkable layers of protection that we have to be suffering quite a bit to go through this. I go back to some amazing lines in my journal. No one showed up here on a winning streak. Like, I mean, I'm not going to name who said that, but I bet you can remember who said that. I mean, could not be more true.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
When I think back to us all sitting there on day one, the 12 of us, I mean, what a collection of losers we were. I mean, if we're just being honest, we were all on the outs. We had lost everything. And we were there not because we wanted to be, but almost because we had no choice. How often do you see that?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
How often do you see people that somehow managed to show up there on the basis of pure introspection as opposed to, if I don't do this, I'm going to lose my family. If I don't do this, I'm going to lose my job. If I don't do this, I'm going to lose my life.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
It's good to see you. Likewise. I thought long and hard about how I wanted to structure our discussion today, knowing that this was a conversation I wanted to have for a very long time. Maybe the easiest way to start is just to talk a little bit about this loaded word of trauma. When I first was introduced to this idea of trauma, I didn't know what it meant.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
You alluded to control. One of the huge impediments to people, I think, making the journey to a place like the bridge is that you have to completely cede control. So you show up and you hand over your phone and you go to your room, which is literally a room from a camp.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
You're sharing a room with somebody else sleeping on a cot that's not comfortable and there's no luxury and you're sharing bathrooms with a bunch of other people and they rummage through your books and they sign off on everything. I mean, I didn't bring any contraband, but I know that there was very limited in what I could bring. Basically, you didn't want anything there that would distract me.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I don't think I could have brought books about F1 and sports or whatever. Talk a little bit about the control. I know many people who have ultimately gone to the bridge and this was the thing that made it almost impossible for them to go. And they had to fall to a certain level of pain before they would go. And I know other people who just haven't been able to pull the trigger.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
And I put myself almost in that situation, which is I can't go off the grid for two weeks, four weeks, six weeks. That's not possible. You don't understand the complexity of my life. Surely knowing that you must have a very strong conviction for why it's required.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
And I think today it's become such a catchy buzzword that everybody is traumatized by something. And I don't know if that represents a pendulum swing or a normalization or what, but Why don't we just start with how you describe trauma as a trauma therapist and as someone who's been doing trauma therapy for many years, not just in the recent trendy years, for whatever that means.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
The one thing you didn't take away that I think if it had been taken, I'm not sure I could have gone was exercise. So I was still able to run at 530 in the morning in the woods and do some pushups and stuff like that. Had I not been permitted to do that, I might have lost my mind. Has that ever been questioned that, hey, for some people, exercise is also a bit of a numbing distraction?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
That's an excellent point.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I did a lot of coloring. Okay. And I did a lot of dot to dot. You guys had a book of super elaborate dot to dots, like a thousand dot puzzles that would actually make beautiful pictures. I never thought I could find something like that so interesting, but I enjoyed it.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Can you describe what a check-in is? Because it is actually a pretty interesting experience and I needed a piece of paper to help me do it because I didn't know what the words were.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
But how do you describe this to people? Well, I would have described it the same way that you described it initially back in the day.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
When you guys went to a 12-step program off-site.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I think that's profound actually, because you could argue if you simply look at that experience and say, I need to up the dose, up the dose, up the dose. I mean, at some point you're going to be comatose. So in other words, there probably is a dose at which there will never be a breakthrough, but then you're also not alive.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
So maybe we're better off, as you said, taking this as a gift saying, wow, the fact that I got hysterical is now going to point me to something historical that I still need to go and resolve.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I'm going to day two of my journal here. I can't help but feel like it's a mistake to be here. How could this place, this experience, possibly make a meaningful difference in my life? Trust the process, they say. Surrender to it, in quotes, I'm told. Okay, I'm here, and I guess I'll try. That was day two.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I didn't journal until I got to the bridge, and now it's reams and reams of journals that have been filled since. What fraction of folks show up there with a journal, do you know?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
That's the question. So let's talk about the different versions of the kid. There's the kid that's born, the unwounded child. Remind me the name of that child again. The inner child. Inner child. Yeah. That's right. Yeah. Okay. So inner child.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
And then we have a wounded child that goes through this experience or these experiences. Again, very important to remind everybody, this could be a bunch of little T's, none of which look like much. It's too easy, I think, to look at the big T's and say, I don't have a big T. Could be that the sum of the little T's actually matters more than a big T in some individuals.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
And then you have this adaptive child. So the example is that kid who figured out that by being deceptive, he could protect his mom. That was the right thing to do. I mean, clearly the right thing to do. He should do that all day, every day. Yeah.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Yep. And then talk about some other examples of how these adaptations that occur to trauma are really valuable. And then they start to become net negative as opposed to net positivity. This to me is the Darwinian nature of trauma. We're such resilient, adaptive creatures. The case of this kid, right? That's brilliant. That's adaptive. That's great. All the things that we do to not succumb.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Maybe just share a few other clinical examples so that people get a sense of how insidious this can be and why when that kid is 30 and he's in a relationship and he's misbehaving and manipulating his spouse, who's not his father, it starts to backfire.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
How do you differentiate for folks the difference between shame and guilt? Because for many people, when you show up at the bridge, there's a component of something that you've done that's wrong. You've hurt people along the way. Again, that's, I think, part of the hitting rock bottom that gets you there. It's not just that you've hurt yourself. You've probably injured others.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
And that's a part of this maladaptive behavior. behavior that's now spiraling out of just being adaptive. So how do you talk about the difference between guilt and shame and how do you work somebody out of that?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Why do you think one chooses preferentially one of those? I mean, I know that my tendency is always more towards grandiosity than inferiority. What do you think it is in some individuals that steers them one way or the other when they're in that? And by the way, I love that these are, I don't even say this to be judgmental. I just think that this is a really interesting way to observe.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
But I know that when my inner monologue becomes more judgmental, that's a great yellow light for me. It's like, oh. Look at the judgy words you're using. Look at the black and white thinking that permeates every statement that you're making that tends to be the gravitational pull. Why do you think certain people have that?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
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The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Yeah, absolutely. Simple and complex, never to be distinguished. There were a bunch of interesting rules at the bridge. No minimizing. You got to stand up to get your own Kleenex. Tell me again some of the rules and the reasons behind them.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
And what about minimizing? That was a very interesting rule.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
So I've written about this in the book, which is that you and I met at a place called the Bridge to Recovery in December of 2017, seven years ago. That was a very hard chapter for me to write. And one I wrote somewhat reluctantly, but also in the end felt I couldn't not write it. So the book was incomplete without that chapter.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
How many folks find themselves in a situation where, and I say this because I definitely had a bit of this feeling myself and I can't imagine I was alone, where there's almost a reluctance to get better because there's also a belief that, yeah, I get it. My life's a bit messy right now and I've My response is spilling out into bad areas, but look at all the good.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I remember in particular, one of the rants I went on was about how much good has come from my trauma. I think in telling my life story, it was virtually all good. It was look at this good thing and this good thing and this good thing. And like, we don't want to erase any of this stuff.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
And I suspect you have a number of people who show up and yes, it sounds ridiculous because on the one hand, there's clearly a bunch of things that are not good, but they're sort of like, maybe that's a reasonable price to pay in exchange for all this other stuff. How do you help people think through that process and what the trade-offs are?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Maybe we can even frame this discussion around how a place like that comes to exist. and how therapists like you work at places like that. I'll throw one idea out that's worth discussing, but it's literally one of a hundred, which is it might be shocking to some to realize how much group therapy is done at a place like the Bridge to Recovery.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
It's surreal, actually. I'm looking at a note. This must have been about day four, though this is day five. We went to 12-step meetings every night, and I found it very difficult and awkward. I didn't understand why we were doing it. I don't have a drinking problem. Why am I at an AA meeting? I don't have a sex addiction problem. Why am I in an essay meeting? I don't have a drug problem.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Why am I at the Narcotics Anonymous meeting? I just kept going from one to the next to the next to the next. But I wrote something here, said the essay meeting last night was amazing. Three men shared painful, shameful stories. One of them said that he was getting, I can't even read my handwriting, something, his wife said things about him and his kids. He was losing his family, right?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
He was losing his wife, he was losing his kids, and he was so upset. But his sponsor told him that he had no right to complain about how his wife feels. I found that very powerful. And it was like he was taking responsibility for his action. And this was interesting because I remember walking into that meeting kind of thinking, good Lord, another one of these meetings?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
How many of these things do I have to sit through? People have to remember too, like we're doing these meetings in a part of town where you're seeing people on the wrong side of the tracks. You are not looking at the affluent part of society showing up to these meetings. You're really seeing people who are hurting beyond just, this is my dirty little secret.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
How many people have the same reaction I do initially, which is, I'm not a fill in the blank addict. Why do you keep making me go to these meetings every night? By the way, I've already done 12 hours of group therapy. Can't I just go to sleep?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
In fact, as I looked through my journal, which I brought back recently, Looking through the notes, it's amazing how complex it was for me to be able to open up in front of a group and how I spent the first few days saying virtually nothing, largely because of that discomfort. Maybe tell folks a little bit about the bridge, the type of work that's done there.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
So if I recall, Jeff, the end of week one was when we do our story, right?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Talk about what the instruction set was for each of us as we went off and prepared to do that.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I forget exactly how I described it in the book, but I described it as this wonderful, horrible place in the woods of Bowling Green, Kentucky. Yeah.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Yeah. It happens so often. How do you break that cycle? It's very, very difficult.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
You do a lot of work now with clients individually as well. I wonder how that is different. I've recommended a number of people go to the bridge. I've recommended a number of people go to PCS, a place I went to three years later. And taking together those two places changed my life. And one of the things I've said when people ask me, yeah, but Peter, it's just such a huge commitment.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Do I really need to do it? I don't know the answer to that question. I'd love to hear your thoughts. But what I do say is... For me, in the state that I was in, it could not have been done any other way. I had to have immersion. And I say, I suppose it's not unlike learning a new language, where if I decide I want to learn Portuguese and I'm willing to take lessons two hours a week,
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I wrote some other names down here. Do you want to know what I have? I have camp misery, the sadness factory and the tree of pain. Those are the names I wrote down.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I'll get there. But if I move to Brazil and no one speaks English to me for a month, I think I'm going to get there a lot faster. And it's not just the sum of the hours. There's something accretive about the total and utter immersion literally in the experience that changes it. So
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
How do you think about the difference between the work you do and have done at the bridge, which is indeed what we're talking about here, this immersive residential type of treatment versus someone who's listening to us that says, I hear everything you guys are saying. I just can't do that. I can't go there yet. Is there something in between? Can I start by
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Working with Jeff just an hour or two a week, how does your work with clients differ and how do you help somebody decide? Maybe I'll start with this question. How would you give somebody the way to think about whether or not they could find some success in individual therapy versus whether or not it's really just rearranging the deck chairs on the Titanic, you got to go hardcore?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Meaning, from their end, from their standpoint, why are they seeking therapy if it seems all right?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
One of the things about the bridge that I assume it's still true, but it was remarkable to me, was that everybody who worked there had been a client there. Is that still the case?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
That's really an amazing feature. And I sort of imagine that through the lens of anyone who takes care of another person. It's sort of like people, I think, are right to be frustrated when they have a doctor who's asking them to take care of themselves when the doctor clearly doesn't take care of themselves.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
How is it that you can tell me that I need to eat better and exercise when looking at you, it's clear you're not doing those things. It doesn't mean that the advice is incorrect or that you shouldn't listen to it. It's just you're asking me to do something you won't do.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Whereas, yeah, at the bridge, we can talk about some of the other things that are very difficult to do there, such as in the second week when you're beating the shit out of things. Those are not easy things to do. But to know that when Jeff and Julie are asking you to do it, they did it.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guest this week is Jeff English.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Right.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
2016.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Okay. So only a year before me. So you'd been a therapist, obviously, for many years before. How did you find the bridge?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I don't take it lightly what I do and what clients trust me with. I think you have a really special talent for it, Jeff, and I just wonder is that something that only comes because you've experienced the pain as well? Does someone have to have necessarily been through this journey to be able to guide someone through it? Do you think that's necessary?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
You alluded earlier to the generational nature of trauma. Terry Real has written about this in some of the most eloquent ways I've seen. And I think that for some people that can be the motivation to change once they realize that there's a pattern and that it's not linear. If you have a belief that it's linear, then it's really easy to say, well, I've already stopped it.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
So for example, if your parents were alcoholics and you're not. Right. Well, the story's over. I don't need any help regardless of whatever other behaviors I'm manifesting. But if a person can accept that, no, that's not how it works. There could be this type of trauma in generation G minus two that manifested as a different trauma in G minus one.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
And now here in G zero, where you are, you have this blind spot to what's going on. I know that for me, that was among the most powerful motivations to stop the cycle as Terry described it. How much do you think that that factors into people's willingness to kind of endure the challenges and discomfort of the journey?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
to change this thing in my case reverse the cycle you must encounter a lot of people who have these socially acceptable maladaptive behaviors in many ways it makes it even more difficult to reconcile because society is externally sort of patting you on the back for your workaholism your perfectionism your achievements and all of those things I don't know.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Is one pattern in your view harder to address than the other, or is it all about the individual? In other words, if you think about the individual characteristics, the manifestation of the trauma, and the nature of the injuries, those are three things that are all blended.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Do you try to disentangle those when you're working with people and pattern recognize, or do you just say, nope, every person's a clean slate and we're just trying to figure out how those three things fit together?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
For me, that's a very calming message, actually. The, you know what, Peter, you're not unique here. There are lots of people like you out here. It's really easy to think you're the only one.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
When you think about examples, I've seen examples where it seems like everything we're talking about has been taken too far. There's a story I read about a teacher who started every day with her school children, basically trying to get them each to talk about what was making them sad. The story digressed so much. One kid would say, well, I'm sad about the fact that something happened.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
And it was illegitimate. It sounded actually quite traumatic in that kid's life. They were getting yelled at all the time at home or locked in a room. And it sort of derailed the ability to do anything. This is a group of kindergarten kids that ought to be learning how to write and color and stuff like that. Everything was being pathologized for them.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
So what do you say to the person listening to us that says we've gone too far? And I get it. I'm sure that some of the people that Jeff works with who have genuinely been abused deserve to be there. But aren't we just coddling people too much? And don't people just need to sort of buck her up? I mean, isn't this what makes us who we are? Yes and no.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
What would you say to a person who's listening to us who's trying to even understand if they've experienced trauma, which sounds like a dumb thing to say, but let me give an example, right?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
So you have a person who's listening, who's either introspective enough to realize that some of those things we described as the four branches of the trauma tree, whether it be codependency, attachment disorders, some sort of maladaptive behavior, et cetera, addiction, maybe. They're like, okay, I mean, if I'm being brutally honest, I'm not flying on a perfect level.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
My spouse has complained about X, Y, and Z, and there does seem to be a little bit of interpersonal discontent in this nature, in this relationship, et cetera. Okay, fine. And then they, if they're, again, in a particularly charitable mood, they look at the kind of five roots of the tree and they're like, well, okay, yeah, I mean, these sort of things happen.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
But they can't make the leap to say, but does any of that stuff actually rise to the level of quote unquote trauma, even little t trauma? Is the answer just that I need to get my act together and drink a little less and just try to be more present with my kids?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
It doesn't matter what the fix is, but they're just not sure that going back and stirring the pot of what happened to them during the first 10 years of their life is going to be an exercise worth engaging in. How would you help that person decide that you're right? It's probably not worth stirring that up. Let's just work on some behavioral tools right now.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
to address the behavior versus actually, I don't think you're ever going to truly fix these things until you go back to the root.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
So how do you begin to do that integration? Let's go back to the example you gave because it's so profound and probably tragic where that four-year-old boy that learned how to manipulate and deceive to protect his mom has now carried that behavior into his marriage. So step one is obviously getting to the point where we uncover that story and make the connection, which was...
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
An inner child is wounded. That inner child adapted with a strategy that was very positive. Everything about that strategy made sense. But guess what? Your dad isn't kind of hurting your mom anymore because luckily she got a divorce and he's gone.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
That first day there, that Monday, it's a very unpleasant day, I'm sure, for everybody. I don't think that's a stretch to take my experience and say that that was unique. Maybe it's worth explaining, what are the objectives of this phase one that you describe?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
You're now applying that same behavior pattern in relationships that have nothing to do with the relationship in which that was developed to be protective. And he says, okay, I get it, Jeff. How do I change? What are the next steps? How do I go from the understanding of that to creating a new pattern of behavior? Because this is really wired.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
These paths are heavily, heavily myelinated at this point.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
There tend to be these moments along this journey, I assume I'm not unique in this, where people have really significant breakthroughs in beliefs. And it's mostly that a belief gets shattered. Again, this is, I think, one of the real joys of having a journal is you can kind of go back and read what that was like. And read, on this day, through this exercise, this really profound thing happened.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I mean, I wrote about two of them in that last chapter of my book. I wrote about one at the bridge and one about PCS that were undoubtedly the two biggest breakthroughs in beliefs I've ever had in my life. They've had a far greater impact on anything in my world. And they both happened in an instant. they were huge step function changes in a radical belief system.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
And what I find interesting about it is how much easier it became to make any change after the fact. I never want to represent that I'm better. We're all in recovery here. But when I think about the December 2017, April of 2020, or maybe it was by this point May of 2020, those particular days when those things happened, literally within an instant.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I don't understand the neurobiology of how it happens, but something really switches. And I never look at the world the same way I did before. there's an immediate acceptance of something typically. That's the shattering of the belief system is the acceptance of something that is more honest and more close to the innate child that we all were. Is that common?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
First of all, that people have these major, major life-changing appreciations of something. And then secondly, is that by itself sufficient sometimes to drive change?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
what exactly was it and can i prove that that was the thing it's interesting for me in both cases it came down to a therapist pushing very hard but very kindly against a set of assumptions it was me saying something offering it up the same answer and the person saying What about this? What about this?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
And just maybe describe it as a loving confrontation that when fully backed into a corner in an unthreatening way, collapse the scaffolding of a mental model.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I think that's absolutely maybe the lesson I would want somebody to learn from this is in science, there's an expression that I think it was Louis Pasteur that said that chance favors the prepared mind. And the idea is that great scientific breakthroughs don't just happen.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
They happen to people who are toiling in the lab, failing, failing, failing, trying again, trying again, constantly thinking about the problem. And yes, usually something lucky happens that trips them in the direction of a discovery. It's often very much an accident. But that accident can't happen if you're not on the field. That accident doesn't happen if you're in the stands.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Maybe that's the takeaway I would want somebody to have here, which is you're very unlikely to have that eureka moment if you're not mired in the trenches of going through the painful work of figuring out your story, understanding, trying to create the map of what's happening. It's unlikely to happen when you're continuing the distractions or the numbing behaviors. Right.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Do you view your work today, the work you do just with individual clients, as something that you prefer to only do with people once they're coming out of a residential program? Or do you take clients that are saying, hey, I think I need help. I'm not ready to fully commit to doing something as intensive and committed as residential care. Either one.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Jeff, what advice do you have for somebody who's out there trying to find a therapist? They've listened to us today and they've been like, okay, these two guys have got me at least thinking I ought to maybe scratch this a little bit, see if this scab bleeds, what are the attributes they should be looking for?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
First of all, how do they even begin to like, what do you go on Google and search trauma-based therapy? How do you find somebody? And more importantly, when you find somebody, how do you say, look, I'm going to give this three or four sessions to determine if this is a good use of my time. What are you looking for?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Is it, Hey, if I'm not uncomfortable in three or four sessions, this person probably isn't doing a good job. What are the metrics?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Is there a certification that people should be aware of that says you're a true trauma based therapist?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
What else should they be looking for? So they find somebody, they think they even get a personal referral that says this person is good. How should they evaluate what is going on? And if they're on the right path within a month, for example, what's a sign that things are going well? What's a sign that things are not going well?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
What's a good sign? Is going in apprehensive and coming out exhausted a good sign?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Jeff is a trauma-focused clinical counselor with extensive experience working with adults, teens, families, and groups. He's worked in multiple settings, including career counseling, life coaching, addiction recovery, professional workshops, and private practice. He's a licensed professional clinical counselor, a nationally certified counselor, and a certified clinical trauma professional.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I'm looking at my last entry before I left the bridge. I see a couple of great lines here. One of my favorite other co-residents there, she said this. She said, I asked God why he beat me down this year. He said he broke me open. I thought that was very powerful. You said on the way out, the more you cry here, the more you win here. That was pretty interesting.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
There's just no escaping it, is there? Like it's very, very difficult. If the name of the game is I have to become vulnerable to become connected, that's the central thesis here. I am disconnected and I am using something to stay disconnected. Sometimes those things are obviously bad, like drugs and alcohol. Sometimes and many times they are not that obviously bad, like work and perfectionism.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
or cleanliness, or you pick it, right? Depending on the extent of it. But I have to get vulnerable to be connected and being vulnerable feels like getting broken down and you're going to shed some tears.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
You talked about the trauma tree. Maybe we can describe the roots and branches of that tree in some detail because that is kind of the meta structure that I think that story gets told. It's the cause and effect piece of it. At least that's how I sort of came to understand it. I've seen many different ways that trauma is described. Obviously, since I... left the bridge.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Of course, you can only really say that if your partner is equally vulnerable, because if your partner is not vulnerable, that that message isn't going to land and that's going to be triggering to that person. And I guess all of this is a long winded way of saying you have to have two healthy people to make a relationship work. You can't just have one.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
If you're in that relationship where one of you is feeling like, hey, I can be vulnerable here, but it's not being reciprocated, what are the tips for maybe helping your spouse if this is thinking about it as a marriage or something like that? What can the vulnerable member of that relationship do to help the other one? Because it's not going to be tenable indefinitely.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
How do you lovingly get that person to come to a place where they want to get help?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Jeff, I want to thank you very much for not just coming today, but for obviously being a really important part of my life. I owe you a great debt of gratitude as I do a number of therapists who I've been really lucky to work with, but I will forever reflect on what can only be described as just an unbelievably difficult experience that
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
I'm so glad I had no idea how bad it was going to be when I reluctantly agreed to go, because I just don't think I ever would have done it. And I've had the privilege of encouraging many people to go since then, not just to the bridge, but to other places as well. I think almost without exception, it's helped them. In fact, I know it has. I can't think of an exception where it hasn't.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
It's a topic I'm personally very interested in for myself, for patients, et cetera. Jeff, I always come back to that structure and I think it is the single best one I've seen. Now that doesn't mean that it is the best one. It's just the one that resonates the most with me because causality means so much in my world. And I like the idea that even though it's not a one-to-one mapping,
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
So if someone's listening to us and they're sort of contemplating either dipping their toe in by working with a therapist and trying to probe some of these things, or if they're thinking about jumping in the lake, then going to a residential place like the bridge, what would you say to them?
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
For all of my disclosures and the companies I invest in or advise, please visit peteratiamd.com forward slash about where I keep an up-to-date and active list of all disclosures.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
Everyone who experiences this trauma will have this manifestation. Clearly not. But if you accept a little bit of the randomness in the system, it's pretty powerful. So maybe walk people through the five roots and the four branches of the trauma tree.
The Peter Attia Drive
#339 - Unpacking trauma: How early wounds shape behavior and the path toward healing | Jeff English
He's an outreach specialist at the Bridge to Recovery, a residential workshop for individuals suffering from the effects of trauma. I met Jeff in 2017 when I attended the Bridge to Recovery as a client, and we've stayed in close touch ever since. In this episode with Jeff, we discuss the profound impact of trauma and the impact that it has on certain individuals.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
In today's conversation, Mike shares his personal journey from his early experiences in powerlifting and bodybuilding to his academic training in exercise science. We discuss the core principles of resistance training, including exercise selection, volume, intensity, and frequency. Mike debunks the common fear that strength training will make people overly muscular without intention.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Do you think it should be, I've talked about this before, in cycling, a sport where they're very clear on what the rules are, no performance enhancing drugs, but to date, all of the performance enhancement has been on the generation of power, EPO, testosterone, things like that. But anybody who's ever ridden a bike knows it's half power, half weight. Cyclists spend a lot of time being hungry.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Mike, thank you very much for making the trip and for explaining a lot of things that I think a lot of people are going to find super interesting. I think we should probably sit down and do this again because I had a list of topics, not questions, but just topics I wanted to go through of which I didn't really get through many. Although tangentially, we did talk about a few things.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Sorry for blabbing so much. No, no, it was always a pleasure.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Sounds great. Thank you for listening to this week's episode of The Drive. Head over to peteratiamd.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
For all of my disclosures and the companies I invest in or advise, please visit peterottmd.com forward slash about where I keep an up-to-date and active list of all disclosures.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Hey, everyone. Welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So let's unpack this a little bit because there's actually two things I want to go into, but one of them I think will be a better entry into it, which is you talked about how, boy, if you were going to put eight hours a week into your strength training, you're kind of at the upper limits of what a person might do. Conversely, if your goal is to be a really good endurance athlete,
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
He explains why this belief is unfounded and highlights the dedication required to build significant muscle mass. We outline what a resistance training routine could look like for someone new to the gym or transitioning from sports. For more experienced lifters, we explore how to optimize resistance training for muscle growth.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
You're not at that level yet if you're only putting in eight hours a week. A world-class cyclist, I mean, God, they're probably on their bike 30 hours a week. Something like that. Easily. Full-time job. Now, of course, not all of that is at maximum intensity.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
A lot of that, in fact, probably 70% to 80% of it, it also varies a little bit by gender, but let's just say 70% to 80% of that time is going to be at zone two. And they're really only burning matches 20% of the time. Yet there's something very different about strength training, which is, are you really getting benefit at the equivalent of whatever we would call zone two in the gym?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Like if you're at that far of a submaximal effort, what is the training stimulus? And is this just where the comparison between cardiopulmonary training, where there's a clear benefit from submaximal efforts and strength training, don't jive? That's not from the case. Strength training...
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Because that's why you would say hypertrophy and strength are outputs of resistance training. Correct.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Mike shares his personal experience with anabolic steroids, outlining their impact on muscle growth, mental health, and performance. He discusses the pros and cons, including the significant physical changes and potential long-term health risks.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
But yeah, any much more than that gets to be like, oh wow, I'm sore and tired a lot more. And Mike, do you think this is simply a consequence of the fact that endurance training relies more on type one muscle fibers and strength and hypertrophy training are more dependent on the actions of type two fibers? Is that why?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I don't know why philosophically, I just think this is such an interesting contrast to make of how optimization of one is a totally different philosophy than optimization of the other. And the only reason I'm harping on it is I just know that when you take people who are very used to doing endurance training and It's a hard switch for them to adopt what you just said in the gym sometimes.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
It's not the way they're wired, but is the best way to explain to that person the why that's the difference between a type one and a type two fiber? That is probably the core difference.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
It's really worth pointing out here that Mike is one of the most candid individuals I've ever met when it comes to discussing his use of anabolic steroids, growth hormones, and things of that nature. What is remarkable to me, and you can see this in the podcast, is just how jaw-dropping the numbers are in terms of usage.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Can you say more about the neural part of this? I find this to be a very interesting piece. And of all the pieces you've described, and I agree with everything you've said, I know the least about that component yet. I've heard people talk about this, right? Which is you cannot discount the CNS fatigue literally that comes from doing this type of work.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And I remember as an example, watching sprinters train. And obviously people understand that sprinters, I shouldn't say obviously, but if you study the mechanics of sprinting, you realize it really comes down to force per unit mass. That's how hard they can hit the ground with their foot relative to their mass.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And so these are athletes who need to be almost comically strong without gaining any excess weight. So even though we look at sprinters and we think, gosh, they're very muscular, it's their strength to weight ratio that's really profound. And so they have to train in a way that minimizes hypertrophy and maximizes strength.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So for example, they'll focus heavily on exercises where they can push the concentric phase and not the eccentric phase. It was explained to me once that doing this allowed them to also spare themselves from some of the neurologic fatigue. Is there any validity to that or is that just true, true and unrelated?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And what is actually happening in both the central and peripheral nervous system during the recovery phase between those, say, three day or six day bouts when you're trying to recover a system after the set you just described?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
When you're talking to an individual like me, who's prescribed testosterone for many patients under physiologic circumstances, it was impossible to fathom just the types of doses that bodybuilders are using. We discussed the role of genetics in muscle growth and strength, as well as the influence of age and other lifestyle factors.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
This conversation offers insights into the science of resistance training and practical advice for anyone looking to build muscle while also exploring the experience of someone who has been in the bodybuilding world. So without further delay, please enjoy my conversation with Mike Estratel. Mike, thank you very much for making the trip to Austin. Thank you so much for having me.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
It's so interesting how what we could do up to a certain age. And I don't know what that limit was because I really stopped pushing to those limits at about the age of 19. So I don't know if the limit was actually 20 or 21 or 24, but I never trained maniacally after the age of 19. Everything I've done since 19 has been smoking and joking. Okay. But what I could get away with then was ridiculous.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And I attribute it only to two things, right? Youth... Obviously with youth, I mean, stupidity and inexperience and all the things that come with you, but also like having started very young. So age 13 to 19, I was training literally six hours every day except Sunday. Sundays, I only trained two hours per day. And I look back at the workouts I did and I think like, I don't know how I did it.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And more importantly, like how much better could I have been if I didn't train that much? It wouldn't be uncommon for me to do six super hard rounds of sparring with three fresh opponents. One guy a weight class below me, one guy in my weight class, and then one guy for two rounds a weight class above me. In sequence? Yes. Six straight rounds.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
You definitely did that backwards, but you probably know that now. Yes. And I would mix it up sometimes, but actually it was much harder and more dangerous to do it in that way. And I kind of liked that. The idea that the guy that could hit the hardest was my last guy. Yeah. When you were the most fatigued, your defenses are the less accurate. But I would be in the weight room six days a week.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I saw something on social media. You were here a week ago. Have you been here the whole time or? Yes, week and a half long social media collaborative trip.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Like it was just running hard. Anyway, it was kind of crazy, but I want to go back and just put a bow on something you said before, because I think it's so important and it's going to come up again and again. I want to make sure people understand the point. Your example was great, by the way.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
the non-linearity of force is very counterintuitive it is not obvious why for example being on a bike even if you are riding at a very high level of power so remember on a bike your leg is going around at 90 times per minute so even if you did a one minute all out that's 90 reps or call it 45 reps That's nothing compared to when you're doing an all-out set for 10 reps in the gym.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
It's such a difference in force. I love the example of the wiffle ball going by you versus a 50 cal. The 50 cal could kill you without hitting you. The wiffle ball you wouldn't notice. So I think this idea of The profound level of difference in tissue destruction is a very important one.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I was on Dorian Yates' podcast a few months ago, and poor Dorian, he wanted to interview me because it was his podcast, but I just wanted to interview him. I have nothing interesting to say. Let's just talk about you right now, right? Yes. It was very interesting to me to understand how little time he spent in the gym for a bodybuilder of that era.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
It was very, I guess, progressive, even though he was really going back to Arthur Jones and Mike Menser and those guys. But he was really just sort of doing one set to failure per exercise, and he was doing each body part once a week. The question I sort of posed to him, but I'll pose it again to you is, are most people even capable of pushing that hard?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Because I want to bring it back to where we were a moment ago, which was, hey, for a person who just wants to train 30 minutes twice a day, they can get all the benefit in the world. But there's an asterisk there, which is that 30 minutes twice a week is going to be the most difficult 60 minutes total of your week.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So going back to Dorian for a second, what has to be true to be able to only train that much in terms of total hours, volume, however you want to measure it? How much work needs to be done in that window of time? For the, not the Dorian Yates example, for the- For the Dorian, let's start with Dorian. Why could he produce such a massive physique? And again, let's just normalize all the drugs.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
We're going to talk about drugs later, so we'll explain where the drugs are and aren't helping. But all the drugs in the world aren't going to give you that physique if you can't generate the destruction of the muscle. Is that just the sort of thing where virtually nobody can actually push that hard, that consistently? Or was it just that nobody thought to do it the way he was doing it at the time?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Of course. I not only have the app, I'm the premium subscriber. My bad. So I can listen to all the chatter of every moment between every car and their mechanic. And yes, of course.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Well, Mike, there's going to be some folks listening and watching us who are probably very familiar with your work, and they've probably come to learn about you as I have through just endless years of being both amused and educated by your content on YouTube. But there's probably a group of people here just in my audience that aren't overlapping with yours.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Now, if Dorian was doing 14 sets per body part per week, would that mean 14 sets to failure of 14 different exercises, so we're not counting the warm-up sets and things of that nature? It's a complex question.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Maybe there's like a total throwaway set and then there's a modest set. And then there's a two rep and reserve set that again, that's a real working set. Which for him wasn't. And then there's a set to failure.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And when you compare that to the example of the three-hour chef, so now the person who's willing to put in 30 sets per body part per week, do any of those sets need to be to failure or are you counting those as, hey, these would be sets of two reps in reserve, one to two reps in reserve?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So I want to give folks a chance to kind of get to know you. I will have introduced you already in the introduction, but Let's talk just a little bit about your background. Remind me, you came to the US from Russia when you were eight? Seven. Seven. Okay.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Which says nothing of the risk of injury when you drop that dumbbell on your pec, which I don't know anybody that's done that, but I've been told it really hurts when you fail in a set of dumbbell presses and totally collapse with a dumbbell on your pec that turns black and blue. Oh, good God. Yeah.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
What'd you study in undergrad? Movement science, kinesiology at the University of Michigan. Okay. What sports were you playing then?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So let's go back to the person who's listening to us who wants to take the plunge, wants to start doing resistance training. They're clinging to what you said a while ago that, hey, I can get some really good results if I'm in the gym 30 minutes twice a week. And I know that Mike trains eight hours a week, but I don't need to be Mike. So tell me what a program looks like.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Let's construct the program. Let's start with a young person. Let's start with a young person who actually has been somewhat active throughout their life, but it's mostly been in sports. They play tennis. They did cross country in high school. They've just never been a gym rat. But they've listened to this podcast enough.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
They've listened to you enough to know like, hey, there's value in developing strength. And I'd like to have some hypertrophy. I want to look a little better. Okay. So I'm coming to you. I'm 40 years old. Kind of a little intimidated if I'm truthful. Don't know what to do. Good.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
What's our two 30-minute day workout look like?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
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The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So invariably you've been asked this a thousand times, but when this person's coming into this situation and they don't have a high training history, what are the tools you use to teach them how to do these compound movements safely, especially the lower body ones? So squats and deadlifts, admittedly, they're not going to be starting out with a ton of weight. That's the biggest tool. Yeah.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And just for folks who might be confused about all the different disciplines, power lifting is the sport where there are three and only three lifts. There's a deadlift, a bench press, a squat, and you win by having the highest total weights across the three, I believe. Correct. Yes. I'll add it up.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So you were not at that point into bodybuilding or anything yet? No. Got it. No. And then you went off and did your PhD right away after undergrad?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
There's a lot there I want to go back and touch on. Let's start with the idea of how does a person find a good trainer? Because it's hard enough to find a good doctor. And that's a highly, highly regulated industry. You either are an MD or you're not. But still, there are lots of different flavors of doctors.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And there are some who really think a lot about prevention and really care about how you exercise and how you eat. And there are others who I think do, but frankly don't have the time to really noodle that. As difficult as it might be to find a great doctor, it's probably even more difficult to figure out a trainer who's really good. So what are the questions that a person can be asking?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
when they go into their gym or are looking online for a trainer to say like, is this the person who is going to help me learn to do a squat and a deadlift safely? Is this a person who can integrate whatever preexisting injuries I have and really help me? Because again, I've worked with people who I've watched people coach and I'm like, wow, that person really knows what they're doing.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
They have picked up the absolute subtle art of how to cue somebody to lift. They can focus on the non-obvious. And there's other people who literally have no clue. They look like they just watched the YouTube video and they're sort of parroting the YouTube video to you, but they have no real intuition about it.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So what about the person who's been lifting weights for a long time? They're in there, they're doing this stuff, but they're not happy with their progress. They're in the gym. Let's just say they're in the gym three, four times a week, an hour at a time. How hard are they working? Are they really trying or are we saying that maybe they're trying, maybe they're not?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Let's say they are. They're actually trying quite hard. And you actually look at them and you think, you know, gosh, they might actually be slightly overtraining. And by overtraining, let's say they're training three days a week and they're doing a whole body three days a week and they're in there 90 minutes at a time.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
They're going to one to two rep and reserve on every set and they're hitting 20 to 30 sets per body part per workout. To be clear, they're doing okay, but they're just saying, you know what? I want to be really jacked.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
What do I need to do?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guest this week is Dr. Mike Istratel.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Volume intensity would be on the checklist.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So for intensity, you would say if they're at least hitting two reps in reserve, you're okay with that? Golden. No need to improve above that. Yeah. But if you went in there and you observed them at the end of their set, if you said, let me see you do a few more and they were constantly getting four more reps. Yeah. So there are four reps in reserve.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
You would say the literature says you're not hitting in a high enough training stimulus. Correct. This is a very important one. Very important. Because I think I talked about this once on Instagram. And if I didn't, I meant to, and I just forgot, which is equally likely. In fact, more likely. Yes. But the point I wanted to make was at least for me, and it might be that I'm just not good enough.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
You don't know what two reps in reserve means until you go to failure. You have to fail many times to actually know how bad two reps in reserve is and one rep in reserve. And they're not the same every workout. That's the other thing. You could have the same weight on their different days and you fail at a different number of reps.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
But there's like a signal, there's a twitch, there's a discomfort that you have to experience it, but you can't experience it until you blow past it.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So is it safe to say that if a person is already, and by the way, we talked about what's sufficient for exercise selection, technique intensity, we didn't specify volume. What would be a red flag for you in that individual? If their volume sets per body part was below X, where would you say, well, it should be expected? Per week?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I mean, if you're beginning a few sets, but this is for this kind of intermediate.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Per muscle, not per body part. In other words, bicep would need to be 20 sets per week. Correct. Wow. Yeah. I think we have a pretty good explanation for why somebody at this table has small biceps. I'm not saying. How dare you?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And when did you start putting out these videos on YouTube that I probably only discovered a couple of years ago, but I think you've been doing this much longer, right? So YouTube, I haven't been doing too long.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And do you think you attribute this to the hypertrophy of type 2 fibers, which are necessary for the power generation that's necessary for producing the gains we're talking about?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Well, it'll be interesting to see if even if we can turn myostatin off as adults, if it will have the same impact that it has in the cartoons, right? Like when we look at the animals that have myostatin knockouts, which are just some of the most enjoyable things to look at.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Truthfully, it's like, you know, our favorite things in med school, we're looking at the myostatin knockout chickens and cows. But it's not clear if you took a mature adult and inhibited myostatin, if you would get the same benefits. But let's go back to out of the gym. One more thing we didn't discuss.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I just kind of want to hear your thoughts on when something out of the gym is playing a role in your unjackedness. Is nutrition often a factor or is that generally not? In other words, is it so rare that someone is not getting enough protein or not getting enough calories that that's the problem? Is that just not something you see much? It's a thing. Okay.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I would assume it's more a thing with women than with men and maybe more with older women than men and maybe even older men when you just see more anabolic resistance.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I wish I knew more about how the algorithm worked. I clearly don't. The ever mysterious algorithm. And then just kind of going back to your personal evolution, as you're going through this journey of master's, PhD, industry, are you still focusing on powerlifting personally?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
If not, they are soon, yeah.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I'd like to come back to it, but we've now twice broached the topic of anabolics as another tool, because a couple of times you've made the point, which is, look, this is going to be about the limit. Your genes are going to start to become your limit. So I guess my question is, you've spoken very openly about anabolic steroids.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I've had several podcasts where I've covered this in detail, but let's kind of tell people what we're talking about for reasons that are maybe a little bit elusive. There's some confusion about is testosterone an anabolic steroid? Of course, the answer is absolutely yes, it is. Wait a minute. Let's talk about anabolic steroid use in the context of non-medical use.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Let's take testosterone replacement therapy where testosterone in a hypogonadal man is restored to typically the upper limit of a normal physiologic range. It's nice that they do the upper limit, right? Yes. Give everyone good genetics.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And then we'll just sort of take that off the table for a moment, park it in the context of what is anabolic androgenic steroid use look like in the physique bodybuilding community? Let's talk about the different drugs. Let's talk about your experience with it. Let's talk about how much it can unleash.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And let's frankly talk about what the pros and cons are, because I personally have no experience with this. That's not our patient population. We don't have patients that are coming in saying, My goal is to be jacked. I want some D-ball. So there's this not something we just have any understanding of.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Let me just pause there for a moment and just give some people some doses because we've talked about TRT before in the podcast. So we typically dose patients twice a week to try to get a smoother level as opposed to once a week.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
If the ideal dose for a given individual to get them in the right spot is 100 milligrams of testosterone cypionate weekly, we would always prefer that the patient take 50 milligrams intramuscularly twice a week or sub-Q. I will tell you, Mike, I don't think we have ever given a patient more than 70 milligrams twice a week or 140 milligrams a week, probably median dose of
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Yeah. Help me understand what that even feels like. So let's just say you're taking 700 milligrams a week, 100 milligrams a day. So 7X physiologic. Do you feel something different?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Now, at that level of testosterone, are you taking an aromatase inhibitor or are you literally letting the estradiol get... I can't imagine how high the estradiol level becomes at that... As high as you want. So typically, estradiol would be over 100 at that point.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
It's actually quite amazing, and this is not entirely unlike women. If they're undergoing hormone replacement therapy in perimenopause, it's not a one-size-fits-all. They can have tremendous variability in their response to estrogen and, of course, progesterone. Yes, huge, huge, huge.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Which to me makes me wonder, is there any difference in androgen receptor expression that you're able to appreciate between 250 and 2000? Are you so saturated in your androgen receptors already that do we actually know if there's a benefit to all the additional testosterone that you could have been on at almost 10x your current dose, 8x? You won't know until you try.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Did you appreciate a difference in positive effects? I don't doubt that there could be a difference in negative effects, but if the positive effects are accrued through testosterone binding to the androgen receptor, that complex leading to more nuclear transcription, wouldn't what you said suggest that you might have already hit maximum benefit at 250?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
What were you looking like at the time?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Mike holds a PhD in sports physiology and is currently the head science consultant for Renaissance Periodization. He's a competitive bodybuilder and was formerly a professor of exercise and sports science at the School of Public Health at Temple University in Philadelphia.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
How do you differentiate between when you're using testosterone versus nandrolone? Mostly by experience.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Okay. I know I look 50. Not where I was going. What would you look like now? I'm going to just pause it. I'm guessing that you have good genes. You eat well, you train very hard, and you're using enough anabolic steroids to fuel a small country.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
If we subtracted that last one out of the equation, because I don't have a sense of what the relative contribution is, what would you look like if you did everything the same minus the anabolic steroids? Or if you run regular TRT, you were taking 100 milligrams of cipionate a week. Do you have a sense to quantify how many pounds lighter you would be in terms of total muscle mass?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Me personally or the average person? No, you personally. Yeah, I want to get a sense. Having had used steroids before at high doses or not having ever had used them? Oh, good question. Very different answer. Yeah, good question. Let's do both. I can do both. Yeah, let's do both. When did you start using high doses of anabolic steroids?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Okay. So let's say we go back to 27 years old. We put you on the same path of doing everything you're doing in terms of your training intensity, all of the scientific principles that come into it, et cetera. But you've never gone down the path of taking mega doses of steroids. And if you've ever taken testosterone, it's literally to bring your total T up to 800 nanograms per deciliter.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Versus 230.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Yeah. FFMI, for folks not familiar with it, is fat-free mass index. So it's total fat-free mass in kilograms divided by height in meters squared. And just for reference, it's pretty hard to be above 25 without anabolic steroids. It's unlikely. Right. That right there suggests some interesting genetics that you were probably 29-ish, 28, 29. Something.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
It's easier to do when you're really fat, though. But your ALMI was probably very high as well, I'm guessing. Sure, sure.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
It's been a while. And so now the reverse question, which I guess is tomorrow you just decide, you know what? I'm going to keep doing everything I'm doing training-wise. I'm going to gradually taper this thing down because at this point, you're going to need to be on testosterone for the rest of your life, I assume.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I find it hard to believe you would continue to make testosterone.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Yeah. I can't imagine it's 90-10 though, Mike. I cannot imagine that 90% of people that use anabolic steroids for more than two years would be able to resume testosterone production.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So what do you think, back to the original question, if you were to come off today, how much of the, call it the 35- Going down to regular TRT, not super TRT. Correct. You went down to 100 milligrams a week or none if you were able to make that on your own. Sure. Of the 35 pounds of delta supplemental muscle, how much of it would you keep, you think? About half. Yeah.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So in other words, there is a difference between the muscle you gained versus the muscle you never had. Huge.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Yeah.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
235 pounds, substantially lean. We'll talk a lot about bodybuilding and cycles and are you in a cycle now? And if so, are you on the way up or on the way down in terms of mass?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
What is your personal calculus for the number of years remaining where you want to be doing supraphysiologic doses of testosterone? Do you think about the trade-offs of long-term health? Incessantly. Yeah. And so how do you sort of think about it? Because obviously everything has a trade-off. I suppose if you're winning Mr. Olympia and you're one of the top five bodybuilders in the world.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
As I am, JK. then the trade-offs might be worth it. What's your personal calculation on it? There have to be, I don't know, hundreds of thousands of people that are using super physiologic doses of testosterone in the country, I would guess. For many of them, it's for themselves. It's like they're not getting paid to do it. Almost all of them. Right? Almost all of them.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
It's not because of how they look in a movie or whatever other reason. So yeah, what's your calculation?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Total cholesterol at 79, that's almost impossible to imagine. You're on lipid-lowering drugs, though. Nope. That's really hard to believe.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I was going to ask you about your blood pressure.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
What would your blood pressure be if you weren't treating it with medication? Peter, I have absolutely no idea. Don't give a shit. I won't ever try. But do you have to come off the blood pressure medicine when you're off the testosterone or anabolic aging? I'm never off. I see. Okay. So what's the lowest you're on then?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I didn't want to say anything, Mike, but yeah, you're looking a little chubby. Looking pretty fat. Yeah. I'll cry about it later. I normally don't let people of your chubbiness in the studio, but- Yes. And you can't let us out without letting us know, like, hey, you're fat, by the way. Just want to let you know. No big deal. I mean, it's kind of a big deal. It's a really big deal.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And that's your nadir.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I see. But your BP at 250 and your BP at 2000, you would be on the same dose of a blood pressure drug?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Is your blood pressure the only noticeable deviation from normal health that you experienced that you and your wife were able to measure in this?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And your body fat right now, if you had to guess, would be what? 8%?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
By the way, do you use a 5-alpha reductase inhibitor to manage DHT? No. So your DHT must be 200. Yeah. Who knows? I could give a shit for hair on my head.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Yeah, it does. I mean, I'm way less optimistic than you, Mike, about longevity escape. Certainly on that time horizon, I think of the hedge as the exact opposite. So my hedge is it would be wonderful if in a decade we had technology that treated disease in a way that could restore my heart to the heart it was when I was 20. Because I think about the reduction in function.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So my coronary arteries are still clean as a whistle, but my heart's nowhere near what it used to be. I know this, for example, because my maximum heart rate is 30 beats, 40 beats per minute lower than it was when I was a teenager. Directly in aging. thing. Right. Directly an aging thing. If you look at the electrical system of my heart, and these are things I can't treat.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I can do all the things possible to not have my blood pressure go up so I don't get LV, left ventricular hypertrophy. I can keep my coronary arteries clean as a whistle indefinitely. We have the modern pharmacology to do that. Isn't that crazy that you can say that? Yeah, it's wonderful. It's incredible. But I can't change the architecture of the muscle yet. We don't have that ability.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
My hedge is, how about I just stave off chronic disease as long as possible, stay as healthy as possible, stay in the game as long as possible, so that if it turns out that that was for nothing, we're sitting here, it's 10 years from now, I'm in my early 60s, and someone comes along and says, Peter, all that stuff you did was totally unnecessary. You could have been eating Cheetos forever.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
drinking margaritas all day long. I have a pill that's going to make you 20 years old again. I would have no regrets. I would be like, I don't care. I am really glad I did what I did, but I would have regret if I put my eggs in the basket that said, I'm going to drink the margaritas all day. I'm not going to exercise.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I'm going to wait for the exercise pill to come along and it just doesn't come along. I also think we just have to accept one of my favorite thought experiments. I was talking about this with a friend a couple of weeks ago. If you just consider modern human history, we're just talking about 250,000 years. Let's forget everything that came before Homo sapiens. You go back in time 250,000 years ago.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
200,000 years ago, 150,000, you do this in like 50,000 increments until you hit 10,000 years ago. And then 5,000 years ago, and then 2,500 years ago. And then a thousand years ago, and you go in and you ask them to predict the future, letting them see everything that's happened before. Cause of course that would be a difficult thing to do most points in time.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
They don't even know anything beyond that. Like what's the future. You're like, Oh shit, I went back too far. Yeah. And it's sort of like, it would be impossible to, to imagine because the pace of change during that 250,000 years was pretty much nothing. 5,000 years ago, we get agriculture. Then a couple hundred years ago, we get the industrial revolution.
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#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
We really start to get these- The first industrial revolution. Yeah. We start to get these big step function changes. But even if you go back in time 100 years, so 100 years, we're in the roaring 20s. Life couldn't be any better. Nobody knows that there's this depression coming. Nobody knows what technology is coming. All of these things. So we couldn't predict anything.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
You go back in time 40 years, I don't think anybody could have predicted what we're doing today. Ray Kurzweil successfully did. What did Ray predict?
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#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
He predicted this when.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
This is where I'm less optimistic, no more confident, to be clear. I want to be very clear.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Yeah, but just as a point of discussion, my optimism is less everything you said I agree with in terms of compute velocity, et cetera. It comes down to the manipulation of biology. I think certain things would need to be true. I'll give you a silly example.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Do we believe that in 10 years we will be able to take an egg that has been put into a frying pan, fried, the clear part has turned white, and make the white part clear again? Do we think 10 years will bring the technology to do that?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
But why? Why do we think that we'll be able to unfold proteins again?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Again, I'm very familiar with it, but that's a remarkable problem for which obviously a Nobel Prize was awarded. but a very different problem. Like I'm just not sure that the entropy will allow the reversal, right? So what DeepMind did, again, it's incredible that they could actually take an amino acid sequence and predict the protein structure in foldings.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
But when the protein has folded, which is why the egg goes from clear to white in the pan, how do we undenature that?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I don't necessarily think that. Sure, sure. I think that some days about myself. No, but they might look at me and say, Peter, you are so pessimistic. How can you be so pessimistic? It's not that I'm pessimistic. It's how can you not be more optimistic? But nevertheless.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
As a co-founder of Renaissance Periodization, Mike has coached numerous athletes and busy professionals in both diet and weight training. Mike also has a very popular YouTube channel where he loves to do debunking videos that are both informative and endlessly amusing.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Well, whenever I think of an artist mucking around with a canvas, of course, I only think of Bob Ross because I don't have much experience watching an artist create something. You know, usually I'm seeing the finished product, but I still, like most people who grew up in the 70s and the 80s, recall watching Bob Ross on Saturday mornings with great fondness. He makes it look so easy. Oh, my God.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
No, but like AI is going to do a great job at the first step of the process, which is what's the molecule? Right now it's trial and error. It's brute force. It's super painful. Yeah. Not anymore right now. Right. Exactly. Alpha fold changes that. How is AI going to streamline the phase one trial where we have to prove once we have the IND? Oh yeah. No, no.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Right.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Yeah, so your example would be, it's like coming up with retatrutide in 2014 when we had liraglutide as the first generation GLP-1 that sucked.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
I hadn't really thought of that.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
But how will it know that? Because... Again, this is such a silly philosophical discussion, but didn't we kind of need to see that, okay, semaglutide was better than liraglutide, but we had to see, I don't know if this was predictable. You had to actually see the experience. to then go from semaglutide to terzepatide and realize that, oh, maybe it's the GIP as well as the GLP that's really good.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And yes, now when we look at the pipeline, it's different. So I do wonder, it's a very tantalizing proposition, but I wonder how much of it can be figured out through simulation, which is what would be necessary.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Yeah, I've thought about that a bunch. I'm not sure I like it. Why not? you can always just unplug. Yeah. Let me ask you an interesting question.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So if you had to choose in the matrix, whether you wanted to just stay in the matrix and be completely oblivious to the swamp that you actually live in, or would you rather be like unplugged from the matrix and eat the porridge every day and hang out with Morpheus? I have a worse answer.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Well, what you have to do when you see the final version of The Matrix, you have to go and watch the first two three times over again to purge it.
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#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
All right. So I want to try to bring this up to the present. So right now you compete in bodybuilding. You obviously provide a lot of education to folks. So I think my audience is clearly interested in exercise, clearly interested in strength training, clearly interested in the aesthetics of strength training. Because again, I think it's very easy to look at bodybuilders and say,
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Can you explain to a subsistence farmer what Uber Eats is? No, I mean, look, you couldn't explain it to the king of France. No. 500 years ago what it is. And so the only thing I will say on this entire point is I agree completely that, well, maybe this is not what you're saying, but I would argue I have absolutely no idea. I can't fathom.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And I spend very little time trying to imagine what a world looks like in a hundred years, whether I'm here or not, because the only thing I know is it will be more difficult to predict than going back 100 years and trying to predict today was. That's the only thing that I know is capital T true.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
If you go back in time 100 years or 500 years and try to predict today, that is easier than what's going to happen in the next 100 to 500 years based on the trajectory of growth. And I guess I just bring it back to what can I do today?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Gosh, that's a little odd. It's a lot. But what is obvious, if not self-evident, is that's just a spectrum. Anybody who wants to have more muscle and less fat probably has something they can learn from a bodybuilder. I often say to my patients, If you really want to understand how to manipulate nutrition to be lean, you probably need to understand what bodybuilders are doing.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
If you had kids, and it's a dumb question because you don't, and you don't know until you do, but would it change your philosophy around training anabolic steroid use? I want to be really clear. This is not a moral question at all. It's really a question of trade-off. It's a trade-off question, right?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
It's at the doses you're taking them, do you have any concerns, and would you play it differently if you had kids?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
You do think that even with your great genes, which it sounds like based on everything you've said, you really have wonderful genes. That suggests that your steroid use, by your calculation, is a 20-year reduction of lifespan. Worst case.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Yeah, yeah, yeah. Okay, that's interesting. Always. How are you quantifying that?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
And I just want to make sure people listening haven't lost the plot. We're not talking about physiologic replacements of testosterone because the evidence is abundantly clear that we do not see any reduction in lifespan. We don't see any increase in the risk of cardiovascular disease, cancer, or these other things. But huge quality of life increases concomitantly.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
There's probably no athlete, there's no person out there that truly understands how to manipulate exercise and nutrition in the context of body composition. And that's true even in the presence of anabolic steroids. Anabolic steroids don't preclude that. They might make that a little easier, which I think we should talk about.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Sort of unrelated but related, are we seeing more bodybuilders now use GLP-1 agonists? Yes. Yeah, I was about to say, right? Like, why wouldn't you? It would make the most difficult part of bodybuilding easier, which is the calorie restriction, right? You said that in a way I cannot say any better.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Just to be clear, there is a category of bodybuilder who fully endorse the liberal use of anabolic steroids, but oppose the use of GLP-1 agonists? Vehemently. And the moral argument is?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Yeah. I mean, look, I think having never done bodybuilding, I'm probably not a good person to offer a point of view on that. You could argue that if the stripes are earned through that type of suffering, let's take a step back. If the stripes are earned through suffering, there's two types of suffering.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
There's the suffering you do in the gym, the pain of the gym, and then there's the pain of the second one, the starving, the calorie restriction. Lifestyle. And if they're saying you have to have both of those to be one of us, then steroids are not a problem. In fact, they allow you to suffer more potentially. They allow you to push yourself much harder. Definitely true.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So maybe in that sense, steroids are an important part of bodybuilding if the suffering is the card and the GLP-1 agonist is not. So maybe that's the argument. I probably wouldn't have come to that argument. I probably would have said, well, if we're in the business of using any form of pharmacology to enhance our physiques, we should take whatever we can get, provided it's safe.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So maybe we just start with where you see the value of strength training. Do you think that there is a diminishing return at some point? Do you think that there is a diminishing return in the amount of muscle? I've said very tongue in cheek that the list of 90 year olds out there complaining, wishing they were not as strong and not as muscular is a very short list. Very short list. Right.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So Mike, what do you think that tells us about the morality of GLP-1 use much more commonly? Because obviously the majority of people using GLP-1 agonists and dual agonists, et cetera, are not bodybuilders and are professional people whose livelihoods depends on their physique. It's normal people.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
But again, why am I saying that? I'm saying that to say that most people at the end of life are saying the exact opposite. I wish I was stronger. I wish I had more muscle. But from a practical standpoint, Mike, what is your view on muscularity and strength at the expense of what it might take to achieve them? Are there extremes that people should be mindful of?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
Again, let's also take out the category of people with type 2 diabetes or with such significant obesity that it's impacting their health in ways that are direct and measurable through the excess adiposity. Let's talk about what is probably the majority of people who would use a GLP-1 agonist right now, which are people who might actually even be healthy.
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
They might be overweight, but still be perfectly healthy. Tell me, why do you think that there is a bit of a moral panic about this?
The Peter Attia Drive
#335 ‒ The science of resistance training, building muscle, and anabolic steroid use in bodybuilding | Mike Israetel, Ph.D.
So has that been your experience, which is it hasn't actually changed What you're eating, it's just given you the privilege of focusing less on the starvation and the management of diet? That's exactly been my experience.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
Hey everyone, welcome to a sneak peek, Ask Me Anything, or AMA episode of The Drive Podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com forward slash subscribe.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
So without further delay, I hope you enjoy AMA number 66.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
Oh, well, given the subject matter, surprisingly good mood. And, you know, I've taken a couple beta blockers before, so I'm riding the cool wave, man.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
Well, look, it wasn't always this way. There was a day when I really enjoyed talking about nutrition and writing about nutrition. In fact, you could argue I cut my teeth on that. That was my very first foray into doing anything publicly back in 2011 was blogging, and it was blogging mostly about nutrition.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
But I would say there are a handful of reasons that my interest in continuing to obsessively talk about it has sort of diminished. So you've alluded to some already. So the problem with nutrition research is that it doesn't really lend itself to having rigorous discussions on the topic. I read a really interesting and timely article the other day on LinkedIn
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
And it was titled, Something to the Effect of Food Can't Be Medicine Until We Can Research It Like Medicine. In fact, we should link to that article in the show notes. I mean, it was so spot on. It's like everyone loves to probably misquote Hippocrates with the let food be thy medicine line. And yeah, it makes sense in a way. They're molecules.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
You put the molecules in, they clearly have an effect on your body. The problem is... There's no relationship whatsoever between food and medicine. The nature of which we can do controlled studies with medicine is completely different. The homogeneity of medicine, if we're going to study a medication, you're getting the same molecule every time, and that's the one molecule that you're studying.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
So without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to Ask Me Anything AMA episode 66. I'm once again joined by my co-host, Nick Stenson. In today's episode, we cover a topic that is generally one of the most talked about topics and also one that comes with a lot of confusion, and that is nutrition.
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#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
There are a few exceptions to that. If you're taking, for example, desiccated thyroid hormone, where you have a hodgepodge of pig thyroid gland mixed up, You're getting some T3, some T4, some T2, et cetera. But for the most part, when you take a drug, you're taking a single molecule. That's obviously not the case with food.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
So all of that notwithstanding, the real issue I have, because that's just, I think, a function of food, what rubs me the wrong way is that the ratio of certainty with which people speak about this subject matter to the quality of data. So take that as a ratio. So on the top, you have certainty. On the bottom, you have quality of data. That is really, really high.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
That's a really big number, meaning people have tons of certainty despite a paucity of data or quality of data. You don't have a paucity of data. You have a paucity of quality data. There's nothing that compares to this. There is no discipline of science or engineering for which our magnitude of certainty is so high relative to such poor quality data. And then I think the final point I would make
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
of many, but I don't want to spend the whole time on this, is that the zealous extremes and the cultish religious buffoonery that goes on in this space is just very off-putting to me.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
Whether we're talking about one end of the spectrum of carnivore to vegan, when people speak about their diet as the one true diet, I find it very off-putting, which is not to say that a person who's vegan is off-putting. I've met many people who say, look, this is the thing that works for me, Or this is my belief system. I just can't bring myself to eat animals.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
I'm not saying there's anything wrong with that. What I'm talking about is sort of the really cultish people who will tell you with absolute certainty that if you are eating anything other than this diet, and this diet can be any diet, you're going to go to hell, basically. There's a warm place in Hades that's waiting for you.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
And of course, they're not saying that, but the point is they're speaking with such conviction about something for which such conviction is impossible.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
No, I think it was pretty gradual. There's not a moment I'll point to that says when that happened or when I read that one study or meta-analysis or article, I had a change. I think it was in part maybe as my clinical experience grew and I saw more and more patients and realized more and more the complexity of nutrition and the heterogeneity of people's response to nutrition.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
different nutrition, in other words, how 10 people could respond in six different ways to given nutritional inputs that you start to realize, well, a couple of things are true. One is that the body is remarkably adept at dampening the effects of nutrition.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
So it's like, if you think of an engineering system, there are some systems where when you put a signal in to the box, the box amplifies the signal. So you put something in that's a two out of 10 and it amplifies it to like an eight out of 10. And sometimes you want that.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
Sometimes you need a signal amplifier, but then you have the opposite is true where you put something in and it dampens the signal. So you put something in that's like a blinking eight out of 10 and the thing gets attenuated. It gets dampened. It comes out at a two out of 10. And in many ways, the body is that way with nutrition.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
And so a lot of the things that people pontificate about on the margins end up being really not that important. And I've talked about this a bunch, and maybe we'll even speak about it a little later today. But once you get beyond total energy consumption, our total energy content of the food, total calories, protein content...
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
And the essentials within minerals and nutrients, most of the rest doesn't matter that much. The body's pretty resilient. You have to hit certain minimums on fat to avoid severe malnutrition and problems that occur there. Carbohydrate tolerance is staggeringly variable. You can get away without eating any carbs and still function. And you can get away with eating a ton of carbs and still function.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
Given this, we wanted to do a special episode to answer any and all questions that routinely come in on this topic. So in this conversation, we speak about nutrition and weight loss and weight maintenance and how nutrition compares to exercise, the complexities of nutrition research, what, if any, is the so-called best diet, and how to think about choosing the right diet for oneself.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
So that's actually kind of amazing is our variability on that one particular macronutrient. But beyond those big principles, there's very little that can be said with high certainty. And one might even ask the question, how much really, really matters? I mean, we're now talking about fourth and fifth order terms on a polynomial here.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
And those don't tend to really sway the outcome because the first, second, and third order terms are really clearly set.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
Well, I think there are many. Obviously, nutrition plays a huge role in anthropometric data. So using a DEXA scan, which will tell you how much lean mass you have, how much body fat you have, and if the scan is calibrated correctly, at least give you a good estimate of how much visceral fat you have, that's a great readout of nutrition.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
You could go even detailed in that and actually do scans of the liver specifically to look for liver fat. Also, a fantastic readout of nutrition quite specifically. You could look at biomarkers that pertain to metabolic health and specifically to glucose regulation or glucose homeostasis.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
If you look at either impaired or enhanced glucose disposal and other markers of metabolic health, this is everything that would range from how your CGM performs, your hemoglobin A1C, things like uric acid, things like liver function tests, your oral glucose tolerance tests, all of those things are going to be very important readout states of nutrition.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
Now, of course, those markers are also readout states of other things. They reflect your sleep and exercise quite a bit as well, but there's no doubt that those nutritional status. In some cases, we would say otherwise unexplained inflammation could probably be driven by nutrition.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
We certainly see that outside of very extreme examples, for example, celiac disease is a pretty extreme and specific case, but even absent something like celiac disease, there's clearly an intolerance to wheat on the part of many people, and it only shows up
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
in a biochemical assay that surveys for inflammation, such as a C-reactive protein or a slight change in the white blood cell count or things of that nature. And we know this because when we do empirical elimination, selective elimination and reintroduction of these things, we'll see those inflammatory markers move. So there's no question that food plays a role in that as well.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
And then obviously we can measure certain deficiencies and or excesses in the blood most commonly, but also in the urine or even in the hair. So in other words, you could give you an example, right? You could see a person who is B12 deficient. That's a very common finding in people who don't eat meat.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
And similarly, you can see an excess of mercury, which would be considered quite toxic if it gets to a high enough level for someone who, for example, is eating a lot of seafood and especially seafood that is coming from really large fish who are high enough on the food chain that they're eating a lot of other fish and accumulating mercury themselves.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
So I would say probably those would be the big four categories of things where nutrition is easy to read out in testing.
The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
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The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
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The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
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The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
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#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
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#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
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The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
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The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
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The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
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The Peter Attia Drive
#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
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#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a “best” diet, complexities of nutrition science, and practical steps for building a sustainable diet
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The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And given that Sanjay and I have a shared passion for them, and in fact, that's how Sanjay and I met, we do end this discussion with a little bit of a deep dive into CARS. But of course, back to the main point of this discussion, we talk about the evolution of breast cancer, including the shift from radical mastectomies to more conservative approaches like lumpectomies and sentinel node biopsies.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Tell people what that means because that's obviously going to come back later in our discussion.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
When I think about where, for example, something like a CT angiogram used to be, that would easily have exposed a person to 25 millisieverts to do a CT scan of the heart. You're doing it, slowing the heart down, getting the contrast in there, et cetera. Today, the really fast scanners, the best of the best scanners are somewhere between one and three millisieverts for that same procedure.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I certainly favor having patients getting a scan with that, acknowledging though that I don't have amazing data to point to, to say that the 25 millisievert one versus, just to make the math easy, the 2.5 millisievert one, tenfold difference, poses any difference in risk. Exactly. How do you think about that?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
We talk more broadly about the role that radiation plays in modern oncology, how doses have changed, and how advancements in targeting tumors while minimizing damage to surrounding tissues have rendered side effects much more rare, certainly more rare than they were even 20 to 25 years ago.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
What would be your confidence in saying that 2.5 is not actually better than 25 from a cancer risk standpoint?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So in other words, you're saying, I don't really care if it's 25 or 2.5 as well. And the good news is these brand new scanners are faster, which is why they're giving you less radiation. Exactly. they seem to have better resolution.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So what should people be thinking about in terms of extraneous radiation? When should people be saying to their doctors, hey, do I really need this? For example, when you go to the dentist every year, they typically want to do a set of x-rays. Is that anything? thing people should be worried about?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Sanjay talks about the role of low-dose radiation for inflammatory conditions such as arthritis and tendonitis, and how this approach is more widely used outside of the US, and why it's his hope and mine that becomes more adopted here in the US. We speak about the history and misconceptions of radiation exposure, including radiophobia, nuclear accidents, and early uses of radiation.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
By the way, just on the PET scan. So if you do a PET CT, for example, which again, these are not routinely done. These are typically done in oncology patients only. But just for my own understanding, are we talking 50 to 100 millisieverts if you're doing a whole body PET CT?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So now let's pivot from the diagnostic to the therapeutic. Is it safe to say that the majority or the most prevalent or common type of radiation oncology treatment would be for breast cancer?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Well, let's talk a little bit about breast cancer, given how common it is. I'll tell you something funny. Despite training at Hopkins, I never once did a radical mastectomy. I mean, it was already long gone from clinical practice 25 years ago.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And again, just for listeners to make sure they understand the difference between a radical mastectomy and a mastectomy, or what's called now a modified radical mastectomy. The current version of a mastectomy removes all the breast tissue along with the lymphatic tissue in the axilla.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Certainly, I did more than my fair share of those, but the radical mastectomy, the Halsteadian procedure, removed also the entire musculature of the pec, pec major, pec minor, the whole thing. It basically was a disfiguring operation- debilitating, disfiguring. With nothing but ribs. Imagine what it's like to not even have pec muscles.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
You sort of take for granted what you need to do to move your humerus. And yeah, to think that it's only been 40 or 50 years that someone had the courage, I think it was probably Fisher. Right.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So without further delay, please enjoy my conversation with Dr. Sanjay Mehta. Sanjay, welcome back to Austin. Thank you, Peter. Pleasure to be here. I think this is the first time we're together not driving, right? I think so. Yeah, that is true. I don't know. Somehow we're going to resist the urge for most of this discussion to not talk about cars. Don't want to bore your audience. I know.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Yeah. For folks who want to know more about that, Sid Mukherjee, I think it was in The Emperor of All Maladies, has a chapter on this.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So let's talk about that. So a woman has a stage one or a stage two breast cancer. Typically these days, I think they're moving mostly to neoadjuvant chemo before resection.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So tell me a little bit about that. I was completely unaware of that. So I'm a woman, I've had a lumpectomy, sentinel node was negative. So I've got an incision about this long for the listener, five centimeter, six centimeter incision. They've probably closed it with beautiful internal sutures. I've got some steri strips. They're off in a week and I've got a nice little scar a week later.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I come and see you how many weeks after that?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
We do a CT scan. Just to be sure, planned pre-resection because you're seeing the tumor itself? What I meant was pre-treatment. Got it.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
It is called The Drive.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So I feel like we will reserve the right to have some automotive discussions at the end. For listeners, Sanjay might be one of the most knowledgeable human beings on cars. He's also a very dangerous friend to have. Because he's always the bad one on the shoulder when you're contemplating a new set of wheels or a new something for your cars.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And it's also, I'm guessing, where the tumor was in the breast. So if you have large breast and a superficial tumor, definitely prone would be amazing. The tumor bed is so far from the patient.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Okay. Yeah. So this is infinitely more involved than I thought, which means I'm not the only one that probably was ignorant of what is involved. How long does each session take?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
When did this become so automated with the robotic arm and stuff? Did you do this in your residency or were you the ones manually doing that in residency?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
But in his other life, in addition to being the founder of MD Motorheads, right? That's right.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
which is a Facebook group of doctors who are gearheads. We're about to crack 3,000 members. It's exploded. Yeah. That's awesome. So shout out to MD Motorheads. You're also a radiation oncologist, which we also spend some time talking about. Right. I guess we thought it would be a really fun idea to do a podcast for a couple of reasons.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
The actual radiation beam is generated by what? The ion is generated by?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
When you say that a typical treatment might be 15 gray over the course of the three weeks fractionated over 15 treatments. So it's actually about 40.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Okay. That's actually what I was going to ask. I was going to ask if the 40 gray is distributed completely uniformly across the breast. The answer is no. It is, but then you have that boost.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
One is just the bread and butter of what you do as a radiation oncologist is a bit of a black box to many people, myself included, if I'm going to be completely truthful. Even training in surgical oncology, I feel like I had much more familiarity with the medical side of oncology than I did with the radiation side of oncology.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
If we go back in time to 25 years ago, 30 years ago versus today, what are the typical side effects that a woman experiences from this treatment? And by the way, was she typically getting 40 gray 25 years ago or was that a little more? I think you said, and now they've come down a bit. It was sort of 50, 60 gray.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So for myself, for the audience, I think it would be wonderful to understand more about as it's a field that has evolved a lot. I'm guessing the last 25 years has seen a lot of change.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Did anybody ever look at when you had the very disparate hot and cold spots and follow women for recurrence? Yes. Was there any association between the cold spots and recurrences?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
What is the impact of breast implants in this type of treatment, either saline implants or the older... Actually, they're not older now. They're back in vogue, right?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
It's essentially tissue equivalent. Pardon my ignorance. I completely forget. Are those implants typically under the pec or between the pec and the breast? So we see both. What's the current standard?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
It's pretty incredible. Just out of curiosity, when did it become its own discipline, its own set of boards and everything like that?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Do women experience any systemic symptoms from radiation like nausea or vomiting, or is that pretty much?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Okay. Let's talk about prostate, which is obviously also the bread and butter of the field. So first off, which patients are typically being radiated?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
You've gotten to know Ted Schaefer, who's not only good on the podcast, but is equally, let's just say, interested in cars. He sure is. So you, me, and Ted have a lovely little text thread about cars.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Let's talk about a patient that comes in to see Ted for a biopsy. They've got a Gleason 3 plus 4, and then another patient who's a Gleason 4 plus 4 or 4 plus 5 or something like that. How does that patient navigate their way through the system as to whether or not they need radiation or should they undergo surgery? And does androgen deprivation therapy necessarily come with radiation?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Or is there a scenario where you undergo radiation But you don't require androgen deprivation.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And is the main selling point, because most patients just want things taken out, I have cancer, take it out, is the reason that a person might select radiation therapy, especially if it comes with androgen deprivation therapy, because of the sexual function and urinary function? What's the main advantage?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
It is extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member-only content and benefits above and beyond what is available for free.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And I know we've talked about this before. You're just not seeing the proctitis. Yes, almost none.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And does the patient need to be coached to time their breath or anything as the beam is at that most delicate edge of the rectum?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Everybody I've talked to who's had LASIK eye surgery always says they're so worried that they're going to do something, they're going to flinch. And do patients feel the same way when they're undergoing radiation? Like, what if I just flinch my pelvis or do something like that? It's going to get too close.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
What about patients that are inoperable? First of all, what leads to a patient being inoperable and how do they show up?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Got it. I had no idea that it was that new. And in terms of medicine, that's obviously like very new. The second thing that I wanted to talk about on the radiation front is this idea of using very low dose radiation to heal injuries. I think that while people will be incredibly interested to understand the ins and outs of radiation oncology, again, given the ubiquity of it in treating people,
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Now, is this an apples to apples comparison? Because the patient who undergoes the robotic prostatectomy today does not go on androgen deprivation therapy. They get to walk around. In fact, you've probably heard Ted on the podcast. He says, we'll give those patients TRT if they're hypogonadal.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Why does the patient after radiation therapy still need to be androgen deprived if in theory the radiation is as effective as the surgery?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Has there been a trial of Gleason 3 plus 3 watchful waiting versus XRT no ablation? No. Unfortunately, there's no actual trial. There's just observational studies. That's kind of what we're dealing with there. Oh, gosh. And obviously, you can't figure out what the biases are. But what do those observational studies show?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So it's really interesting. There would be a very interesting and elegant study taking, let's call it medium to high risk 3 plus 3s. So people based on family history or some other phenomenon, genetic or otherwise, you randomize them to watchful waiting versus radiate them without androgen deprivation. I mean, you'd have to do this as a very long-term study.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I think a lot of people are going to be very interested in this idea that why aren't we using low-dose radiation more to heal some of these nagging orthopedic injuries that people have? And of course, we'll go far down the rabbit hole on that. But I don't think we can have this discussion without giving people some understanding of what radiation is.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So the question is, outcome number one could be conversion to three plus seven requiring surgery and or androgen deprivation therapy. And then of course, outcome two, the very long-term outcome would be overall survival. That's the key.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And again, what fraction of Gleason 7s can do radiation without requiring androgen deprivation therapy?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
What about these patients that show up with two spine mets? How effective is radiation there, given that that's a favorite spot for a prostate too? You're talking about initial presentation with oligometastatic disease?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And I would like us to do it in a way that's both rigorous enough that we can really get into some of the science of this, but also get into it gently enough that people that maybe don't remember high school physics well enough can come along for the ride and not get lost.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And what is a more favorable presentation, oligometastatic to bone or oligometastatic to para-aortic? Bone, for sure.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And has he suffered any debilitating fractures?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
This guy's in his late 70s now.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
But once we get into grays and millisieverts and all that stuff, I want everyone to be fluent when we start talking about doses. Right, right, right.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Four digit PSAs.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Ted has told me about some of the most terrifying cases are the exact opposite. These guys that show up- With a low PSA. With a very low PSA. Yes. PSA of 1.9. Those are worse.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Anything else you want to talk about on the oncology side of this, as far as what should people know as they're engaging with a radiation oncologist? What questions should they be asking? It sounds like it's no different than surgery, where there's clearly a difference between good surgeons and not so great surgeons.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
There presumably are people that take the kind of care you take and agonize over the details. How can somebody find out if their radiation oncologist is practicing in your philosophy?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And not only that, the best surgeons often are treating the hardest cases.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Let's spend a minute just on the brain, because I guess that's sort of a unique case. I know it's not where you are. Still do a lot of it. Oh, you do?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Okay. Not as much as prostate and breast, but yeah, both primary and metastatic. Yeah. So again, because the brain is such a sink for mets, A, it's a source of a lot of primaries, but it's also where a lot of cancer spreads. It's often a place where you can't operate. either because the tumor, the met or the primary is too close to, say, the brainstem or something too vital.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So radiation is a pretty common tool there. So talk about the history of radiation in the brain. Sure. And the spectrum of everything from whole brain radiation to gamma knife and stereotactic and all sorts of things in between.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
This is a staggering amount of radiation.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And just to be clear, do you need to use way more radiation because that's what you're delivering to the brain? Is this an example of where the sieverts and the gray are very different because you have to get through the skull?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Doesn't that mean you need much more than 30 gray coming out of the machine?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
The bone doesn't do that much?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Do we know what the survival difference is for an unresectable glioblastoma with and without radiation?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Why is this cancer unsurvivable?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I find GBMs to be just such a frightening type of cancer. And I do wonder if it's going to require some sort of injectable immunotherapy or something. I think so. I just, you have to basically figure out a way to treat the brain systemically. You have to mechanically overcome the blood brain barrier and come up with some sort of systemic treatment for it.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Okay, so today, how many patients are undergoing whole brain radiation?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guest this week is Dr. Sanjay Mehta. Sanjay is a radiation oncologist at St.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I'm sorry, this is done with every small cell patient, no matter how early it's caught? If they have a complete response to primary treatment, yes.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So we've talked a lot about radiation. We've touched a little bit on the idea of radiophobia, but maybe let's use that as a bridge to talking about using radiation to enhance tissue as opposed to eradicate a subset of tissue. Does it stem from nuclear accidents? Is that largely where radiophobia comes from?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Why is it that the shorter the wavelength, because that's what's changing as you go from radio waves to microwaves to visible waves to ultraviolet, why is it that as the wavelength gets shorter, the energy gets bigger?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Is there a way to quantify how much exposure they had to radium?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Again, hearing you say this, Sanjay, the listeners are going to be thinking, what?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Because we're all so brainwashed into believing that radiation is horrible.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So this first came up maybe a year or two ago when I was lamenting. It must have been two years ago, I guess, because I was kind of lamenting my Achilles tendon, which I wouldn't say it was injured. I just had a little bit of tendonitis. It was just bugging me a little bit. You and me both, brother.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And so it was through that discussion that we got into what we're talking about now, which seemed crazy. I just decided I didn't feel like driving to Houston all the time to undergo therapy. And my Achilles is fine now. I just did sort of standard therapy. But I've sent a few patients to you who have had similar injuries, both high hamstring tendinopathies, Achilles tendinopathies.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So talk a little bit about this idea. How prevalent is this type of treatment in Europe? How prevalent is it here?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
You were giving 40 gray total to- A breast. A breast. And now for the Achilles, you're giving how much?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
The radio wave is too long. That's That's right. The microwave is too long. It doesn't have the energy. You can stand on it all you want. It can heat, but it can't damage.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Which is kind of remarkable because anybody who's had it, you know, I had it once back in med school, exactly 25 years ago. Did you get it treated or was it just resolved? No, I mean, I just went to PT and rolled on golf balls and did the usual thing, but it took months to get better. It's such a big deal.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So you're saying of the patients that are coming to see you with plantar fasciitis, how many of these patients, how long have they been hurting, first of all?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
The other area that is of huge interest, for me at least, is the very, very high hamstring tendinopathies. So that ischial tuberosity pain, very, very common for runners, seems to be anecdotally much more common in women than men based on pelvic anatomy. I've only treated women for some reason with that, and they've all had tremendous results.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Is there any literature looking at this for spine injuries? By injuries, let me be clear what I mean.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So when you think of all the times that people are getting spinal epidurals for irritation of spinal nerves, herniated discs, things of that nature, is there any reason to believe this could have any efficacy there if indeed there's some efficacy, which there clearly is due to spinal injections or epidural injections?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Interesting. And do you think it's because of patient selection? Like if you knew you were dealing with a facet arthropathy, that should in theory respond well.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
But your ability to center... the beam is remarkable. You're using the same high fidelity equipment you're using for radonc. So you can hit a P inside if you want to.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So let's talk about how these are measured. How do we quantify them? Because people on the podcast have heard me talk about this, I suspect. We talk a lot about calcium scores and CT angiograms and PET-CT. I think the frequent listener will have been somewhat familiar with how we talk about how to dose those things.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So- If you're treating somebody that comes to you and they've got an Achilles tendinopathy, usually there's a point of maximum tenderness, but it usually hurts up and down the whole Achilles. How do you position the beam? And are you literally hitting from mid-calf down to heel?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
15, 15.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
It's almost cancer.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I've seen, obviously, patients with debilitating keloids. What does it look like after the treatment?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I think what's amazing to me is I just think there's too many people that don't know this. I think there's too many people that are walking around suffering either from something that's cosmetically upsetting, like a huge keloid, especially on a visible part of their body. Obviously, everybody listening can relate to some nagging injury, tennis elbow, golfer's elbow.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Achilles tendinopathy, hamstring tendinopathy. These things nag for years at times.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I was very encouraged to hear you say a second ago that Medicare is covering some of these things.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So I think the question is, do we need more radiation oncologists? Because how are you making room in your practice to treat these patients when your cancer patients are probably ringing you off the hook as well?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Yeah, this is definitely an area where we are way far behind.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I'm hopeful that people listening to this, so if there's a million people listening to us have this discussion, and one in seven of them, let's just say one in 10 of them, at some point in the next couple of years are going to experience the type of injury that would benefit from this, how can they go about finding They can't all come to Houston to see you. I'm trying to get you to move to Austin.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
But regardless of where you end up, they can't all come and see you.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Well, I think at the end of the day, look, I don't think patients will have any patience for turf wars. Yes, that's true. And so if I'm a patient, every doctor needs to be a fiduciary. They need to put my interest ahead of their interest.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
But again, I mean, for Medicare to improve something is a huge bar. How are you getting Medicare to approve this? Are they basically acknowledging that, well, hey, if Europe's been doing this for 100 years and it's working, like, what's their bar?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Do we have a sense of the durability of this? So for example, I have a little bit of osteoarthritis at my AC joint on the right. It barely bothers me, but every once in a while, if I'm doing something really violent overhead, reaching for something, or I play a ton of football with my son, it'll bug me for like three weeks. I'll take a little bit of Advil. It's fine.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
If I did a treatment there, would it be done or am I doing this treatment annually? How would it work?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Now, what about non-osteoarthritis like rheumatoid arthritis and things like that? Is there any reason to believe that this could help with the debilitating injuries that those patients experience?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So if a patient has rheumatoid arthritis where they're really experiencing a lot of deformation in the hands, you think you can help that patient with the local part of it? Yes.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
But if they were treated early enough in the course of the disease?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
What are some other examples of where this could be used, at least in your experience so far, in terms of reducing reliance on NSAIDs or opioids or other things like that? Tennis elbows become a big one. Doing several of those.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
What's the relationship between a gray and a millisievert? Is it a one-to-one relationship?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Yeah, we failed to mention at the outset that you're also a remarkable musician. How much do you still play the drums?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Yeah, I was commenting recently on a podcast how much I regret not seeing Rush during their last tour. Again, because of the GBM. Tie it back into what we're doing here.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And can you appreciate it from an auditory perspective? Does it get too technical where it's hard to appreciate and distinguish?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
AMG Drift Academy, I think it was. Yeah, yeah, yeah. Which by the way, not to crap all over it, I ended up doing it because at the last second, I got a phone call from my driving coach and he was like, hey, I'm doing this AMG driving school and they got an extra spot in the advanced drift school. Do you want to come? But I'd already been to the Drift Academy with my friend, Josh Robinson.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I was like, yeah, sure, I'll go. And I was like, well, this is the last time I ever do one of these schools. Josh's school is a hundred times better.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
If you want to learn how to drift, yeah, if you want to learn how to drift, you go to the Texas Drift Academy.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Anyway, we met, but it was totally random.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
You've been kind of a car nerd your whole life. What is it about cars that has you as excited as you are?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Correct. Correct. So when you give 70 gray, you're giving 70 sieverts or 70,000 millisieverts over the course of the treatment? That's correct. Okay. Just so people can kind of anchor this to things that are familiar. Living at sea level exposes us to one to two millisieverts of ionizing radiation a year.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
It's funny. I just bought my youngest his first Lamborghini poster. He's mostly got sports posters on his walls, which is great. But I was like, you got to have like a Lamborghini poster. So let's go pick one out. So we scrolled Etsy for hours because I wanted to figure out what his taste was. Did he want to go retro? Did he want like a Countach?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
But in the end, I think we went with, I can't even remember now. Actually, we just ordered it. I think we went with an Orocon. Huracan, yeah, modern car.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Oh, yeah. It was going to be an Aventador or a Huracan. But get the color right and get the angle right. Have you driven a Countach yet?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I mean, you clearly don't expect it to perform like a modern car, but even if you judge it for what it was in the 80s, is it still not enjoyable?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Yeah, yeah. I've driven a Testarossa. Have you ever driven an F40? I have not.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So if you could have three road cars, but you can't sell them, you're not making the decision based on economics, what are the three you want? Three road cars, not daily drivers.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
If I could only have one, that's the one I want.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
A Carrera GT today is going for about one seven, one eight. 10 years ago, it was half that. Yep. And what's an F40 going for today? It's got to be three. I think at least. Yeah. I mean, six, seven years ago, it was half that. Yeah, it was half that. Do you think this is a bubble or do you think these things are not coming down in value?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
If you live in Denver, it's easily double that or triple that, correct? Just another thing for comparison, a pilot who spends a lot of time traversing The North Pole, which is typically how they're going to fly, they're not going to go all the way around the center of the Earth, might get another three or four millisieverts of radiation.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I'll tell you what's interesting about the Carrera GT, which, by the way, would be on my list of three as well. Most people listening to us now, if they're not car nerds, wouldn't spot a Carrera GT if it ran over their toes.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Joseph's Medical Center in Houston, Texas, where he's been in practice for more than 20 years. I wanted to have Sanjay on the podcast to talk about all things pertaining to radiation oncology, but also the history and some of the misconceptions around radiation exposure and radiophobia.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
That's like a bigger Boxster, right? It's just like- They're like, what is, is that a Porsche? What is that car? Like that doesn't even look, like it doesn't stand out at all. Whereas if you saw a McLaren F1, you don't need to know anything about a car to know you saw something special. For sure. For sure. And I think the same is true of the GT. The GT is absolute head turner, no matter what.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Okay, now of the modern cars, anything that you really, really fancy? Let's define that first wave of hypercars in the 2015. So when the LaFerrari, the P1, and the 918 came out, which is 2014, 2015, so 10 years ago. They call it the Holy Trinity for some reason. Yeah, golly, that was staggering, right?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So from that era forward, what do you fancy the most?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Well, that's why, by the way, I've got a friend who has all in silver 959 Carrera GT 918. That's the Trinity right there.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Tell everybody about the time you took your Tesla Plaid to Koda. How long did it take you to smoke the brakes on that? So when it was stock, one stop. Incredible. One stop. Make sure people understand this because they don't know. So that means you came out of pit lane, right? So you're going up to turn one. I did an outlap.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
But the first coming down.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I was running DOT 4 in the sim.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
30, 40, 50.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So we did the big brakes. Now I see guys out there with Teslas. They're clearly not pushing as hard as you.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Now, the NRC recommends that a person not be exposed to more than 50, I believe, 50 millisieverts of radiation in a year. Now, someone like me, that's easy unless I'm out there getting a lot of diagnostic radiology or, of course, undergoing therapeutic radiation treatment. But for someone like you who has to set patients up or one of your techs Are you guys approaching that level of exposure?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Because they all have great traction.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
It's literally just power to weight at that point.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So I didn't realize that. So the Taycan Turbo S was only 750.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
By the way, we failed. You very, very briefly mentioned it, but my favorite car post the Holy Trinity of 2014 and 2015 is, of course, the McLaren Senna. The Senna. Yep. How does the Senna stack up for you, and what was your fastest lap time in a Senna?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
That's insane for a street car with street tires.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Yeah. And the pro Mazda we're 2.3. Yeah. Yeah.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
I mean, that's just, and that's not even on a Pirelli. I'm a cheap guy. So I run, I run hard.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
So faster than your old GT4. Yes. The McLaren GT4. McLaren GT4.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Do you think McLaren is somehow underperforming relative to what they should be doing given both their quality as an automotive brand and as a racing brand? underperforming in terms of sales.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Is that a mode issue? No. Like if you were in track mode.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Well, I think it's safe to say nobody's listening to us anymore now anyway, but... case anybody still is. This has been an awesome discussion.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Well, hopefully today we delivered a lot of insight, both to people who are obviously interested in radiation therapy for cancer, which unfortunately is going to be a lot of people. And then of course, this other application around the treatment of inflammatory conditions, which again, inflammation lies at the root of so many other things.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
And just in case anybody cares about a little drumming in cars, hopefully we got something too.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
For all of my disclosures and the companies I invest in or advise, please visit peteratiamd.com forward slash about where I keep an up-to-date and active list of all disclosures.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
We talk about some of the very interesting applications that I only learned about recently that are very common outside of the United States that involve low-dose radiation to treat inflammatory conditions and athletic injuries. Now, of course, those of you who are interested may recall that because this podcast is called The Drive, I do occasionally talk about cars.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
Let's talk about some types of x-rays that people are familiar with and give a sense of radiation dose. I'm also curious as to how much this depends on the size of the individual. In other words, does a person that is larger receive more radiation for this same test, like a chest x-ray?
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
But let's take something like a chest X-ray. So chest X-ray, people should anchor to this idea for what it's worth. And we can come back to this. NRC says, hey, limit your annual radiation to 50 millisieverts. You've got 2% of that just being alive because you happen to go outside and be exposed to the sun. So the other 98% might come through flying diagnostic. Let's say you fly a lot.
The Peter Attia Drive
#343 – The evolving role of radiation: advancements in cancer treatment, emerging low-dose treatments for arthritis, tendonitis, and injuries, and addressing misconceptions | Sanjay Mehta, M.D.
That might get you up another 10%. So let's talk about a chest X-ray. You got a cough, you go to your doctor, they do a chest X-ray. That's how many millisieverts for a normal size person?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Autism spectrum.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
We'll park for a moment the use of the word disorder and maybe come back to that a little bit. But tell me today, how is the diagnosis of autism made? Because I think when many people think of autism, if they're old enough, they might think of Rain Man. You're going to think of somebody who... In a very short interaction, a non-clinician would go, oh, that person is not neurotypical.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
That person clearly has something about them that's quirky and very different. And you might think of even more extreme examples of children that are nonverbal and things of that nature. But again, given the nature of this and the fact that it's a spectrum, that must make it even more challenging to find the diagnosis, correct?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
We spoke about the diagnostic processes for autism, ADHD, and anxiety, which he calls the three A's, discussing how these behavioral diagnoses are made based on clinical traits and the criteria depending on the age of a child. We focus on the overlap between the three A's and how comorbidities are common in children with each of these conditions.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Is this something that is done during one assessment or is this something that's done over repeated assessments?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Who in your clinical team does this? What type of training does this person have? Is it a physician?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Trenna emphasizes the importance of a personalized treatment plan to consider the whole child, including their environment at home and school. We talk about the changing diagnostic criteria for autism between the DSM-IV and the DSM-V, and what some of the drivers might be for the increase in the prevalence of autism today. This is a very hotly discussed topic.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Say more.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So you mentioned that the diagnosis in probably more severe cases can be made earlier and earlier in life. Sounds like sweet spot is three to four years of age, but then you said half of the kids are diagnosed above six.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So is that something that is a relatively recent phenomenon of the past decade since the DSM-5 broadened the inclusion criteria? Or was that even true in the 70s and 80s?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Trenna provides a very thorough discussion of what the factors are that may be contributing to this. We discuss the various therapies, including applied behavioral analysis, or ABA for autism, behavioral interventions, and parental training for ADHD. We cover pharmacologic options, particularly for ADHD and anxiety, including the use of stimulants, non-stimulants, and SSRIs.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Something's different.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Now, this is a question I'm sure you get asked all the time. So the CDC said in the year 2000, one in roughly 200 kids, 150 to 200 kids had autism. Now, of course, that's pre this change of the DSM-5. So we can only take that to mean that those were the kids in that bucket of more extreme autism that did not include the PDD-NOS. Was that what the other one was called?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And Asperger's. But if you look at the data up until prior to that change, the last year prior to that change in 2012, it was down from one in 150 to one in 69. So in other words, there was something that was increasing the prevalence or diagnosis by about a factor of two. Then we get the change in the DSM, and today we're at one in 36. So...
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
It begs the question, what is it that is driving the increase in the prevalence of ASD, notwithstanding that there has also been a larger net cast around it?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Well, again, that's what the CDC said in 2020. So I'm going to go with whatever numbers you take. I'll believe your numbers more than mine.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
If you're at a dinner party and you get cornered and everybody wants to talk about this, how are you walking people through this? What are you saying? Let's put the diagnostic criteria aside. Let's put the keys under the lamppost aside, meaning wherever there's more attention, you're going to see more things. What are some of the environmental things that you think could be amplifying this?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Trenna explains how these medications are used alongside behavioral interventions to help children manage symptoms and improve their daily lives.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And we talk about the challenges families face in accessing care, particularly outside of major urban areas, and the importance of bridging healthcare and education to create a more holistic approach to support children with these developmental conditions. So without further delay, please enjoy my conversation with Dr. Trenna Sutcliffe.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Let's start with the genetic piece.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
We've had a number of folks on the podcast over time, so the listeners are probably familiar with what we mean by the heritability of something, but maybe just for folks that need to brush up on that, we would talk about the heritability of a condition, whether it be depression, whether it be schizophrenia, whether it be bipolar disorder, as largely determined by you have identical twins separated at birth, raised in completely different environments.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What is effectively the probability that they're both going to come down with the same psychiatric condition? And that's unfortunately, fortunately, that's the purest way we can get at what the genetic heritability is of something when you don't know what the genes are or when there are so many genes and it's very complicated. And my recollection is that the heritability of autism is quite high.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I don't remember the number. Can you enlighten me? Yeah.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Wow. I didn't know it was that high. I thought it was in the 80s, which is still very high. Am I also correct in my recollection that the heritability of autism is higher than it is for any other condition in the DSM?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Yeah. In other words, even schizophrenia, even bipolar, even depression and things that we know have very strong genetic components. None are as high as it is for autism.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Yeah, I was just going to say. So let's make sure people understand.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Yeah, so I think maybe a way that I would explain this, and please correct me if you don't like this analogy, I liken it to cancer with a fundamental difference. So hear me out for a second and feel free to shoot this down. Cancer is mostly about somatic mutations and not germline mutations, meaning most of the time when a person gets cancer, it is not based on genes that they were born with.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
It's based on genes that were at one point normal that have since acquired mutations in their mutated state they no longer function normally the person develops cancer So this complicates my analogy because only about 5% of cancers arrive from germline mutations, whereas the genes that are implicated in autism are indeed germline. You're born with them.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
However, the point I want to really make is comparing the somatic mutations of cancer to the germline mutations of autism. And the point I'm trying to make is that when you've met a woman with breast cancer, you've met a woman with breast cancer. You're not going to find too many women that look the same with breast cancer. And that's really why gene therapy hasn't panned out for most cancers.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Because to say that a person has breast cancer tells you some stuff. You could dig a little deeper and say, well, it's estrogen positive, it's progesterone positive, it's HER2 new positive. But still, why wouldn't they all respond the same? Well, it's because they have many different underlying genetic changes.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Furthermore, they have completely different immune responses in terms of what their tumor looks like. And so the way I try to think about it myself is, If you see 100 kids with autism, and let's just pick a number that's somewhat conservative, we would say that that's 85% to 90% heritable.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Well, Trina, thank you so much for coming all the way out to Austin. Really nice to meet with you in person. I've heard a lot of things about you from various colleagues in the Bay Area. And frankly, this is just a topic that I think a lot of people are interested in. Obviously, many of them parents, but I just think people in general are kind of interested.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
It simply means that the underlying genes for each of them were inherited, but they might have nothing to do with each other across all of those children. Just as we would say all of the women who have breast cancer have acquired mutations that gave them breast cancer, but they could all be very different.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Again, I could poke holes in that analogy, but I think that's maybe an easier way to think about it because polygenic things are harder to wrap our heads around, especially when we don't know what all the genes are.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
The thing I'm still struggling with is, let's take another example that I think we can all point reasonably at. 50 years ago, the incidence of type 2 diabetes was in the ballpark of 1.5 to 2%. one and a half to 2% of people in the United States had type two diabetes. Today we're, God, I haven't looked in a while, but it's over 10%. And I'm talking clear type two diabetes.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I'm not talking about in the gray area of pre type two diabetes. So let's just say we've had a five to seven fold increase in a condition over the course of one generation. So then the question of what are the environmental triggers? It would be very difficult to explain that just genetically, that there's been some genetic change.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
We might have genetic susceptibilities, we might have genetic manifestations, but the thing of it, something must have changed. And I think most people would point to our food environment as the leading thing that has driven that change because the change in the food environment in 50 years is dramatic. So when we apply the same logic to autism,
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Do we see big enough changes in these environmental triggers, even just over the last 20 years or 25 years, to say, okay, 25 years ago, kids were born with the same genetic predisposition. There can't be that much genetic drift. Unless we believe we are seeing more people pair together to combine four genes or genetic combinations that are producing this phenotype more than we saw before.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
We can come back to that. I'd love to hear your thoughts on that. But let's put that aside for a moment.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
If we're saying that whatever epigenetic change is happening is triggered by something in the environment, and we're talking about if paternal age is going up, if maternal stress is going up, if maternal nutrition is getting worse, if environmental toxins, microplastics are all over, everybody's talking about those things, heavy metals, whatever it is, I would love to go into a little bit more detail and get your thoughts on epigenetics.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And so maybe just before we jump into it, let's spend just a couple of minutes on your background so people understand who you are and why I wanted to spend so much time with you. So you trained in pediatrics, developmental and behavioral. Well, let me not try to summarize what you've done. Tell me what you've done.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
How those things are changing it. And we have to talk about vaccines, of course. There's going to be a subset of people here, I think, who understandably would think, hey, what about vaccines? Haven't we changed the way we vaccinate kids? Is that participating in it? Now, you mentioned that this is an in utero genetic condition, if that's the case.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
then childhood vaccines might be less responsible than some might think. But I'd just like to hear you riff on all of this stuff. Because before we get into the what to do, I still think there's a lot of people asking, how did we get here?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Yeah, I was going to ask you about that. Do we know that to be a fact that the epigenome is being transmitted?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
It makes a ton of sense to me because I think about this problem night and day. I do want to make sure the listeners understand that, first of all, this is not established. Not at all. And I want to make sure they understand what we're saying. So let's explain it one more time. We have these four things that make up DNA, your C, G, A, and T, and that is the code. That is the code of life.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
But on the backbone of those things, you can put little methyl groups, which is just a little carbon with three hydrogens. And that's called epigenetics. And by the way, we're all born with methylated groups all over our epigenome, back of the genome. Over life, no, that changes.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So we know that simply aging changes methylation, but we believe that there is differential methylation in individuals in response to all the things that you've talked about. And we know that methylation controls gene expression. In fact, methylation is probably the single most important thing that controls differential gene expression in different tissues.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So the question, the jugular question is, if you have a methylation pattern, can you pass that on to your fetus? And what you said a minute ago is even more remarkable, which is, would that child, when they develop, pass that methylation pattern on to their fetus? At that point, methylation epigenetics would start to become genetic, right? It starts to become a part of the germline.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So, I mean, this is an answerable question, by the way, in my book. When I think of things that we should know the answer to in a decade, I'm going to put this in the list of things that we should know the answer to just based on the fact that we will have enough longitudinal data, I think, to be able to get at this. I don't know if you're as optimistic as me.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And so in that sense, the child is now susceptible to two things. The germline that they inherit from both parents and as a fetus, the methylation impact that occurs. as a result of any of these other factors you've discussed. Who are the people that are studying this most closely? Is this in the purview of the geneticists? Is this in the purview of the epidemiologists?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Who are the people that are most working at this? Because again, as a general rule, I always think that it's very foolhardy to work on a problem, an epidemic, without understanding the causal nature of the epidemic. I use the example of heart therapy. Change the face of HIV forever. One of the greatest success stories of infectious disease, medicine.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
But it was all predicated on understanding what the cause was. If you didn't understand that HIV was destroying CD4 cells, you didn't have a prayer of developing that therapy. And do you ever worry that what's to say this isn't going to get to be one in three kids in 30 years?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And are there enough people like you that are going to be able to help parents and help families and help children with that? I don't want to sound alarmist, but I worry when we have an epidemic potentially and we don't have a great sense of causality.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And I'm just throwing that out as, hey, what if this trend continues, right?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What do you know about the change in the frequency or the prevalence of, let's pick one subset of that, which is the nonverbal or child that is so impaired that I could diagnose them or a parent could diagnose them? Do we know if that has remained relatively constant over the last 25 years despite the change in diagnostic criteria?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Do you have a ballpark idea? So if the overall diagnosis of autism is increased five fold in the last 20 years, has that more severe part gone up by 50% by a hundred percent? I mean, what do you think it is or what do you know it is?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Your interests today primarily revolve around behavioral therapy for three things that we're going to spend quite a bit of time talking about. I won't commit to the order yet because that'll come out of our discussion, but somewhere along the way, we're going to talk about autism, we're going to talk about ADHD, and we're going to talk about anxiety.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And I'm going to guess that sub bucket three is not the totality of the children that were called autistic prior to 2013. Is that a safe assumption?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So you can't even say, assuming the data existed and it sounds like they don't, we can't just say, what was the prevalence of autism in the DSM-IV and how does it compare to ASD sub three today? That wouldn't even be a meaningful comparison.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Okay.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Now, if you go back to DSM-IV, when, as you mentioned, physicians are struggling to know which of these buckets to put them into, as an outsider looking in, my first question is, does it matter in terms of treatment and resources? Does it matter more in terms of outcomes and support? There must be a reason why people cared about that.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
In other words, if you had a child in the year 2000 who one clinician said, this kid has Asperger's syndrome and another person said, no, they're autistic. Was that going to make a material difference in the type of support that they got? And most importantly, the type of person they were going to turn into, like, were they going to reach their full potential interdifferential capacity?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And what about PDD-NOS?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So coming at this through the lens of what you do today, which is running a really large, successful, multidisciplinary clinic, I assume this is just for children. So this is up to 18 years old, basically, is your patient population?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Help me understand the natural history of those kids back in the 70s and 80s. Back in the 70s and 80s when you and I were kids, nobody thought anything of those kids, right? Certainly weren't going to get labeled with autism. They certainly weren't going to show up with in-school programs to help them with their social skills and with their communication skills.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
As you pointed out, they're intellectually not impaired, so it's not like they're going to struggle in school. But there's clearly something that they're struggling with. Obviously, this hasn't been studied, but I'm very curious based on your experience and your judgment.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Are those people that just went on to pick careers where they didn't have to interact with people, but they could still do challenging cognitive work? What was the natural history of them? There are clearly a lot of them.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
let's start by just getting some of the diagnostic criteria straight i think that in general most people listening to us have a gestalt for what each of those things are but i think it would be helpful to maybe understand clinically how you look at each of those so let's start with anxiety
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I just think there's zero chance that there aren't thousands, if not tens of thousands of these people listening to us right now because they're adults today. And I wonder if they're listening to some of this and they're saying this resonates. I get that. When I was a kid, I was hyper-focused on this stuff. I wasn't interested in a whole bunch of stuff.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
It was a little harder for me to interact with other kids and things like that. And yet I found my path and here I am today.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What do you say?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
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The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Yeah. And how is it defined? How clear are the diagnostic criteria? What does the DSM-5 say about it? And how does a practicing clinician use that or maybe modify that in the way that they try to come up with a diagnosis?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Yeah, and I would imagine it helps them a lot with their child because they're seeing both, hey, my child has this diagnosis that now partially explains, you know, the challenges we might be having, etc. But at the same time, because I can empathize with that child if I've experienced it, it makes you a better parent. So everything you said makes a great case for widening the diagnostic envelope.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Because if we go back 40 years, we had this narrow, narrow envelope. In other words, we had a test that had very, very high specificity, but very low sensitivity. You were missing a lot of people. But you didn't get any false positives. That's for sure. You didn't over pathologize. When someone was autistic, they were really autistic. Today, we have the opposite problem.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
We have a high sensitivity, low specificity test, sort of. I'm making that up, but just to bring it to cancer diagnostics for people. So now anybody who's autistic should get diagnosed, but then we're stretching what that means. And a lot of the people getting diagnosed today, frankly, maybe without any support would go on to do just fine.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Do you worry that when the DSM-6 comes out, it could have a wider envelope and we could start to get to a point where someone might say, hey, are we over-pathologizing this?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And are we getting to a point where, well, what does normal even mean anymore?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And when does that do?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What was the gap between three and four and four and five? 15 years?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
It could literally be another decade.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
See, to me, the way I would think about that is I would hope that by the time we have to make that decision, we would have enough data. And the data would ask the most important question, which is how are we impacting outcomes? In other words, when we widened the diagnostic envelope and said that we're going to now have this ASD class one in here, that opened the door for more resources.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
That meant more kids had programs at school. What's a IEP?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
IEP. More kids have IEPs at school. What does that stand for? Individual.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Education plan. And at the end of the day, what we want to know is, are those kids doing better? And if the answer is yes, then it's probably worth keeping. If the answer is that didn't make a darn bit of difference, all we did was create a bunch of anxiety for the parents and maybe it didn't. Now, again, I don't know how one goes about answering that.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
But I would hope that somebody a lot smarter than me is thinking about it through that lens because we can't lose sight of the whole purpose of this. Like the purpose of a diagnosis anywhere in medicine should be to impact an outcome. A diagnosis for the sake of a diagnosis is not a particularly valuable tool unless you're an epidemiologist.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
But even there, it should be all in the spirit of how are we making people better?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Yeah.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And if we need to call it something by a different name, who cares? As long as it gets the service that makes them better off than they would have been had they received no service. Before we get into more of the details about what you do specifically treatment-wise, I want to finish one other bit of the diagnosis piece, which is can you talk a little bit about the overlap?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
You just did it sort of a second ago about ASD, ADHD, and anxiety. How often do they overlap? What do those Venn diagrams look like?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
If 50% of them have ADHD and 40% of them also carry a diagnosis of anxiety, is there a percent of those that are overlapped and have all three?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Okay.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Okay. So now what can we say about kids with ADHD and anxiety? What's that overlap?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Say more about oppositional behavioral tendencies.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I want to come actually right back to that. I don't know what fraction of kids are getting that type of insight and attention, but my concern would be not enough. My concern would be that we're just in a world of ever expanding labels and codes and the so what is missing when of course.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
There isn't really a field of medicine in which the so what matters more. If you think about this person has hypertension, hyperlipidemia, insulin resistance, it's important to understand why. But at a minimum, we have great treatments if we don't know the why. If at the end of the day, it's just deemed essential hypertension, we have no clue why, worst case scenario, we can put you on medication.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
If weight loss isn't enough to reduce your blood pressure and fix your insulin resistance, at least we've got medications that work really well. But- A lot of people would be hesitant to give their kids medication here.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I want to talk, of course, about this in length, which is all the more reason why, boy, if you don't understand why this kid has oppositional defiant disorder, because if it's like sensory overload, it's a totally different treatment path than if it's anxiety.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Yeah. And I'm trying to think about how you compare this to adult psychiatry, right? Where psychologists and psychiatrists who really help people tend to focus less on their DSM-5, in this case, diagnosis. They use that. If there's a diagnosis there, we should know what it is. And it paints the contours of what we think about.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
But as my friend Paul Conti always talks about, he's like, if you don't know their story, you can't really help them. Now, that doesn't mean that knowing their story precludes using pharmacologic agents when appropriate. But what it means is you have to really understand the root. Is this a response to trauma? Is this a response to an underlying biologic condition? And again, I feel like
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Based on the little bit I know here, adults seem to have more access to that kind of mental health care than children do. Is that a misperception on my part?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
You were the first person at Stanford in that group. You created the group.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Let's talk a little bit about your journey. You got to Stanford in 04?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Yeah, probably one of the three largest children's hospitals in the world, right?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So tell me a little bit more about why, what was happening prior to 2014 that you didn't enjoy?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
You need to see what the kid's doing at school.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So tell me about your team. You said you have 25 people on the team.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So there's something called ABA. Remind me what it stands for.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Okay. It seems to be a somewhat polarizing topic in the field of autism therapy. Maybe describe what ABA is and explain perhaps why it's so polarizing.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What's an example?
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#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guest this week is Dr. Trenna Sutcliffe.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Are there limitations to treatment in families with single parents?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Yeah. And I'm just trying to understand what the socioeconomic toll is. So I guess think about that in multiple ways. So what is the typical cost of therapy? So how much of this cost is covered by insurance typically? How much of this cost is embedded within the school program? So obviously I think an IEP is included if a kid's in public schools, correct? Yeah. If they qualify for IEPs. Yeah.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
But is ABA therapy or PRT or any of these things, are they covered by insurance companies for kids?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And what about the impact of other siblings? So is there anything that you've noticed about the nuances around if a kid has an ASD diagnosis and they have other siblings that don't have diagnoses or they do and where they are in birth order and trying to understand the overall family environment and how it pertains to treatment?
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#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And how much of that is based on the fact that this is a largely genetic condition? And if they're siblings, they share genetic traits, even if they don't have all of them. And how much of that is the siblings develop those in response to anything from mimicking the sibling with autism to responding in frustration to the behaviors of the kid with autism?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What would you say is the youngest age that each of those could be diagnosed? And I do want to talk a little bit about what the layers of diagnostic criteria are. But just starting at the first question, which is if a parent says, hey, I think my child has such and such, I really want to get a workup. Is there an age beneath which you would say this might not be a good use of time and energy?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Okay. So going back to ABA, if I'm hearing you right, I'm not hearing you say it's good or bad. I'm hearing you say it's just another tool in my tool bag and it has elements of it that are valuable if applied probably in the environment of the child.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What is the current size of the autism treatment industry and how does it compare to what it looked like 20 years ago? In other words, has it grown commensurate with the increase in the prevalence or is there a greater burden on the per capita therapist today?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So what do you say to a parent who's listening to us, who's trying to navigate this for their child? And they don't live in the Bay Area, so they don't get to come and see you. What questions are they asking? What are they trying to do to find the best care for their kids, regardless of where they lie on these spectrums of anxiety, ADHD, or the various levels of ASD?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
How likely is that?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Yeah, if you don't live in Boston or San Francisco or the major cities, I'm guessing that this multidisciplinary approach does not exist.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So what are the options then? What's the next best thing?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What is a parent asking when they meet a provider to figure out, is this going to be a good fit? I mean, obviously one option is just ask nothing and wait and see how it pans out. And in six months, ask yourself the question, hey, is my kid doing better today than they were six months ago? But if you, as a parent, had the chance to meet somebody several providers.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So the, Hey, look, I happen to be lucky. I live in a city. There's three ABA providers here. I'm going to go and interact with each of them. What could I as a parent do to understand where should I go first? Which of these three should I pick? What are the clues that tell me this person is going to have a higher probability of success?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I think that's a great list. I'm thinking about this through the lens of how do you scale what you're doing? And there's two ways to do it. One is you just keep replicating a model that looks just like yours. So really big multidisciplinary model, but that can only be supported in a certain geography.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I mean, to have a team at the size of yours, you're not going to be able to put that in every town. And yet I think it seems unlikely that this is a condition that discriminates by geography.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
and therefore there's got to be half the kids in this country that have any of these conditions are going to be in areas where they're never going to have large turnkey multidisciplinary offerings at their disposal. So their parents are going to have to do sort of the heavy lifting. And unlike cancer, so if a child gets cancer, a parent and family can go to another city for treatment. If you
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
happen to live in Austin, Texas when your kid gets a certain type of cancer, but Boston Children's Hospital or pick your favorite city that has the greatest center for that. It's not an unreasonable thing to potentially go there for treatment, but this is not something you're going to go and do in another city. It has to be an integration into your life where you are.
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#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What percentage of the children that present to your clinic with a diagnosis of ADHD plus or minus anxiety require pharmacotherapy in your clinic, in your experience?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
There's a selection bias into your clinic. If this were straightforward, they wouldn't be coming to you.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Okay. Yeah. Makes sense.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Define young. What does that cut off for you?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I want to dwell on this point, Trena, because I have to believe there are a lot of people listening to us. Maybe not so much because I don't think my audience is quite where I'm going, but they're going to be people who understandably come at this and are really judgmental. And their narrative is going to be the following. These goddamn preschools trying to tell me a kid has ADHD.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Maybe it's because the preschool is just overcrowded and the people who work at the preschool are too lazy to actually let these kids play. Let kids be kids. There's nothing wrong with a kid that's hyperactive. You just got to give him more to do, blah, blah, blah, blah, blah, blah. This is sacrilege that we would ever give a child medication just because they're hyperactive. So that's a narrative.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Now again I don't think a lot of people if they're sophisticated subscribe to that because I think a person who's sophisticated would hopefully not make a judgment like that without understanding the fact base a little bit more.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Would you agree that the best argument against that logic, which is not an argument that says every kid should be on medication, it's an argument that says you have to weigh the pros and the cons of being unmedicated and what the impact on your education is going to be and the long-term success you're going to have as an adult, as a well-adjusted adult.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
versus the accepted risks of any medication and the potential upside it has towards allowing that child to learn. Because again, I always like this framework you have, which is you bring it back to what is the adaptation of the condition? What is the adaptation of the phenotype?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
if it is disruptive, if this is a difference in a child's education, if this is a difference between a kid going to college and not, if we believe that matters anymore, or being successful in their career or not, or having pro-social relationships versus not, then maybe we accept the risks of medication.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So maybe you can articulate that more eloquently if you have a different view, but that's kind of how I like to think about things that seem at the surface absurd.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Their kid is not a statistic to you.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I've discussed this on some previous podcasts. So is Vyvanse still used? Is Ritalin still used? Is Focalin used? I mean, what's in your toolkit in that world?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So that would be for most kids, when you say school, you don't mean preschool, you mean actual kindergarten, five to six?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What was the other one after Focalin?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
And how do they differ? Are they differing in pharmacokinetics and half-life? What separates those three drugs, for example?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Okay, so it's just a timing of release in pharmacokinetics.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
But it's literally the same molecule.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So in other words, if a kid comes in and you try one of these and you don't get the response you want, you don't necessarily abort the entire molecule. You might switch to a different formulation. And I only say this because I can't tell you the number of parents I have spoken with who have said, my kid was on Ritalin. It was a disaster. When they switched to Focalin, it got so much better.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Okay. And then the other one you said was just straight amphetamine?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Again, same deal. The difference between Vyvanse and Adderall is release and kinetics.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Again, it's very counterintuitive to people why you take a hyperactive kid and give them a stimulant. Do you want to just give the brief overview of why that works?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What are the most common side effects you caution parents about with these drugs?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
But these are generally single administration first thing in the morning drugs, I assume.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
It's like they've never been on it.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What are the differences then between the Ritalin class and the Adderall class? Do you have any suspicion one way or the other as to which is going to be more effective if you were to prescribe Focalin versus Vyvanse?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Let's talk a little bit more about that. I don't know much about anxiety, and I'm guessing most people listening have a sort of hand-waving sense of what it means, but you said separation anxiety is an example. Anyone who's been a parent can appreciate moments of that. 99% sure our puppy has separation anxiety. What are some of the other types of anxiety, and how do you look to spot those in kids?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Interesting.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
You mentioned a second ago that if your kid's been on this drug every day for a year and experienced all these benefits, and then they come off the drug, it's like they were never on the drug.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Does that suggest that in the, I hate to use the description this way, but I think you understand what I mean, in the drugged state, you don't get to do behavioral therapies that also have a positive impact independent of the drug, such that if the drug comes off, the phenotype is changing? Is that not to be expected?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Yeah. In theory, they should be able to do a better job. It should be easier for them to practice the skills on the medication.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Training specifically for family, not just child.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So does that mean that you're telling parents or at least holding out a hope that, hey, your kid is seven or eight years old. We're going to put them on Ritalin. This might not be a lifetime thing. Do you give them that hope or do you not commit to anything one way or the other?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I get asked that question all the time for the types of medications I put patients on. If I put patients on a lipid-lowering medication, generally their first question, once you get through the why should I be on this and what are the side effects, et cetera, is, am I going to be on this for life?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Is it naive to think that because ADHD primarily impacts the prefrontal cortex that you would see at least a subset of people when they reach their late teens as girls and mid-20s as boys, when they reach maturation of that part of the brain, that at least a subset of them should be able to develop potentially the skills to overcome the genetic component of this?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Or is that not necessarily correlated?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So what about the non-stimulant class of drugs here?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Yeah. Do you ever mix these two or is it one or the other?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Are there any medications that typically show up in kids with autism but without ADHD? So let's just say kids with autism, plus or minus anxiety, what is the role of pharmacotherapy?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Got it. So you don't need the diagnosis to decide. In other words, there are kids with autism that are going to be on medications, and it's really just a function of the symptom.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Again, I think it's just got to be so hard for parents to potentially stomach putting children on psychiatric medication. But what you said earlier is sort of interesting, right? Which is most of them are coming back after saying, I wish we did this sooner, which I suppose would be the most affirming thing you could ever hear in that situation.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What are the things that they typically notice when they come back to you and say that? And how long does it typically take?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What do the kids say? Let's assume a child is old enough. So let's assume you're working with a seven-year-old or a 12-year-old who can articulate their feelings. What do they come back and say to you?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What other side effects do they complain of besides appetite suppression?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
You hear this phrase from time to time, which is that kids with autism have superpowers. We might think of an example like, okay, well, Dustin Hoffman's character in Rain Man, I mean, obviously highly, highly impaired for most of life, but clearly had a superpower. He could count cards and toothpicks. Obviously, that's kind of the Hollywood version of that.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
But is there truth to this idea that kids with autism have superpowers? Or is this something that you would put more brackets around and say, well, sometimes those kids who are in class three where they're really impaired, maybe there's something there, but it's a lot harder to see than the kids in class one, for example.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
There are a lot of famous people I won't name who have even talked about themselves as having mild forms of autism, Asperger's. So you would almost think that it's predisposing them to some of their greatness in the fields that they're in, often very technical fields. Is that consistent with what you see in the children?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
A more of a predisposition towards engineering, technical fields, STEM in general.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What do you think is kind of the most important thing you want people to understand about anxiety, autism, ADHD, that you think is either misunderstood or not understood at all?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Trenna is a developmental behavioral pediatrician and the founder and medical director of the Sutcliffe Clinic in the Bay Area, which partners with patients and their families to evaluate and provide supportive care for children dealing with issues such as behavioral changes, developmental differences, and school struggles.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
This has been really, really fascinating. I guess my only frustration in this discussion is the concern that there aren't enough people like you and your colleagues out there to match what is very likely the psychological burden of these conditions across kids today. And I'm only speaking to the United States. So I think if you were to think about this globally,
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I won't attempt to make a statement because I simply don't understand what the prevalence is or what the resources are. But I think we could probably say in the United States that there are far more children and families that are impacted by the AAA than there are multidisciplinary teams that can take care of them. Are you optimistic that 10 years from now, this model is going to be different?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
There are going to be more people that are going to want to come to practice this in the way? Where is the long pole in the tent? Is it getting more people to simply go into these fields? Is it a better payer reimbursement structure to incentivize more people around a multidisciplinary approach? What is it going to take in 10 years to close the gap between demand and supply?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I was literally just about to ask you the following question, which dovetails into that, which is, are we thinking about this the wrong way? Are we thinking about this as something that should be done through healthcare when maybe this should be done through education? If you had unlimited budget, one way or the other, this has got to get paid for.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So it's either going to get paid through health insurance or it's going to get paid through systems in education. Do you think that the burden is disproportionately on the healthcare system today and it should be a shared burden with the education system? And I'm not saying that to be critical of the education system. They would need the funding and the resources to do this.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
You've reiterated it twice now, which tells me how important it is. It really has to come down to this impairment thing.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
But is that part of the issue? Is that you're always going to see these things manifested in the education system and that's where you're going to get the most bang for your buck when you address them?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I'm really hopeful that this message spreads and that we see more and more of this type of integrative approach because it really makes sense. So thank you so much for your time and appreciate you coming out here.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
All of us could probably read through the DSM-5 and place ourselves in each of these diagnostic buckets. I know I can. I've done that exercise and it turns out I could make the case I have everything. But the truth of it is what I try to ask is which is maladaptive, which is mostly giving me the negative response that is impacting relationships or work or these other things.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
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The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
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The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
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The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
I like that framework for kids because if you think to yourself, oh, my kid has ADHD, but they're doing well in school. They're progressing in reading, writing, arithmetic. They enjoy playing sports. Yeah, maybe they're a little bit more rambunctious, but they have friends. How would you help a parent sort of navigate that?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
If they came to you and said, I think my son or my daughter has ADHD, like what are kind of the impairment style questions you would be asking to paint the contours of this condition? even if you acknowledge that that kid's got a lot of energy?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
In my conversation with Trenna, we explore her journey into developmental and behavioral pediatrics. In fact, she was the first person to be practicing under this designation at Stanford when she arrived about 20 years ago.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
How do you assess self-esteem? What questions are you asking the child when you actually get to sit down with the child to determine that? And is there anything you can glean on that dimension from speaking with anybody other than the child?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
What is the age window in which you can utilize that technique?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
This includes her background in genetics, pediatric neurology, and her current work in leading multidisciplinary teams around the care of children with autism, ADHD, and anxiety.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
About other people, you mean?
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
Interesting.
The Peter Attia Drive
#330 – Autism, ADHD, and Anxiety: Understanding the rise in autism and a multidisciplinary approach to diagnosis and treatment of each condition in children | Trenna Sutcliffe, M.D.
So you've, in that description, actually made a pretty clear, I think, case for some of the traits that are showing up in ADHD and in anxiety, all the different variants of it. Let's talk a little bit more about autism. Now, of course, it is referred to as ASD, right?
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
Hey everyone, welcome to a sneak peek Ask Me Anything or AMA episode of The Drive Podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com forward slash subscribe.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
And finally, discussions around oncology, cancer drug development, and how AI is impacting medicine now and possibly in the future. If you're a subscriber and you want to watch the full video of this podcast, you can find it on our show notes page. If you're not a subscriber, you can watch the sneak peek of the video on our YouTube page.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
Yeah. The first place was called the Bridge to Recovery. I went there in 2017. That's actually where I met Jeff English. We talk about that a lot in the podcast. The second place I went in 2020 was called PCS, Psychological Counseling Services. And I would recommend both of those places very, very highly. And I think PCS focuses on more than just trauma, but it's very trauma-focused.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
The Bridge is really a trauma-based residential program. And again, I'm sure there are others out there that are maybe equally wonderful. I know that for many people, obviously, I've encouraged a number of people to go to these locations, and many have. Everyone acknowledges, as I did up front, like, are you kidding me? How about I just keep working with my therapist for an hour? twice a month.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
That can work, but sometimes it doesn't. And sometimes you actually need to undergo immersive therapy.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
I mean, truthfully, and this is obviously just terrible rationalization. I think most things I buy in my eShopaholic bursts, I'm pretty happy with them. Not all of them. I have bought some really stupid things. And what I tend to do is give them away so that I don't see them again, which is actually counterproductive because I should keep more of those things as a reminder of my bad behavior.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
In other words, I should surround myself with more of the consequences of those actions. That's a great answer. Spoken like a true shopaholic in that.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
Right. It's this horrible selection bias. I keep the things that are awesome. I give away the things that are not awesome. It's awful.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So without further delay, I hope you enjoy this special quarterly podcast summary AMA of The Drive.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
Yeah, boy, Ashley is a force of nature. We had sketched out a lot of things we were going to talk about, but we never got out of insomnia and CBTI because I felt like it was just too important to stay there and gather all that information. So yes, definitely we'll have to have Ashley back. So I learned a lot. Honestly, what I came away with is thinking that
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
Okay, I feel like I almost know enough to help people through part of the CBTI playbook without even having to refer out to CBTI. And I think that the takeaway from this episode should be that you can do a lot of CBTI on your own. which is not to say you shouldn't reach out to a practitioner if you're struggling. But the good news is so much of the heavy lifting was covered here.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So first of all, let's just start with the semantics, right? So insomnia must persist for months. It must interfere with life and it must cause distress. This isn't just a few nights of bad rest. So we don't want to over pathologize this. So we're really trying to focus on a meaningful reduction in sleep.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
CBTI or cognitive behavioral therapy for insomnia is one of the most effective tools for addressing serious insomnia. 50 to 60 people who utilize this achieve a complete remission and 70% show improvement.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
so there are lots of contributing factors to the development of insomnia so you have predisposing factors like genetics past experiences you have precipitating factors such as a life crisis divorce enormous stressful experiences at work and then you have perpetuating factors or coping strategies like what you do when you are in this state of insomnia Now, CBTI only focuses on the latter.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
It does not concern itself with what your predisposing factors are, doesn't even care what the precipitating factor is, and doesn't try to stratify people based on those things. It basically says, you're here, you're having significant insomnia, what are you doing to cope with it, and how do we address that? So in that sense, the treatment is independent of the first two.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
Of course, I should just say this before we go on. You do need to address any sleep pathology like restless leg syndrome or sleep apnea before engaging in this. So you have to rule out that kind of stuff. Okay. So CBTI is really about addressing this triangle of thoughts to feelings to behaviors. So picture a triangle, thoughts, feelings, behaviors, where each one is influencing the next.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
And the discussion with Ashley was really a great way to kind of go through all of the behavioral changes to mitigate insomnia, which fall under the themes that are, I think, bucketed as sleep hygiene, stimulus control, time in bed restriction, cognitive techniques, and relaxation techniques. So let's just talk about each of these.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
Sleep hygiene is something that listeners of this podcast are very familiar with. These include things like keeping the room temperature cold in the mid-60s, even if you need to wear socks, keeping the room as dark as possible, and using an eye mask if that's necessary. It means not drinking too much fluid after dinner to reduce the probability that you need to get up and pee at night.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
This means addressing prostate issues if you're a male, things of that nature. It means getting rid of down comforters and heavy blankets, which disrupt the circadian temperature rhythm. Remember, when we're in bed, we're supposed to get into bed and rapidly begin a process of cooling to get into our deepest sleep before we begin to warm a couple of hours before we wake up.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
No place you'd rather be? No place I'd rather be. Nothing I'd rather be talking about. Even a race car?
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
She said anything with duvet in it should be banned. So basically anything that's going to keep too much heat in is a bad idea. Okay, what's stimulus control? Stimulus control means limiting the bed to only two things, sleep and sex. Everything else happens somewhere else. That means no phone. That means no reading.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
And while those are obvious, the other thing she made a really clear point about was no worrying. Now you might say, well, who sets out to worry in bed? But what she really means by that, and I think this is very important, is that you don't want to spend time laying in bed awake.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So if you're laying in bed and you're awake, especially if you're worrying, you need to get out of bed and do something else. So she talks about people who suffer from insomnia. One of the important things you have to do is get them out of bed for 20 to 30 minutes to do something really low key.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
She had a funny description of get out of bed and do something that you would be embarrassed if your colleagues at work saw you doing it. In other words, don't get out of bed at three in the morning to go and work for 30 minutes.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
Get out of bed for 30 minutes to read a trashy magazine or watch some silly sitcom, but something that's not really activating and allow yourself to get a little bit sleepy and then come back to bed.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
By the way, not long after the podcast with Ashley, and I rarely experience insomnia, but I went through a couple of days when I was being jolted up at two or three in the morning and could not get back to sleep. And my inclination was sort of to sit there and just fight it and fight it and fight it. And finally, on the third night, I was like, why am I not just doing what Ashley said?
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So as soon as it happened, I got up, went out to the couch in the family room, threw down an episode of Silicon Valley, which as you know, you and I talk about this all the time, like one of the greatest shows of all time, and then just went back in and went to bed. So that's an example of something that's super low key that allowed me to get back into it.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
The next one here is really, really hard for people to wrap their head around sometime, but it's called time in bed restriction. Previously, people referred to this as sleep restriction, which the name of that is obvious. So why would you do such a thing? Well, the problem is for many people with insomnia, they're actually spending too much time in bed and their sleep efficiency is really low.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
They're spending a lot of time in bed because they're tired, because they're not sleeping and it becomes a vicious cycle. Now, anybody who's used a wearable for sleep or uses anything that measures sleep probably notices a calculation that gets spit out called sleep efficiency. Sleep efficiency is time sleeping divided by time in bed. You want to be able to hit at least 85% here.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
I should say you want to be able to hit about 85% here. So to be clear, if you're hitting... 95%, you're not giving yourself enough time in bed is almost assuredly the case. And if you're hitting 75%, you're probably spending too much time in bed. So to restrict time in bed, you want to first understand your typical time of sleep with a sleep diary.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
And then you add a 30 minute buffer to get your target time in bed. So you can also determine the ideal wake up time and base your time in bed off this wake up time. So getting your wake up time right is key. This is the thing that you want to be fixed. And then your bedtime starts to take care of itself as you build up sleep pressure over time.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
You've probably heard me talk about this on the podcast before. The more consistent your wake up time is, even on weekends. the easier it is to control sleep hygiene. The term of people who let their sleep schedules move on weekends and they sleep in a lot later, which is understandable, right?
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
Like if you work Monday through Friday and you're getting up at five in the morning, it is a real tempting on the weekends to sleep till eight or nine o'clock. The problem is that process of social jet lag is devastating for your circadian rhythm. So she describes focusing on process S, which is sleep pressure, to standardize what she calls process C or circadian rhythm.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
And we talked a little bit about sleep trackers. She does not recommend using them if you're struggling with insomnia. And I couldn't agree more from our own practice. One of the first things we do when people are struggling with sleep is we get them to take their sleep trackers and at best put them away, at worst throw them out. Once this kind of gets in your head, it becomes a brutal cycle.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So you don't need this to fix the problem. Cognitive techniques. I found this to be very interesting. Schedule time for worrying. Again, for many people, the waking up part then triggers the set of ruminating thoughts. Insomnia sometimes arises from not processing information enough during the daytime. spending too much time in bed ruminating.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So she has her patients schedule worry time by intentionally putting something on the calendar where they literally write down all the things that they are worried about. And they might have 20 minutes a day to do that. And then they don't have to feel the need to process this at night.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So you think about the things that you would normally think about laying awake in bed and all of a sudden it gets a lot better. She does something called tracking the degree of belief, which means asking yourself, how much do I believe this is true? So a lot of times people will find the things that seem absolutely certain in the evening may turn out to be kind of unlikely during the day.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
They just feel more certain of it before bed, which increases worrying. So again, these are some of the techniques. I won't go through all the other stuff. There's some stuff she talks about on relaxation, which I think is helpful. And she also talked about A-B testing, other things that are probably less effective.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
She wasn't a huge proponent of blocking out blue light, but she said it's always worth trying. If wearing red light or blue light glasses in the evening helps, she's like, by all means, great. Give it a shot. Obviously experimenting on timing of caffeine, medication, supplements, all great. But her view is just test those things out. So yeah, I would say those are kind of the big things.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
This was an episode I was really looking forward to doing. As we discuss in the episode, I've obviously known Jeff for many years. I owe him a great debt of gratitude. And this is one of those episodes where between the time we recorded it and the time it came out is probably eight to 10 weeks.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
During that period of time, I sent the unedited, just straight audio file of it to no fewer than 15 to 20 people. Meaning I couldn't even wait for this episode to come out to be sharing it with people. So I think that probably tells you something. I will be completely comfortable stating that that will be a record that will last for some time.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to another quarterly podcast summary episode of The Drive. In today's quarterly podcast summary, I'll discuss what I learned from some of the recent episodes of The Drive, focusing on what I think were the most important insights, as well as any changes in my behaviors as a result.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
There's no scenario I can think of where I've taken a podcast before it comes out and shared it with so many people. I would say that most of the people I shared it with not only found it to be incredibly valuable, but actually wanted to sort of engage with Jeff on a professional level after that. So it's one of those podcasts where if it resonates with you, it's really important.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
You're gonna share it a lot. Okay, so what was this episode about? I mean, it really was a great episode about understanding trauma And it's such a loaded word that I think it's understandable why people might have some skepticism around that. I think the word does get used a little bit too much.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
But Jeff has a great definition for it, and I jotted it down right, which is that trauma is a moment of perceived helplessness that activates the limbic system. This can be a wounding event, a major event, or maybe a series of smaller events. And those typically get referred to as big tree and little T traumas.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So a big T trauma is something really obvious, being the victim of a violent crime, for example. And little T traumas are like a thousand paper cuts. A parent that was there, but just really wasn't paying attention to their kid. And those can be damaging in different ways. So
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
What Jeff talked about was that in trauma, too often people focus on the what happened part of the equation, but he thinks that it's more important to focus on the how did I adapt part of the equation.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
And as he talked about it, the sine qua non of trauma is that there's a disconnected version of a person that shows up to life relying on maladaptive strategies to replace connection with something else. I think that is... a remarkably succinct way to explain things. And it's not judgmental. It's just saying that something happened, a series of things. There have been adaptations.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
Those adaptations have led to disconnection and maladaptive strategies. This could be things that are perceived of as quote unquote bad, like alcohol, drugs, gambling, but it could be also things that are perceived of as good, such as work or perfectionism. All of those things replace the sense of connection. So this is just an episode that I think you have to go back and listen to.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
But to me, that was the most important takeaway. He spoke about implicit and explicit memories. So people can explicitly remember an event and think objectively as I think about that. It didn't really impact me, but implicitly it is impacting them through anxiety or some other type of discomfort. He had a great saying, which is if it's hysterical, it's historical.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So I think about this often when I overreact emotionally, when I calm down, I'm usually asking myself, what was that really about? Was it really about the thing that you blew up over or was there something deeper that this is reminding you of in terms of a vulnerability or something like that? Very important distinctions here between guilt and shame.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
Guilt is about, as he described it, making a mistake. Shame is about being a mistake. Some people refer to this as healthy shame and unhealthy shame. Again, it's not necessarily one way to think about this. Okay, we talked about the trauma tree. I've heard so many different people talk about trauma in so many different ways. I still think this is one of the better models.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
And it's a tree because it has roots and it has branches. And the roots are below the ground and the branches are above the ground. And that is a metaphor for the fact that the roots or the causes... are not necessarily visible, while the adaptations, the branches, are indeed visible. So very important to understand in this model that intention is not a requirement for the roots of a tree.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
What do I mean by that? Sometimes the wounding events, i.e. the roots, are not intentional. They're not driven by people who are intending to hurt. This is, I think, a very important thing for people dealing with trauma to understand because it's very easy to minimize an event that had an impact on you as a child.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
For example, if you believe that the person who was responsible for this wasn't trying to hurt you, and that's often the case. So keep that in mind. So what are these? So the five roots of
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
This shouldn't be seen as a replacement for listening to or watching any of the original episodes, but this may be a great way to reinforce things that you already saw or at least point you back to an episode you missed. In today's episode, we cover interviews that I did with Jeff English, Ashley Mason, Sanjay Mehta, Sean Mackey, and Sue Desmond-Hellman.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
are broken down as abuse which can be physical typically that is pretty deliberate emotional sexual again obviously these are generally quite deliberate religious so there's an example where it might not be with a mal intent but of course it has bad outcomes the next would be abandonment this can be physical abandonment literally someone being abandoned by a parent but it could also be emotional
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
Neglect, which is obviously distinct from abandonment in that the care provider is still present but is not paying attention to the child. Enmeshment, which is basically boundary violations, emotional incest. This happens when kids have to grow up far too quickly to be emotional caregivers or peers with parents typically. And then tragic events. These are pretty obvious, typically not subtle.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
We talk about war, we talk about things of that nature, violent events. Okay, so then we have the branches. And again, the branches are the adaptations here. And the important thing to remember here, and I think this is really helpful for anybody thinking through this for themselves or for others, is that adaptations typically work very well for the child that has been wounded.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
And again, I use the word wounded as kind of a broad emotional term. The problem is they tend to become maladaptive later in life. He gives a great example of a father who is physically abusing the mother of his child. And whenever this happened, the child would run into his bedroom out of fear because dad is getting violent. He's hurting mom.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
But one day, the child's fear that his mother was going to be hurt was so great that he ran into the bathroom and pretended that he was sick as a way to distract the father. So the father screams at the mother and says, look what you're doing. Your hysterical whining has made your son sick. And this temporary distraction actually prevented his father from injuring the mother.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So that was an amazing adaption. That child basically learned that he could be deceptive and manipulative, and it actually worked. It was a really good adaptation, and it probably will serve that child well for some time. The problem is it will not serve that child well as an adult.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
He describes these adaptations as old friends that serve you well, but lose their utility and become destructive as you age. And so, again, what are these four branches? These four branches are codependency, which he calls an outer reach for inner security, addictive patterns. Again, these are the most obvious in some ways, so substances, but also work, process, obsession, things of that nature.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
attachment issues where the common thread is sort of insecurity. So there's kind of an anxious attachment, avoidant attachment, disorganized attachments. He goes into these in details. And then just kind of a bucket for all other maladaptive strategies here. And I'm sure people can think of many examples.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So I think I've learned a lot over the past seven or eight years on this, but I think Jeff sums it up so well. And I've seen this over and over in myself, in my patients. When you're working through trauma, or if you're on the fence about whether or not you should work through trauma, it's worth remembering. you're either going to deal with it or it's going to deal with you.
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
We revisit topics around trauma, therapy, mental and emotional health, insomnia, cognitive behavioral therapy for insomnia, and improving sleep. radiology, radiophobia, common misconceptions around it, how radiation is used in not just cancer therapy, but also for treating inflammatory conditions such as arthritis and tendonitis, pain, chronic pain, and how to treat them,
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#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
These things cannot be buried. They're going to always, like a whack-a-mole thing, always show up at some point and you can't play whack-a-mole indefinitely. The first step, I think, is just accepting that that's the case and that there's a better way to be and that these coping strategies, while incredibly valuable, are probably not helping you.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
that you may indeed be passing on maladaptive behaviors to your kids if you're a parent, and dealing with something that he describes as putting the adaptive child out of the driver's seat and into the back of the car. So those are probably some of the important things I would take from that episode. I don't think that this summary even remotely serves as a substitute for listening to that.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So if you missed that episode and anything I said even remotely piques your curiosity, I think you've got to go back to it.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
to practice, we've talked about this on other podcasts, but practicing or understanding what your practice looks like to expand your distress tolerance window. I write about this quite a bit in the final chapter of Outlive, but it's sort of knowing the things that you do that give you a greater operating window.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So for example, for many people, meditation is a great tool to increase the probability of responding as opposed to reacting when something happens. learning the language of I statements, basically taking ownership for what you think, what you feel, what you do, working through this triad that he describes as the triangle of vulnerability.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
So sadness, shame, and fear, and trying to be curious about where you are on that triangle and being more responsive to your own emotional vocabulary around these things, noticing what your coping skills are. Again, I talk and often joke about some of mine that still exist to this day. E-shopping is an enormous coping skill for stress.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
I just can't stop buying stupid things online when I am stressed out. I feel fortunate in some ways. I'm really glad that it's not drinking too much alcohol, but it's still a distraction. Even if the worst thing it does is set me back a few dollars, it's preventing me from connecting and it's preventing me from accepting and dealing with what it is that's happening.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
I think there are other things, but I think those would be a great place to sort of start. And obviously we talk about so much more in this episode.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
I just can't say enough about it. It's one of the things I enjoy talking about with patients more than anything, because even though patients come to our practice because they want to improve their lifespan, they also care about healthspan. And it's easy to forget that emotional health is a piece of healthspan.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
And I think when a person is sort of caught in the vicious cycle of what's often the response to and the adaptation to traumatic events, not necessarily exclusively as children, but often as children, they're not living this connected life that Jeff talks about. And I can just share from personal experience that being disconnected versus being connected is all the difference in living.
The Peter Attia Drive
#347 – Peter’s takeaways on mastering sleep, dealing with chronic pain, developing breakthrough cancer drugs, transforming healthcare with AI, advancing radiation therapy, and healing trauma | Quarterly Podcast Summary #5
And it's not like you flip a switch and everything is fine. It's a process. It's a journey, of course. But I've never met a person who's addressed their negative adaptations and come out on the other side and said, I wish I didn't do that.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Yeah, and I'll tell you this. I do most of my VO2 max testing outdoors now. I use that VO2 master device, which I love. I'm going to leave from my house. I'm going to ride 10 to 15 minutes to the place where I do my hill repeat. So that's a warm up in and of itself.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
And by the way, getting there, there are a couple of short little climbs where I'll do 30 seconds of relatively high power just to get up over a little pitch. I will do two to three full runs of the hill at escalating power before I'm truly going to hit my max. So I'll do like a four to five minute up, maybe 85% of what my maximum power would be for that climb.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
come down for the same amount of rest period, go up again at maybe 90% of what my maximum power would be, come back down, and then maybe I would go and give it. The third one would be out there. So by the time I've done it, I've really warmed up. And so the other day I was talking to a patient who did his VO2 max test at a facility. It was at a university that he went to do it.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
zone to resistance training and learning all of the effects of anabolic steroids and yeah that sounds like a hodgepodge of topics but that's because it's pulled from all of these discussions if you're a subscriber and you want to watch the full video of this podcast you can find it on our show notes page if you're not a subscriber you can watch the sneak peek of the video on our youtube page so without further delay i hope you enjoy this special quarterly podcast summary ama of the drive
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
It was just like a place where you can go and pay to do it. And I was kind of surprised at what his number was. It was lower than I expected given his training. I said, tell me about the protocol. And he's like, yeah, I just got on the treadmill and they just started cranking it. And I was like, and how long after you started on the treadmill did you hit VO2 max?
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
And he's like, I don't know, five minutes. And I was like, yeah, that's a garbage protocol. You were not warmed up and ready to do that.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
In the spring. And the reason is because I like doing it outdoors. I have noticed because I live in Texas, how much of a performance hit I take in the summer. Like it's a noticeable difference in the summer. So I'm like, yeah, I just would rather do it in the spring. Fall, winter, spring is when I prefer to test.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Hey everyone, welcome to a sneak peek Ask Me Anything or AMA episode of The Drive Podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to peterattiamd.com forward slash subscribe.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Not at all. This is just a data check. It's just like I had my blood drawn this week, had my DEXA scan a couple of weeks ago. I'm doing a VO2 max.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Just one day a week. Yeah, it's three days a week of zone two and one day a week of interval training. But interval training at that specific four, five, upper limit, eight minute intervals.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
VO2 max training hurts less than a true Tabata. I mean, a true Tabata, that's where I think people have a hard time understanding what all out means. I mean, technically, I don't think the human body is capable of going all out for more than 10 seconds. So even at the level of a Tabata, which is a 20 second effort followed by a 10 second rest repeated eight times or done eight times,
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Even a 20 second, there's just a governor that is self-regulating how hard you go. The reverse Tabata, where you go 10 seconds all out, 20 seconds rest for eight rounds. That's about the closest thing that I think we're capable of doing as a truly all out
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
You will increase your VO2 max doing that type of an exercise, but not nearly, not nearly as much as if you're doing intervals in the three to eight minute range. And by definition, if you're doing something for three to eight minutes, you're not going all out. What you're trying to do is go as hard as you can for that distance and for that time. So it's a different animal.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Obviously, I think it hurts more because it's a lower level of peak pain, but it's spread out over a longer period of time. So the area under the pain curve is greater, but it's far from all out and at any moment in time, the pain is not the same.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Yeah, technically the power is constant throughout the four minutes. So I know in my mind how many watts I want to produce and what I want my average wattage to be over the five minutes. So let's just say I want to do five minutes at 300 watts. Of course, you're outdoors, so you don't have complete control. It's always jumping around.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
But I'm really watching the three second power tracing and the average power to keep it there. Well, after the first minute, I barely know I'm on the bike. It should be really easy after a minute. If you're dying after the first minute, you've set your target too high. Two minutes in, or two and a half minutes in when I'm halfway done, I still feel pretty good.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
My heart rate is now going to be within about five beats of what its maximum is. But I still feel pretty good. It's really at about minute three, three and a half that the pain train starts to leave the station. And that's when it really starts to feel miserable. And that last minute is really, really difficult.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
If you've done this right, when you finish this, you're really going to need that four or five minutes of very, very easy pedaling. to let your heart rate come back down to then repeat it. But again, the goal is not to have killed yourself in that five minutes such that you can't do it again. Because what I'm trying to do is actually preserve that power across all the intervals.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Well, again, for people like me and probably most people listening to this podcast, this is not something that should be on our radar. I don't think there's ever going to be a day when I'm doing a 10-hour endurance event again, and therefore I don't really need to worry about it. If I'm exercising for two hours, that's kind of a long time. So at two hours, I'm fine with just water.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
I'm living off my own glycogen and whatever. But it's very difficult now to think about people competing at a world-class level in cycling and Ironman because what Olav and many others have now argued is the problem of peak endurance is effectively an energetic problem.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
It's basically a question of how much chemical energy in the form of food can you convert into electrical energy via the metabolism of food back into chemical energy in the form of ATP back into mechanical energy. It's just an energy transfer problem. And More energy input means more energy output.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
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The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
The more logs you can put into the fire, the hotter the fire burns, the more steam it makes, the faster the wheel turns. That's basically what it comes down to. And what we've seen over the past decade is quite literally a more than doubling of the feedstock that goes into the furnace.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
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#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
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The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
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#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
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#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
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The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
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The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
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The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
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The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
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The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Yeah, and before we dive into this, at least in as long as we've been doing quarterly podcast summaries, I will say this might end up being the longest because just by the nature of coincidence and which podcasts fall into the past quarter, this is probably the most voluminous set of notes I've ever taken across a set of podcasts.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
In fact, I would say that two of the episodes that we've covered here, the one with Ralph and the one with Sam, We're easily 3 to 4x the volume of notes I normally take. Impute from that way you will. I've done my best to try to synthesize that, but nevertheless, there's a lot going on in this past quarter. Okay, you're right.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
I wanted to make the Olav one at the outset just straight into less technical things, and I could not resist the tractor pull of trying to at least explain some technical things. So we started the discussion by explaining the difference between things like functional threshold power and critical power.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
I hesitate to bring these up now because I just don't think they're relevant unless you are a cyclist. But if you are interested, I'll just state it. The functional threshold power or FTP is the power that you can hold for one hour. That is one way to test it.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
So without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to another special AMA episode of The Drive. Today's episode will be the fourth installment of the quarterly podcast summary.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
You literally get on a bike, usually on an erg, so it's a stationary bike, and you ride as hard as you can without blowing up for one hour and whatever the average power is that you held as your FTP. Much more typically, for example, when I was a cyclist, we would do this in a 20-minute test and we would discount it by typically 10%, although Olaf suggested only 5%.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
In my experience, 10% was necessary. There's something called critical power, which is very similar, but rather than it being the power you can hold for an hour, it's the power you can hold for 30 to 40 minutes. I think the more important distinction here is that you can calculate critical power much easier.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
You can do it from a set of curves that are derived from three to four individual tests that are much shorter. Why is this relevant? This is relevant because if you want to have other metrics beyond VO2 max for higher end aerobic efficiency, you might want to know your FTP or critical power and critical power is much easier to measure.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
So these days, and this ties into another insight, by the way, these days, I don't spend a lot of time worrying about my FTP. In fact, I don't know what it is because I haven't done a 20 minute power test since NAMM.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Don't necessarily think I'm going to do one anytime soon, probably because I don't want to see how low it is, but it made me realize maybe I ought to do a critical power test just so that I have another benchmark to be tracking. So we talked about a few other things, which I'm not going to go into, anaerobic threshold and stuff. We covered a little bit of that in the first podcast.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Another very interesting insight that came up for me in this podcast, which was really just a personal insight, and I hesitate to spend too much time on it, was talking about the relationship between VO2 max and PVO2 max or VVO2 max. So if you're a cyclist, what does that mean? PVO2 max means what is your power when you are at VO2 max?
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Again, VO2 max, just to make sure everybody knows what I'm talking about. This is maximum ventilation, meaning maximum oxygen consumption. It's usually sustained for at least a minute when you're doing the test. So what's the highest amount of oxygen in liters per minute that can be consumed for a minute?
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
And this is achieved during a ramp exercise, almost exclusively done on a bike or on a treadmill, stationary bike. And when you hit that VO2 max, if you're on a treadmill, you will note that, hey, there's a velocity, assuming you're running flat. Or you might see, oh, actually, I'm on a bike and my PVO2 max is the power that I've achieved.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
In this conversation I discuss what I learned from the last quarter of interviews and what I think were some of the most important insights as well as things that have resulted in a change in my work and behavior. Please note that I do not think listening to the quarterly podcast summary even remotely constitutes a substitute for listening to the actual episodes.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Now, some have argued that VVO2 max or PVO2 max are actually more predictive of sport-specific performance than just the number VO2 max. And I think there might be something to that because I shared my numbers with Olav And the truth of it is, I have always had a very low PVO2 max to VO2 max.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Stated another way, I have always had a VO2 max that is higher than many people who are much better cyclists than me. It wasn't uncommon when I was training that my VO2 max was 15 points higher than people who had a higher FTP than me, for example. And what all I've suggested there is it speaks to really inefficient, probably overtraining aerobically, undertraining anaerobically.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
So there's an inefficiency there. And that inefficiency means that I am actually requiring more energy across the board to put out more power. Now, something very interesting that comes from that is there might be an association between people like that and a lesser propensity to gain weight.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
And it is true that every time I've done a resting metabolic expenditure test or any time I've done the more elaborate stuff, I've actually done the doubly labeled water test in the metabolic chambers. I always seem to have a through the roof energy expenditure for my body weight.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
So I guess for the first time that all kind of came together, which was, wow, on the one hand, I have an advantage perhaps in that I have a very high energy expenditure. So relative to somebody else who eats as much as I do, I'm going to be leaner. But the flip side of that is I'm actually quite inefficient at utilizing energy. So again, I found that very, very interesting.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
One of the other things we talked about was, hey, is there anything that a person can do besides the obvious, which is training to boost their VO2 max? He mentioned something about beetroot. Wasn't familiar with this, but beetroot concentrate, he said, is rich in nitrates. Body converts it into nitric oxide. And that, of course, helps with vasodilation, opens up capillary beds.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
It should be stated then, of course, that anything that impairs nitric oxide synthase, and there are many things that do from homocysteine to insulin resistance, is going to impede it. Again, he said at the elite level, This doesn't have much of a difference, but in amateur athletes like the rest of us, it can be about a 5% boost.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
The other thing he talked about that I thought was really interesting was, and again, this was to me just more gamesmanship than anything else, and I can't wait to try it the next time I do a VO2 max test, which, by the way, is probably going to be this weekend or next. He said, as you approach failure, do a few breath holds, and he said that that produces a significant boost in VO2 max.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Again, it's just a reactive overconsumption of oxygen. I don't know if that means anything. One of the other things that I asked him about was the use of acetaminophen. Again, there are some data that suggests that acetaminophen use can boost peak endurance performance by one to two percent. I asked Olaf if Christian or Gustav use acetaminophen themselves during Ironman, and he said they did not.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
And he raised a point that I thought was interesting, which is While acetaminophen or Tylenol can obviously reduce the perception of pain, which has been one of the arguments for why it boosts performance, it may impair the athlete from giving off heat from heat dissipation. And so he just questioned whether or not that might be a worthwhile trade-off.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Of course, for me, that begs the desire to do an experiment and find out.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
My hope is that it basically helps you think about refining what you might have learned there, and if something you hear in one of these summaries is of interest and you missed the original episode, I hope you'll go back and listen to it. In today's episode... We cover the interviews that I did with Olav, Alexander Boo, Ralph DeFranco, Sam Sutaria, Trena Sutcliffe, and Mike Istratel.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Another area that we talked about, which again, isn't relevant to me and the way I train, but if any of you are listening and you are really high performance athletes, I think this is arguably probably the single most important takeaway from this podcast is what the upper limits of carbohydrate consumption are while doing cardio activity and racing.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
So again, if you're a triathlete, if you're a cyclist, if you're a runner, less applicable in running because the races are typically so short. But of course, if you're an ultra marathon runner, that would not be the case.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
So everybody's kind of done this math, which is if you're doing an Ironman or something like that, you're probably, depending on your level of fitness, expending somewhere between 700 and 1,000 kilocalories per hour. Let's even be conservative and say you're really, really just going easy. You'd be at 600 to 700 kcal per hour. Now, we don't have that much stored glycogen.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
You've got maybe 50, 100, maybe 200 grams of glycogen if you have really big muscles stored, which you're going to run out of pretty quickly. That's going to supply you for maybe an hour and a half. So thereafter, you have to meet your needs from body fat and intake of carbohydrates. And the conventional thinking has always been that you can only consume about 60 grams of glucose per hour.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
And 60 grams of glucose, of course, is only about 240 kilocalories. This has always been one of my main arguments for why being fat adapted is very important, because if you're consuming that 60 of glucose and that's giving you whatever it's giving you, you have to get the balance from fat. And you're only going to do that if you're heavily fat adapted. So you get into this cycle.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Well, what we've seen unquestionably is I think the biggest, honestly, the biggest innovation in endurance sports like the Tour de France and Ironman over the past decade is the amount of glucose that these guys are able to consume. He talked about numbers I had never heard before. As some of you may recall, I interviewed Tadej Pogacar recently, the greatest cyclist on the planet.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
His numbers blew my mind of the type of carbohydrate intake that he was tolerating, 150, 180 grams per hour. Olaf said that they're now pushing triathletes at the world-class level to 240 grams per hour. Again, this is unbelievable to me. And what that basically tells you is you can meet all of your glycolytic needs indefinitely through that.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Now, again, just as Tadej said, you have to train this system. These are athletes that are required to now consume gels and eat carbohydrates at a 12% mixture. What does that mean? 12% mixture means 120 grams per liter. 10% mixture is 100 grams per liter, etc. Conventional wisdom. is that we can't tolerate, meaning our gastrointestinal system cannot tolerate more than a 5% mixture.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
And I know for me personally, when I used to be doing ultra distance stuff, I had a hard time going above 5% to 6% myself. But what Olav said and what Tadej has also said separately is you can actually train your GI system to double that. And so how these guys are drinking two liters per hour of a 12% mixture, which would be 240 grams, I simply can't fathom.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
But clearly that's what they're doing or they're doing it in some combination. So they're consuming gels plus water that amounts to that mixture. But I think when you look at the hyperbolic performance of endurance athletes today, it's very quick and tempting to just say, oh, they must be just using drugs we haven't figured out yet.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
Yeah, it's also the fact that I think another explanation and the one that I find more appealing is that they literally figured out how to double the octane of the fuel. I mean, that's effectively what's happening. It's like a car that went from racing at 70 octane to 140 octane and I'm not going to bother explaining what octane is.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
I'm not even sure if there's a 140, but you know what I'm getting at. So I would say those are probably the most important things. I guess the last thing that I would take away from this is he offered a great protocol for how to make sure you're giving it your best when you do a VO2 max test.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
And throughout these, we talk on various topics, VO2 Max, Power at VO2 Max, insulin resistance, metformin, SGLT2 inhibitors, GLP-1 agonists, US healthcare costs, diagnosis and treatment approaches to autism, ADHD and anxiety,
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
This has already been something that I've started implementing a little bit more with our patients and making sure For example, if they do a VO2 max test, I've always asked people to describe the protocol, and many times I'm not pleased with the protocol, but this was the kind of, I think, really super-duper protocol.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
You want to do this at the time of day that is a normal time that you would be training, so you want to be well-rested, etc. Minimize traveling the day before, so we try to tell our patients the same thing. If you're coming into Austin... For a VO2 max test, boy, it would be really great if it was just a short flight the day before.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
And if it's international, please come in more than a day before if you want to maximize the test. The warmup should be basically six minutes. Very, very easy. Six minutes zone two, three minutes at threshold or FTP.
The Peter Attia Drive
#338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4
two to three times at a 10 to 15 second burst at about what you expect your pvo2 max is then a relatively short rest of 10 to 15 minutes get a drink and then get on with it yeah so i would say that those are probably the most important things nick that i took away from this podcast
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Tom took me under his wing and has been one of the more important mentors I have had in the field of clinical lipidology. In this episode with Tom, we talk about the foundations of atherosclerosis, why it is the number one killer in the US and abroad, both for males and females, and how the disease works from a pathologic perspective.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Yeah, thank you for making that point. And I was actually not aware of the fetal studies in FH. We're going to obviously come back and talk about FH or familial hypercholesterolemia, as it is sadly not as uncommon as one would wish. So let's talk about the risk factors here. There are a solid seven or eight really, really well understood risk factors.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Many of these are modifiable, but some are not. So take them in any order you like, Tom.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Yeah, I like that distinction of looking at the causal and the non-causal as you could almost have a two by two causal versus associative and modifiable versus not. So I would say two of the most important non-modifiable or really three would be obviously age, one particular gene that we don't yet have the ability to fully modify its phenotype, which is LP little a, they will talk about.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
We talk about the various risk factors for cardiovascular disease and the role of insulin resistance and chronic kidney disease, which are two things that don't get talked about quite as much as high blood pressure, smoking, and lipids.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And then, of course, there are other very strong lines of family history that aren't necessarily transmitted through lipids, the way the FH gene or sets of genes are. In other words, there seem to be other polygenic causes here that run very strongly in families. I would argue that I have some of these genes, Tom.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
As you know, my family history is riddled with cardiovascular disease, and yet it doesn't come in the flavor of profound dyslipidemia. I have a normal LP little a. I never actually had a very elevated ApoB. And in fact, when I had that first calcium score at the age of 35 that already showed the presence of calcium, it was in the context of an LDL cholesterol at about the 50th percentile.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
It was about an average Joe as you could be. And yet there was clearly something else going on. I wasn't insulin resistant. I wasn't a smoker. I had none of the risk factors. Normotensive. There was something else going on.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
We could probably spend a minute on talking about why I've had zero evolution of that disease over the past 16 years, which also speaks to the nature of interrupting causal pathways. And now on the causal side, I don't think there would be any dispute from any reasonable person on the causality of ApoB hypertension. Let's talk about two other things, though, specifically.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Let's talk about insulin resistance per se and chronic renal failure. Do we have strong enough evidence on the causality of these, which are clearly highly associated with the condition? Or how do you think about that?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
We then do a bit of a dive into cholesterol and lipoproteins, discussing the role of ApoB, the development of atherosclerosis, and also talking about other particles that make up ApoB, so LDL, VLDL, IDL, in addition to HDL and their associations on cardiovascular risk.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
One other thing I might add there, Tom, is when we do see people with even compromised kidney function, we generally see homocysteine go through the roof. And while it might be a bit of a stretch, as you recall, we used to spend some time looking at markers. I don't even want to get into it because it's such a mouthful, but you'll recall the days of asymmetric and symmetric dimethyl arginine.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And we would see these things skyrocket in people with high homocysteine because homocysteine impaired their clearance. And of course, there's at least reasonable mechanistic data to suggest that high amounts of symmetric and asymmetric dimethyl arginine impaired the enzyme nitric oxide synthase, which produces nitric oxide, which leads to vasodilatation. So to put that entire path together,
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
There's a very clear link between kidneys that don't work fully, high homocysteine, and then the buildup of amino acids that prevent the body from making a vasodilator. I don't know that the causality of that has been clearly established in humans, but it would serve as at least one additional plausible mechanism for why renal insufficiency could be leading to an increase in vascular disease.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Yeah. And then let's talk a little bit about hyperinsulinemia and insulin resistance. Again, let's try to disentangle what's obvious, which is, as you pointed out already, that condition tends to traffic hand in hand with hyperlipidemia and hypertension, which are clearly and independently established as causal.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
What do you make specifically of hyperinsulinemia and hyperglucosemia as independent risk factors beyond the lipid and hypertensive components?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
talk about testing the various biomarkers, as well as the impact of nutrition, particularly saturated fat and fat consumption on lipid levels. We then talk about the impact of cholesterol in the brain, where cholesterol in the brain comes from, how it's synthesized there, how that differs from the periphery, and the role of pharmacology in that.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
I think I tend to lean towards some independent causality there. And I point to some of the diabetic research where they look at studies where you take two different approaches to maintaining euglycemia. So as you know, Tom, there are obviously pharmacologic aids that can do that. without the use of exogenous insulin and with the use of exogenous insulin.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So in other words, you could have two different ways to bring glucose down, one by increasing insulin sensitization and one by actually just giving more insulin. And interestingly, when you parse apart the results of these studies, you see something interesting, which is that there appears to be some vascular damage that is mediated by insulin
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
just the hyperinsulinemia alone, even in the presence of normal glycemia. Of course, we would understand why hyperglycemia is problematic for microscopic vessels, but it's kind of these larger vessels that seem to have a negative response to hyperinsulinemia. It almost comes back to this idea of what's going on with uric acid and homocysteine.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So without further delay, I hope you enjoy my conversation with Tom Dayspring. Hey, Tom. Thank you so much for joining me. It's actually probably been a while since we've done an actual podcast together, though, of course, we speak so frequently that it almost feels a little strange to be talking in this way. But anyway, thank you for joining us.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Are these things somehow inflammatory to the endothelium and therefore render the endothelium even more susceptible to a given concentration of lipoproteins? Again, it might be a moot point because I think when it comes to ASCVD, the goal is probably to address everything. And therefore, we might be sort of having more of an academic debate on this.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
I think the other point that is probably worth mentioning to people when we talk about causality in biology is distinguishing between things that are necessary and things that are sufficient. And obviously once in a while you find something in biology that is both necessary and sufficient, but many times it's neither and it can still be causal. So I'll use the example of smoking.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So is there any doubt that smoking causes lung cancer? There's no doubt in anyone's mind. Anybody who doubts that probably shouldn't be having a discussion at this point. So smoking is causally related to lung cancer. But is it necessary for lung cancer? No. Only about 85% of people with lung cancer are smokers. 15% have never smoked. Is it sufficient for generating lung cancer? No, it's not.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Because there are many smokers who don't go on to develop lung cancer. So in that sense, you can have something that is very causal, meaning it's about a thousand times increasing the risk of lung cancer, but it's neither necessary nor sufficient. This will be relevant when we pivot to our next topic, which is ApoB.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
It'll be interesting to talk about ApoB through the lens of necessity and sufficiency. So before we do that, maybe give folks the little explanation on what ApoB is and maybe why we shouldn't think of it as synonymous with, say, LDL cholesterol.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So Tom, we're obviously going to talk about cars today because that's, no, I'm just kidding. Everybody knows what we're here to talk about. We're here to talk about ASCVD, cardiovascular disease. I think in part, I'd like to do this because there aren't many people who probably heard our first podcast series together. I think that was a five, seven part series, something of that effect.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Let's maybe go a little bit further into that process just so folks understand it. Let's, for the purpose of this discussion, assume that it is indeed the most common ApoB-bearing particle. It's a low-density lipoprotein. An LDL molecule carrying its load of cholesterol, maybe a little bit of triglyceride to boot,
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
makes its way from the lumen of the artery through the endothelial barrier between a couple of cells into a potential space called the subendothelial space. What set of factors increase or decrease the probability that it is there long enough for its cholesterol package to begin the process of oxidation? Do we have any sense of this idea of retention?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
I still obviously get many notes from people who are just discovering that or who listened to it way back. But I also think if I could be critical of that discussion, as much as you and I enjoyed speaking for what I think amounted to eight or nine hours, it's a little bit intimidating for someone who's trying to understand this topic.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And probably worth noting, Tom, that's almost assuredly where things like smoking and high blood pressure make your odds worse. Those are things that are damaging the endothelium, making that barrier more permeable, which is simply a probabilistic game. This is all probabilistic. What increases the odds of an ApoB getting in? More particles. That's higher ApoB. more porous endothelium.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
That's what happens with smoking. That's what happens with high blood pressure. That's, in my view, probably what happens with things like high homocysteine, high insulin or renal insufficiency, high uric acid, all of those things. So anyway, yeah, it's all about the probability of making the gradient such that the ApoB is going where it's not supposed to go.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And so the two things I would like to accomplish today would be to sort of bring a little bit of brevity to what we discussed then. And of course, also to update people on all the things that have changed since then, because that's sort of the beauty of this field is that a lot has changed in the probably six years since that discussion.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
But maybe we should at least start by letting you define for people what is meant by atherosclerotic cardiovascular disease.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
That's a great explanation. Maybe I'll just summarize it a little bit. So we already talked about how we get into this process where you have the ApoB carrying lipoprotein. Let's again, just simplify it and call it the LDL in this situation. Although as we'll talk about, I'm sure they can also be an LP little a.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
It enters that subendothelial space and its presence alone makes it susceptible to have its contents oxidized. Cholesterol is a rich target for oxidation. And as that happens, we once again have this example of the immune system, which is out there basically surveying, constantly looking for things that are bad, usually in the form of monocytes.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And they're sensing, they're seeing a chemical signal for that oxidation. And as they enter that space, they become this other type of cell. They metamorphose into something called a macrophage. And the job of the macrophage is to literally consume, to phagocytose, to eat the thing that it is concerned with. And when it begins to eat that oxidized cholesterol, that produces the foam cell.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
I want to pause there for a second and talk about how way down the line, when we ultimately have that calcification, as you said, that's actually quite visible. A calcium scan is exactly looking for that phenomenon. But I often get asked the question, Peter, is there anything I can do today to know if there is any damage to my endothelium? Are there any foam cells in me?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Are there any fatty streaks? And then, of course, the next thing we kind of talk about is a CT angiogram, which in its first phase, when it's run without contrast, which it usually is, you have the opportunity to potentially see calcifications. And then once the contrast is injected, you get a higher resolution image that shows more anatomic detail of the lumen.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
But in my experience, Tom, you have to have a reasonable amount of soft plaque, non-calcified soft plaque to show that, suggesting that there's probably still quite a bit of damage that could occur before you would see anything on a CTA. And of course, I realize there are some people listening to this saying, well,
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
What about newer tests clearly that are using a fat attenuation index to look at the changes in the character of the fatty tissue in and around the adventitia and to see if that is in and of itself predictive of damage? So I'll just kind of let you take that in whatever way you see fit.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Outside of research-based tools such as intravascular ultrasound, do we have tools to really understand these early stages of disease? If a person says, look, I don't want to get treatment now, but I don't want to wait until I actually have calcium. Is there a middle ground?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
I just haven't been that impressed with HSCRP's specificity. There are too many people I have seen who have a normal HSCRP, and I actually define normal as less than one. So I'm not even talking about the actual assay cutoff of two. So these are people that walk around with an HSCRP of 0.8. And yet you actually do a calcium score on them and you find they've got a calcium score of 10.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Which again, this is not a person who's going to die anytime soon. But they've already progressed to a calcium score of 10. This is a person who might be in their 40s. So this is a person who's actually on the path towards premature atherosclerosis.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So I just think that inflammatory markers are probably not specific enough, or in the case that I just gave, even sensitive enough at low, low levels of this disease, in particular because I think that this disease has multiple paths. Even though we're not going to talk about it today, another topic we love talking about is Alzheimer's disease and brain health.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And how there are different paths that patients will take to get Alzheimer's disease. Some patients come at it through almost a genetically pre-programmed path. Others come at it from much more of a vascular disease path. And yet others come at it from a more metabolic and an inflammatory path. And there are all these different paths.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And I almost wonder if there are similar paths towards atherosclerosis. And there are some people who are arriving at it. It's almost genetically programmed in them. And then there are others who are showing up through this very lipid-based path. And yet there are others for whom inflammation is the dominant path. And maybe those are the people where the HSCRP shows up very early in the process.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
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The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Again, I'm completely making this up as an analog to what we see more commonly in the paths to dementia. But I guess what I'm saying in a long-winded way is I find myself rather unconvinced that we have great tools to measure the phenotype of early atherosclerosis.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Maybe they had a CRP blip five years earlier when that plaque was still being oxidized. Yeah, I understand that for sure.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Well, there's a lot you said there that I think is a great place to go next, but maybe just to finish a little bit of housekeeping, we've now both brought up LP little a at least twice.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So I think we've done many podcasts on this, but what would be the three minute explanation for the person who either needs a refresher or maybe who is new to this and hasn't heard of what LP little a is yet and why should they care about it?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
That's a great analogy to think about it. You don't need a lot of something that has high virulence and potency to cause a lot of difficulty. Let's pivot for a minute to talk a little bit about something you also touched on briefly, which was that when we're young, we have what's referred to as a physiologic level of ApoB or LDL cholesterol.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So the concentration of LDL cholesterol in a child is low. The concentration of ApoB is low. We don't see this very often because we're not used to checking these things in kids, but occasionally you'll even notice it as a parent if your kid gets sort of a comprehensive blood test.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Their total cholesterol might be 60 milligrams per deciliter with an LDL cholesterol of 30 milligrams per deciliter and an HDL cholesterol of 25 milligrams per deciliter. I mean, the very, very low levels of this. Why does this change as we age? Why is it that aging seems to be associated with a monotonic increase in lipoproteins?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And this is absent something that we could even get to later if we have time, which is what happens during menopause for women, which is more abrupt. But just talk to me about ages 10 to 50. Why does everybody seem to go the wrong way?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
It is interesting that on average, more of the things that we do that are quote unquote less healthy, whether it be gain weight, eat a certain way, tends to result in decreased hepatic clearance. So on that topic... One of the questions you and I get asked all the time is, look, hey, doc, I buy your thesis that ApoB is bad.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
I buy your thesis that mine is too high, and I buy your thesis that I should probably lower it. I'd really like to start with my diet before I turn to pharmacology. Typically, there's two things I tell patients here. The first is I think your two best levers are nutritionally to reduce ApoB are lowering triglycerides and lowering saturated fat intake.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Now, of course, this assumes that you have high enough triglycerides that lowering them further will indeed lower ApoB, and it of course assumes you're eating a high enough amount of saturated fat that reducing it significantly will lower ApoB. Let's assume for a moment that those things are true. We're talking to a patient, Tom, whose ApoB is 100 milligrams per deciliter.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
You and I have just, I don't want to say read him the riot act, but we've given him the education that says, look, you'd be a heck of a lot better off if you were at 60 milligrams per deciliter. His triglycerides are sitting at about 162 milligrams per deciliter. And when we query his diet, we realize it's pretty high in saturated fat.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
He's probably getting, call it, I don't know, 40 or 50% of his calories from fat. And he's probably getting 50, 60 grams per day of saturated fat alone. So in other words, he seems like a really ideal candidate if he's willing to switch more of his fat calories to monounsaturated and polyunsaturated or even just reduce fat altogether.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And he's willing to take the dietary steps to reduce total calories and maybe even carbohydrates specifically to kind of bring down his triglycerides. So Without getting into how he's going to do that, can you explain why lowering triglycerides and lowering saturated fat intake, those two things, could bring this guy from 100 down to 60?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
I just want to reiterate a few things you said there, which is probably the role I'm going to try to play today is play the interpreter sometimes. So we talked about how obviously we have arteries in all shapes and sizes, largest artery in the body, of course, the aorta coming off the heart.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
running up in an arch to supply the vessels of the head and then down into the abdomen where every artery of the body arises. And as you point out, it's not that the arteries of the heart are uniquely susceptible to this process you just described as atherosclerosis. It's just that two things are conspiring against us. The first
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
is that they are very small arteries and therefore it does not take a significant amount of obstruction or occlusion to create ischemia, which is just the technical term for when oxygen is no longer able to perfuse the tissue.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So, Tom, it seems like the reason ApoB is going up in a high triglyceride environment is because you need more LDLs to carry the same amount of cholesterol ester. because so much of their carrying capacity is going towards also managing the transport of triglycerides. And therefore, while LDL cholesterol might remain constant, it's being spread out over more particles.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Therefore, ApoB, which is the marker of particle concentration, is going up. And of course, that's the metric that matters. This, of course, is the classic example of where we see discordance between LDL cholesterol and ApoB particle concentration.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And then, of course, at the risk of stating the obvious, the second fundamental problem is it happens to afflict an artery that is, let's call it, specifically sensitive to the demands of oxygen. I remember explaining this to my daughter when she was in grade school and I came in to do a little dissection for her seventh grade class.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guest this week is Tom Dayspring.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And I explained that part of the reason we don't have butt attacks and we have heart attacks is that the glute muscles are not quite as sensitive to oxygen and there are many forms of collateralization.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
I think that's a very important point, which is it's always worth taking a shot at modifying your nutrition to fix ApoB, but don't forget the goal. The goal is lowering ApoB. We have these two proxies that are quite helpful. Triglycerides, if they're high, great. great way to approach, usually in most people, caloric reduction is the key of doing that.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And therefore, if you have a person who's eating a lot of saturated fat, a lot of carbohydrates, you know, low quality carbohydrates, sugars, hypercaloric, that person can actually do a lot of ApoB reduction with nutrition. Conversely, when you see a person whose trigs are
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And of course, saying that to a group of seventh graders or fifth graders or whatever turned out to be maybe not the best judgment because that was all they remembered for the rest of the class was butt attacks. head or brain and heart have this issue where tiny blood vessels, not a lot of collateralization, catastrophic things happen.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
50 milligrams per deciliter, who's not mainlining saturated fat and eating in relatively normal amounts, I typically advise those people against draconian fat reduction, which admittedly will indeed lower cholesterol, but often comes at the consequence of something else nutritionally. And so we tend to steer clear of that and save that for people who have an obvious reduction.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
I think this point, by the way, about the conformational change in the relationship between the LDL receptor on the liver and the LDL particle is a very interesting one. Of course, it begs the question, Tom, do we believe that LDL particle size should be of concern given that you just acknowledged that these smaller cholesterol depleted LDL may linger longer?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Or can we largely ignore that if we have a good handle on ApoB? In other words, is all of the risk of everything you just discussed captured in the ApoB marker?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And I also want to highlight the other point you made, which was, look, this can happen in two ways. One tends to be catastrophic and one maybe not as frequently catastrophic. The gradual occlusion of the arteries is probably what more often leads people to complain of chest pain under demand.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
A couple of very important points there, Tom. The first is, yeah, it's true that the remnants, just like the LP little a's, are captured in the ApoB concentration. But it's almost like you have three populations, for lack of a better term, really four populations that are buried within ApoB. You have the majority of them, which are LDLs. You have VLDLs, your garden variety VLDLs.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
You have your LP little a's if you have too many of those. And then you might have too many remnant VLDLs. And of these four, it's that remnant VLDL and the LP little a that pack more of a punch than their counterparts, the regular garden variety VLDL and the LDL. And so this is where I think ApoB by itself can be a bit misleading. In other words,
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
You could have two people that both have an ApoB concentration that's identical, but if one of them has it in the context of basically it's all LDL cholesterol and some VLDL, yeah, they're okay. And then the other person might actually have a disproportionately high LP little a and or remnant concentration. And you won't know that unless you're doing some of this additional analysis.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Is that a fair rationale for saying why we want to look at everything?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
You know, gosh, I was climbing the stairs or I was at the gym and I just felt a tightness in my chest and under normal circumstances, I don't feel it or maybe I do feel it, but then I take a nitroglycerin and everything goes away. We'll talk about why all of that's happening.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
All right, let's talk about HDLs, the most confusing of the lot. Now, we've already done dedicated podcasts on this topic. We've spoken at length about this. So we're not going to be able to obviously cover this in too much detail and we'll point people back towards the previous podcast where I've done this. But you've already alluded to the fact that HDLs can be protective.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
This has led many people to refer to HDL as the so-called good cholesterol. And if your quote unquote good cholesterol is high, you don't need to worry about anything. I'm not going to ask you to debunk that because the tone of my question already suggests that that's nonsensical.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So let's have a modest but brief discussion on how HDLs work and why is it that when they're functioning, they can be quite protective, but at the same time, maybe say a word about why unfortunately we can't figure this out or discern this from blood tests.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
But it's that really frightening scenario where a person in a moment has a complete occlusion of a coronary artery when a plaque ruptures. And as you explained it, the clotting system of the body responds in the way that it should respond when damage occurs. If you, for example, cut your skin, but it turns out to be absolutely the worst thing the body could have done.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
In an ironic way, the body kills itself. This clotting response is what creates a sudden occlusion. If that occurs in the wrong part of the anatomy of the heart, that person will be dead within a matter of minutes if an intervention is not performed. With all that said, anything you would add to that, Tom, as far as just setting the stage for what we're about to talk about?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And you recall we had a nice email exchange about a friend of mine who I've known for many years. He's always had a very high HDL cholesterol and a very low LDL cholesterol. In fact, his HDL has routinely been above 100 milligrams per deciliter, and his LDL cholesterol has always been below 100 milligrams per deciliter. So this is a guy that by anybody's metric looks like he's in tip-top shape.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
But I did suggest to him at one point, it would be reasonable to at least do a calcium score because I've seen these case studies of individuals with high HDLC, low LDLC, who still end up having atherosclerosis. And it can be quite aggressive because it could be that that high HDL cholesterol is actually a marker of dysfunctional HDL that are having a difficult time clearing it.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
To make a long story short, he ended up having quite a high calcium score. And so now he's on very aggressive treatment to take any residual risk out of that ApoB. So he's on double therapy now, and he walks around with an ApoB in the 20 to 30 range, and hopefully that's going to be sufficient to retard this. But again, always a great story.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Yeah, I distinctly remember reading a case study 10 years ago about a woman who looked just like that and ended up having very advanced atherosclerosis. Let's pivot and talk about the brain a little bit. This is an area where your own knowledge has grown rapidly, Tom.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
This is clearly an area of immense curiosity for you, for me, because cholesterol plays an important role in the brain, I think, to put it mildly. And people have many questions about the role of cholesterol lowering therapy and brain health. So let's just start with a basic question, which is what role does cholesterol play in the brain?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And what do we know about the different pools of cholesterol? We have cholesterol outside of the central nervous system, cholesterol inside the central nervous system. Can they move back and forth? Can lipoproteins go back and forth? Is LDL taking cholesterol into the brain and back? Tell us about how that whole system works.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
I like how you said dragged initially. I mean, pulled slowly. Yes. Yeah.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
I just want to make sure people aren't confused on that point. So definitely people listening to us are familiar with the APOE4 gene. But just to reiterate, you're going to have two copies of these genes, just as you do for every gene. This is a gene that exists in three isoforms.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So none of these are considered mutations, meaning there are three types that occur in nature, the E2, the E3, and the E4 isoform. So you have six combinations of these. And therefore, three of these combinations include at least one copy of an E4. So there's the 2,4, the 3,4, and the 4,4.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So we know epidemiologically that there's a clear increase in the risk of Alzheimer's disease as you move from 2,4 to 3,4 to 4,4. And I just want to make sure people understand that we're kind of going back and forth between the gene and the protein. If you have an E4 gene or a E3 gene or a 2 or whichever combinations you have, you still make an APOE protein.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
What is different is what the protein looks like in response to the gene. And what's very interesting is, if my memory serves me correctly, I believe it's only a single amino acid substitution between each of these. In other words, one amino acid difference between the one made by the 3-isoform and the 4-isoform
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Yeah. So let's talk a little bit about the pathophysiology of this. Before we get into what the non-modifiable and modifiable risks are, because we have two categories of risk, let's just talk a little bit about the timeline of events. Of course, I'm spoon feeding you an answer here that I know is a very important teaching point, but
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
results in what you just said, which is individuals who have the ApoE4 gene have an ApoE4 protein that wraps their brain lipoproteins that gives it less affinity for doing this job of transferring cholesterol from astrocytes to neurons. is a very important explanation of why it is that people with an ApoE4 gene are at an increased risk. This is not to say it is a causative gene.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
It's not a deterministic gene. It's not a gene that if you have a copy or two copies of the ApoE4 gene, you're going to get Alzheimer's disease. This just explains why there's a greater susceptibility and why an individual who has one or two ApoE4 genes needs to work that much harder on all of the other variables that factor ASCVD.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And again, to your point, why does this not really play as much of a role in the periphery? We could save that for another day, but it sort of does in the edge cases. And that's why we see a higher incidence of ASCVD and ApoE4 carriers. You did already allude to it, but only the astute listener will remember it when you talked about the ApoE and the conformational change in lipoprotein.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
This may be a familiar name to you as Tom has been a guest on the podcast several times already. Tom is a fellow of both the American College of Physicians and the National Lipid Association, and he is certified in internal medicine and clinical lipidology.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
I'm not going to go back to it because I want to stay on the brain But anyway, I just wanted to interject that point so people knew the relationship between the genotype and the phenotype of the structural protein.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
When we think about atherosclerosis being the leading cause of death, which it is, I guess we should have stated that at the outset. This is the leading cause of death in the United States. It's the leading cause of death globally. It's the leading cause of death in men, and it's the leading cause of death in women.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So it's hard to really imagine anybody listening to this who shouldn't be concerned by it. I suppose if you're a squirrel, you can probably skip this podcast. So given that it's the leading cause of death, it doesn't exactly show up as the leading cause of death in people too young.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
My speculation has been that the reason that the place we see desmosterol in the periphery in the steroidal tissue is that that's the tissue that has the highest demand for cholesterol production, maybe suggesting that the desmosterol pathway is more suited to a high demand pathway vis-a-vis the astrocytes and the steroidal tissue.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Again, we're so far in the nerdy stuff on this now that it's just a speculative comment
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
It's not like we're watching teenagers, 20-year-olds, 30-year-olds, or many 40-year-olds, although there are some tragically, who die of this disease. This is largely viewed as a disease of the elderly. Does that give us any insight into the time horizon of this disease or the pathophysiology?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Before we leave that, Tom, what is our hypothesis around the hydrophobicity of various statins? And do we think that certain statins are more likely to cross the blood-brain barrier? Are there certain statins that should be ignored in patients with marginal desmosterol?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Yeah, we actually covered this at length in one of the previous AMAs, and I went through every meta-analysis on this topic. It's important for people to understand that at least at the time, and I don't think this has changed, there has not been any statin trial where the primary outcome was dementia.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
The primary trial is always cardiovascular disease, but there have been more than a dozen such trials where the secondary outcomes are dementia. It's worth noting that in every one of those trials, regardless of statin used, there has either been no change in the risk of dementia or a reduction in the risk of dementia. Now, it's interesting.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
These studies were almost all done in the setting of trying to determine if if lipophilic versus hydrophilic statins were more, less, or better. And the answer always emerged, it didn't seem to matter, which of course makes sense if you understand now that they probably all cross the blood-brain barrier.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So the question remains, will there ever be a study done that tests this question specifically as the primary outcome? In other words, where the study is powered to ask the question, does the use of a statin increase, decrease, or have no effect on the risk of Alzheimer's disease and dementia?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Or will we instead be forced to rely on these secondary outcomes, which are always subject to some potential misinterpretation? Again, I take much more comfort in knowing that they are all either neutral or favorable. That would certainly be better than the opposite. But again, that remains a bit of an unknown. And you might be right, Tom.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
It might be that on average, it's having no effect on the brain. On average, it's having a beneficial effect through the vascular system. But then there might be edge cases that are not being captured in large clinical trials based on hundreds of thousands of people.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And it might, in fact, be those patients in whom a little extra knowledge goes a long way vis-a-vis cholesterol synthesis in the brain. And the final point I'll make here is what a privilege it is to be practicing medicine in 2024 when we don't have only statins, but we have ezetimibe, we have benpidoic acid, we have short-acting PCSK9 inhibitors. We now have long-acting PCSK9 inhibitors.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
We have ASOs around the corner. There really is no need for a patient to ever endure a side effect of lipid-lowering medication today. We can lower everybody's lipids without side effects, and that's only going to become more and more true in the next decade.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Well, Tom, my final question, I guess, really comes down to what are you most looking forward to in the next three to five years? I have an answer for what I'm most excited about, but I'm obviously more interested in hearing what you're most excited about in the entire field of cardiovascular medicine. Is it something on the drug side? Is it something on the diagnostic side? Is it something else?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
What has you most excited?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
He was the recipient of the 2011 National Lipid Association President's Award for Services to Clinical Lipidology and the 2023 Foundation of NLA Clinician Educator Award. Boy, have I known Tom for a while. Tom and I met back in 2011. At the time, I had a budding interest in cardiovascular disease and lipids.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
It was a huge honor last year to receive that award from the NLA and no small part at all. That's obviously due to your mentorship and the mentorship of others. So thank you very much. And thank you, obviously, for your continued education, both for me personally and also for everybody listening. You're an absolutely tireless educator.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Your zeal for teaching, your generosity of knowledge is really unparalleled. And you and I joke all the time about that first time we met way back in Reno, total chance coincidence. certainly one of the more fortuitous things that's happened to us both. So thank you again. I think this was a great discussion.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
I know that at times it got a bit technical, but I would encourage people to maybe go back and listen to this again, really go through the show notes on this one. All the stuff we talked about, you'll find summarized there and links to other studies if you want to be able to go into some of the details.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
So thank you once again, Tom, for everything you've taught me and obviously everything you've taught the listeners.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
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The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
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#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
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The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Yeah, I've told this story before, but it probably bears repeating. In medical school, so now this is almost 30 years ago, the pathology professor, this is first year of medical school, said, what is the most common presenting sign of myocardial infarction? This was true at the time. I don't think it's still true today, but it's close.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And everybody, of course, every medical student put up their hand and went through the litany of symptoms that you might have, chest pain, shortness of breath, left shoulder pain, nausea, et cetera. And he said, no, it's actually sudden death. The last thing I read suggested slightly fewer than 50% of people's first MI will be a fatal one. Do you happen to know the most recent stats on that, Tom?
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
It's very high. Yeah. It's just not more than 50%.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
Yeah, which is staggering. And to think that only 25, 30 years ago, that number was north of 50%.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
The other statistic that I've shared before, but again, it always bears repeating, is that if you take all of the men who are going to suffer a major adverse cardiac event, so heart attack, inclusive of stroke, cardiac death, et cetera, you take that whole group of men, and that's a pretty big number, 50% of them will experience their first event before the age of 65.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And 33% of women in the same boat will experience their first event before the age of 65. Now, the older I get, the younger 65 feels. So there was a day when 65 seemed, those are old people. I don't think of 65 year olds as old people anymore. I'll tell you that much.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And therefore, to think that 50% of men and a third of women who are going to ultimately suffer a cardiac event will suffer their first one, which could potentially be their only one if it's fatal prior to that age. Also, I think puts in perspective the temporality of this condition. So we've just established that this is a disease that begins at birth.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
This is largely established through autopsy studies where children, teenagers, people in their 20s die for other reasons, car accidents, homicides, war. And in the process of doing an autopsy, we begin to see the early stages of atherosclerosis. I think it's quite conclusive that this is a disease process that might be inevitable to our species if we live long enough.
The Peter Attia Drive
#334 - Cardiovascular disease, the number one killer: development, biomarkers, apoB, cholesterol, brain health, and more | Tom Dayspring, M.D.
And what might separate the people who never get it or the people who die from something else at old age. versus the people who do, simply has to do with the rate of the accelerator and the rate of the brake application vis-a-vis these modifiable and non-modifiable risks, which I guess we should talk about now.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And just so that folks who are maybe thinking about other ways that they've heard this, because I know you've described it this way, which is it's often presented as half of the healthcare dollars are flowing into the facilities. One third of the doc is going into payroll and physicians, and then one sixth is going into drugs. That's right.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
But the problem with that view and the reason I like your one-third, one-third, one-third better is it's more transparent, which is in the previous world where we say half goes into the facilities, we're discounting how much of that contains physician salary and how much of that also contains pharma.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I wanted to have Sam on this podcast to discuss the US healthcare system for a long time. And the reason is, this is one of the most complicated systems in the United States, and it's one that I just didn't feel I had a great understanding of. I certainly understood parts of it, but I couldn't put it all together.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So when you strip that out, it's actually more elegant to point out it's one-third, one-third, one-third.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Hey everyone, welcome to The Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen.
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#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Okay. That's where we are today. Let's go back. It's 1950. Someone comes home, you know, it's late 40s, early 50s. The U.S. is on top of the world. we're the greatest country in the world. Our GDP as a percentage of global GDP has never been higher and may never be higher again. In fact, even today, by the way, I just looked this up because I was so interested.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
If you look at the percentage of global GDP that is the US's today, it's quote only 20 to 25%, which is still staggering. It was close to 40% post-World War II. So what's happened over the last 20 years is China's GDP has expanded so much that as much as we continue to grow, our relative share has gone down. So economically, we've never been more dominant than we were post-World War II.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
What is true of healthcare? How does a person take care of themselves?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Yeah, we're almost 20 at this point.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And of course, part of this is that I didn't actually spend an enormous amount of time working on healthcare when I was at McKinsey. Even though I was recruited to do it and spent some time on it, I actually spent more of my time in financial services and banking. I never really got the education maybe that I wish I did.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Do we have a sense historically why as the NHS is coming into its existence in the UK and as most developed nations are developing systems that look far more like the NHS than what we've done, Was there something about our geography being much more vast than, say, England was in the 1940s that led itself to this? Was it the nature of states' rights versus federal power? What was the difference?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And more importantly, enough has changed in the time that I've left that I think it was time to have this discussion from scratch. Now, My hypothesis going into this podcast was that if you understood all the dollars that flowed into the system and all the dollars that flowed out of the system, you would understand the system. And I will tell you now that that is exactly what happened.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Now, why did we not do with Medicare what was done with Social Security? In other words, my understanding, which again, I'm embarrassed to say how little I understand this, but my understanding is Social Security is funded directly. It is not a budget line item. When I pay my Social Security on my paycheck, it's directly going to pay somebody, correct?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
It's not like building up a war chest that the government has to use to be paying down in the future. But Medicare works not the way Social Security does. But I still make a Medicare payment every month. So in other words, why haven't we at least been able to eliminate the challenge of Medicare and make it more like Social Security?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Well, then it's a fungibility issue as well. You can use a Medicare tax to do something else.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I came away from this discussion with a really thorough understanding. of this. And it has actually made it much easier for me to engage in the subsequent discussions that I've had with leaders in this field. And it's made it much easier for me to digest the information that I've been reading.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
We're taking some things for granted here. Tell people what CMS is, what Medicare and Medicaid actually do. Who do they cover?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
How long does one have to have paid into it to qualify for it?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
It's not like Social Security where you had to- It's not like Social Security.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Anyone who is a US citizen will qualify.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And Medicaid, just to round that out. Yeah, okay.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And I suppose you'll be able to tell by the end of this podcast, this has become a real obsession of mine, is truly understanding US healthcare from a cost perspective, a quality perspective, an access perspective, and trying to understand what it will take to make this better.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Do you have a ballpark sense of where those cutoffs are
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Medicaid covers 90 million people.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
What is the federal poverty level today?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Yeah. In other words, there are people who will not meet the criteria for poverty who maybe should based on purchasing power.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Now, let me ask you a question. I'm sorry to interrupt you and you can tell me to just punt this and come back to it. I want to go back to the 1960s. We go to the great lengths to create Medicare and Medicaid. Why did we not at that moment say, hey, why don't we just roll this out for everybody just as the NHS has done?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
In this discussion, we begin with the overview of how the US healthcare system currently works, how it is structured, and how these costs flow. We also do a little bit of a comparison to how the United States compares to other developed nations. We also talk a little bit about the history of how we got here.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Why did we instead continue to keep two completely different worlds, which is we have a government funded system for people of low socioeconomic status. We have a government funded system for people over 65 or with very chronic conditions. But for everybody else, we're going to do this crazy thing where your employer takes care of you.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So that was a decade earlier.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I think until I understood the history of this going back to the 1950s and the 1960s, it was impossible for me to understand some of the baggage that we have in the current system. We looked at the intricacies of insurance, looking at private insurance, Medicare, Medicaid, and the challenges of employer-sponsored coverage in the United States.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I loved your analogy there. I've told this story before on the podcast, but assuming someone's listening who hasn't heard it, it's a great example. So I had a friend who is American, but he lived and worked most of the year in Riyadh in Saudi Arabia. And I was out visiting him in Saudi Arabia, this was 15 years ago.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And we're at his flat and it was in the spring and he was just kind of getting ready to head back to DC where he lived. And so I said to him, I said, God, you know, I can only imagine how hot it gets in Riyadh in the summer. So if you leave here in May, you come back in September, how hot is your apartment when you get back? Just out of curiosity, like, is it a sauna? And he goes, no, 70 degrees.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I'm like, what do you mean? He goes, I leave the air conditioning on the whole summer. I'm like, you leave your house and leave the air conditioning on for four months? He goes, yeah. I go, that's crazy. He goes, I'm not paying for it. The government subsidizes all of our energy costs here. I pay the equivalent of a few cents per whatever it is.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Like it was, he pays a few dollars over the summer to air condition his place. This is the exact point. When you don't have skin in the game, you can't make rational economic decisions. I shouldn't say that. It's a rational economic decision for him, but you can't make decisions that are wise in the context of resources. Yeah.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
We speak, of course, about drug pricing because this is one of the major areas where the United States is at a supreme disadvantage compared to other countries. We talk about the impact drug pricing has on pharmaceutical innovation and, of course, the role of PBMs in addition to the administrative burdens and what role technology may play in these areas going forward.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Is this manifested in the financials. So if you look at the insurance companies and you strip out their ASO business, the part I referenced earlier about the administrative part where they administer insurance to the employers. But if you look at the part of their book of business where they bear the risk, do they look like Travelers? Do they look like Geico?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Do they look like the types of companies that Warren Buffett is obsessed with because of float? Or do they just totally function differently?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
It's not car insurance. It's not life act. It's not death. It's not disability.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
If you and I wanted to start an insurance company tomorrow, I'm going to hang up everything I'm doing. You're going to hang up everything we're doing. We're going to go start the Peter Somm Insurance Company where we take risk. We don't have an ASO business. What would it take for us to be successful?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
There's so many more questions I have on that that I'll punt for when we get to the ACA.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
We connect healthcare spending to the broader topic of economic issues and discuss potential reforms to the system, considering what might be possible in the future.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Yeah, I was trying to think of that, Sam. The only two things that I could even put alongside it as huge sectors probably still don't create as many jobs would be energy and agriculture. Those would be the only two industries that could even come close to being in the same zip code as healthcare.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I came away from this, again, I make the point in the podcast with at least my objectives met, which were I wanted to emerge from this podcast with the ability to sit down with anybody, regardless of their level of sophistication, and explain what is going on with the US health care system economically. And as I said, I came away from this feeling that my needs were met.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
It's sort of the equivalent of the private insurance in the NHS system where you get the state-sponsored thing, but you want more choice.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And that is entirely a credit to Sam's ability to understand and deconstruct all components of the system. His breadth of knowledge is virtually unparalleled in this regard. And I am forever in Sam's gratitude. So without further delay, please enjoy my conversation with Sam Sutaria. Sam, thank you so much for coming down to Austin to have this discussion. I appreciate the opportunity.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I would even add another point to that because we're going to go deeper on those two, but you even mentioned that the number of physicians has doubled basically over the last 40 years while the number of hospital bed days has fallen in half.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
The other thing to keep in mind is physicians in this country spend infinitely more than in any other country to become educated and therefore the debt that they assume upon completion is also a big part of what drives presumably we must have the highest physician salaries in this country.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
We've been talking a lot about choice, but is it worth maybe spending a minute to explain to people some of the terms that I'm sure they've heard but might not fully understand? Like, what's a PPO? What's an HMO? What's value-based care? How does Kaiser work?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Can you explain what those things are so that people understand when they're making their selection at open enrollment, they get a sense of what those things are?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
They don't try to cover everything. If you have a child that's born with the most obscure congenital cardiovascular malformation, they might just say, you know what, that's something we will just send up to UCSF because they've got the right person there.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
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The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Yeah, this is a conversation I've wanted to have for a long time, both for my edification, but also because I think it's such an important topic. And interestingly, for whatever reason, it waxes and wanes in public consciousness over time. There are periods of time when healthcare is on the forefront of everybody's mind. in some aspect, right? It can either be cost or quality or access.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I grew up in Canada, and I still have experience with the Canadian healthcare system because my entire family is there. And I don't know if you have experience there previously, because I know at McKinsey, you did a lot of work for different provinces and stuff like that, and obviously through the NHS. Here's my take. And again, it's so anecdotal that I'm curious if it's reflective.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
My take is that if you needed heart surgery, if you need a aortic valve replacement and a root repair and a cabbage, there is a surgeon in Canada that's just as good as the surgeon in the US, meaning the top 10% of the surgeons in Canada and the top 10% of the surgeons in the US are going to be indistinguishable in that regard. You're really going to get great care in that regard.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
The difference is you're going to wait a heck of a lot longer. The hospital experience could be entirely different. Obviously, you're not paying for it.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Yes, yeah. It's not coming out of your wages directly, and you're not paying out of pocket, to your point. Again, you're shielded. You're more shielded from the cost. But boy, if you're dealing with something like you've injured your knee and you need an MRI, the difference in how long you will wait to get that- It's immense. The speed, the choice, the access is really what goes down.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
The quality is not really the thing that has, at least in my experience, been degraded in a system like Canada.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
It's an infrastructure.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
For what it's worth at this moment, it seems to be dwarfed by other affairs, but that doesn't mean that it's not going to be front and center in six months or a year or whatever. And therefore, I think in many ways, this discussion today, my hope is serves as the masterclass on the United States healthcare system.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And this is what I want to come back to. So we're going to go into PBMs because I'm amazed we are as far into this podcast as we are and we haven't discussed PBMs. So we're going to get right to it for the people who are listening to us going, how have you not talked about drugs yet? But here's the fundamental difference. You made a great point.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So post-World War II, Bretton Woods Accord, the US makes a deal with the rest of the world effectively. which says, there's a cold war coming. And if you choose to be our ally, we will provide you security. Specifically through our Navy, we will ensure that your ships can pass freely throughout this entire world. We will not plant a flag on your soil. We might use military base.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
We're not here to be conquerors. We're not here to be emperors. But if you pick our side, we will assure your security. And so that's an example of how we greatly subsidized defense for the world, but we got something out of it. Now, when we are subsidizing drug costs for the rest of the world, because as you point out, we develop all the drugs.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
It's not like we get different drugs than everybody else. Everybody else in the world gets the same drugs we developed. Everywhere else in the world has price controls that lower the cost of that. And in true economic fashion, it's sort of like somebody is squeezing down on the tube of toothpaste. All that toothpaste is exploding in the United States with drug costs.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
One other point I think I would make just for the listeners to understand is I fashion myself as a person who tends to get deep into things and then quickly come to an understanding of them. I have been rather unsuccessful in understanding healthcare. I'm sure my understanding is greater than the average person. It still feels woefully inept relative to the effort I put into understanding it.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So the question becomes, what are we getting for subsidizing the rest of the world's drug price?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
What's the closest the US has come to trying to enforce some measure of price control in pharma in the US?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Right. We gave away negotiating power.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Just go back to 2000. Did the U.S. government, at least for Medicare, say we will resign the right to ever negotiate?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Was that a concession to pharma to get something else?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Yes, but what did they get in return for that concession?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So I'm personally just looking forward to how much more I'm going to understand this in a few hours than I do today.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Because the cynic is going to say, you know, Sam, that sounds to me like pharma had better lobbyists than anybody else.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
They're price takers from private insurance for the most part.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
We're going to talk about the things that people care about, which is why is it so expensive? Why isn't everybody covered? Why do we not have the best life expectancy? In fact, on average, why do we have horrible life expectancy despite spending twice as much as anybody else? But we can't have that discussion if people don't understand the system. And that gets to what I just said a minute ago.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Let's talk about this drug thing because going back to the very beginning of the discussion, a third of the 85%, so again, I always like to anchor people to it. We're spending $4 trillion a year on healthcare. 15% of that is administration. That's something that exists virtually nowhere else.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Of the 85% of that 4 trillion that's not administration, roughly a third of that is drugs and devices, and more of that is drugs than devices. So drugs are a really, really, really expensive part of the US healthcare system. It also should be patently clear to anybody listening to us right now that we in this country are singularly paying
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
infinitely more for every given drug than our peers are elsewhere for the exact same drug. Let us now talk about the elephant in the room, the blessed PBM.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
It's a really complicated system.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
You're one of the most structured thinkers I know of, so I'm going to actually just defer to you as to what framework do you want to put to this for people to understand how so many trillions of dollars flow in, how many so many trillions of dollars flow out, who's paying, who's receiving, how is this thing organized, and why are we different than every other country on the planet?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
This is the classic example of, and I'm sure, I don't know who said it first, but it's been said a million times. Show me how a man gets paid and I'll tell you exactly how he's going to act. This is straight from the horse's mouth.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I will not identify this individual other than to say it is the CEO of a major pharma company who shared with me that he wanted to price one of his drugs at a low level. He wanted to undercut similar products on the market and come in at a lower price. The PBMs flatly told him, we will not put your drug on the formulary until you triple the price.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Don't worry, we will make it up to you with a rebate. I mean, I don't even know how this is legal. I mean, you understand why that is happening from the incentive system? How is this legal? How do these things exist?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
But even if it's not as overt as a situation like that, subconsciously, what we've done is removed any incentive for a drug company to be concerned with the sticker value of the price of their drug. It's a meaningless entity because of these machinations and payments that you've outlined where Where rebates and kickbacks completely change the economics.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Again, the system was so opaque to begin with. You've already outlined this idea where we're so uncoupled from our decisions. I don't just mean as patients. I mean, as doctors, we have no earthly clue what a drug costs when we prescribe it.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
If I'm trying to decide to write somebody for resuvastatin versus atorvastatin, it couldn't possibly enter my stream of consciousness why one of those might be 10 times more than the other. And yet we continue to just add unnecessary cost to a system.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I never thought of it that way, which is how much they throttle supply in a system where demand could be unlimited and they have no control over demand.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Well, now I'll bring up my favorite thing I've heard recently when Paul Tudor Jones was speaking with Andrew Ross Sorkin. He wanted to put it into just the simplest terms for why there was no rational argument why anybody should buy a US treasury, which was... Imagine I have $700,000 of debt. You've lent me $700,000. My income is $100,000 a year. So what does that mean?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
He's taking that from $35 trillion of debt currently and $5 trillion of tax revenue. So my income is one seventh my debt. And as you pointed out, I'm going to continue to assume $2 trillion of debt a year in perpetuity. And I'm saying to you, the US bondholder, the person who's going to buy a 30-year treasury, I have $700,000 of debt. I make 100 grand a year.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I want you to lend me 40 grand a year for the next 30 years. And I promise you at the end of 30 years, I'm going to pay it all back. I mean, what do you have to believe for that to be true? You really have to believe I'm going to have a remarkable growth of income or a remarkable reduction of cost somewhere along the lines.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Yeah. I'm going to have to inflate my way out of this thing. And again, none of these things are desirable. But when you say healthcare costs over the next two decades can potentially go from 20% to a third, How in the world could we imagine that the other costs contract to accommodate that?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So you and I will be right there.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
But let's give a number to that. People don't understand how big the US economy is. So how many dollars are we talking about?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peteratiamd.com forward slash subscribe. My guest this week is Dr. Sam Sutaria.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Two to one.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
One of the things you pointed out that I was unaware of, although it totally makes sense and we could argue it's another potentially shining spot is most people are very familiar with the fact that relative to our peers as developed nations, the US has a pretty paltry life expectancy in aggregate. Most people can point to two things that tend to be the biggest drag on this.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So the first has to do with fetal maternal health. The second has to do with overdoses in middle-aged men. And we spent time on both of these. These are related to both access to health and deaths of despair, respectively. But the point you made was once you reach about the age of 70, your life expectancy in the US exceeds that of any other nation.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
To your point, that's when the system actually kicks in, in terms of dragging out life pretty well.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Especially when we're spending 60 to 100% more.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Yeah, there's so much you've said there is pretty typical of your brilliance, which is you'll say something for 10 straight minutes, and at the end, I'll be like, that's a thesis that might've taken me a year to come up with. What I took away from that that's just very insightful is prior to the age of 65,
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
The reason that we're in last place is a few of these things that are unfortunately more American than they should be. So we talked about access to guns, a culture of violence, things you haven't even alluded to, but greater mental health crises that just go hand in hand with all these things.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
poor access to prenatal care relative to other developed nations that's leading to a far higher degree of infant mortality. And these things just add up. We talked about the drugs. I mean, for heaven's sakes, we have a fentanyl pipeline coming into this country that's an embarrassment. And as a result, 100,000 people a year, more than that now, are overdosing.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
What I really thought was interesting is I talk about it in terms of medicine 2.0 and medicine 3.0, and I've talked about how our system is really good medicine 2.0. It's really good at treating chronic problems and grinding out incremental years of life when you're chronically ill. And that shines so much when you become a senior citizen.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And that's how we leapfrog every other country between ages 60 to 75. We go from last place in life expectancy to first. because our machine shines, it really kicks in. And of course it begs the question, why can't we have the best of both worlds? Like these don't have to be mutually exclusive.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
You can preserve the latter, which is we have all of these remarkable pieces of technology and innovation and access and infrastructure and quality that give us that boost of life expectancy at the end. Why don't we increase the number of people that enter that sixth, that seventh decade of life? Let's increase that by 10% by applying Better Medicine 3.0 and Access Early in Life.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And by the way, I think you would increase it by more than 10%. The other thing that I keep playing back in my head is I've always talked about these as three variables. So when I've talked about this, I've always talked about three variables. I've always talked about quality, cost, and access. But you've made me realize that choice is a part of that as well.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And that's the part that I think is also very American. And I don't think we should be apologetic for it. It is just our culture. It is who we are. We want the best and we want to be able to pick what we want. And that fourth variable puts even more pressure on the one that is unconstrained. So cost is unconstrained. We have said we want maximum quality. We want access.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And meaning when I want it, I want it now. And I want to choose where I go. If I control those and I leave one to balloon and that one is cost, away it goes. The other systems, as we've discussed, have said, no, cost is constraint. Cost is a capped resource. Now you see what's going to happen to the others. And that's where we get into the supply side throttle to lower access.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Let's eliminate choice and you'll still get decent quality. That seems to be the choice that the rest of the world has made.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I actually like to keep them separate. Even though in my former model, they were the same. I think the way you've described it is better because choice also means you have more drugs than you know what to do with. You have a formulary with how many thousands of drugs?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Right. And we'll do meniscectomies. We'll do meniscus repair surgeries. We'll do hip resurfacing. We'll do hip replacements. I mean, we'll do PRP. We'll do anything and everything. You have more choice here. This is the biggest buffet on the planet when it comes to healthcare.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Do we know that it represents roughly 20% of the workforce as well?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Let's even start with the choice before that, because I always think we should start with the null choice, which is we can do absolutely nothing. We can sit here and say, Peter, Sam, thank you for explaining this system. Actually, you have a better understanding of it now. I want maximum choice, maximum access, maximum quality. Let cost be damned. Let's just leave it alone.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Let's revisit it in five years. How about that? Let's just come back in five years and tell me if it's 22%. Tell me if it's 23% of GDP. Once it hits 25, we want to do something about it. We could literally just be ostriches and put our head in the sand and ignore this. Okay, let's put that aside and say, no, most people at this point probably think...
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
We should at least have some ideas for how we can manage this. So now that's your first point, which is Medicare has made the hospital and the physician a price taker. Shouldn't it be able to do that to pharma? Now, let's talk about what's going to happen, because now you just added one more squeeze on the toothpaste tube while you're taking the cap off.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Because if Europe and Canada and CMS force pharma to be price takers, what's going to happen to drug prices that are outside of CMS in the US?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
But is that an extreme?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
No, I agree. But someone will have to make a concession. And I think that somebody is actually the shareholder because I agree with you. I do not think innovation stops. And it's because innovation isn't even happening at those companies anymore anyway. Innovation is the biotech's job at this point.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
You're saying the shareholders shouldn't actually even be forced to suffer here.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So how do we reconcile that, Sam? Because on the one hand, you're saying if pharma, if drug development and distribution had to become more economical, we are innovative enough as a country to do that. But at the same time, the whole reason we're saying that has to happen is we must have some measure of price control in drugs, which feels like a very anti-American thing.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Do you think it is reasonable that Americans could expect to pay for drugs what their European and Canadian counterparts pay?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Do you think it makes sense, Sam, and feel free to shoot this idea down, does it make sense to go back to the 1950s to start with Hilbert and to start with and then progress into Medicare and Medicaid? Does historical context give people a sense of what happened after World War II?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I wasn't aware of this, but you said that the Inflation Reduction Act cracked the door on that.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Meaning the third that's currently drugs is going to go up relative to the rest of the pie. Yeah.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
But that's going to widen the gap between us and the rest of the world.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Yeah, they have a dollar amount.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
While the aging pressure might be taking a little bit of air out of the balloon, it's hard for me to imagine that it's taking more air out of the balloon than that which is being put in with the rising burden of obesity and type 2 diabetes. Let's talk about that for a moment. We haven't really explicitly and directly spoken about that.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Obesity maybe, but type two diabetes, the year we were born is 1%. And today, 12 to 15%. Right.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Yeah. Very conservatively, a single log fold, but likely more.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Yeah. So here's the question. We have drugs now. They seem pretty remarkable. These GLP-1 agonists are doing something we have never seen before, which is simultaneously delivering the best efficacy we've ever seen. coupled with what appears to be remarkable safety. So maybe there's some marginal edge cases, but this is not fen-phen. This is not stimulants, right?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
We are dealing with truly efficacious, truly safe drugs. The problem is they cost so much money. I'd love to hear what you're reading about this, because what I'm reading is two different types of things, right? I'm reading, on the one hand, the bull case that says this is going to change the world.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
We are finally going to address the burden of obesity and type 2 diabetes and metabolic disease with these drugs, because now all we got to do is give these drugs to everybody. And then the bear case says that might be medically true, but economically, if you run the math, we're going to take a system on the verge of bankruptcy and bankrupt it if we have to rely on those drugs.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I don't even know the dollar numbers, but let's just assume that the drug is $15,000 a year for one of these drugs. You're saying you have to get a multiple of $15,000 a year of productivity out of it from the individual who's now more able to work because their knee doesn't hurt as much, their back doesn't hurt as much due to the sequelae of obesity.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Even though, as you pointed out earlier, the Me Too train on this class of drugs is so long, I can't see the caboose at this point. When you actually look at the pipeline of GLP, GIP, glucagon, and other incretins out there, we've got 25 of these things in the pipeline. And will it simply be, if we go back into the American ethos of choice, quality, best, best, best,
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Are they just always going to be priced so high? And maybe you're right. Maybe semaglutide trades at a discount and nobody wants it because that's so 2020. Right.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So I'm making a note here to myself. I'm just listing out the players in the system, the government, the employers and the payers. I'm going to lump them as one. The consumer, the medical system that I'm just going to call hospital, ambulatory center, physicians, the staff, the delivery system of healthcare, and then pharma. And I don't really know where to put the PBM.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Would you make them their own separate thing as a system or would you put them in with the payer or where would you put them in with pharma?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Okay. So if we were somehow given the ability to do anything we wanted and we said, we want to keep quality essentially where it is, maybe restrict choice a tiny bit, kind of leave access where it is, but we want to shrink cost by 25%. Is that metaphysically possible? And if so, how does that list of participants play a role in that?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
No, it's a huge contraction. It's a huge contraction. 25% over the next X years. It's not going to be an overnight 25% reduction, which by the way, let's just make sure people understand this. A 25% reduction in our healthcare spend would still have us being the most expensive country of healthcare in the world. We're not even getting to cost parity with other developed nations.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
But I'm just thinking about, I'd like to get it closer to 3 trillion than 4 trillion. That's all I'm saying. Sure.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So what you're basically saying- It's not healthcare.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
You can't do this without cutting jobs.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I was just about to say, the administrative piece is how much of that is payroll. That's mostly payroll, isn't it?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Yes.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
By the way, why isn't AI doing that, Sam?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Isn't that the poster child indication for AI? Yeah.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Sam is the CEO of Tenet Health, a healthcare service company that owns and operates hospitals, ambulatory, surgery centers, diagnostic imaging centers, and other healthcare facilities. Sam joined Tenet in 2019 after working for two decades at McKinsey & Company, where he was the leader of the healthcare and private equity practice.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
That's relatively unique. Let's make sure that people appreciate that because someone listening to this might say, I have a health insurance card and it says Blue Shield on it. So doesn't Blue Shield provide my insurance?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And is this just due to bad training?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And I guess your point that you made at the very outset of our discussion is we always hear administration and we think that's garbage, cut it. But the truth of it is that administration is the price we pay to have the choice we have. That is right. We couldn't have the environment of choice if we didn't have the administration to adjudicate.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
But the reason everybody else gets to avoid administration is it's draconian. Well, everybody else has administration.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And it also limits choice by just saying there's not going to be a line-by-line adjudication of this. That's right. It is what it is. It is what it is. Here are your three drugs.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
But the point is that the Humana, the Aetna, the whoever is on the card is usually providing an administrative service only if the employer is large enough that the employer is bearing the risk, which maybe we'll get into that. Maybe we should explain that a little more quickly. Okay.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
That's exactly right, Sam. My view is we all know when Noah built the ark. And I feel like it's important to have these discussions before we're driving off the cliff because nothing that we're talking about can be fixed quickly. I'm having this discussion because I want to understand it. And I really hope that people far smarter than us, who are far more influential and far more important perches,
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
are putting as much thought into this as they are into whatever other important policy decisions are out there, because it's very difficult to imagine that the private sector alone would solve this.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Right, if you have a CMS regulated operating room, you have a great operating room.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Where do you think the overregulation is being counterproductive in healthcare?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Let's just give an example. Give an example of a procedure that is done in hospitals and out of hospitals and give an example of the cost delta.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
One, we've lowered the cost of each colonoscopy, but we've probably flattened or even raised the total cost because now more people are doing it.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
The per unit cost went way down.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Really?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
What is the difference there in the payer rate for those two? It's about half.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Let's spend a minute on this. This is another one of those great, great opacities in the healthcare system. So I need a heart surgery. So I need a coronary artery bypass and maybe throw in an aortic valve replacement. I've got aortic stenosis. I go to the hospital that is within my PPO network to get that procedure done. How do the economics of that work?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Does the hospital act as the single entity that bills the insurance company for everything? The surgeon's professional fee, the hospital fee, the device fee for the valve, the drugs, the ICU stay, like how does it work? Is it bundled?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Does the anesthesiologist also have a pro fee in there?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
What would be the single reimbursement on the three vessel cabbage AVR, aortic valve replacement?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
But pick an average payer.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And how much of that is pro fee? How much of that is technical fee?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Isn't that kind of amazing when people think about how low that is? Yeah.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I think what people can't fathom is that the cardiac surgeon who's operating on your heart might have a pro fee of $2,000.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
People can't fathom how low that is because that also bundles them seeing you in clinic, them taking care of you. It may or may not. They're taking care of you for five days in the hospital when you're in the ICU and they're on the floor. And again, it could be lower. Medicare might be below $2,000.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
But if we look at now that $25,000 of technical fee to the hospital, I've seen some of these bills and I don't know what to make of them because it seems like, yeah, the hospital collected a lot, but they're getting ripped off on paying things. This is where you hear the stories of like the gauze costs $16, that little piece of four by four gauze that you have
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
tens of those that you're going to go through in the case. It's almost like you're back in PBM land.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So why does that even exist?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
When last I looked at this statistic, medical expenses were the leading cause of personal bankruptcy.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And it's difficult based on what you just said, though, Sam. It's difficult based on the idea that this uninsured individual... Now, I want to come back to why is anybody uninsured in 2024, 2025? Let's come back to the ACA. But You're uninsured, and maybe it's because you made a risk-adjusted calculation, which is, hey, insurance is going to cost me this many thousands of dollars a year.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I'm young. I'm healthy. I don't need it. In an ideal world, I wish I had some catastrophic coverage. Now, lo and behold, I'm back. And guess what? I'm getting charged $4 for Tylenol, $16 for gauze. And all of a sudden, I've got a $250,000 bill that if we weren't playing with stupid monopoly money would be $14,000, and I could manage that. That's the problem.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
By the way, going back to that $1 trillion that employers are spending, That is a pre-tax benefit, basically, to employees.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
out of the system is uninsured.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
It's important to do that if you're truly trying to manage risk, because if you don't have an individual mandate, and we can talk about whether or not that's a fair thing to ask, but if you're just putting on your risk hat, an individual mandate is essential because you cannot have adverse selection into your risk pool.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Why do people not fight about individual mandates and car insurance?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Because of the risk-
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Right. I'm young, I'm healthy. I'd make far too much to qualify for Medicaid. And my employer doesn't give me a health insurance. I'm choosing not to buy. How many people is that today?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So a silly semantic question. The ACA is the Affordable Care Act. It seems like an odd name given that its mandate was not to address price, but to address access. And if anything, it drove up price. It drove up cost. It's just silly, but was there an attempt?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
What was the view that the ACA was not only going to address what it clearly set out to address, which was access, but that in doing so it would reduce cost?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
It is. You can still call it ACA. It's the Coverage Care Act, right?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
What's the approximate cutoff in company size, at which point it makes sense to self-insure, which is what you're describing?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Has there been any credible proposal put forth to create a Medicare program that covers everyone? What would be required to make that happen?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So Medicare for everybody isn't solving the problem we don't have that much anymore.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
100%. 100%.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And your argument is, look, we've made it this far. If healthcare is 18% of GDP, as long as we make sure it never exceeds 18% of GDP, even though the absolute dollars will go from $4 to $4.5 to $5 trillion, we're going to tolerate that because... Our economy is going to grow proportionately, not less.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And that's the price that the United States is willing to pay to be first in class for choice, access, and quality. We're willing to pay that price.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
But to your point, public health has been an abject failure when it comes to dealing with these things.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
But anything that's going to be done over a 10 year period has to be government run. There's no employer or individual who can subsidize something where the remuneration is that far out.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So I've got all my charts here that I've been studying to prep for this. And one of the things that stood out to me is one area where we actually spend less than the other developed nations, because we're spending about 2x what they are on everything. We spend less on long-term care. So I guess my question for you is why?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I should note that Sam was also one of my most important mentors at McKinsey and was the individual that recruited me out of my residency at Hopkins to join McKinsey in 2006. Sam previously held an associate clinical and faculty appointment at the University of California at San Francisco, where he also engaged in postgraduate training with a focus on internal medicine and cardiology.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Secondly, we haven't talked about one specific disease that is also increasing in prevalence, which is dementia. So those two are pretty linked. What do you have to say about that with respect to future costs?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Social Security doesn't come out of tax revenue directly.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
The number that I keep thinking of, Sam, is the government collects $5 trillion a year in taxes. That's the government's income is $5 trillion. And we're putting 40% of that right back into health care, if I'm understanding this correctly.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
On that thread of technology, we touched on it really briefly in terms of how AI can help with the absolute messiness of reconciliation and adjudication. But we didn't talk about technology in other ways and we didn't talk about AI in other ways.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So what are your broad stroke thoughts on the role of technology in any of the variables we've talked about, but obviously in cost reduction being that it's the elephant in the room?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
That's right. There's a deficit. So this is the other thing that we were talking about the other day that just blows my mind, which is we collect 5 trillion a year. We spend 7 trillion a year. So we have a deficit of 2 trillion a year. in perpetuity. Oh, and by the way, we're sitting on 35 trillion of debt. Total debt. We're going to come back to this point.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
So, Sam, three hours ago, we started talking, and I said I had hoped that by the end, I would have, and by extension, the listeners would have a better understanding of the U.S. healthcare system. I can't speak for them, but I do speak for myself when I say I honestly think I understand this better than I ever have.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
And that's a clear testament to you. Maybe just to spend one moment on the personal. I've talked a lot about my time at McKinsey as a great chapter of my life. When I left medicine, didn't know what I wanted to do, but knew I didn't want to do clinical medicine at the time.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
What probably many don't know is you were single-handedly the person that plucked me out of Johns Hopkins and brought me out to San Francisco. And you, along with Hamid Samandari, were the two single most important mentors I had there. I owe you such a debt, Sam, and it is such a pleasure to be sitting down with you today. I wouldn't be where I am today without you.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Your influence on me is hard to overstate.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I appreciate that, Sam. And thank you for this incredible, truly masterclass on a complicated system. I will say this, the single most optimistic thing I take away from this is we might not have to slash the cost by something dramatic like 25% if we can enact the right combination of policies, technologies,
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
I'm going to borrow from Paul Tudor Jones on his very eloquent explanation for how do you put that in context?
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
perturbations in behaviors and incentives that simply bend the cost curve towards GDP growth, we might actually be fine in the long run.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
Thank you for listening to this week's episode of The Drive. Head over to PeterAttiaMD.com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter, all with the handle PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you use.
The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
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The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
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The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
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The Peter Attia Drive
#327 - Choices, costs, and challenges in US healthcare: insurance intricacies, drug pricing, economic impacts, and potential reforms | Saum Sutaria, M.D.
That's through programs like Medicare Advantage and things like that.