The 4 Causes of DECREASED LIFESPAN & How To Prevent Them For LONGEVITY | Peter Attia

I wanted to start Peter by thinking about our general approach to health and well-being so if we think about your patient population and we think about Health and Longevity where is it that you see many of us going wrong well I think um I think of it more through the lens of the medical system than perhaps individual Physicians um and I sort of described this as medicine 2.0 which is the current system that we're we're in and Medicine 2.0 is obviously uh something that would have followed medicine 1.0 I wouldn't have called it that and it's been a remarkably successful evolution in medicine and it really solved the jugular problem that our species faced for most of our existence and that was the problem of fast death so historically we have died from things that killed us quickly and that's namely trauma and infections uh and again we collectively take this for granted today but as you know and anyone who's sort of studied the problem realizes you know human life expectancy was relatively short um you know shy of 40 years up until about 150 years ago and again that was largely the result of having very few tools if any to cope with trauma and infection or communicable diseases to be more Broad so something really fundamental happened to shift medicine from this 1.0 to 2.0 about a hundred and you know 50 years ago roughly and it was largely sort of three things one was a new way of thinking and that new way of thinking was the scientific method you know really proposed initially in the late 17th century I write a little bit about that but it was this idea that diseases were not caused by the gods and things like that but were actually caused by things that existed in the world and obviously in terms of infectious diseases that was microscopic organisms the second thing then was the development of the light microscope this is something that actually Sid Mukherjee has written about very eloquently in his most recent book the cell where he kind of talks about what a pivotal moment that is in medicine when finally scientists and Physicians were able to with their own eyes see some of these microscopic microscopic agents then of course the third piece of that was developing treatments to combat those things so the development of antibiotics and later on vaccines um so again these three things you know basically doubled human life expectancy in a very short period of time we went from about a life expectancy of 40 to 80 inside of a generation and a half but here's where we are today today we're at a point where not only his life expectancy flattened but in many parts of the developed world it's actually declining a little bit and the question is why right why is it that life expectancy isn't going up if anything it's slightly going down and more importantly quality at the end of life is going down and so it's a long answer to a very simple question you asked but I think it frames the problem right which is what should we do about this individually there is no physician who's out there on the front lines who's taking care of patients who doesn't appreciate that the problem is not that we don't have you know better drugs to lower blood pressure or better drugs to lower cholesterol we do have all of those things but we're not really in a system that allows us to use those things correctly and I think the physician also understands that while at a high level the obvious things are still obvious for example it's important to maintain a normal weight not to have type 2 diabetes to be exercising to sleep well they don't have the training to inform how to do that for a patient so let me kind of give you a glib example think about how long it takes to become a medical oncologist right so if you finish medical school at least in the United States that would be a five or six year post-graduate Fellowship after medical school now a person walking down the street who's never gone to medical school knows that a cancer patient needs chemotherapy they you know they would have some sense that if you have you know metastatic colon cancer or breast cancer you probably need chemotherapy but of course the person walking down the street has no idea what chemotherapy they need or how many cycles how many courses where it should be placed in proximity to surgery radiation what biomarkers you would track of that patient as they go into remission and hopefully remain there that's why the medical oncologist needs five or six years of training to do that and now think about the fact that every doctor knows exercise is valuable but how many of them know your VO2 max how many of them know how many watts you can produce at your aerobic threshold how many of them know how strong you are what your appendicular lean mass index is how you should train to improve those variables which by the way have a greater bearing on your lifespan and health span than any other Factor we are aware of inclusive of the absence of a presence of diabetes hypertension renal disease or even smoking it's it's a very backward situation if you view it through such a stark lens The Physician truly has no training in how to at a granular nuance and individual level help their patient with nutrition sleep exercise or stress yet these things are clearly the most important determinants of our length and quality of life yeah it's fascinating there has been I think a growing movement you call it medicine 3.0 in my first book I called it Progressive Medicine that's a movement in the UK called lifestyle medicine and I think really all of these different movements are in their own way trying to challenge the status quo and go wow listen we kind of need to update things we need to improve uh the tools that we have think about our education differently and what's really interesting and what you said that Peter is one of the pushbacks often tends to be what just what tell patients to eat better and exercise more and sleep more yeah that's obvious any good Healthcare professional would already be doing that and I disagree a I don't think any good Healthcare professional is doing it for a variety of reasons including the bias we have in our training towards a particular style of medicine but as you've just pointed out with something just just like exercise alone there's so much Nuance isn't there into the type of exercise the intensity of exercise what exactly are you exercising for in the book you made the case that exercise May well be the most potent longevity intervention that exists number one do you still stand by that since you pressed Prince and the manuscript went off to the to the Publishers uh and if so why do you put that right at the top uh the answer to the first question is very simple yes I certainly do um and the answer to the second question is also quite simple which is it really is not a matter of opinion it is simply a matter of the data the data make it abundantly clear I kind of alluded to this a moment ago but um maybe for the sake of the audience we can explain what a hazard ratio is right so a hazard ratio is a number that communicates the relative risk of one condition relative to another so for example the hazard ratio associated with all cause mortality for a smoker versus a non-smoker is about 1.4 and so statistically what that means is a smoker is about 40 percent more likely to die in any given year than a non-smoker all other things being equal that's what the 1.4 means and you know if we were to look at something some intervention I'm making this up but you know drinking a certain type of tea if that had a hazard ratio of 0.91 we would say that that intervention is associated with a nine percent relative reduction in Risk if the hazard ratio is one it means there's no difference okay so that's that's the math on Hazard ratios so when you look at the hazard ratios associated with all cause mortality and of course all cups mortality is the gold standard of thinking about lifespan we're going to talk about health Span in a moment but we'll just bracket this on lifespan um let's consider the the the known things that Rob people of lifespan type 2 diabetes high blood pressure coronary artery disease smoking end-stage renal disease those would be the big ones what are the Hazard ratios associated with each of those conditions well at one end of the spectrum you'd see hypertension has a hazard ratio about 1.2 it's about a 20 increase in all-cause mortality meaning you're 20 more likely in any year to die than someone who's otherwise equal without hypertension smoking as I said is about 1.4 1.41 uh coronary artery disease about 1.3 type 2 diabetes about the same end-stage renal disease about 2.75 somewhere between you know 1.75 and 2.75 so anywhere from a 75 to 175 percent increase but now when you do the same analysis based on different metrics of cardiorespiratory Fitness strength and muscle mass the numbers are simply bigger and they're bigger by a lot so for example when you look at comparing the VO2 max of somebody in the bottom 25 of the population for their age and sex so meaning someone in the bottom quarter of their age in sex in terms of maximal oxygen uptake which is a test that we can readily do on people it's a measure of peak aerobic capacity and you compare that to someone in the top two percent of the same age and sex the hazard ratio is five slightly over five meaning it's a 400 percent difference in all-cause mortality in fact if you just go from being in the bottom 25th percentile to being slightly above average from the 50th to 75th percentile the hazard ratio difference is 2.75 meaning it's even more significant than having end-stage renal disease I could go through this analysis all day long and I could do the same thing for muscle mass and I could do the same thing for strength but across the board the difference in all cause mortality is significantly wider when it comes to measures of strength and fitness than it is for any disease condition we know and so the coral area of all of this is by definition whatever it is you have to do to have that higher VO2 max greater muscle mass and greater strength must be hands down the most potent thing we have at our disposal to live longer and of course the only way one can have those things is through the right type of exercise yeah I really appreciate how you broke that down Peter very very clear I definitely want to dive in here but let's just clear up a couple of things before we do um you mentioned Health span and lifespan I wonder if you could explain exactly what you mean by them and then I think it would be useful to talk about your four horsemen because I think it's such a beautiful concept for people to get their heads around the kind of core philosophy behind your approach I think it would be quite useful to start here if that's okay sure um so the word longevity is kind of a shorthand word that people sort of loosely have an idea what it means but it's also a word that's been largely bastardized by uh a sort of you know Shady collection of people who prey on the fears of you know people who are afraid of one of the most frightening things we experience which is the fear of dying so um I generally don't love the word longevity despite the fact that it's part of the subtitle of the book but I use it because again it has such an obvious shorthand for what we're talking about but if we want to be more technical what we're really talking about with longevity is two vectors one is the lifespan vector and one is the health span vector now the lifespan Vector is the uh more you know call it objective easier to understand binary digital whatever word you want to use it's on or off you are either alive or you are dead and there are certainly going to be some gray areas around brain death but for the most part people have a clear understanding of what it means to be respiring versus not and so you know your lifespan ends when you die and at least one part of longevity is on some level extending lifespan but I think unfortunately there's kind of a you know like a Silicon Valley ethos around extending lifespan to you know magical numbers we're gonna everybody's gonna live to 150 or 200 and um you know the round of it is I just think that that's not only far-fetched um but but I don't think it's really what most people are interested in I think what most people are interested in even if they can't articulate it is the other side of the equation which is the health span side which is the quality of life piece I alluded to this earlier this is the piece that medicine 2.0 is failing in dramatically so not only is medicine 2.0 failing to add much years to lifespan Beyond what's already been done but we're doing so at the great expense of Health span and health span is harder to explain because it's more nuanced first of all I think there are three components to it but it's also analog it's not binary it's not on or off it's relative and it declines in slow perceptible ways and at times it declines very quickly for example a person that suffers a devastating injury would experience a dramatic reduction in one of the three areas of Health span which is the physical component right the body the exoskeleton there's also a cognitive piece and an emotional piece and then further complicating all of this is that two of those three are heavily age dependent the physical and the cognitive while the third the emotional bucket is actually not age dependent very much at all in fact sometimes we get wiser with age to enhance our emotional health and we will with other get to emotional health but I really appreciate you outlining that how does these four horsemen fit into this conversation around Health span versus lifespan so when you want to think about the lifespan side of this equation it seems only logical that one must have a great understanding of what the impediments are to lifespan in other words what takes our life away and for a non-smoker this can be pretty easily distilled into the big four and the big four are the diseases of atherosclerosis so cardiovascular and cerebrovascular disease Far and Away number one followed by cancer of course as you and your audience know cancer is not just one disease of you know cancer of the breast is different from cancer of the colon but collectively all of cancer number three is neurodegenerative disease and related dementias so neurodegenerative disease includes Alzheimer's disease Lewy Body dementia Parkinson's disease and it also includes other types of dementia such as vascular dementia frontal temporal lobe dementia and things like that nature and then the fourth Horseman is not so much on the list because of the number of lives that it directly takes but because of the number of lives that it indirectly takes and that's less a disease and more of a spectrum the Spectrum ranging from insulin resistance and nafldi or non-alcoholic fatty liver disease all the way to type 2 diabetes it's basically what we think of as the metabolic diseases which again in terms of how often those diseases show up on the death certificate as the proximate cause of death is not that large you know we're talking about in the United States Maybe a hundred thousand or so I would imagine in the UK slightly less but it's how those things amplify the risk of the other three Horsemen by typically about twofold so um what we really want to be careful of is understanding that when you have type 2 diabetes non-alcoholic fatty liver disease insulin resistance your risk of cancer neurodegenerative disease and heart disease goes up significantly and so by understanding everything we can about the four horsemen we have a chance to delay their onset and that's really the objective here I don't think we are in a situation barring science fiction to completely eliminate the horsemen certainly some of these diseases seem somewhat inevitable to our species cancer for example at the end of the day is ultimately a tug of war between acquired genetic mutations that alter cellular properties and the ability of our immune system to detect them and evade them um but we can certainly delay these and we have great proof already that that happens and the proof exists in the long-lived people the so-called centenarians people who live already to the age of 100 or more and we know from studying these people that their superpower is not living longer with the four horsemen it's living longer without the four horsemen once they come down with the same diseases as the rest of us the time it takes for them to die is about the same it's that they get the diseases about two decades later than everybody else yeah and that's what we have to figure out yeah super interesting that's really quite something for us to reflect on but these super centenarians once they get the same problems that we get the time to death is pretty similar it's just trying to delay that so coming back to the problems with the medical system the way it's set up the way we're trained the way many of us are still practicing we can involve very very late you know we diagnose type 2 diabetes that's um you know theoretical uh point that we have defined um for many years I've been teaching doctors in the UK saying listen guys we're we're still reporting in hba1c of we we have slightly different cutoffs to you guys so we have 6.5 yes as the cut-off for type 2 diabetes but we call pre-diabetes here uh from 5.7 where I believe you guys start at six but nonetheless you know a lot of the time we're reporting these sub-optimal blood sugar levels as normal and the way it works in the NHS typically here the National Health Service is what will often happen is that you will get your blood drawn and you'll often be told if you don't hear from us everything is okay now first of all that is unsatisfactory on a number of levels a it's such a big Juggernaut of the system things go wrong things get missed all the time so I would always say to my patients phone up make sure you've got your result make sure someone has said something about that result just don't rely on the fact that nothing's come in the post so you're okay but the wider point is is that even many doctors are not getting involved with their patient or not taking preemptive action until it's quite far Advanced you know type 2 diabetes Alzheimer's you know dementia for example you know Dale bredesen will say that that condition maybe starts in the brain maybe 30 years before you actually get a diagnosis for example and so from your perspective Peter I know you have quite a bespoke and very targeted practice you know what are the things that we should be looking out for what are the things that we can all start looking at in ourselves to make sure that we're not waiting until these diseases have set in and we've got Advanced end-stage disease you know what what are these key things that maybe we're walking around with but we're not aware of them well it certainly varies by disease but let's take the clearest uh example of where prevention is unmistakably able to get us to the point where we would be far more likely to die with a disease rather than from it and that's the ultimate goal right so you know I'm sure you've shared this with many of your male patients I mean any man who lives long enough will die with prostate cancer but some will die from it right but most men do not die from it they die with it and so the most broad example of that from a disease perspective is atherosclerosis um everybody has it to some extent the goal is to not die as a result of it not to die of a major adverse cardiac event a heart attack a stroke so what would be required to delay the onset of atherosclerosis something that I argue is probably somewhat inevitable to our species um well again this is where understanding your opponent matters now heart disease it turns out atherosclerosis we have a great understanding of its pathogenesis and we know that while genes play a significant role those genes play a significant role often through the modification of the following Pathways lipid related Pathways blood pressure related Pathways endothelial dysfunction related Pathways so what are the big risks for heart disease smoking high blood pressure elevated apob and metabolic disorders so the most extreme example being type 2 diabetes but again any dysregulation of glucose and insulin is going to be amplifying the risk of type 2 diabetes pardon me of cardiovascular disease so how can we take that information and act on it so that we delay its onset by two decades well this comes down to how you view the world through the lens of prevention so I can't speak to how it's done in the UK but I can tell you that in the United States we tend to view things through a Time Horizon of about five to ten years so we use risk calculators the risk calculators incorporate information such as your family history whether you smoke or not what your lipids look like your blood pressure things of that nature sometimes they even incorporate information such as a calcium score and they spit out probabilities they say the probability of you having a major adverse cardiac event so heart attack stroke death in the next five years or in the next 10 years is X percent and the consensus view here in the United States is you do not need to treat a patient for primary prevention unless that number is above some threshold typically five percent so if you're talking to a 39 year old patient by definition it is mathematically impossible for them to have a five or ten year risk above five percent in fact most of the risk models don't even allow a calculation if age is below 40. in my case that was the case I first began to pay attention to this 15 years ago when I was 35 and there were no risk models so basically no one would consider having treated me preventatively even though my family history was significant I even had a speck of calcium on my calcium score which is a symbol of late atherosclerosis um my view is that that's completely backwards logic it's backwards for two reasons the first is the time Horizon is completely wrong yes it's true that if someone's 10-year risk is high we need to act dramatically but to wait until a person's 10-year risk is high is tantamount to driving a car towards the edge of the cliff and telling the driver you're only allowed to hit the brakes when you actually see the edge of the cliff yeah as opposed to telling the driver I can't quite see the edge of the cliff now but I know that there is an edge there let's slow the car down but the second reason to me is even more frustrating and I think if I'm going to be critical of the medical establishment in one regard it's going to be this which is there's often a failure to appreciate the implication of causality and causality is a is a complicated topic because it's so often confounded with correlation and Association but I'll spare The Listener kind of all of the details because I write about it at some length but there is no ambiguity about the causality of APO B and its effect on atherosclerosis I don't know how much your listeners are familiar with APO B and if it's worth explaining what that is but yeah Pizza I was going to ask you so please do expand because it's also not a test that the NHS offer people in the UK either so not only is it I know very well a very powerful if not the most powerful predictor but at the same time it's something that people unless they pay privately here which is a very different model really don't have access to so yeah please do please do explain okay well the good news is first of all it's a very inexpensive test even in you know even in the United States with our grossly and disgustingly elevated costs that are artificially inflated even in the United States the APO B test is only on the order for about 20 somewhere between 12 and 25 dollars so I would imagine that in the UK even if one were to pay out of pocket we're talking about a test that probably would cost less than you know 10 pounds but putting that aside for a moment um a poor man's substitute for APO B which I assume the NHS would cover would be non-hdl cholesterol yeah is that something that would be readily available to anybody yeah okay so non-hdl cholesterol is a poor man's surrogate for apob but what APO B is is a it's a protein that's wrapped around all of the particles that cause atherosclerosis of which the most common is the low density lipoprotein or LDL and by measuring the APO B concentration you are directly measuring the concentration I.E the number of particles per unit volume of all the lipoproteins the ldls the vldls idls lp little A's that cause atherosclerosis and that turns out to be the most powerful predictor of any lipid or lipoprotein as it pertains to cardiovascular disease and what you want is for that number to be as low as possible in formal logic we would describe apob as necessary but not sufficient for atherosclerosis so you need it to get atherosclerosis but by itself it's not sufficient to cause atherosclerosis which means that there are some people walking around with very high levels of apob who do not go on to develop atherosclerosis but you can't get atherosclerosis without it so we've established through epidemiologic studies primary prevention studies meaning the treatment of people who don't yet have cardiovascular disease secondary prevention studies the treatment of people with cardiovascular disease and mendelian randomization perhaps the most powerful of them all we can explain that if people want in a moment but I don't think it's Germaine we've established through all of these different levels of evidence that low density lipoprotein or apob is causally related to atherosclerosis this is so important again I don't think there are many doctors worth their salt that would not acknowledge that so now the question becomes why would we not reduce dramatically at an early age the level of this lipoprotein and I would use an example that I've used before I think I use it in the book of smoking everybody knows that smoking is causally related to lung cancer meaning it's not just an association that we see a tenfold higher prevalence of lung cancer in smokers and by the way it doesn't mean that every smoker will get lung cancer or every person who has lung cancer was a smoker neither of those things are true but neither of those things diminish the causal relationship between smoking and lung cancer and because we know that smoking is causally related to lung cancer we take a very simple preventive strategy which is we tell people out of the gate do not smoke and if you do smoke stop right away can you imagine if we used models to predict the likelihood of people getting lung cancer and waiting until the probability of that event was you know 10 and then saying well listen Johnny your your risk of lung cancer is now 10 it's time to stop or let's wait until on the chess CT we see calcified lesions in your lungs that are suspicious for cancer now it's time to stop of course not once you've established causality you remove the causative agent and yet we don't take that approach in treating atherosclerosis which is why atherosclerosis is the leading cause of death globally 19 million people die every year from atherosclerosis number two is a distance second cancer 11 to 12 million per year atherosclerosis not only shouldn't be the leading cause of death it shouldn't even be in the top ten based on the tools we have to delay its onset significantly yeah I really appreciate the analogy to smoking I think it makes it really clear how how backward short-sighted frustrating limited our approach currently is to how we look at these things what's really interesting is that you mentioned APO B and it's necessary but not sufficient in and of itself of course there's all kinds of other things I'm guessing inflammation immune dysfunction all kinds of sort of um ingredients to put into the mix really to combust things up where you actually end up having the atherosclerosis but you also mentioned you want to um bring APO B down as much as possible the lower the better now what's interesting about that for me when I hear that is most things in life I would say there's upsides and there's downsides right and often we just look at the upside and we negate or we we fail to take into consideration what is the downside here so let's say APO B um let's say we've measured it and it's higher than we would once and let's say the patient is of a reasonably high risk which I guess you would say by definition having a high apob puts them in a risk category of sorts the question then is how aggressively do you decide to lower it what therapeutic intervention do you use to lower it and then just to add on that pizza is we're talking about these four horsemen that end up bringing life to a close early right atherosclerosis cancer neurodegenerative disease and I think poor metabolic health information is not enough to make change in your life you have to take action so to help you take action after watching this video I've created a free nutrition guide for you this contains the five most important practices I've seen in over two decades of seeing patients they work for you no matter what your dietary preference there's a step-by-step action plan to help you implement those changes in your life if you want to receive that free guide right now just click on the link in the description box below right it's a Everest scenario where you are aggressively attacking one Horseman to bring your wrist down off of that one that's then inadvertently increasing your risk of one of the other horsemen yeah there is and I think staying on this example I think let's use two let's use two examples right so um we know that aggressive use of a class of lipid lowering agents called statins has a small but non-zero risk of increasing insulin resistance in some individuals in other words there are some people who when you put them on a Statin so a dose like rezuvastatin atorvastatin things like that you reduce the rape OB which is the desired outcome but you get an undesirable side effect which is glucose levels and insulin levels go up and you are pushing them now further towards the risk side of the spectrum on the metabolic Health plane well that's a problem right because to your point if you're if you're solving one problem and creating another that's a sub-optimal solution so we have to look for Optimal Solutions now the good news is where we are today we have so many tools for reducing APO B that don't come with those side effects now the good news is most people and it's hard to quantify this but it's seems to be in the neighborhood of about 90 to 94 percent of people have no measurable discernible subjective or objective side effects to statins meaning they don't have muscle pain they don't experience elevations in transaminases they don't have insulin sensitivity issues or anything but let's just say 10 of people do we have pcsk9 Inhibitors we have acetamide we have bentinoic acid these are drugs that really don't seem to come with any side effects uh sometimes when I look at the mechanism of action of a Statin I'm surprised the side effects aren't higher because it because of where it acts in the inhibition of cholesterol synthesis and how it does so ubiquitously in the body but when you look at how these other drugs work we don't I think need to go into the mechanisms of each of those I Do cover that very briefly in the book um it's intuitive that the mechanism of action of those drugs matches the clinical experience which is basically virtually nobody has any side effects to these other drugs they're much cleaner drugs than a Statin if we can use that lingo so um yes the goal is to get APO b as low as possible we'll talk about how low that is um but you have to be able to do that without creating another problem and I think you know 15 years ago 20 years ago that was a much harder proposition than it is today before we go further Pieces Just on that point which I think it's a beautiful uh illustration of some of the kind of upsides and downsides that have to be weighed up if we move away from pharmaceutical medication for just the moment and we look at these four horsemen and go okay what do we know that is probably playing a role in all of them most of them chronic unresolved inflammation would probably be something that most people would agree on is one of those core Roots causes that are going to increase the likelihood of each of those four so therefore if we can adopt a certain lifestyle behaviors that help us to lower chronic inflammation then those lifestyle changes are likely to aggressively start to reduce our risk of all four of those we're probably not having to weigh up you know lowering risk of one and increasing risk of another I first of all I I wonder if you agree with that perspective or whether you have a slightly different perspective and then following on from that is it only typically when we're bringing in foreign agents let's say a pharmaceutical drug that's these considerations of you know Improvement here problem here start to become an issue because you mentioned statins and of course statins are known for some to impair negatively mitochondrial function and then you write about basically in the exercise section of the book about the importance of mitochondrial function for a whole variety of different reasons which hopefully we'll get to during this conversation so it's it's kind of these upsides downsides up size downsides that appears for many people if they're listening to this trying to take ownership of their health and I know your book's going to help them sort of walk them through this and try and figure out how they do this it kind of comes across maybe as man is this confusing am I going to reduce my risk of atherosclerosis but at the same time increase my risk of type 2 diabetes so how would you help us kind of how would you help the General Public you know look at these problems and what can they actually you know practically do to sort of manage this risk for themselves if it's all they can all right so I think the first question was is the problem of whack-a-mole where you lower the risk of one only to potentially amplify the risk of another is that a problem we only see in Pharmaceuticals and the answer is unfortunately no uh in fact that's that's a general problem of Life there is no scenario that I am aware of by which you can take an action that addresses one issue that does not potentially have an impact on another so let's take two lifestyle examples quote unquote lifestyle examples where you have a clear positive impact in one Arena and a clear negative impact in another uh the first would be fasting okay or let's let's just be more you know let's just talk about caloric restriction extreme caloric restriction so there's only two interventions in the entire literature of zeroscience that have reproduced reproducibly extended life in virtually every model organism across which they've been tested one of those is caloric restriction when you calorie restrict an organism it in a laboratory environment it generally lives longer there are some caveats but as a general rule you calorie restrict mice rodents flies worms everything they just tend to live longer do we believe calorie restricting humans to 30 percent of their required caloric intake so a person who would normally need you know 2500 calories per day you're going to knock 30 percent of those calories off day in and day out do we believe that that is a net positive in their life and the answer is it is probably not because while you will have undoubtedly reduced their risk of diabetes and metabolic disease and probably by extension reduced their risk of cancer and maybe heart disease in the process less clear on the neurodegenerative side by the way you have undoubtedly and this has been demonstrated in animal models increased their susceptibility to trauma and infectious diseases in fact those people are very likely to end up in a case of sarcopenia they're far more susceptible to one of the other great Horsemen that doesn't quite rise to the level of being the big four but it's a very close number five and that is accidental death which is virtually entirely dominated by Falling once you reach the age of 65. so these are individuals who lack muscle mass or Lac bone mineral density and the mortality from a hip fracture or pelvic fracture when you reach the age of 65 approaches 30 percent in the first 12 months yeah so you solve one problem you create another and that's again just dealing with something that's as beneficial potentially as caloric restriction let's take another example if an individual goes from never exercising at all to exercising to an extreme level they might get injured right they so they're going to accrue lots of cardiovascular and muscular benefits of exercise let's say they take on a very aggressive regimen where they're you know running an hour a day and lifting weights for two hours a day there's an enormous benefit to that but if they injure themselves and I mean a bad injury you know they damage a disc in their back that ultimately requires a two level Fusion well that's going to have a terrible outcome on the duration of their life not necessarily in terms of how long it is but in terms of the quality of life and the pain that they're in so so I just want to make sure that everybody understands that everything we're talking about has a trade-off and that's why we have to be nuanced and we have to apply the right tool at the right time and I think what you know what I tend to to bristle against is the idea that we would individually or collectively view tools as binary Goods or bads yeah right you know and and I get this question all the time of course I'm sure you do which is are statins good or bad uh you know is metformin good or bad and it's sort of like that's the wrong question right that's like asking a carpenter is a hammer good or bad is a screwdriver good or bad well it depends what you're using it for and it depends if you know how to use it you know if you try to take a hammer to a Phillips screw that's a sub-optimal use case if you try to take a Phillips screwdriver to a nail that's a sub-optimal use case so we yeah we have to get away from kind of what I call paint by numbers into sophisticated nuanced approaches to pharmacology exercise nutrition sleep Etc I think that's one of the things I've loved about your book the most is that it isn't a prescription for optimal aging it's not if you do the Peter attia plan you will live to this age or whatever it might be it's much more nuanced it's much more aligned with I think the philosophy I have as a doctor which is different things work for different people it is very hard to give generic guidelines that work for absolutely everyone and I think what your book does beautifully is it helps people think differently about that life about the choices they make that's that idea that there's nothing good or bad really it depends on the context I think is it it sort of applies as you say to everything in life beyond Health but even if we just stick to health for a minute as you were explaining those examples of um caloric restriction or over exercising you know good sides bad sides I was thinking about okay what's neutral here okay improving our sleep is probably neutral then I thought well hold on a minute what about if you're working hard and the cost of switching off for the evening and going to bed early so that you can get your sleep hours in to reduce your risk of a b and c if that means that you don't get to spend quality time with your partner because of that then sure on one hands you might be getting more sleep but on the other hand you are potentially impacting a really important relationship and I know that seems like quite an extreme place to go but I think it has validity I think everything in life what we choose we could be doing something else with that time and it's something that I think a lot of people who are really focused on biohacking and health optimization I think really needs to understand yeah but that's another part to life as well and are you missing out on that I think I've been guilty of this at various times in my life for sure what about walking though Peter walking how where's the downside I mean I guess you could apply what I just said to sleeping to walking but you know all that let's let's put it like this in your heads right now are there any generic Health recommendations you can make to people without knowing their personal history yeah I mean I think the the most obvious ones um would certainly be around exercise adequate sleep and adequate protein consumption I mean I think those are three almost across the board recommendations that can be made now what adequate means will differ for different people so so for me the amount of exercise that I now need given my training history right I've been exercising you know my entire life so for me to receive what we would call the training effect requires me to do quite a bit whereas a person who doesn't exercise only requires about three hours a week to get an even greater benefit than I'm probably getting incrementally going from say nine hours a week to 12 hours a week if I were to make a change of that that magnitude so the details still matter but exercise really has shown no upper Bound in terms of benefit at least through the lens of strength muscle mass and most importantly cardio respiratory Fitness there is there does not appear to be an upper bound of benefit but that doesn't mean there isn't an upper bound to what you do in the pursuit of those things using your example in terms of time and opportunity cost and also using injury as a risk I mean I do have a patient who was just hell-bent on getting 20 000 steps a day this became like this person's mission in life well until they developed an injury in their foot from walking so much because it turns out they're mechanics and their shoes weren't really optimally suited for what they were doing so in pursuit of something that was clearly beneficial they actually created a little bit of a problem you made another good point that I think is really worth emphasizing which is you know this biohacking movement which I've certainly been accused of being a leader of um I I think has a couple of problems and and one of them is certainly the failure to appreciate the opportunity cost argument now many people who partake in sort of the elaborate um aspects of biohacking say look I don't care about the cost it's a worthwhile trade-off to me if there's potential upside but what they're often discounting is the opportunity cost of time and that's something for which we are all equal right we might be disparate in our economic means by which we can pursue crazy ideas but we're completely equal and we all have 168 hours in the week and so to give you one example I had a patient who said look I'm I'm really thinking about getting into hyperbaric oxygen and you know it gave me all his reasons for it and I said well let's just be clear none of the data on this topic suggests it's remotely viable for what you're interested in there are indications for hyperbaric oxygen but if your indication is zero protection cognitive enhancement I've reviewed that literature 10 Ways to Sunday and there appears to be absolutely zero benefit and he said well that might be true but even if there's a chance it works I think I want to pursue it and I said okay how far is the Chamber from your house 30 minutes okay you have to sit in the chamber for an hour six days a week that's right and then 30 minutes back okay that's 12 hours a week you're putting into something but I'm telling you has a very low chance of succeeding and you're acknowledging that by the way why not put that time into something that is demonstrated to succeed right taking that 12 hours and saying I'm going to spend six of those hours exercising I'm going to spend you know three of those hours socially with people who matter to me building relationships with my kids or my spouse I'm going to spend three of those hours out in nature walking like you know just using that as an example so so this is where I think we have to be very cautious about you know sort of taking the shotgun approach to biohacking because it does come at a cost that is the financial cost is the lowest cost by the way yeah I think it's a great point and that approach I think is important for people of all income levels actually um I wrote about this in my last book a little bit about uh time and I I you know just to Briefly summarize this case I wrote about Peter I was in a a practice an NHS practice in an area of very low social economic status a lot of low income a lot of poverty and there was someone who you know was coming in was all kinds of issues which I was trying to help him with and you know he was struggling for time and he was saying look I I don't have time to do this I'm busy I'm doing this but when we actually figured it all out and actually went through how he spent his time when he was not at work he was doing things like going for three or four shops a week to different shops to save money he was uh driving I think 20 minutes out of town to get cheaper petrol and in the context of everything I won't go through the whole story but essentially we figured out that actually he was saving very little money but spending about four hours a week for that and so we came up with a like a four-week challenge say okay for these four weeks instead of saving that and I appreciate that money's tights and he agreed to this it wasn't me sort of cajoling him into doing something he didn't want to do I said would that time saving you could go for a walk you could spend time with your kids you could do all kinds of other things and I I kid you not Peter that one change literally over the course of six to 12 months starts to transform his health because he suddenly realized wait a minute everything in life has a cost and actually the cost of actually just going to the petrol pump down the roads which is a bit more expensive but actually it gives me so much more time to look after myself and he you know a year later the guy had lost weight he's got a better relationship with his children with his wife simply because he needed somebody outside of him to help him understand that actually everything in life has a cost we're often simply not weighing it up yeah look that's a beautiful example um and and it's uh I think it's something that you as you point out it's not always easy for you to see it yourself and you're the one in it it's it's this is where it really helps uh he was lucky that he had a doctor who with the limited system of having 10 minutes with a patient because most I think most doctors wouldn't have necessarily what the ability you had which is to say hey um I'm gonna think beyond the the immediate problem in front of me which is that your blood pressure is too high and you're overweight and I'm going to start thinking about this from the standpoint of your life so he's very fortunate that that he had that and you know unfortunately I think that that's that's probably not common right yeah I think many of us go through life making these trade-offs that in the big picture are uh quite irrational so we've mentioned APO B right so in terms of the things that you feel that many of us should be looking at and then potentially treating aggressively if it's elevated or if we have a strong family history or whatever it might be and and to be clear you you set this out really beautifully in the book for people who want to dive deep that's one thing that we've mentioned that not everyone can have access to both in the US I think and here but look before we move on from APO B if someone cannot get that and all they have available to them is a standard lipid panel of total cholesterol triglycerides LDL and HDL how would you advise them to look at that with a view to assessing their risk well as I said non-hdl cholesterol which you can calculate by taking total cholesterol and subtracting out HDL cholesterol that gives you a number um that is you know that's a poor man's version of APO B and it's a better predictor than LDL cholesterol of risk and so you know I assume in the UK your units are millimole not milligrams per deciliter so I'm not I'm not familiar with the unit system as well but there are readily available tables that will demonstrate percentiles yeah and so what we suggest is that a young person really should be below the 20th percentile at or below the 20th percentile and the younger you are the less aggressive you need to be because this is sort of an area under the curve problem so it's really about lifetime exposure just as blood pressure is right you know if you if you have um high blood pressure even mildly elevated for a very long period of time it's going to cause you know proportionally similar damage to a person who has higher blood pressure but over a shorter period of time and similarly with APO B you know if you start lowering this when a person is in their 30s you don't have to make an enormous change outside of cases where people have familial hypercholesterolemia or things like that versus when somebody shows up in their 50 and they already have evidence of atherosclerosis on a CT scan then you're going to have to be much much more aggressive so you know I mean I would just say directionally somebody who has any evidence of atherosclerosis you're basically now treating them as a very high risk secondary prevention case even if they have not had an MI which is normally what we would use to move into the world of secondary prevention if a person has calcification on a CT angiogram or a CT coronary CT that's effectively secondary prevention we would want that non-hdl cholesterol cholesterol below the fifth percentile that's such a good point Pizza which I I think many many people haven't really grasped that if you've already got signs you don't have to wait it's it's that smoking analogy again you know wait until you're off the cliff you know wait until you've had the heart attack okay now we know what we're dealing with now we can Implement secondary prevention it's kind of like no you know we we don't need to wait for that moment it's it's so basic and obvious when you lay it out like that it is quite remarkable that we seem to have gotten to a system where we we don't treat early and I I get it I understand the pressures within the medical system I understand why we've ended up uh working like this why of course you've set out the case we need to upgrade medicine now rethink medicine um but that's a that's a really really good point do you have numbers that you look for I know don't worry about the UK units people can easily convert are there you know do you have numbers with these ratios like triglycerides or HDL ratio do you like to see it below a certain amount for example well it's important to understand that while the ratio of triglyceride to HDL cholesterol um is suggestive of insulin resistance it has no bearing on atherosclerosis risk in fact um I think we we wrote about this in our newsletter we have a newsletter that comes out every Sunday and it it usually goes pretty deep into these topics and um we did a newsletter on this particular issue around the value of knowing triglyceride level um we certainly pay attention to it and we're alarmed anytime the triglycerides are over about 100 milligrams per deciliter that tends to be alarming and certainly If the ratio of triglyceride cholesterol a triglyceride to HDL cholesterol is above about two we also tend to think that that's a red flag even though most people would say three four or even five would be the threshold we think anything over two is a red flag as a ratio of triglyceride HL cholesterol but here's the interesting thing once you normalize for APO B there is no residual remaining predictive value of HDL cholesterol triglyceride total cholesterol those things completely become irrelevant once you know APO B and basically non-hdl cholesterol as well so in other words once you have the non-hdl non-hdl cholesterol level pegged that captures all of your lipid risk now the only exception to that is LP little a but we can talk about that separately So based on what you've just said in a hypothetical scenario where people were given an option say you can have one test to measure your risk of atherosclerosis one blood test and you had to pick and I appreciate we're not in that scenario but as a thoughts experiment you would say that one test should be a per B yeah there's no ambiguity about this it's it's the literature is overwhelmingly uh in fact I'm not aware of a single study that would suggest that there is a superior lipid biomarker to apob uh there are some studies that would suggest that non-hdl cholesterol is almost as good but on balance when you look at the overall body of literature it is unambiguous that apob is the superior biomarker but I want to be clear and I don't want us to get hung up on this because I know your audience might not have access to apob so I don't want perfect to be the enemy of good yeah if you don't have access to apob that's okay the the the jugular Point here is know your non-hdl cholesterol know your LDL cholesterol and manage those aggressively and the reason that not that non-hdl cholesterol is better than LDL cholesterol is it includes vldl cholesterol by proxy and therefore it includes the negative impact of excess triglycerides so you asked a question earlier about triglycerides and you're absolutely correct elevated triglycerides are a risk for cardiovascular disease and they're a risk that is not captured by the LDL cholesterol but they are captured in the vldl cholesterol and that's why apob captures them both because APO B is the concentration of all atherogenic particles and so as the triglyceride level goes up so too do the number of lipid transporting lipoproteins because they now have to make way not just for the cholesterol that they're trying to carry back to the liver but also this High burden of triglyceride and that's again why apob is a superior metric but if you don't know apob and you don't know for some reason non-hdl cholesterol then yes you do need to know triglyceride and LDL cholesterol to capture the full risk before we move on from this topic thank you for summarizing that Peter for people who don't have access but let's say by whatever means you found out that you have higher levels of APO b or non-hdl cholesterol than you would ideally want you've mentioned there are some pharmaceutical interventions that one can use what sort of Lifestyle interventions can people do to to bring that down the most important ones come down to those that reduce triglycerides because of everything I just said a moment ago namely that the higher the triglyceride the more lipoproteins you need to carry them and namely that's the vldl the very low density lipoprotein which ultimately becomes an LDL a low density lipoprotein so the question then becomes what do you need to do to lower triglycerides so the people for whom dietary interventions are most potent at lipid lowering are the people who have the highest triglyceride level as a general rule so when I see people that show up with very elevated LDL cholesterol apob and very low to normal triglycerides we don't waste any time with dietary intervention with one exception which I'll come back to in a moment but for the most part we recognize a genetic defect usually at the level of the LDL receptor that is responsible for this problem and it must be addressed pharmacologically so but let's go back to where we still see a lot of room for um Intervention which is a person with elevated APO b or LDL cholesterol non-atl cholesterol and also very elevated triglycerides so the easiest solution here is typically carbohydrate restriction so carbohydrate restriction generally is the quickest path to reducing triglycerides but it comes with a catch and that is carbohydrate restriction usually means increasing fat consumption and in susceptible individuals increasing fat consumption especially saturated fat consumption will via a totally different mechanism increase cholesterol production and that's what I was actually referring to earlier which is the other dietary thing you have to always be mindful of when you're staring down the barrel a very elevated LDL cholesterol or apob is what is this person's consumption of dietary fat and in particular dietary saturated fat yeah if a person is sensitive to that they will increase cholesterol synthesis and dietary fat High degrees of saturated fat will impair LDL clearance from circulation via the liver yeah it's a great point and I would agree in in my experience as well there's nothing faster and more effective to bring triglycerides down than some form of carbohydrate restriction but as you say you've got a not just look at the triglycerides in isolation because you don't know what else might be going on as a consequence of that it's another example of the question you asked earlier you do something in the lifestyle you you cut carbohydrates and fix the triglyceride problem but if you do it by mainlining coconut oil or whatever your saturated fat du jour is you'll drive APO B up through the roof you're probably worse net off than you were at the outset everything has a yin and yang yeah and there's obviously this big online debate over how much does that matter on an aggressive let's say a low carbohydrate diet for example there's you know I've I'm sure you have been involved with this seen it all like the conversations around how much does this really matter if the hscrp the marker of information is down you know how much do we need to worry about other things potentially going up and you know so I don't think this question is as nuanced as those proponents would argue it's no more nuanced than you saying uh how much should a smoker worry about smoking if there otherwise healthy and fit maybe less than a non-smoker maybe less than a smoker who is not healthy and fit but does anything about the fitness of or otherwise good health of that smoker diminish the causality of smoking in respect to cancer no yeah and similarly if you tell me that a person is on a low carbohydrate diet and that they're insulin sensitive and their inflammation is low but their APO b or LDL cholesterol is still through the roof that doesn't change the fact that they're still at risk as a result of that so again this is why causality matters so much the person that has familial hypercholesterolemia can be completely metabolically healthy in fact many of them are right okay you know you diagnose this in a child who's 15 20 years old they're thin they're lean they're healthy their hemoglobin A1c is five percent their biomarkers are pristine yet they have premature atherosclerosis because of Lifetime exposure to LDL cholesterol of 200 milligrams per deciliter so I think that the people who are suggesting that just because you're on a low carbohydrate diet and your other biomarkers are fine but you know you and you can ignore your LDL cholesterol I think those people are playing a very dangerous game of Russian Roulette and I hope that people who are paying attention to those people um get a broader aperture on their view of Health blood pressure of course is also a very important uh metric for us to pay attention to and of course for many years now there's been home blood pressure cuffs available right so whether your doctor is doing it or not and of course there are some pretty big limitations of rushing uh getting your car parts rushing in and actually hey you can take my blood pressure dark but of course there's some real problems there but speak a little bit about blood pressure because what I love about addressing blood pressure is that first of all in terms of us being blind to what is going on inside our bodies and then somehow at 50 or 60 running into problems blood pressure is something that we could get on top of pretty early if we started paying attention so how do you view blood pressure how do you frame it with your patients um yeah and then we can maybe dig into treatment potentially depending on where we go with this yeah I'm really glad you bring this up there are a handful of regrets I have in writing the book and regrets is the wrong word there's nothing that could have been done about it but I guess I would say there are a handful of topics that I wanted to go much much deeper into but as you know the book is almost 500 pages there was simply no margin to go longer so so this book is 60 000 words shorter than the previous version of this book in other words an entire book was stripped out of this book and one of the topics that I really wish I could have put more energy into is this exact topic and I I would argue this is just as important as the APO B discussion but for a slightly different reason and the reason is here you have a physiologic parameter that not only shortens your length when it comes to cardiovascular disease but also does so with respect to Alzheimer's disease and Dementia by the way we didn't talk about that with APO B but APO B is also probably lowering APO B is I would say one of the three most potent interventions you have to avoid dementia and Alzheimer's disease we should maybe bracket that and come back to that that doesn't get nearly enough attention yeah right there you know along with exercise reducing lipids is unambiguously the surest way to prevent Alzheimer's disease and dementia but so too is lowering blood pressure and the other thing that doesn't get nearly as much attention is the impact of elevated blood pressure on kidney function and how significant this becomes in an aging population and while you know this rarely gets a 40 50 or even 60 year old into trouble it starts to become very problematic when people are in their 70s and 80s and when you have very compromised kidney function one it makes it much less likely that you're going to live to say 90 and also you become far more susceptible to toxins that you know your kidney would normally filter out when your kidney is functioning at a quarter of its capacity so blood pressure as you said is partially Complicated by the fact that we as a medical community don't do a great job measuring it in our patients so you very accurately alluded to the exact problem right which is patient you know Parks the car has to run up the stairs sit in the you know Reception Area get quickly shuttled back have their blood pressure checked with an automated cuff and that number doesn't tell us much I mean we know from the Sprint trial that there is a really clear protocol for how to measure blood pressure and you need to be sitting comfortably with your legs uncrossed not speaking for five minutes the automated cuff or the manual cuff needs to be placed in exactly the right way such that the marking on the cuff aligns with the brachial artery and such that the cuff is at the level of the right atrium I.E where the vena cava Superior and inferior empty into the heart you know I think it's interesting and I do this all the time just to show people take a blood pressure reading with your arm significantly above or below your heart and you will be amazed at the difference in pressure it is very sensitive to this finding for this reason we typically recommend that our patients get a very high quality Monitor and we typically direct them to two or three that we fancy and let them buy it on Amazon or at their local drugstore we give them a log electronically and we ask that they check their blood pressure twice a day in the morning in in the afternoon or evening according to this protocol and we don't even make assessments on this until we have at least two weeks of data but those data now we can believe we can trust those data and now we know if those numbers average above 120 over 80 we need to take action because again this is where the largest most well-conducted blood pressure studies make it abundantly clear that treating either with lifestyle or pharmacology to better than 120 over 80 has significant benefits and outcomes over even 130 over 85 where we used to historically consider the upper limit of normal yeah it's such a good point measuring it correctly of course this were the important otherwise people can go out buy something from the local drugstore try and take ownership of their health I then start to stress themselves out that actually whoa my blood pressure is really really high there's a couple of couple of things there for me uh to discuss Pizza one of them is trackers in general because certainly as someone who's observed you online for a number of years you've been pretty open with what you track you've shared lots of times about the sort of things that you do track and of course not everyone is pro trackers and um my view is is that it often depends on the personality type in terms of you know I have had patience in the past let's say 10 years ago for example um I seem to recall but maybe you know and I say 50 of patients this is just you know a rough guess but basically around half of my patients when they would say should I get a blood pressure monitor would it be helpful I said hey sure why don't you pick one up and um you know let's let's sort of see what happens or you know measure it at these times what I found is that maybe half of the patients would measure maybe three or four times a week and they would use it as a way of keeping them on track with lifestyle change it would help motivate them whereas the other half I found would start checking it six times a day if one of them was slightly elevated it would make them anxious it would probably drive up their blood pressure for the rest of the day they'd be phoning and so I thought okay is this good or bad coming back to what you said previously Peter Well it kind of depends right it depends on who you are so I like what you're doing as a practice where you have this set protocol you're not really looking at those individual numbers it's like just do you know do this for two weeks and then let us have a look and see what the overall pattern is I think that's useful so given that many people will get their blood pressure at the doctors in this sub-optimal way or they're going to pick one up from their local pharmacy where do you see trackers here I know I heard you say in a conversation a little while ago that you were checking out a few of these risk trackers you know I hope we get to cgms because I think cgms are one of the most powerful tools I have seen to change behavior in my two decades of practice I I don't think I've seen anything as powerful in real time do that but just to finish off on blood pressure a little bit where are you up to with that with your sort of Investigation into this kind of non-invasive monitoring at home so first of all I just want to reiterate what you've said and I agree completely um I do think people tend to major in the minor and minor in the major a little bit and the the tracking is a tool people tend to get distracted by the tool and they miss the substance the substance is the the Insight from the tool and what you do with it and for some people tracking is a very valuable Insight generating tool and for some people it's also a very valuable behavioral tool well as we will talk about with CGM um but when I see the debates between the tracking and the anti-tracking community it strikes me as religious political partisan and uninformed yeah and so I actually try to distance myself from that a little bit um I have a point of view on the benefit of these things um but I'm I find myself less interested in debating it because I don't find the debates to be full of Merit they tend to be um again they just tend to you know degrade into sort of unhelpful uh debates especially online right that's never in my experience you know on Twitter or on Instagram you you especially on Twitter you're yeah very unlikely to you know get to some sort of meaningful place at the end of it where everyone's learned a little bit everyone's involved their understanding I I know as a fellow podcaster I feel these debates or these kind of things long-form podcasting I feel is the best medium to have those conversations because the nuance and contents comes out within them whereas online it's just like as you say it deteriorates very very quickly so like you I I just stay out of them and distance and and say what I have to say on this podcast basically yeah yeah and I've had really interesting discussions with people um about people who might disagree with me on on various things and yeah these discussions when you have them properly over the phone or whatever they tend to be much more productive um so as it pertains to blood pressure um I would have to guess that even the harshest critic of tracking as a general concept would at least have to maintain some interest in continuous blood pressure monitoring yeah because this is something where there are so many limitations of spot checking so even if you get over the limitations we just described which are numerous you still have the limitation of even if you do it perfectly you're only looking at two points in time yeah you don't know what your blood pressure is at night you don't know what your blood pressure is when you're working when you're on a phone call and you're stressed out or when you're making dinner or all these other things and what we really would like to know potentially is what is your average blood pressure over the course of a day and today the only way to really do that is with a 24-hour ambulatory blood pressure monitor what's called an abpm and I've worn one of these before so it's an actual cuff that you wear on your arm that's hooked up to a regular blood pressure machine except that it's smaller and it's set to cycle every 15 minutes and so you wear this thing for a couple of days you take it off when you shower but otherwise you're wearing it 24 7 and it's just cycling like a regular blood pressure cuff every 24 hours but the problem is it's so cumbersome that it doesn't really lend itself to Great use and I for someone like me who actually doesn't mind being tracked I found it so cumbersome that I I quickly got rid of it so there are devices out there now um one of which I've played quite a bit with um that measure blood pressure optically off the back of the wrist and they're calibrated to um an automated cuff measurement it's too soon for me to say what I think of these devices but but I'm very curious and I'm very hopeful and optimistic that these things pan out because I I really think that that's a piece of information I would like to know for all of my patients I would really like to know what their average blood pressure is and I I think that would probably be even more important than knowing what their average blood glucose is yeah I mean I'm pretty sure we'll solve this problem weren't we with technology the way it is whether it's now or in six months or 12 months or two years it's it's inconceivable to me that we won't some point have an excellent non-invasive um blood pressure tracker that really gives us that information I guess in in a way that CGM does right in a way that that gives us information in a very in a way that you can barely know you're wearing one just just going back to blood pressure your target of 120 over 80 as you say is is lower now it's more aggressive than what we were certainly doing five or ten years ago in medicine um is there a specific trial that made you realize there's I think there's quite a few but you know where yeah I think I think the most recent Sprint trial right where we where we saw that what was then described as aggressive management versus standard management was there a difference and the answer was yeah there really was a difference uh would you go even lower so again lower you're saying with APO B you strongly uh believe is better for your risk of uh atherosclerosis um can we say the same thing for blood pressure you know what if it goes to 150 into 110 as long as of course you're not getting dizziness or well that's that's the big if right I I mean you know blood pressure is one of those things where symptoms matter a lot on the low end they don't matter on the high end in other words we're not going to wait until people are symptomatic to say your blood pressure is too high but we would certainly back off if the symptoms are low and that's why you know I'm Eve I'm you know I'm much slower to turn to pharmacologic interventions on blood pressure than I am on lipids because you don't pay as heavy a price on the lipid side right you don't need APO B this is a pigment misconception you have plenty of essential cholesterol in your body floating around without apob kids have an apob concentration of 10 to 20 milligrams per deciliter it's nothing and yet kids have no problem with the profound and Rapid period of growth that they go through including in their central nervous system yeah right so think about that all these people who say oh my God you can't lower cholesterol because your brain will starve I mean there's categorically nonsense right the the most aggressive ravenous appetite that the CNS has for growth is during a period of life when you have the lowest level of cholesterol so there is no downside to lowering cholesterol except for the side effects of the medicines that you use to do it and that's we've discussed those and they're important and you need to understand them with blood pressure it's quite different it's not so much the side effect of the medicine it's the side effect which by the way there are side effects to those medicines but the far more dangerous side effects are the dangerous side effects of hypotension and orthostatic hypotension in particular and so I would much rather use exercise and weight loss and sleep improvements as you know that includes correcting sleep apnea if it's present as the three first second third line agents to fix hypotension because the body is much better at Auto regulation under that setting than if you have to turn to something pharmacologic and we would really only want to use pharmacologic agents when we have reached the limit of those other three yeah it's such a great point and any practicing physician will know full well the problems with blood pressure medications especially with our elderly populations you know you you put them on a tiny dose and then suddenly you know they get dizzy when they're standing up there's all kinds of things to manage and so I think that's a really nice way of looking at it you know it's your threshold of risk will depend on the downside or the potential downside of that treatment so that makes a lot of sense blood pressure when you look at of course we have a med in person so over Zoom you can't tell how tall I am but I am six foot six and a half I'm nearly two meters tall right and why that's relevance is when we look at these generic uh figures like blood pressure you want to treat to 120 over 80. and this is of course where Nuance comes into the practice of Medicine what if someone like me super tall comes in you know and you could make a case potentially that some people at the extremes may you know I may need a slightly bigger blood pressure because I've got so much more vasculature to you know to pump my blood around my body I'm not saying I do necessarily I'm just putting it out there as a theoretical how much do you take these things into consideration or when the data is so clear as it is with blood pressure you just go well let's still treat aggressively as long as we're not getting negative symptoms yeah no it's a great question you know it's a question I've been asked before when it comes to especially tall patients um I guess so the short answer is I don't know yeah um I don't think I know the answer um one way that I would think about it is um considering that as tall as you are and you know you're seven eight inches taller than the average person the real question is what is the difference in height between your aortic valve and you know the vasculature of your brain because that's really the part of blood pressure that is working that's the most important perfusion part of the equation right that's the part we're most worried about is are we getting enough Central perfusion in you because the rest of your body is working a little less off gravity in other words that's the part where the heart has to pump Against Gravity obviously your heart is receiving perfusion regardless of your systolic blood pressure that's being perfused during diastole and everything that's kind of below your neck has the aid of gravity to some extent so so that might be one way to think about it which is even though you're eight inches taller than an average person how much taller are you in an area where your work your heart is working against gravity another way to think about it and I haven't done this analysis um is to look at the blood pressure of say a Giraffe versus another large animal that's not quite as long or doesn't have quite as much distance between ventricle and brain then I'm curious as to I've I remember at one point reading that analysis and I but I've just forgotten the answer yeah really really interesting I love the way you think about this quandary um the the the the sort of looking at giraffes is really interesting not least because you know it has been known for colleagues or friends of mine to call me a giraffe uh so you know I I kind of like I like what you're doing there without that knowledge um but also this is a wider point for me that I've been thinking about particularly I know you have a movement coach I think her name is Beth from recollection from the book I and I see a lot of similarities between you and me Pacer in terms of approach to Medicine certain personality traits that we may currently have have had are trying to eliminate or reduce but I have my equivalent of I guess what I perceive to be your relationship with Beth I have a lady called Helen Hall in the UK who is just one of the most knowledgeable people about the human body and movement I've ever come across and you know there's all kinds of things we do together to optimize the efficiency of my movements and you know my muscle sequencing and efficiency and all kinds of things but let's take running for example a lot of people who talk about running will talk about the Cadence should be around 180 uh you know Force per minute something like that that should be your Cadence and you know I'd read this stuff and I'd absorb it and I'd try and implement it I'd get metronomes I'd try and stick to 180 and be like this is kind of I'm struggling here this doesn't feel like I think it should feel through my work with Helen I've been working with her for about three years now she says wrong I just I just don't think that's the right thing for you you've got super long legs it's just a simple example of where generic advice can start to become problematic if we don't put a bit of context in So currently my Cadence which is beautiful for me is about 162 and she's watching me run she's measured me which is quite a lot different from 180c but then I'm also quite a lot different from the average Runner so that's the kind of context behind my question no I I I I actually it's funny is bring that example up I was the same way in swimming I mean there's really a clear sense of what your Cadence should be in swimming in terms of arm turnover and um my Cadence is significantly slower than anybody else's that I've ever swum with I've never swum alongside people I've never swung alongside a person who has a lower Cadence so um for whatever reason my style of swimming was such that it was better for me to turn my arms over less and just pull harder and glide try to Glide further and anytime I would try to pick up that Cadence it would usually backfire so there was no Rhyme or Reason for it and it frustrated me to no end until I finally just accepted it and said this is my case um there one other point I want to make going back to your particular example which is you know this is where I think we can be more judicious in our use of other biomarkers to help us understand the trade-offs so for us one of the most important biomarkers is systatin C which we we tend to rely exclusively on that and not on creatinine when it comes to understanding kidney function we we tend to ignore creatinine entirely um because it is so influenced by muscle mass exercise status things like that that it always seems to I mean I would say without being facetious 80 of the time I think it's under or overestimating kidney function to the point of being unhelpful so we're looking at systatin C which I think the literature makes very clear is a far superior biomarker for kidney function then of course then we look at you know once a year so we'll look at that every time we look at a person's labs and then once a year we'll also look for urinary protein and things of that nature and so that might be another thing that you can can be tracking if you're saying look I'm going to go off the beaten path a little bit by measuring blood pressure and accepting a slightly higher level is saying well is myocystatin C very very you know is is it low enough that I can say my my estimated GFR based on Statin C is still very high and if you're seeing any compromise there the first place we look of course is at blood pressure and of course the the benefits are taken around that approach using more than one metric to make decisions of course is always going to be a good thing we didn't sort of cholesterol as a big sort of term we've mentioned blood pressure so I wonder if we should just finish off trackers a little bit we've we've touched on CGM briefly of course one of the four horsemen is metabolic health so maybe we could just briefly speak to you know metabolic Health what is it and why do you think that a CGM a continuous glucose monitor is potentially more helpful for us than the standard markets that we have for example hba1c which is that two to three month average blood sugar measurement that many people have um ready access to yeah so I I'm gonna guess that your your uh your listeners know what a CGM is it's a device that you you wear it's implanted in you it has a tiny filament that like there's a needle that inserts a filament the needle comes out but the filament stays in and it stays in um the you know basically the subcutaneous tissue and it samples interstitial fluids so it's not actually measuring the glucose level in blood directly but it is indirectly doing so by measuring the glucose level in the interstitial fluid of the subcutaneous tissue and it is calibrated to then know how that translates to glucose so if it's working well and that's a big if um it's giving you the real time maybe delayed by five minutes reading of your blood glucose so why is that important well I think first of all it's important for patients to understand how various factors impact their blood glucose and the reason for that again comes down to understanding the relationship between average blood glucose and glucose variability and health and at the extreme levels this is not disputed in other words there's I I have yet to meet a person who has tried to argue um which isn't to say that somebody's not trying to argue that but I certainly haven't met the person or read the argument that type 2 diabetes is harmful in other words that when a person's blood sugar averages more than 140 milligrams per deciliter which is the cutoff at a 6.5 percent a hemoglobin A1c that poses increased risk to an individual relative to a lower hemoglobin A1c that is beyond outside of the diabetic range so the question then becomes well what if you don't talk about it through the lens of type 2 diabetes so if you took a hemoglobin A1c of 5.7 percent or 5.6 percent which would translate to approximately 120 milligrams per deciliter in our units uh that's probably about six millimole in your units right um and then the question becomes how does that compare to a hemoglobin A1c of five percent so now we're talking about two people who have neither diabetes nor type 2 or pre-diabetes and we're asking how do two quote unquote normal blood glucoses compare when one is higher than the other one is say 120 and one is 100. well it turns out that that analysis has been done we've written about that and the analysis is pretty clear there is a monotonic decrease in all-cause mortality as average blood glucose goes down even within the normal range outside of type 2 diabetes similar analysis exists for other parameters of glucose and so the takeaway here is that things that can result in a lower average blood glucose even in the normal range I.E below the type 2 diabetes threshold are probably beneficial for all cause mortality and so therefore by measuring those things using a hemoglobin A1c would be the crudest way to do that there might be an advantage to measuring that in other words you would you would tell a patient whose hemoglobin A1c is 5.6 let's work on getting it down to 5.2 even though both of those patients are considered normal and can I say pizza just that I just want to highlight for people that that is what you've just um laid out there for me is one of the big holes in how we currently practice medicine it is normal but not optimal it's right the the the the lack of recognition that these things are on a Continuum and we don't want to wait until it's too late we want to get involved early so please continue I just I I think it's such an important point for us to get for all of us to understand no thank you for making that point actually that's a more eloquent way to say what I was trying to say which is we tend to confuse normal and optimal and they should not be normal is generally a term that's reserved for being inside the extreme ends of a bell curve right so if something is normally distributed on a bell curve we might say you're in normal if you're above the fifth percentile and below the 95th percentile you know the 90 of people that are not at the extremes are quote unquote normal but that says nothing about being optimal and this is true with blood glucose this is true with kidney function this is true with APO B this is true with liver function tests transaminase is it's true with hormones it's true with everything so um the CGM is a tool that offers at least a couple of advantages over I would say three advantages to be clear over measuring something using a hemoglobin A1c the first is the hemoglobin A1c tends to be inaccurate in any scenario by which red blood cell life is not exactly as predicted by the assay so the you know just so folks understand hemoglobin A1c is something that is directly measured you draw the blood you measure the amount of glycosylation on the hemoglobin molecule that's the number you get that's the 6.1 percent or the 5.7 percent the average blood glucose is imputed not measured it's imputed from the hemoglobin A1c based on a belief that the red blood cell lived about 90 days but if that red blood cell was in circulation for a much shorter period of time for example in a person with low-grade anemia either due to Red Cell turnover or bleeding low-grade bleeding you're going to get an artificially low estimate of their average blood glucose because the red blood cell hasn't been long enough hasn't been in circulation long enough to accumulate the glycosylation so if it comes back at 5.0 and you assume their average blood glucose is 100 you're grossly underestimating it similarly conditions that lead that you would also see this by the way in macrocytic anemia and things like that you would also see the reverse in conditions where the red blood cell sticks around longer so microcytic conditions such as beta Thal trait and things of that nature that result in small red blood cells that aren't getting chewed up at the same speed through the spleen you're going to see longer residence time of red blood cell you're going to see artificially elevated estimates of hemoglobin A1c or average blood glucose Visa be hemoglobin A1c so that's the first reason a calibrated CGM and I do insist on calibrating them when I use them I don't rely on the manufacturer's calibration so I insist on doing calibrations the entire time I would wear a CGM a calibrated CGM is a far more accurate tool to measure average blood glucose and glucose variability the second reason is that the person using it even if they only use it for a month and never put it back on gets a far more profound relationship or Insight relationship to how various factors most notably what they eat how they sleep how they exercise and what stress is doing they get to see how those things affect blood glucose and those are you know having now used a CGM on myself and with patients going back eight years there is simply I I've yet to meet a person who isn't amazed the first time they wear one at those relationships yeah wow I didn't realize how eating in the evening is different from eating in the morning how eating after I exercise is different from eating when I don't exercise how sleeping six hours a night changes my blood sugar the next day versus sleeping eight hours a night how being under stress versus not under stress I mean the differences are so pronounced that people are really blown away so there's this phase of what I call Insight generation for which there is no substitute and which can't be done without real-time feedback and then the final reason and this is more for people who like me find Value in using this tool beyond the state of insight it becomes a bit of a behavioral tool yeah so if I'm wearing a CGM and I go into my pantry and I see a bag of my favorite junk food I'm less likely to consume it when I'm wearing the CGM there's just a gamification that goes on with me where I don't want to see the number go up I don't want to see the number Skyrocket because I ate five cookies so I'm just gonna be better at not eating those cookies and for some people that doesn't that doesn't mean anything they don't need that they might have the willpower to do that to avoid those five cookies without the CGM but for many people it is a valuable tool we'll be back to the conversation in just a moment now many of us struggle to find time to eat all of these incredible Whole Foods that's why I'm a big fan of good quality Whole Food supplements like this one that's been in my own life for over three years now it contains over 75 Whole Food Source ingredients vitamins minerals pre and probiotics and can help us support our energy focused digestion and our immune system athletic greens are giving my audience a fantastic offer one year's free supply of vitamin D and five free travel packs with your first order you can see all the details at athleticgreens.com forward slash live more or simply click on the link below now back to the conversation opponents to wearing cgms will often say it could promote disordered eating or an unhealthy relationship with foods and of course for some people it could do yeah I agree I agree I agree with that completely I think um we are very careful in who we prescribe the CGM tube and if a person has any history of disordered eating and we do have some patients in our practice who do we simply don't use CGM as a tool and we're very careful about other things as well such as you know macro tracking yeah um you know so so yes of course this is an example of Nuance which again I think the listener by this point of the podcast understands if there's something that has to underpin everything you're doing in medicine 3.0 it is nuanced yeah and yeah so you you have to be mindful of who you apply the treatment to you know I'm currently on my journey with cgms I would say I put one on for two weeks every three months or so I found that for me that seems to work quite nicely I I get some insights I then don't wear it I apply those insights and then I I pop it back on a few months later to see where I'm at it can help me modify often if I've fallen off it helps Focus me but again that's what works for me and I'm sure for some people will be less for some people it might be more and of course for some people it may be never but I have yet to see something more powerful in two decades of practice as you just highlighted at changing behavior um we have mentioned blood pressure and it's really interesting to me observing your journey and reading your book as to when you came across emotional health as a key part of the Health and Longevity conversation and I feel that emotional health for me both because of struggles I've had personally but also with patience I don't know if this Rings choose you or not Peter but I always used to observe people and go people say information is power okay great I don't disagree with that statement but what I would see is that patients would make changes we together we'd help them make some changes to their lifestyle you know again that term lifestyle their life their life behaviors let's say and they would start to feel better and sometimes that would be one month sometimes they'd be doing it for four months or six months and their life would be transformed and they'd feel good they'd have energy better relationships better sleep whatever it might be but often people would then flip back to where they were before and I would observe this with patients and I would think okay why is this it's clearly not an information problem they they know the information they've not only know the information they've experienced how they can feel when they apply these things why are they going back now of course there's many different reasons but this is the sort of topic I covered in my last book was that I thought well is lifestyle really the issue here or is it something further Upstream and I I really have come to the conclusion that actually it's something more Upstream than that it's how they approach the world it's how they deal with conflicts it's how they manage their relationships because when there's problems there with let's say emotional health and I think the chats you've written on that is brilliance I think often our lifestyle choices are Downstream consequences of them so one of the reasons I went down this roads maybe five ten years ago is because I thought I know I need to tackle this I also feel Peter I'm sorry for the long-winded start to this point but um um trying to get a couple of points across it feels to me that you throughout your return to Medicine have had access to a lot of testing so you can do a lot of testing with your patients for whatever reason that may be whereas as someone who has typically spent most of his career in their National Health Service not having had access to testing means that I feel I've had to really pay attention to other things so I don't have the testing so what's going on here oh they're telling me these words what's the story behind their words and so I feel maybe the different ways in which we practiced have meant we've come to this from slightly different approaches so a couple of things there Peter I wonder if you could maybe give me your perspective on what I've just said no I think what you said is beautiful um and I think that's such an amazing way to think about the differences between you know the the two ends of you know opposite or extreme ends of um how you know we could talk about two different practices right so I'm sitting here in the United States which is a private health insurance only right there is no National Health Care and even within private insurance you know you can move from insurance to just pure fee for service and you know the US is sort of the sky is the limit when it comes to testing testing testing we can do anything and everything right you're at the other end of that spectrum and yet you're absolutely correct I think that our system pays very little attention to the problem that you address and I think it's very astute and I I'd be curious if you know to know what fraction of Physicians within the NHS would recognize what you've recognized which is look I have less at my disposal right now in terms of fancy tools so I'm going to rely on more of these human tools these interpersonal tools these skills that once made a physician what a physician was and I'm going to rely on those to try to better understand how I can apply the fewer tools that I have so no I think I think that's that's really interesting of course um you know my foray into this as an interest was was very personal right it started through my own experience um and I I would say that prior to my own experience with it I was not necessarily that attentive to how much of uh struggle maybe others had and how much of a role this played in the behavior of other people especially in the examples that you use around you know the ability to make changes and then the ability to sustain changes you have shed very openly in the book but also in some of the podcasts you've already done you've you know really opened up about some very very personal things in your life uh parenting things with your wife um your your your child being sick when you were I think in New York and it's really interesting I've I've been listening to those as part of the preparation for our conversation Peter and I know that you have and I think you've admitted to this you have perfectionist Tendencies or you've certainly had them for much of your life I'm really interested as to what it's been like for you as someone who for much of their life I think at least has seen themselves as a perfectionist being on these large platforms these large Global platforms and now being truly quite vulnerable sharing things about yourself that potentially a former version of you would maybe not have admitted to yourself certainly not shared to hundreds of thousands of people what's that experience been like for you like have you reflected afterwards have you after these conversations thought oh man did I say too much like what has it been like for you on a on a sort of human level well it's very uncomfortable I mean I don't think um I appreciate you thinking that maybe I'm a former perfectionist I think I'm a perfectionist in recovery and uh like I think any addict we you know I think we have to have humility around our addictions and uh and keep a close eye on them so um I I think I'm always going to struggle with vulnerability and with um with letting people see my faults and acknowledging my faults and my own Humanity to myself that said um I also realize that I'm very lucky and that um you know I think to to whom much is given much is expected and so to be sitting here having this discussion to have you know survived the ordeal of my you know my past and what I went through in you know 2017 2018 2019 and 2020. um relied on me being very fortunate meaning I had a lot of people around me and there have been some people who have commented to that effect which is hey you know most people don't have the resources you have to get the help that you got right you know you went and spent you know I was five weeks collectively in an inpatient Residential Treatment Center um and that's that's not something our health insurance pays for here in the United States I mean that's I don't even remember what that cost but it was a lot um and I have access to these incredible therapists and so that's not lost on me that there are many people who can't necessarily afford either in time away from work or in financial costs what I have been very fortunate to afford and while I can't apologize for those things I'm not going to apologize for my good fortune what I am going to say is how can I pay it forward right how can I take my fortune my blessing and help other people with it and I think the best thing that I Can Do Is Write a chapter like the last chapter in this book and be open about my story even though it doesn't feel good it doesn't feel good to talk about or write about these things the way it feels you know easy and autonomic to talk about exercise and sleep yeah thank you for sharing that you know perfectionism is a growing problem actually I was reading some research um from a psychologist in London recently how perfectionism is growing across the world um there's a particularly dangerous form of perfectionism social perfectionism about what we think other people think of us which if we just break down that you know we think what they think about this it's based upon a lot of assumptions that we may not know what they think and we're imagining what people think of us and and the link between social perfectionism and suicide so I've I would also describe myself as a perfectionist in recovery um I often think about it in terms of you know when there's a gap between our ideal self and who we actually are our actual self in that Gap the greater that Gap the greater the inner conflicts I think we experience that's how I've I've been thinking about it recently um but you're right it is uncomfortable you know you know you mentions that you think you will always struggle with being vulnerable I find that interesting and I've also heard you say in previous conversations Peter that you know given that it's taken me 40 50 years to get to this point I can't see this going quickly it's going to take a long time to go as someone who's maybe been on this journey since my father died in 2013. I don't think it necessarily needs to take as long as people think I I really don't and and I really feel that with again it depends on access of course I've done a sort of a former therapy called internal family systems Peter um yeah which has just been incredible really incredible about going back into childhood situations reframing them and then you know when you sleep with consolidation and weak consolidation in the brain you almost lay down a new memory of what has happened it's really been quite profound so I as someone who also describes himself as a perfectionist in recovery I I would like as you know as a fellow human to say to you I I don't think necessarily it is something we always have to struggle with I do believe that we can I passionately believe that we can get to the roots of these things and rewire them and change and and I've certainly come to the belief piece that a lot of our personality is not who we are it's simply who we became and if we apply ourselves to certain practices we can actually change how we show up in the worlds um when I say that to you Peter or when I share my view with you um does it hit do you push back do you think nah I'm a difficult case it's going to take me a long time I mean what what comes up for you when when I sort of share insights like that oh no I I completely agree and I if I think about the progress I've made in three years um it's it's profound I mean I'm not the same human being I was three years ago that there's simply no comparison and actually I think I talked about this on the podcast with with Andrew huberman or maybe it was on with Rich Roll but it was one of those two where you know one of the hardest things for me to shed um or one of the first things I had to go after was the inner monologue which which was a very very destructive uh inner monologue and it was something that I had never not known so there was never I don't have a conscious memory of not having this harsh at times violent awful voice that would speak to my speak to me and and not just in silently like it would do so audibly as well so if I made mistakes um you know I was gonna berate myself for them and it didn't take a rocket scientist to know that a big part of the problem was was you know what was at the root of that and then how could we fix that because that was then leading to so much other problem and conflict in my life so without going into the details of it um because I do so on those other podcasts which um we can talk about if you like but the process of undoing that which was it was rooted in a very daily deliberate Behavior practice um took maybe six months to undo that voice so that surprised me because I really did believe that that was a permanent feature of my existence that was as permanent as my height or my eye color um and I was very surprised delighted that you know the the the the plasticity uh of of the human mind could allow me to kind of rewire that in only six months and now admittedly of working very very hard in those six months but yeah that was that was very pleasant so no I'm actually incredibly optimistic that you know 10 years from now I'm gonna be you know in far better shape than I am now emotionally yeah might not might not be physically and cognitively as sharp at 60 as I am at 50 but I think emotionally I'll be in a better place and the TR in other words I think the trajectory is positive thank you for sharing that going back to what we said earlier on in the conversation physical cognitive emotional and of course we were discussing how you know physical and cognitive get worse with age and I was sort of saying yeah as you were just demonstrating there I think emotional can get better with age actually and I don't know maybe counteract someone at other sub potentially but that's that's a much uh deeper and longer discussion without sort of going back into the detail you have already shared on those other podcasts I think what might be useful in terms of a practical tool is simply sharing what you had to do to change the negative voice in your head because clearly negative voices in our heads are so common you're sounded particularly brutal I must say when I heard it I did recognize elements of it as well in myself um but to see that change from asking in six months I think it's really empowering would you mind sort of briefly sharing what that exercise was that enabled you to do that sure sure so um the voice was basically uh the voice of a guy a very famous uh college basketball coach former basketball coach in the U.S named Bobby Knight so Bobby Knight was this insanely angry maniacal you know Savant of a basketball coach but who ultimately lost his career over his temper um and every every game was like a witnessing some crazy temper tantrum that he would have um and so the exercise was framed as you know you you have a board of directors that runs your life the board of directors in your head and unfortunately this guy Bobby Knight is the chairman of the board and we have to get him out of the boardroom um we have to get him far enough away from the boardroom that you don't hear him talking all the time so the way we're going to do this is every time you hear him talk and that's going to happen anytime you do something in the pursuit of um what we would call performance-based esteem so basically most things I'm doing in life I'm doing so that I can generate self-esteem so just as an alcoholic might turn to a drink or a gambler might turn to a slot machine I turn to Performance as the drug that's literally the drug that I need to have the the self-esteem and anytime those performance-based esteem uh activities fail to generate esteem because I fail in the activity I turn the rage inward just as an alcoholic would be furious if he walked into a bar and asked for a vodka and received a water he would be furious at the bartender that's basically the cycle that's happening so the exercise was every time you feel that happen I want you to imagine that it is your closest friend that committed the act in which you failed right so for example if you're in your driving simulator you know driving is one of my huge passions so if I'm not on a racetrack I'm in a simulator and you're having a bad day you're just not driving well you're spinning you're crashing your your times are slow whatever it is normally you would get out of the simulator and you'd be yelling and screaming and sometimes even break the simulator instead imagine that your closest friend was the one in the simulator who drove poorly what would you say to him and you know to do this exercise you have to be able to picture the person and so for this exercise I would typically pick a friend of mine named Matt Walker you may recognize Matt Walker wrote The Great Book on sleep and Matt's a very very dear friend who is also a total Motorhead Gearhead uh loves cars whenever he comes over here the two of us are going to be in the simulator the whole time so I would look at Matt I would picture Matt close my eyes and I would imagine what I was saying to Matt if he drove that poorly and of course it would be very kind very loving very supportive and I would record that discussion on my phone then I would send that recording to my therapist so two or three times every single day my therapist would be getting one of these five-minute voice memos from me where I would be talking to one of my friends in this type of situation and that was simply the exercise we've had the advice before on this show particularly when it's about say Kristen Neff uh who's done a lot of the research into self-compassion yeah you know talk to yourself as if you were talking to your best friend or a young child and I think we intuitively get that but I think what makes your exercise the one that you were given to do so powerful there's an extra component of accountability it's not just oh yeah I wouldn't say that oh come on change the record in your heads no you have to record that message and send it to somebody who is going to hear it so maybe you could just speak to what was so powerful about sending it was it embarrassing will you read it with you then I might have to send this to someone like what's the goal that you then play them back to you to sort of subliminally change the message you give yourself or or just just give us a little bit more detail there if you can well I think that I think the recording is important because I think when you say it out loud it's much more powerful than just thinking it so it's one thing to say okay I just you know shot poorly in the with my bow and arrow or I drove poorly in the simulator I'm going to now sort of think nice thoughts but the reality of it is Bobby's voice is too loud for me to out think him in silence I have to outspeak him right this is the the mind works through concentration and there is there are very few things that can harness your concentration more than the audible sound you make with your own mouth so I have to outspeak this otherwise very loud force in my mind who by the way sometimes would actually speak to me right I would sometimes actually speak what he was saying so I I have to one-up him in volume and then secondly they're recording it and sending it is not about being embarrassing it's as you said it's accountability it's there's a person who knows that two three four times every day I engage in some Behavior that is demanding of my perfectionism and is a vehicle for which I generate self-esteem and therefore I'm going to have commentary so it's it's really those two things and and so therefore by forcing the audible overwriting of a historical way of doing things I'm rewriting and by having the accountability I'm making sure that no matter how much I don't want to do it I do it going back to what you said before Peter about having the means to pay for a residential inpatient facility to deal with a lot of the inner conflict you were feeling at the time and wanting to pay it forward I'm just trying to think is there something there in that exercise that people at home can actually utilize themselves for example of course it's not the same as having a therapist I understand that but just as if for example you're recommending to a patient to work out more whatever that may mean you may sometimes I'm guessing you know ask them to have an accountability partner who can show up with them to make sure that they're doing it and they can help encourage each other together could a version of this be with a close friends someone you trust perhaps your partner could it be that you go actually you know what I'm going to ask them if for the next month I can do that exercise with them would they be willing to be that person for me do you think that could be a good thing or do you see any potential problems with that I'd have to give it some thought but my my inclination out of the gate is probably not to select a romantic partner for that exercise I think that probably would introduce some unnecessary strain on a relationship but I think it could be done with a friend that might not be as ideal as a therapist because the advantage of doing it with a therapist is you know in my case once a week I'm going to talk to that person as well and we're going to process those things and by the way some of them were just so significant that she would just call me right away right like she would listen to it and you know call me an hour later just to check on me or something like that so there's something to be said for that but I but I think if the alternative is not doing it yeah than doing it with a friend I think would be you know a far better option than not doing it are there any prizes you try and do on a daily basis or at least a regular basis that keep your emotional health in tune or is it something you just go to from time to time no no it's a it's a huge deal and in fact when I left PCS which I write about in the book it's the place I went to in Arizona in 2020 um you know I had a recovery contract that I made and the recovery contract had red light behaviors yellow light behaviors green light Behavior so red light behaviors were things I never ever ever wanted to happen again and if they happened I understood that that was a trip back to rehab yellow light behaviors were warning signs this was a very important part of the journey one of the things that frightened me so much in my life was how seemingly unpredictable my meltdowns had appeared again I write about this in the book that I was so paranoid that I was like the space shuttle Challenger that just out of the out of nowhere would blow up over the sky and the round of it is that space shuttle Challenger which for people don't remember is the Space Shuttle that blew up in January of 1986. that turned out to be an entirely predictable disaster had people been paying attention to what the engineers were telling them and so there were lots of yellow lights that predicted that the space shuttle Challenger was going to blow up that day it's just people didn't pay attention and so I had to now identify what my yellow light behaviors were and they had to be plastered right in front of me in a contract that I looked at twice a day every day and whenever those things happened which they did that necessitated an increase in therapy and immediate discussion with somebody it was all about cooling the flames and then there were the green light behaviors which were what you're asking about what are the things that I have to do every single day and these are the things that are going to widen my distress tolerance window that's the sort of figure I include in the book right which is like I have to widen my operating range as as much as possible this is something kind of through the the type of therapy I do called dialectical behavioral therapy that's really geared towards making me as emotionally resilient to stressors as possible so it's really through those lenses that I approach the day but just to give you an example of some of the green light behaviors exercise is important so exercising every day but doing so in a non-forced way this is a very important thing for someone like me exercise has always been important to me but what I had to do was not learn to exercise more but at times learn to exercise less and learn that you know if on Sunday you're trying to get a double workout in but it's ultimately the choice between spending a little bit more time with your kids or getting that second workout in maybe the better thing to do is actually just spend time with the kids and not get the second workout and be okay with that yeah um and be okay with that being the key thing there that's right yeah and and over time that becomes easier and easier and easier um for a long period of time for about a year I did not permit myself to score in archery meaning in in archery when you do it competitively you actually have scores you keep scores of like exactly where the arrows are hitting and for a year I did not do that so I still practiced archery but I didn't score it in other words I had to take out some of the performance I also for six months did not ever drive the simulator and do archery on the same day I know these things sound kind of crazy but you have to understand for somebody who's recovering in the way that I was I didn't want to have too many of these performance-based things stacking up I also wanted to not look at my phone from the time I woke up for about you know so let's say I woke up around 5 30 in the morning the goal would be to not look at my phone or do any work until my kids left for school at 7 15. so just hang out with my wife have coffee and play with my kids that that was sort of a very important part of resetting anyway there were about I don't know 15 or 16 things on the recovery contract that were part of the green light behaviors and these things had to be done constantly right that was therapy that was checking in with friends once a week who I asked if they would be supporters for me that was writing in a journal so there were there were lots of things that I had to do and it took time you know this was a this was a time consuming process it was as time consuming as you know exercise was yeah I really appreciate you sharing that again I think what you just said speaks to personalization you had to figure out with your team your your helpers your therapists what was the right approach for you someone else you know not scoring an archery has no relevance to them in their life but it for you that was something that you had to address and I think it it falls on all of us to find what are those things for us I found it really interesting when reading that chapter in your book Peter when you spoke about the issues in 2017 um I know you didn't write about the stuff in 2019 I heard you talk to Rich about that um and then in 2020 so you'd already been through that you were already on this journey yet you said something which I underlined should have found it really interesting at the start of March 2020 when things were kicking off everywhere I let my morning meditation practice go right you let something important go to you know deal with a crisis I get that but it's one of those things isn't it that I've learned in my own life there are certain things I don't call them non-negotiables anymore because I feel a non-negotiable brings me back to an old pattern of thinking yeah yeah so I thought I no longer use that term actually I I feel there's a balance between discipline and compassion and I'm always trying to find The Sweet Spot between those two but I really do appreciate you you sharing that and I think I think it's going to be helpful for people Pizza I I think you've written a wonderful book I I don't feel I've even scratched the surface of where I really wanted to go with this conversation but just to finish off Peter for for people who obviously want to learn more they can go to your book but for people who go okay I get it I get your philosophy it's about getting stuck in earlier and not waiting till it's too late or very late before I start addressing things around my health and my longevity I always like to finish the podcast with some sort of actionable take homes for my audience so for that person who does feel inspired he goes okay right you've convinced me I'm gonna get on top of this now I'm 40 years old I'm not gonna it's not gonna happen to me what happened to my father or my brother or my granddad or whatever I want to take control of my life and my health what would you say to them well if you're if you're really committed I would say get you get the data right let's figure out what your you know what your Baseline is according to all of those metrics that matter and and again I we do lay them all out in the book right so you need to know your VO2 max you need to have a dexa scan and know you know what your almi is I mean again if you if you really want to understand these things and yeah it's you're going to have to invest in doing these things I mean whether you're in the UK or in the U.S no health insurance company is going to pay for that information you're going to have to get it on your own and there are less expensive ways to do it there are ways to estimate those things Beyond measuring them via the gold standard but what you want to do is take advantage of the fact that you're 40 right and take advantage of the fact that you have hopefully four or five decades ahead of you on which to compound benefit this is a much different proposition than if you're in the last few years of your life what I call the marginal decade and you realize oh I want to do something about it there's still value in making change at any point but you're going to be able to move the needle less so if you're talking about this through the lens of somebody who's in midlife or even younger what you want to do is say what changes can I make consistently you know I often say I'd much rather someone do seven out of 10 work every single day then do 10 out of 10 work some days and 0 out of 10 work other days the the ping-ponging back and forth tends to produce inferior results as far as what to do once you have those results I think the results have to drive it right so if you're VO2 max is at the 25th percentile that's an enormous opportunity you have to be doing the type of training that's going to increase VO2 max both increasing your aerobic efficiency your base of aerobic fitness and your Peak if by extension your VO2 max is already at the 80th percentile but your muscle mass and strength are at the 20th percentile then that's where you just need to disproportionately train while you you know do things to maybe maintain your aerobic fitness you know again the list goes on and on if your sleep is really the thing that's suffering then that's where you need to focus and again we kind of lay out how to do that if if you're over nourished and under muscled then you're going to be focusing on strength training protein and calorie reduction and that's probably going to be your biggest Focus to get back onto a Level Playing Field of health so I know that's not a very satisfying answer because it again is an individual answer but unfortunately I think at this level of medicine 3.0 um it's the only way that I can think about talking through these issues Peter I think you'll be doing fantastic work for so many years you're helping so many people improve the quality of their lives I really appreciate you making time to come on this show thank you for providing the book it's fantastic I I really can't imagine that anyone will read it and at least not take something from it that's going to help them make positive changes for them and their family thanks for coming on appreciate it thank you so much for having me on and for as I said taking the time to read the book and allowing us to have this you know I think really nuanced and enjoyable discussion [Music] conversation I think you are really going to enjoy this one about what and when to eat for longevity this is probably the most effective diet that's ever been promoted on the planet this protects our body against Decay disease and the root causes of Aging is not only good for you but will make you live longer

Channel: Dr Rangan Chatterjee

Views: 194,531

Keywords: the4pillarplan, thestresssolution, feelbetterin5, wellness, drchatterjee, feelbetterlivemore, ranganchatterjee, 4pillars, drchatterjee podcast, health tips, nutrition tips, health hacks, live longer, age in reverse, self help, self improvement, self development, personal development, motivation, inspiration, health interview

Id: 85ItRIGdl98

Length: 138min 5sec (8285 seconds)

Published: Wed Apr 26 2023