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
Mon, 03 Mar 2025
View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter In this quarterly podcast summary (QPS) episode, Peter summarizes his biggest takeaways from the last three months of guest interviews on the podcast. Peter shares key insights from his discussions on diverse topics such as aerobic efficiency and VO2 max with Olav Aleksander Bu; insulin resistance with Ralph DeFronzo; economics of the US healthcare system and cost-saving strategies with Saum Sutaria; diagnosis and treatment of autism, ADHD, and anxiety in children with Trenna Sutcliffe; and strength training with Mike Israetel. Additionally, Peter shares any personal behavioral adjustments or modifications to his patient care practices that have arisen from these fascinating discussions. If you’re not a subscriber and are listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or our website at the episode #338 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here. We discuss: Overview of topics to be discussed [2:00]; Olav Aleksander Bu Pt.2 episode: metrics to track aerobic efficiency and insights about VO2 max, and the ability of increased carbohydrate consumption to boost performance [4:30]; The best practices for performing a VO2 max test, the differences between VO2 max training and all-out efforts, and the role of energy intake in endurance performance [14:45]; Ralph DeFronzo episode: the pathophysiology of insulin resistance and type 2 diabetes—how they impact different organs, flaws in conventional diabetes treatment, and more [24:30]; Understanding type 2 diabetes beyond the traditional triumvirate of features: the “ominous octet” describes changes in other organs [31:45]; Pharmacological treatments for insulin resistance and type 2 diabetes [41:30]; The importance of early detection and intervention in insulin resistance [50:30]; Saum Sutaria episode: the economic and systemic drivers of high healthcare costs in the U.S. [54:00]; Reducing health care costs: redefining health insurance, lowering drug prices while maintaining innovation, leveraging AI for efficiency, and more [1:07:15]; Trenna Sutcliffe episode: insights on autism, ADHD, and anxiety in children—definitions and diagnosis [1:11:45]; Exploring the rising prevalence of autism spectrum disorder [1:17:15]; Trenna’s views on caring for children with autism [1:21:15]; Misconceptions around vaccines and autism [1:26:00]; Mike Israetel episode: insights about strength training, minimum effective dose, troubleshooting plateaus, tips for beginners, and more [1:28:15]; Topics Peter is interested in exploring in future podcasts [1:40:15]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube
Chapter 1: What topics are covered in this quarterly podcast summary?
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.
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.
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.
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.
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,
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
Peter, thanks for joining us on another AMA on your own podcast.
We appreciate you coming by. I always appreciate being here. Thank you for having me.
Anytime, anytime. So today is going to be another quarterly podcast summary episode. A lot of words. Basically what it means is we look at past episodes, cover what the main takeaways are, what your favorite insights were, Any changes you made based on behavior to yourself, how you work with patients, how you think about things, anything of that nature from those episodes.
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Chapter 2: What insights did Peter gain from Olav Aleksander Bu on aerobic exercise?
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.
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.
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.
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.
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%.
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.
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.
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.
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.
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Chapter 3: How does carbohydrate consumption impact endurance performance?
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.
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.
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.
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.
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.
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.
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.
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.
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.
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Chapter 4: What are the latest innovations in endurance sports nutrition?
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.
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.
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.
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
So Peter, just a few follow-up questions there. Let's just start with the VO2 max training. So in that protocol, it actually is like a decent warmup that you're having people do. I remember when I've done VO2 max testing, I don't know if they even really had me do any type of warmup. You just kind of went, hit the treadmill and then started going.
So you're having people go through a little bit of a workout before they get going.
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.
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.
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.
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Chapter 5: Can you train your gastrointestinal system to improve performance?
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.
You mentioned you have a VO2 max coming up. When was the last time you tested prior to this?
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.
Let's say the month leading up to it. So the past month, have you changed your training at all? Are you doing anything in particular for it?
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.
In general, so if you haven't changed anything, just as a reminder for people, what is your VO2 max training look like in a typical week? Is that one day a week?
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.
And I always like when we talk VO2 max training, I think back to one of the actually first video podcasts we ever did with Alex Hutchinson. Do you kind of want to walk people through? I think a lot of times, When you think of VO2 max training or Tabata training or like going all out, a lot of times people kind of lose sight at how hard that actually is.
Do you kind of want to walk through, if you're doing actual intervals, real VO2 max training, what that feels like?
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