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.
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
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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.
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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.
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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 –
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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
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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.
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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
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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.
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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.
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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.
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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
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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.
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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!
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.
The Diary Of A CEO with Steven Bartlett
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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?
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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.
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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.
The Diary Of A CEO with Steven Bartlett
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Thank you. Thank you. Thank you. Thank you.
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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.
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Yep.
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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.
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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.
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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.
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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.
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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.
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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.
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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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#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.
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#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.
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#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.
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#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?
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#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.
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#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?
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#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?
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#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?
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#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
#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.
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#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.
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#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.
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#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?
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#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.
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#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.
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#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.
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#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.
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#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?
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#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
#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
We appreciate you coming by. I always appreciate being here. Thank you for having me.
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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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
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
#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
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
#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 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
#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
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
#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.
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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
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.
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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
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.
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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
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