The Ultimate Guide to Longevity: Insights from Peter Attia

Peter attia it is great to have  you on the next big idea podcast   yeah thank you so much for having me um Peter you have built an unusual and  extraordinary career you're a Stanford   NIH trained physician focused on the science  of longevity as you say on your website you   have a wildly popular podcast and blog you  have a medical practice for the stars with   a focus on Health and Longevity and you reach  a broad audience through your broader platform   your own personal Journey seems to me to be  essential to the story here are a few Salient   facts and feel free to add and subtract from this  list you were an athlete as a teenager a boxer   you went to medical school at Stanford then  residency at Johns Hopkins you suffered from   a botched back surgery I think it was in your 20s  which sounded pretty pretty scary pretty humbling   you left Johns Hopkins after going frustrated  with the what you described as the culture   of resistance to Innovation and joined the  McKinsey Healthcare practice advising companies   you were the first person to make the round  trip swim from Maui to Lanai and back which is   astonishing to me having snorkeled those Waters  uh you found yourself nonetheless in your 30s   with a dad bod that you uh you say squeezed your  sausage-like body into shirts which stuck with me   uh you realize many of the men in your family died  young in their 40s and 50s due to heart disease   you built this kind of highly original medical  practice with a holistic long-term approach to   improving Health span you've now written a number  one New York Times bestselling book outlive the   science and art of longevity which as you say is  a a beast of a book I think it's 500 pages as you   put it it's not a two crapper uh how do you think  about your your personal journey and do you see   the setbacks that you've encountered along the way  as critical to your to your path and your success   uh yes I absolutely do um and I I think  the you know look I can only comment on   what I've experienced so I can't really sort of  speculate on what parallel universes look like   but I know that the path I've chosen doesn't or  maybe I should say what I'm doing today doesn't   fall out neatly from any sort of traditional  medical training uh if someone today asks me   which I get asked all the time by people who are  you know in college or medical school saying Peter   I like what you do and I want to be doing that  what's the path it's not entirely obvious it's   probably not doing what I did I mean my path  couldn't have been more bizarre but it's not   like there's a specialty that you would do  and say well I want to practice medicine 3.0   as my specialty so after medical school I'll do  this residency and I generally say look you know   probably doing Internal Medicine makes the most  sense but acknowledge the fact that you're going   to have to do most of your learning outside of  your training you're still going to have to learn   the finer points of nutrition and exercise and  sleep and TR you know true prevention outside   of the the confines of you know a medicine  2.0 system in which we're still training   um and so in that sense yes I  think whatever setbacks I had   you mentioned many of them of course um I think I  can look at every one of them now and say actually   there's there's a there's a net positive that's  come from all of them including um as much as I   it's hard to admit sometimes I mean the bat the  botched back surgery for example I mean I probably   still pay a price for that I will for the rest of  my life always be at higher risk for requiring a   fusion which is something I'd desperately like  to avoid but at the same time that's given me   um that you know that's just given me a gift  which is an appreciation for um the importance   of reducing any sort of Orthopedic injuries and  how much your life changes when you are in a   constant state of pain and immobility and and just  not taking for granted our ability to move right   I mean I you know I had on a much smaller scale  I've injured uh my knee a couple times skiing and   I've gone through you know four to six weeks  on crutches of not being able to run which I   normally do daily and it's like it terrified me  this notion that maybe I could never run again   um and change the sense of joy that I felt so I  can only imagine that that you know how the more   dramatic version of being truly I mean whenever  I've had some minor back problems and you realize   how how um um what's the word you you realize how  fragile we are right that this with these spinal   systems and I mean we're we're really kind of  fragile animals and and until you can very easily   get all the way to you know 45 without without  realizing that right yeah um the um you know   one of the things I I find so interesting about  your journey is that is that all of us are kind   of armchair scientists to some degree I mean it's  it's part of our job as humans right like we we   take the information available to us in the world  and we use it to navigate as well as we can to to   to to figure out how to be healthy and happy and  Thrive um and and we're all dealing with this sort   of limitation of our own experience the historical  moment we're born into what what knowledge and   resources are available to us but we're all sort  of scientific experiments of one to some degree   um but it's it's exciting and suspenseful and  it seems to me that you to some degree have been   on this personal journey of trying to figure out  how to optimize your own health and and how to   flourish as a human and you've shared that Journey  along the way uh and and you've approached it with   an unusual degree of kind of rigor and intensity  right I mean certainly you know you well the name   of your podcast is Drive I I think that you know  you've got a very high level of intensity that   you've applied to this process and and there's it  seems like it's almost been an organic process of   people kind of watching your process of figuring  out what works for you learning learning about   how we can improve medicine in general and how  other people at scale can benefit from that   does that has that felt like an organic process  yeah very much so it certainly started out as   um you know just trying to fix the first patient  so that would have been me and um and then about   the you know roughly 10 years ago starting to  figure out how to apply that to other patients and   um and our our practice is very small and that  allows it to feel a bit like a laboratory where   you know everything is bespoke everything is um  we just have a luxury that I don't think we would   have if we were practicing this in a traditional  way and obviously that's one of the limitations   that I think many doctors have because I it's not  like we're doing something other doctors don't   want to be doing I I've never met a doctor who  isn't doing primary care who isn't on the front   lines who doesn't say God like I really wish we  could bring these actual tools to prevention but   you know that the system they're in isn't isn't  really permitting it so we feel fortunate that   we can do that and I think as an obligation we  have to be able to share that information with   everybody else so that you're you know you're  not just getting this information if you're   Peter's patient um and that's why there's  a there's a podcast there's a book there's   a newsletter you know there's another product  we've uh recently created called early which is   um you know basically a fully digitized  Master Class of everything that we do I   mean it's you know 12 modules 30 hours of  content um but but I do think we have this   obligation to share this so that everybody can  kind of figure this stuff out on their own and   and other doctors can learn what we're doing I  mean we're not we're you know we're not trying   to uh be Coca-Cola here with a little secret uh  recipe we want everybody to know how to do this   so you you referred earlier to Medicine 2.0 versus  3.0 and I think that's your term right I mean   that's a term that you've come up with and and  it's and I think it reflects I mean you described   you know 20 years ago as a young resident of John  Hopkins you felt frustrations with the medical   establishment it sounds like some some of those  frustrations have persisted and you have a pretty   clear vision of how our medical system is failing  us and and how we can make medicine better do you   want to speak to that yeah and I do think it's  always helpful to start with the good right so   um so medicine 1.0 is basically not medicine  but it was the thing that filled the void of   medicine uh until medicine 2.0 come along which  I'll explain but you alluded to something earlier   which is we're all armchair scientists and I think  that medicine 1.0 is what that looks like without   the scientific method so right we have always  constructed stories that's why 500 years ago   we thought that there were gods that determined  everything where the planets were why you got sick   you know bad odors you know it was you know bad  humors I mean it was just there was no there was   no scientific method there was no understanding  of science you can't use a tool that has yet to   be invented and therefore you know medicine 1.0 uh  was largely Witchcraft and um by the way sometimes   that witchcraft worked it's not like you you know  it's not like a blind squirrel can't find nuts   sometimes but it didn't work because the thinking  was right it just you know you happened to stumble   onto things that were via alchemy that sort of  tend to work okay so and there was an upside   interrupt but there was a there was a date before  which you probably didn't want to enter a hospital   right I mean it would be a net negative oh for  sure and some people would put that around early   1900s I mean randomized controlled testing you  know started yeah certainly you know certainly   in the in the mid to late 19th century it was  problematic right so you know if you think about   you know prior to antiseptic technique prior  to even local anesthetic and things like that   I mean a hospital was a really scary place to  be but that transition where we went from the   Dark Ages to where we ended up in the early 20th  century which is really when medicine 2.0 came   into its own it was a remarkable transformation  largely on the basis of three things one being   first and foremost the elucidation of the  scientific method you know a la Francis Bacon   in the 17th century and then of course you had  germ Theory aided in large part by the development   of the light microscope and then you had the  development of antibiotics and those three things   clearly not overnight change the face of medicine  altogether and what they did was result in a   doubling of life expectancy and a literal doubling  in life expectancy between 1900 and the year 2000.   um but if you look at the data closely  you'll realize that that doubling in life   expectancy came almost entirely through the  reduction of what I describe as fast death   so you know prior to that era and up into the  early 20th century we effectively died quickly   meaning you were doing okay and then you weren't  and it was usually infections and Trauma that   were the cause of death medicine 2.0 came along  and effectively solved that problem you never   make it go away but just made it such that it  you weren't constantly at the threat of death   um and in the process we started to  die slowly chronic diseases what we'll   talk about in a minute I'm sure the four  horsemen started to dominate the landscape   and so I don't know that I like to think of  medicine 2.0 as a failure I just think medicine   2.0 was designed and built around solving fast  death yeah but the Playbook doesn't work for   slow death and you don't need me to tell you that  I mean that's like obvious if you spend 10 minutes   looking at the data the approach of medicine 2.0  which is intervening once the problem has started   doesn't really work when it comes to cancer  heart disease neurodegenerative disease diabetes   furthermore the tools of medicine 2.0 which  are largely procedural and pharmacologic are   also relatively limited when applied very late  in some cases they're better than others I don't   want to again I don't want to diminish this I  mean a person who has a heart attack today is   way better off than a person who had a heart  attack 50 years ago I mean no comparison yeah   um you know 50 years ago if you had a heart attack  they were giving you aspirin morphine and oxygen   today they give you clot busting drugs they  can stick a stent in you're going to be on   lipid lowering therapy which of course you should  have been on 40 years earlier um yeah but you've   got way better odds we've got aeds we've got  Advanced cardiac life support all sorts of things   but you know it's it's clear that this Playbook  is only going to produce incremental gains going   forward and therefore we we really need a new  approach and that's what I'm calling medicine 3.0   yeah yeah and if we want evidence that that the  current system is failing us I was astonished   to learn that nearly I think you say half of  Americans are diabetic or pre-diabetic um it   depends on the estimates um I you know those are  estimates that are out there I would say the most   conservative estimate would be a third okay so  call it somewhere between a third and a half yeah   and so there so you've identified four diseases  four primary diseases that are that are killing us   um that we are not addressing as well as we  could and you call those The Four Horsemen   right and three of these diseases uh well so  first off all of these are diseases of modernity   so these are diseases that didn't really exist  in appreciable quantities a hundred years ago   um three of these diseases are what I call  Big death certificate tickets meaning they're   actually the ones that show up on the  death certificates the most and those   are all of the diseases of atherosclerosis  which is heart disease and cerebrovascular   disease so heart attacks and strokes  that's number one by country mile cancer   and then the entire Suite of neurodegenerative  diseases and dementing diseases so that's   everything from Alzheimer's disease Parkinson's  disease Lewy Body dementia Etc vascular dementia   all these things so those three things account  for the majority of death certificates and that's   mostly I mean if if you include the entire  population of smokers you have to include   COPD in there I largely exclude that from this  analysis because most people who are interested   in living longer aren't smoking and therefore  it is it you know so you could argue there's a   fifth horseman in COPD but for the purpose of the  way I'm thinking about it it doesn't make sense   the fourth Horseman is not really a big death  certificate ringer you're not going to see him   on a lot of death certificates in fact if you if  you want to do the death certificate analysis he   doesn't rank in the top five and that's type 2  diabetes but I expand that to include the entire   spectrum of metabolic disease that is Prelude  to that and that begins with hyperinsulinemia   insulin resistance non-alcoholic fatty liver  disease all the way out to type 2 diabetes   and while that spectrum of diseases again doesn't  register at the same level as the other three   Horsemen what's very important to understand  is that it's the force multiplier of them all   so it's increasing your odds of each of the other  three Horsemen by anywhere from 50 to 100 percent   and so it is the Insidious thing that must  be controlled you have to be metabolically   healthy that is step one of this process  right if you if you want to take aim at the   other three Horsemen you must address metabolic  Health your metabolic house as I say must be in   order and then we can begin targeting the other  three in specific disease prevention strategies   and and most of us think of these these uh  these diseases as as something we should worry   about once once our doctor says hey you have a  problem here and and the case you make is that   the the thresholds we have for when we treat  these diseases are somewhat arbitrary right   I think I think you say that uh once your risk  of cardiovascular disease reaches five percent   for the next 10 years you are considered  a treatment priority in the current system   but if it's four percent even though there's a  very clear pathway to to to to to Future problems   it's it's you know you you go to your annual  checkup and they say okay you're fine right   which happens to me I find it very frustrating  I say can you please give me more Nuance you   know I'm fine what does that mean right yeah  so the the threshold you're referring to is   um what's called major adverse cardiac events  so as you said if you're um if your calculated   risk for a major adverse cardiac event so heart  attack stroke or death uh in the next decade is   below five percent yeah primary prevention is  not necessary it's not as deemed not necessary   primary prevention means intervention to prevent  your first heart attack stroker brush with death   um and it reminds me a lot of kind of the mortgage  crisis in 2008 at the time I was at McKinsey and   um even though as you mentioned I was recruited  there to do health care I ended up doing credit   risk so I spent my time in Banks and I write  about this a little bit in the book because   it also really really shaped so much of my  thinking so in that sense while it looks like   a completely random and arbitrary detour out of  Medicine being in the world of credit risk during   what will go down in my lifetime is the  greatest implosion of credit risk uh was   was very formative having formal training in  Risk Management really shaped my thinking in   many ways and one of the most sobering lessons  was that all models are wrong some are useful   so in the credit models we when we first got in to  look at you know the underbelly of these companies   and we were brought in on totally separate issues  we didn't come in because they thought mortgages   were a problem we came in to help them with  compliance on something else called the Basel   II Accord which was this completely dreary sleepy  thing being levied on banks in 2006 that they   couldn't care less for but they just wanted to  have you know Consultants figure it out for them   in playing with the models that they had built we  realized A peculiar finding which was the models   couldn't anticipate or make any prediction if  home prices didn't go up in other words every   single one of these Banks models assumed home  prices would monotonically rise indefinitely   and to even try to put in a negative number for  home price growth what if home prices go down five   percent in the next year the model couldn't spit  out a number you know how that story ended yeah on   the cardiovascular side these models can't input  ages below 40. so if you took a 39 year old with   a train wreck of a situation horrible family  history uh you know lipids out the Wazoo high   blood pressure put all the risk factors you want  on them the models won't even be able to give you   a 10-year risk because the truth of it is even  a 39 year old train wreck is at very low risk   for a 10-year event now the problem with these  models is they ignore causality in other words   when you practice medicine 3.0 you have to Target  causal risk factors regardless of short-term risk   this is a very important distinction that  Is tragically missing for medicine 2.0   a causal risk fact and we do it in some way so  I'll give you an example of where medicine 2.0   does a very good job of this but we're awful  in most ways so here's the only place in my   opinion where medicine 2.0 not the only place but  this is the best example of medicine 2.0 treating   the causal factor of risk nobody disputes that  smoking is causally related to lung cancer yeah   we don't build dumb models that we show  smokers to say when your 10-year risk of   lung cancer hits five percent we're  going to tell you to stop smoking   of course not we know that smoking is causally  related which by the way doesn't mean every   smoker gets lung cancer they don't and doesn't  mean that everyone who gets lung cancer is a   smoker causality is not a one-to-one mapping  but smoking is undoubtedly causally related   we tell people not to ever smoke and the day  somebody starts smoking we try to get them to stop   that's a medicine 3.0 approach towards lung  cancer vis-a-vis smoking we need to be doing   that for every chronic disease and every  modifiable risk factor and sadly we don't so   you know that's that's kind of my long spiel on  one of the big distinctions between 2.0 and 3.0   and and and how how significant are the kind  of um the uh the bad habits we can get into we   know that habit formation is an issue but there's  also the damage we potentially do to our bodies   in our starting as you potentially as early as  our teenage years into our 20s and 30s and 40s   um I had in college I had a friend whose father  was a physician and his advice to his son was   you know what kid go out have a great time party  Smoke Drink do whatever you want then when you   turn 40 clean up your act become a health nut  because most of these conditions are reversible   um I guess you would disagree with that advice  I would yeah um on several reasons right so one   you're doing a lot of damage to yourself when  you're 20 and 30. that's you know the analogy   to me there would be telling somebody when they  graduate from college and get their first job at   22 don't save a penny don't plan for retirement  accumulate as much debt as you can and then when   you're 40 start thinking about things responsibly  there's a grain of truth to this right you should   enjoy yourself when you're young and you can I  mean I fully you know buy this idea I don't know   if you've read Bill Perkins book die with zero  it's a fantastic book um I've had bill on the   podcast and you know in it Bill talks about the  importance of spending money while you can spend   money but that's not incongruent with also being  responsible and planning for you know the future   um so so on the one level I just sort of reject  that and then the other level is to your point   like it's really hard to break horrible habits  um the third reason I reject that advice is   I reject the advice that being healthy and making  healthy choices is only beneficial for the future   in fact this is where the analogy with  savings is actually not a good analogy   yeah because there's no question that when you're  saving money today it's a it's a net negative   today you don't get anything out of not spending  that 200 a week that you're putting into your 401k   so it's a hundred percent downside today and  you're just sort of trying to Arbitrage the   hyperbolic discounting function that tells  you it's going to be worth even more tomorrow   but with health it's actually  beneficial tomorrow and today   it's you're gonna feel better when you're  30 if you're eating reasonably not drinking   excessively and you're fit so even if by some  miracle at 40 you could turn that ship around   and I would argue it's very difficult to do so  and you're not going to erase all the damage   you've also spent two decades not feeling  as good as you could feel yeah so again you   don't have to be a monk that's not that's  certainly not what I'm suggesting I'm not   suggesting that you know we'd be little robots  who are purely optimized around health and no   optimization around Joy or pleasure but obviously  I think that the advice is Extreme yeah yeah um   you have this um this really interesting kind  of counter-intuitive framing around thinking   about our health uh working our way backwards  asking the question in your last decade of life   how do you want it what do you want to be  able to do all right right and you call this   the the centenarian decathlon um and work your way  backwards to you know based on what you want to do   in your 90s or if you're so fortunate to live that  long you're going to have to have to start making   Investments now in that 401k as you say you're  going to have to change your behaviors now to   be able to lift your bag you know and put it in  the in the slot in front of you in the airplane   pick up your great grandkids carry groceries um do  you want to you want to share that logic yeah it's   um I think a lot through this lens  of What's called the marginal decade   so it's one of the first questions I'll ask a new  patient is what are your goals for the last decade   of your life and what are your goals for the next  12 months those are this that's how we frame our   time together and how do we make those congruent  so almost without exception nobody's goals line up   so I don't know if you've ever done archery but  in archery um with a compound bow you have like   a peep which is the thing that's right in front  of your eye it's in the string when you draw   back yeah and then you have a site at the end  of the bow and you have to line those two up   perfectly if there's even the smallest Eclipse  your arrow is going to deviate wildly so you   have to have what's called front sight rear sight  acquisition perfectly before you release the arrow   and that's how I sort of think of it that's  your one-year goal that's your marginal decade   goal they have to line up now most people have  far too lofty a set of goals in their marginal   decade for what they're doing today so you  ask people and we we do this quite formally   eventually not not in the first meeting but  eventually we do this quite formally where we   actually have a list of 50 things and we say  pick the 10 that are most important to you   and their activities of daily living they can be  you know very particular things to an individual   you know lots of people who ski want to be able to  ski when they're in the last decade of their life   and we're not here to tell them that that's  an unreasonable goal we're simply here to   tell them what is the physiologic  requirement to be able to do that   and then we know what the rate of decline is  of these metrics so we know how much strength   declines by decade we know how much power declines  by decade we know how much VO2 max declines by   decade so we say well these are the physiologic  requirements for where you want to be at 90.   based on how they're declining this is where you  need to to be today where are you oh you're here   so you're higher than where you need to be at 90  but you're not nearly high enough yeah so it's   sort of like saying I'm in a glider and I want to  get over here and I'm only here and it's like no   no your glider is not going to make it yeah um  but the sooner you find that out the more time   you have to get that glider back up and and that's  that's effectively what the exercise is all about   that I I love this notion of of Aging as a Glide  path I hadn't thought of it that way and and you   have this list of like you know do you want to  be able to hike 1.5 miles on Haley Trail would   you like to be able to have sex would you like  to be able to open a jar right and I think you   said it most all of your patients say actually I'd  like to be able to do all of those things and they   have and they typically have a few others I'd  like to be able to dance a jazz festival in New   Orleans I'd like to ski play tennis you know but  as you say given the Glide path of what we know   we can be pretty darn confident that that that  our capabilities will erode at a certain clip it   it's it's very eye-opening and I I wonder whether  it's interesting because it's a perspective that   I had that had never occurred to me and I wonder  if that year you spent on your back or a portion   of it on your back being unable to do the most  basic things was part of what enabled you to   think about what it's like what it feels like to  be 95 you know I mean this sense that we have to   fight for these this kind of basic Mobility yeah  it absolutely was um I have a really good friend   Rick Elias who has also been on my podcast Rick  was one of the people who was on that U.S uh Air   flight that Captain sullenberger landed in the  Hudson in 2009 and um Rick has given I one of   the most powerful moving TED Talks you'll ever  hear it's very short it's about seven minutes   long where he talks about that experience  I would recommend everybody stop listening   to this podcast right now go listen to that  seven minute Ted Talk and you can come back and   in it he talks about what a gift it was because  it was it was inevitable that they were going to   die there's nobody on that plane who thought we're  coming out of this one it was yeah you know it was   90 seconds of wow this is it this is over and Rick  talks about that in a way that's really remarkable   but what's also amazing to me is how he says  this has been the greatest gift I've ever   received because when you get someone to take you  to the end of your life so you get to live you get   to see what what exactly goes through your mind  as you're dying and then they snap your fingers   and you're back and you get to do it all over  again what a gift and so on a much smaller scale   I think that's exactly what I experienced at the  age of 27 which was three months of not being able   to walk so just being cons you know just laying  on a floor for three months uh you know my mom   had to come down and literally feed me um you  know for a year being incapacitated with pain   um and that's a long enough period of time that  you don't forget it I've said this before but my   kids get a kick out of the fact that if we  pull into a strip mall like I'm gonna Park   as far away as possible just to celebrate that  I love that I can walk in I don't care if it's   raining I don't care how hot it is I don't care  how many other parking spots are closer let's walk   because it's awesome to be able to walk which  I couldn't right you know so um total gift and   um I don't know that I would want everybody to  experience what I went through but maybe if they   can take my word for it yeah yeah yeah exactly  the death deathbed perspective if the Lord wants   to make a man happy he takes away his donkey and  then gives it back to him I've always liked that   um so um okay so we know that we have you know  a few levers that we can pull to you know to to   achieve our health objectives right we know that  the big three are diet sleep and exercise mental   health is also really important and we'll talk  about that but among the physical things we can   do how if you had to force rank those three  levers you know diet sleep and exercise what   what do you think are the ones that are most  effective in improving the health span of most   people listening how would you rank those three  it's no question that exercise is number one   um there should be no debate on that I'm actually  surprised there is there is by the way but that's   just because I think most people aren't familiar  with the data um and I also think nutrition is so   tribal and religious that people tend to get very  personally attached to nutrition and so um there's   just a lot of weirdness there but um there is no  debate that exercise is the heavyweight champion   of uh all things that pertain to a longer better  life and and I'll explain why in a moment as   far as nutrition and sleep I would generally put  nutrition second sleep third but there's a caveat   here which is if your sleep is really really bad  yeah it could catapult to number one in the short   run and I would also say that there are examples  I've seen and I know people I mean I have I have   a I have a a person who who's in my life who um  you know a friend whose sleep is so bad that it   actually undoes any benefit on the nutrition and  exercise uh in her life and she understands that   we actually spoke earlier this week and I'm like  you know you I mean four hours a night of sleep   is just not sufficient yeah and it is tearing you  apart and and here's all the evidence why right   um but as a general rule I would go exercise  nutrition sleep but the gap between exercise and   the other two is a Chasm uh and here here's here's  the data right so the easiest way to imagine this   is to ask the question what are the gradations  of Improvement or harm that come in the extreme   states of each so let's start with nutrition what  is nutrition all about nutrition is all about   metabolic health so what is the most extreme state  of poor nutrition it's type 2 diabetes and obesity   so how much of a risk does that bring to an  individual and if you look at all the Cox   proportional hazards which are the statistical  tools that we use to generate what are called   Hazard ratios clear that the risk of type 2  diabetes is significant we talked about it earlier   yeah it's you know anywhere from 30 50 in some  cases well if you talk about all cause mortality   it's about 30 to 50 percent more and if you  talk about disease specific mortality it can be   50 to 100 percent more but let's just talk about  all-cause mortality because that's the number that   matters most this is death from anything this  includes infections you name it and let's say   1.4 to 1.5 is the hazard ratio to me that  speaks to just how important nutrition is   nutrition is a very important tool for maintaining  energy balance and metabolic health and when   that's out of whack that's how much of a hit  you take okay when you look at sleep deprivation   or disrupted sleep it's it it has smaller  Hazard ratios than that you know you're   in the sort of 1.2 range to 1.3 range so  short sleep is going to come with a 20 to   30 percent increase in all cause mortality by  the way long sleep does too probably because   long sleep reflects fragmented sleep but it  may also underpin diseases there may be some   um some bias within that system because you may  be sleeping long because of underlying disease   but now let's look at exercise in exercise we  have three really good metrics that integrate   the work that is done and those are VO2 max  muscle mass and strength and I use the term   integrator which is probably foreign to people  because we're not used to thinking about you   know calculus when we think about health but  for anybody who's taking calculus and they'll   remember what an integral function is an integral  function is a function that that adds up the area   under the curve and so in physical systems we  think of this as the work that has been done   and your glucose level if I if you woke up  tomorrow and I checked your glucose level   that's not a great integrator of what's  been happening over the past few months or   years a hemoglobin A1c is a little bit better  right a hemoglobin A1c integrates or tells me   roughly speaking over the past three months what  has your blood glucose looked like but the actual   blood glucose doesn't really tell me all that  much you you could have had perfect blood glucose   but then the night before you just ate like  crazy uh and it's not going to look that great   um but VO2 max like there's nothing you could  have done in the last day or week that is going   to significantly if you're if your number is  high it's not high because of what you did over   a day or a week or a month it's high because  of an enormous volume of training you've done   similarly if it's low it's not because you had  a bad night last night it's it's low because   you are deconditioned the same is true for muscle  mass and the same is true for strength these are   huge integrators of work and the differences  between people who are high and low in those   metrics dwarfs anything you see for nutrition  and sleep so if you have a very high VO2 max   versus a very low VO2 max so by let's just say  if you compare people in the bottom 25 for their   age and sex to the top two and a half percent the  difference is 5X which is a 400 difference in all   cause mortality astonishing if you talk about  bottom uh deciles or bottom quartile strength   to top quartile strength it's a hazard ratio of  almost three that's nearly 200 percent difference   the same is true for muscle mass so what would I  take away from that if your VO2 max muscle mass   and strength are in the top 10 percent for your  age and sex I mean you're bulletproof in terms   of like your nutrition doesn't really matter  that much you could you know it wow so they   talk now again there's a caveat here because you  wouldn't be able to get into that shape without   reasonable nutrition and sleep to support it so  you know there is an absolute cross-pollination   of these things sure but but this type of analysis  is what makes it so abundantly clear why you know   does my 17 chapter book have three chapters more  than anything else devoted to exercise there's   nothing there's no other topic that Garners so  much discussion uh an instruction uh because it it   is the most important tool that we have and that  is obviously inclusive of all pharmacologic agents   I mean the magnitude of this difference is is  kind of astonishing and I was unaware of this   before reading your book that I I believe that  that smoking creates something like a 40 increase   in the probability of dying from from that's right  smoking is about well no no so smoking's increases   your risk of dying from lung cancer by you know  900 okay however you're in the contract of smoking   on all cause mortality is 40 to 50 40 50 so if  it's 40 percent whereas the difference between   as you just said I think top 2.5 VO2 max versus  bottom quartile is 400 percent so so literally   like if you take somebody who's sedentary and  say okay you can continue to be sedentary and   not get much exercise or we can train you to  get at the top of your VO2 to Max potential   and take up smoking versus not smoke and continue  to be sedentary you'd be better off smoking   smoking a package it's hard to know without doing  the experiment but yes the numbers would suggest   that and by the way a lot of people will hear  us say this and say come on you guys are clowns   like who's going to get into the top 2.5 percent  which I would say well first of all I do believe   most people can and I've seen it because we do  it with our patients but let's put that aside   yeah it doesn't need to be that great let's go  from being in the bottom 25th percentile into the   third quartile so let's just divide the population  into bottom 25th you know 25th to 50 50 to 75 75   to 100 like that's if you go from the very bottom  to just the third one there's not a human being   on this planet who is incapable of doing that with  a little bit more training that reduction in risk   that that difference in Risk is that's a hazard  ratio about 2.75 that's a hundred and seventy five   percent difference in all cause mortality in any  given year so you don't have to be talking about   the most extreme difference yeah it's it's I mean  the Gap in perception here is is so enormous I   think if I were to survey my friends I think most  of them would would think that nutrition was more   important than exercise absolutely I think it's  what most people I think most people believe   that [Music] um and yeah they that that's why I  just sort of uh I I have a friend and we joke a   lot about this on Twitter which is there should  be I wish you know there was a way that Twitter   wouldn't let you tweet anything nutrition related  until you do 10 push-ups like you just you know   you got to go out and run half a mile then you  can come and pontificate about your nutrition   um if you didn't if you didn't work out today  for an hour no nutrition tweeting yeah I think   I think a push-up requirement for tweeting just  in general yeah probably a good idea um but the   uh um but I think you said that that you yourself  10 years ago uh did not understand how powerful   exercise how much more powerful exercise was for  our health and and at the time you you saw a diet   as maybe the biggest driver absolutely yep I I was  I was uh privy to this fallacy as well up until uh   God probably about six years ago I would say  yeah and well any and here's the and this is   really I think great news and should hopefully  listeners receive this I mean I mean maybe the   first response is oh oh no I've got to get  off my ass and get to the gym uh which is   true but but the good news is we just had Kelly  McGonagall on the show who you know gave a great   Ted talk about uh she's a social psychologist  wrote a book called The Joy of movement that   you know we have this beautiful cocktail of  neurochemicals that reward us for moving our   bodies right we we got this release of endorphins  and endocannabinoids and myokines which scientists   call Hope molecules we feel more optimistic we  connect better with other humans we have better   brain function so as you say I mean we get we  get these incredible kind of short-term dividends   from exercise as well sleep for that matter  and nutrition um and and then these incredibly   profound long-term health benefits so it's  really kind of a no-brainer and I thought up   until reading your book Peter that I that I  was like had a great fitness program and now   I know I've got to double down it's not it's  not enough we'll get to some of those details   um but is that um I mean you you would do  everything you said is completely accurate   and I agree with it with exactly that point and  and I think I describe it at some point in the   book as exercise is the single most important drug  we have yeah right if it were if it were a pill   imagine how valuable it would be well it's funny  everybody wants to come up with the exercise pill   and I get pitched on it about every week right so  there's always some biotech company that you know   or some lab that says they've discovered this  is the one molecule that's conferring all the   benefits of benefits of exercise and we've got  this mouse model that demonstrates if you just   in fuse them with this molecule you know you're  going to get benefits but but the truth of it   is that's never going to pan out and the reason  is there's too many things going on that's what   makes exercise so remarkable is it is hitting  so many different systems um that that it can't   be put into a pill so as an intervention it has  no peer that's the good news the bad news is you   do have to do a little bit of good work the next  piece of good news is to your point you get all   these incredible benefits in real time and they  just keep paying dividends in the in the long run   and is it so is it counteracting each of the four  horsemen I mean I think it does impact doesn't   it glucose disposal insulin sensitivity  yeah neurons it's it's the single biggest   needle mover on neurodegenerative disease it's the  single biggest needle mover on metabolic disease   cancer is less clear where you know there's no  doubt that it reduces the risk of cancer if for   no other reason through its impact on metabolic  disease and poor metabolic health is the second   biggest driver of cancer after smoking um and  on cardiovascular disease it's hard to say it's   hard to Force rank it because cardiovascular  disease has so much genetics involved and that   just necessitates the use of pharmacotherapy so  it really depends on the individual in other words   you know you can you can be the fittest person  in the world but if your LP little a is through   the roof or you have familial hypercholesterolemia  you're going to need lots of drugs to address that   problem um so I wouldn't be able to say in that  person's case exercise is the most important thing   I would say you know Pharma is uh but clearly for  two of the four exercise is hands down the most   important and for the other two it is important  but the relative weighting is going to depend on   the individual yeah okay and so getting into the  nuts and bolts what do we need to do to get these   extraordinary benefits what what do you recommend  for your typical individual in a given week so I   usually start with the question of how much time  are you willing to give to this process right uh I   I don't want to sort of you know people always say  well Peter what do you do and it's like it's not   that's not relevant what I do right tell me what  you're willing to do and we will we will work with   that and by the way the math is pretty much the  same for everybody it's take whatever that number   is divide it in half half of that is going to be  strength and stability half of that is going to be   cardio the strength stability should be divided  such that about 80 percent of it is strength 20   of it is stability the cardio should be divided  such that about 80 percent of it is zone two and   twenty percent of it is VO2 max specific training  that in a nutshell is the simplest formula for   how to divide your time in exercise and again is  that going to get you the fastest marathon time   no is that going to help you win the local time  trial series if you're a cyclist no not at all   right like so you I'm not for a second suggesting  that this is the most sport specific way to train   I'm telling you this is the best way to train if  you're trying to become a centenarian decathlon   and so to to put a finer point on it let's say  I'm 55. I've um and let's say in my 90s knock on   wood I'd like to be able to do everything on the  list including dance at the jazz festival in New   Orleans and Ski and play Squash um I've um you  know I I I have historically been more focused   on cardio one one of the big learnings for me  reading your book is how important strength   training is which I knew I needed to start doing  more of due to due to sort of strengthening bones   and and and uh dealing with muscle atrophy as we  age but I I'll very briefly give you my current   workout regime because I I've been optimizing  Peter for time efficiency as a busy as a busy   person and that's totally fine yeah yeah so I  so my typical four days a week I go out I used   to run two or three miles but I've gotten it down  to I've added Sprints and so I run about two miles   with six all out 45 second Sprints it used to be  I I'd like to get that higher I've been gradually   increasing the length of time of the Sprints  um but but I can't but that takes 15 minutes   you know to run two miles with with six all-out  Sprints um and and so that's four days a week two   days a week I play squash with for an hour which  is more intensive cardio I think uh more sustained   um on the weekends I'll do um like a three to  four mile longer run and then um uh and then I   do like twice a week I do minimal strength  training basically curls curls and benches   um I I know I need to do more now um so that's a  start what what are you saying so how many hours   does that add up to and like on those two  on those two Mile Sprint days are you doing   a warm-up cool down that's or like how are you  preparing yourself for for those all-out efforts   I'm really not actually after each Sprint I  walk it off for 30 seconds but okay I I tend   to I don't do a whole lot of warm-up and cool  off I I haven't I've never been a big stretcher   um and uh but uh although I realized maybe I  need to modify that plan but I think it I think   it adds up to all in you know three hours and  change a week of exercise roughly okay and are   you willing to do any more I'm totally willing to  do more I I wanna I wanna have sex in my 90s okay   so let's just throw a number out there and say  six hours a week total exercise okay wow okay   so how would I think about that in you um well  again this is very generic this would be all   modifiable based on knowing your metric so once I  saw your VO2 max saw your Zone 2 output I'm going   to assume you'd fail our strength test miserably  and that's because most people do even people who   come at it with a strength training background  so there's not I'm not saying that to be critical   um it's not because you can see me on video  that's not no no no not at all it's just that   like the test is very very hard and the standards  are very very high because we're doing we're   we're building the test we our metrics are set  such that everybody could do everything at 90.   that's the standard we're going to hold you to  and that's why virtually everybody fails at 40.   um so I would say that means you're going to be  doing strength training for three hours a week and   um we would focus on some movement preparation  so we would first do a movement assessment that   movement assessment would probably demonstrate  some very classic patterns I would suspect so I   suspect you're very tight in the hamstrings you  I would have to look at your breathing patterns   and stuff like that but you're you know and I as  you recall I write about this in the book right   there are these three different archetypes  of breathing patterns and those breathing   patterns largely dictate your movement strategies  your movement strategies all of those movement   strategies are counter productive and they need  to be corrected so you'd spend 20 percent of that   three hours on exercises to correct the movement  patterns and the remaining eighty percent of time   strength training because you don't have a huge  background in strength training we're not going   to get too fancy it would probably be three whole  body workouts a week you know we're not going to   do an upper lower split um we're also not going  to you know we're going to start you doing a lot   of single leg exercises this is very important  for runners um so you know running is is a single   leg activity right your each leg is doing it is  is impacting forceful on its own and receiving   force on its own so you're not you know a squat  and a deadlift are kind of not natural exercises   in that sense to a runner so you're going to be  learning a lot of new exercises mostly variations   of split squats uh single leg rdls things like  that so these are much safer exercises as well   for somebody who doesn't come into this  with a huge background of strength training   on the cardio side what are we going to do well  the good news is you've already got an awesome   base there I think what we're going to do is widen  the base of your pyramid because right now just   on what you described you got a little too much  Peak intensity not enough Base building so of that   three hours I actually want eighty percent of that  to be at zone two which is an intensity at which   you can run and still carry out a conversation and  given your level of Fitness that's still going to   be probably a decent clip you know you're probably  that's I'm guessing but that might be like you   know eight minute miles for you or something  like that yeah it's not it's it's it has to be   brisk enough that there's a training effect  so if you can talk easily that's actually too   low in intensity if you can't talk at all which  obviously you can't during a lot of your higher   intensity stuff then that's too much so 80 of  those miles are going to be run right at that zone   two level and then the other 20 I'm actually going  to take you back to intervals but they're going to   be longer intervals so we're going to really  optimize around Zone probably around VO2 max   and so what I'd probably have you do depending on  how fast you are um is do three minute intervals   so I'd have you go as hard as you can for three  minutes walk for three minutes as hard as you can   for three minutes walk for three minutes and we'll  push that up to four and you only do that once   a week so you'll do and that's going to be the  toughest workout you do a week both in the weight   room or or on the track that one workout we would  optimize the other workouts around that one being   your highest performance workout a week we would  structure your rest around that we would structure   everything around you being able to give it your  all and leave it on the table for that one workout   and so I'm guessing the reason that you had that  you uh that your answer to the question what's the   optimal workout is sort of uh about the time that  a typical person listening to this can allocate   is probably because there's some there are many  people who would think a six hour six hours of   working out a week that's a non-starter right  and and we know that there's the opportunity   for a virtuous cycle here partly because of what  we described about these the great the great joy   of how good you feel when you when you exercise  so really what we want to do is get people on a   kind of virtuous cycle of exercising more and  more and more and would you say that it sounds   like you probably work out even more than what  you just described more than six hours a week I   mean would you say that the average person should  be getting on a pathway to incrementally increase   their both cardio and strength training up until  they get to a kind of a total of six hours or more   again I don't think of it that way  I think yeah I mean again the data   show that there is no upper limit to the  benefit that comes from increased Fitness   increased muscle mass increased strength  especially increase cardio Fitness we we   see no upper bound to that limit this  is kind of unusual in biology okay   um most things in biology are used and upside down  use most of biology is the Goldilocks principle   cardiorespiratory Fitness is an exception to that  rule it's one of the exceptions so um you know   I think that everything you said before is  correct and when we start with people who don't   exercise at all we just Peg them at three hours  a week because that increment alone provides the   biggest Improvement that you'll see from any three  hour edition so going from completely sedentary   to three hours a week of exercise will reduce  your risk of all cause mortality by 50 percent   so wow that's a staggering Improvement and if I  never get you to take another Step Beyond those   three hours a week we've still won the game but  you're exactly right virtually without exception   those people six months later nine months later  are like this is freaking awesome I want to do   more of this yeah and you've seen you've seen this  in your practice like right with patients over and   over again yeah yeah I'm getting stronger my aches  and pains are actually going away counterintuitive   right they sort of had this thing which is oh I'm  going to kind of coddle myself my aches and pains   I'm gonna I'm gonna do less and the reality is  there's nothing that's better for reducing chronic   pain than exercising safely now look everything  comes with a Nuance here can you exercise too much   absolutely can any amount of exercise if done  incorrectly increase long-term risk absolutely   um but but you know again the luxury I think we  have is we we have the ability to to to sort of   be nuanced and thoughtful in our approach so I  wouldn't I wouldn't um you know I I mean it's   a broader discussion of course but whether six  hours is the right number for you or seven hours   or eight hours or ten hours is a function  of what else it's competing with and that   doesn't just include other activities such as you  know attention to your nutrition or work but it   includes other things that are equally important  such as your relationships and connection to other   people by the way the one thing I didn't address  in your question is where does the Racquetball and   stuff fit in I would not include that in the six  hours so the six hours is dedicated to training   racquetball is is a sport that's an activity  that's part of why you train is to be able to do   that so so I would just say the six hours I would  like from you to be the the training and then you   know play your sports your tennis racquetball  whatever outside of it and and by the way you'll   be better at those things as well and your risk  of injury will be lower yeah yeah yeah and and   how how many hours a week are you exercising so  I'm at kind of a low number by my standards now   um in part because of the book and just other  things that are a huge demand in my time   um I'm trying to think I'm probably at 10 hours  a week right now I think for me the sweet spot's   about 14 I I'm I'm I think I'm I perform at my  best and and feel my best at about 14 hours per   week so I'm kind of under trained at the moment  and wow and a little a little bummed out about   it but you also have to keep in mind like I have  a much different training age than most people I   mean up until my early 40s I was training over 20  hours a week right there were periods of My Life   as a teenager which is really when I think you lay  a lot of the foundation in the muscle I mean I was   training 36 to 40 hours a week as a teenager from  about the age of 13 to 19. so um this was as a   young boxer and then subsequently as a swimmer  uh setting new records swimming 32 kilometers   yeah and and and as a cyclist later on so there's  always been something that has been very high   volume training and I'll never go back to that  volume I don't I don't Pine for that at all   um and actually in some ways what I'm enjoying  now is the mental Act of being trying to be more   flexible in my thinking and acknowledging that  there's a season for everything and right now is   not the season for me to be absolutely crushing  it in every workout and um you know learning how   to how to read my body a little bit more um  and so yeah so again I don't I don't think   I'm necessarily the the person you should be  saying okay whatever Peter does I'm gonna do   because that's not necessarily you know yeah and  I think there are ways to work the exercise into   our lives I mean I was you know I I walk a fair  amount living in New York City and ride bicycles   a fair amount although the new electric bikes  are very tempting it's a problem for me um but   the but I was very interested in Rocking which is  something that you which are basically walking or   hiking with with a weighted backpack up to a third  of your body weight I actually purchased the uh   the first step kind of inexpensive rocking system  which is a series of sandbags that I could fill uh   before I go to the 350 full wrecking system but I  like the idea that I could go to pick up my kid at   school about a mile and a half walk and back three  miles round trip listen to audiobooks podcasts   which is part of my work right I mean there are  ways of integrating this into your life such that   it's not a zero-sum game of of like you know uh  not being able to accomplish the other things   you want to do yep um I think one of the things  that to me was most surprising about your exercise   um suggestions is the amount of strength training  um and you know so for your for your typical   listener I mean this is I imagine as important  for women as it is for men I mean you don't tend   to in the gyms you don't tend to see women in the  you know moving weights around as often as men do   I mean it seems if you were to speak to what  is most misunderstood about about the benefits   of exercise I think cardio is more broadly  appreciated as something that's really good   for us it seems like the strength training might  be the piece that is not as widely understood   yeah you know cardio has all of these amazing  metabolic benefits it's by far the most important   tool we have to increase insulin sensitivity  um and insulin sensitivity meaning the ability   of the muscles to be receptive to the signal of  insulin to bring glucose out of the circulation   into the muscle is a an absolute Hallmark of  avoiding or delaying death um and and cardio   training has no peer in that regard but what  strength training does is partially factor   into that you see strength training increases the  capacity of the muscle as a reservoir for glucose   so a bigger muscle all things equal is a bigger  sink for glucose interesting yeah so you you get   all these benefits metabolically you also get many  of the same you know chemical benefits that you're   getting the endocrine benefits the cognitive  benefits that you're getting from cardio training   but with where strength training is imperative  and where it has no peer is on the structural side   and this is with respect to bone density and  strength and those two things decline so much   when we age especially in women so women are  more susceptible to this because uh of of   hormone loss that you know if we were ever going  to add another Horsemen to the list it would be   accidental death of which falling is the biggest  cause of accidental death in the person over 65.   so that's a very close competitor for  a fifth Horseman once you're over 65   if you fall and in the course of that fall  break your hip or your femur there's a 15 to   30 percent chance you will be dead in 12 months  worth repeating it's so staggering if you're   over 65 and you fall and break your hip or femur  there's a 15 to 30 chance depending on the study   you're not going to be alive in a year and of the  people who are still alive in a year 50 percent   of them will never regain complete movement  so even if you're lucky enough to live you're   debilitated for life you have lost some critical  capacity so it's it's just hard to overstate this   and my kind of glib way that I explain this  to patients who are somewhat resistant is   um all right so I don't know what the estimate is  for how many billion people have lived but like   it's I think it's like what 20 billion people  we think have lived in all of human history   um so I just said just give me an estimate just  ballpark for me of those 20 or 30 billion or   whatever the number is how many of them do you  think in the last year of their life said I wish   I had less muscle mass like what do you think  that number is I'll tell you what it is zero   zero times is how many times in human history  someone in the last year of their life said I   wish I had less muscle mass it's simply not you  can't have too much muscle at the end of your life   so interesting and and what do you think about  uh I mean I have been under the impression that   ultra marathon runners die earlier that there's  such a thing as too much cardio and that when you   see crazy jacked you know bodybuilders that  bodybuilders die a bit earlier that might be   partly I think those are both probably true so  so again um you know the crazy Jack bodybuilder   is probably dying not from how much muscle he has  but from what he had to do to get that much muscle   um I've actually um you know sat down  with a number of these guys and it's   I'm not being judgmental I'm just insanely  curious about what they need to do to get there   um most people I think look at you know  bodybuilders and think well they're just   kind of freaks and they just take a bunch  of drugs and yeah they are genetic Freaks   and yeah they take a bunch of drugs but they're  training and eating like you can't believe it   um so there's nothing really  healthy about anything they're doing   um and the amount of drugs that they're taking is  Legion I mean it's you know just to give you some   numbers if we're replacing testosterone in a  male patient a typical dose is 50 milligrams   of testosterone twice a week so 100 milligrams  a week is pretty much a physiologic replacement   there are some patients that need a little bit  more I don't think I've ever given a patient   more than 140 milligrams of testosterone in  a week I had uh breakfast with a bodybuilder   um a while ago and um you know he's he's not even  a pro he's not he's not even a famous bodybuilder   like he's just a guy who does this and I was just  picking his brain like well like what are your   testosterone Cycles like his lowest is a thousand  milligrams a week wow there are some weeks that he   has taken now I don't think this is representative  I think this is literally this guy's probably just   such an outlier there are some weeks he said he  took 25 000 milligrams of testosterone good god   um but you know taking six seven eight hundred  to a thousand milligrams of testosterone a   week plus growth hormone plus insulin  plus all of these other crazy hormones   I mean I would argue that that's playing a greater  role in their demise than the actual amount of   muscle not to mention the way they're eating  I just don't think it's healthy to be you know   you know moving you know just putting that much  mass on so so I don't yeah I always want to make   sure people don't use the excuse of the 300 pound  bodybuilder um yeah dies prematurely therefore I   shouldn't lift weights no no that's the wrong  interpretation similarly you're right I think   um obviously what is it Chris McDougall wrote  that book Born to Run and yes there's a very   famous example of the protagonist of that  book who did die um and probably died from uh   either a cardiomyopathy or you know an electrical  basically an electrical failure of the heart due   to the heart getting stretched out a little bit  um we do see a slightly higher incidence of atrial   fibrillation uh and cardiomyopathy in in people  who are exercising very very excessively but again   I find it a little disconcerting when people who  are couch potatoes use those people as the counter   example to why they don't want to do it so I'm  more than happy to talk to the patient who's doing   90 miles a week of running and get them to back  off yeah uh yeah I'm happy to have that discussion   um but but yeah it shouldn't be used as the excuse  to not do it for for 99.99999 of people they don't   even have the capacity to push as hard as those  two extremes are pushing and they shouldn't worry   about it I can assure you Peter this is not a risk  for me there's no ultra marathon or bodybuilding   uh excessive uh risk for me I'm a little  disappointed that you're not giving me credit   for my for my squash and Tennis workouts in my  six hours but we'll we'll go and again I love that   you're doing that because I think that I think  that play is important right and I think that that   type of stuff is great the reason I think it's  hard for me to put it in your six hours yeah is   um The Sweet Spot around exercise is  when you control the Energy System   and the not the problem but the difficulty  of doing that in Us in in any sort of sport   like squash or tennis is it's very up and very  down right so you're you're your training effect   but it's and it's not just interval training  it's inconsistent interval training yeah where   you're never at a high enough intensity for  long enough to get the true VO2 max building   and you're never low enough for long enough to  get the plateau or the aerobic Base building   um so again there's nothing wrong with that but if  we're truly trying to optimize your energy systems   around long-term things we you want to be able to  to train in a very specific way so specificity is   very important um again it's not an accident  that I've called it the centenarian decathlon   a decathlete is generally regarded as the  best athlete overall but they're not the best   at any one thing so they're a generalist yeah  who's very good at a bunch of things never the   best but think about the specificity  with which that athlete has to train   to to accomplish that feat yeah and so so it  really is kind of a you know I used to refer   to it as the centenarian Olympics when I first  started talking about this five six years ago   but I realized that the centenarian decathlon  is a much better mental model yeah interesting   well on the topic of controlling energy cycles  that that could be a good segue to sleep   um which which for me is a great topic because  it feels like a relatively easy win I I I I guess   we don't want to use the term easy because for  for many people I know sleep sleep is for many   of us sleep is a real issue but the benefits  that I felt in my own life when I decided to   just allocate more time to the sleeping process  and get a little bit disciplined about trying to   get good sleep it just feels good right and and  I think it's it it's an easy way to easy your way   perhaps to feel a lot better and and get some some  real benefits is that would you agree with that I   I do I Echo your sentiments completely which  is it's nothing's easy yeah but this one has   the shortest gap between decision and execution so  for each of these things whether it be nutrition   emotional health exercise sleep the first and  most important step is the committed step you   have to decide you want to do this none of this  happens by accident you're not just gonna kinda   oh look oh my God accidentally like my VO2 max  is so high no no you got to decide like I want a   high VO2 max I want to be strong I want to be Etc  um when it comes to fully embracing the decision   to optimize your sleep which is the hardest step  once you do that the path to doing it is by far   the easiest of any intervention we have yes  right right yeah but that's a big first step   and and the Dividends are I mean it profoundly  affects mood cognitive function glucose removal   memory formation libido empathy right yeah  it's just it's just such a it's just it's   it's really wonderful um it's definitely  the easiest thing that we work on in the   practice and that doesn't mean that it's easy  and it doesn't mean that there aren't patients   um who we don't send for cbti so cognitive  behavioral therapy for insomnia which you   know some people who after we pull all  the levers fix all of the underlying   um you know hygiene issues rule out medical issues  such as sleep apnea they're still struggling with   insomnia yeah I mean there's some really important  and wonderful behavioral tools that you can that   you can do but I've never seen a I've yet to see  a patient who doesn't resolve with cbti when we   have to go down that rabbit hole but you have  to get to this point where you're saying this   is so important that I'm willing to do it which  means I'm willing to make eight hours of my day   for this thing and you know that's about what it  takes to get seven and a half hours seven fifteen   to seven and a half hours of sleep you gotta be  able to devote eight to eight and a half hours   to this activity yeah I'm gonna be consistent  when I go to bed and when I wake up including   weekends the room is going to be dark it's going  to be cold and I'm not going to have Electronics   in the room got to get the phone out of the room  just no phone in the room and you you gotta set   the mood for sleep by not doing stimulating  things beforehand and the most notable of   these for virtually every human being is email and  social media so yeah you know people say oh Peter   does that mean you can't watch TV before bed no  not at all I mean a lot of times you're watching   TV it's kind of like more relaxing enjoyable you  know it probably isn't the optimal thing to do   but no one's saying you can't just you know sit  there and watch some TV before bed but you want   to make sure you don't fall asleep on the couch  if you're doing it too so um again there's there's   lots of ways to work through it and and then there  are a lot of supplements that I think really help   and and are great for optimization that aren't you  know habit forming and don't come with a lot of   the negative Health consequences of traditional  sleep medications such as Ambien and Lunesta   interesting so what what supplements do you like  so you know what I what I personally use is I use   three grams of glycine 600 milligrams  of ashwagandha um magnesium L3 and 8.   um I take I mean those are those are kind of  the big ones I take a few other things before   bed but that's not because they're aiding with  sleep it's just I'm like for example EPA and DHA   I'm spreading out between morning and evening um  I feel like there's something else I'm blanking   on that might be it um and I and I also use um uh  depending on like for example like I'm traveling   to Europe this summer for a week to do some book  stuff and I'm all about kind of Maximum efficiency   when I travel so if I'm going somewhere for six  days even if it's a seven or eight hour time zone   difference I don't want to waste any time getting  over jet lag so in a situation like that I've got   a few big guns that I really help like I will  use a high dose melatonin say three grand three   milligrams I'll use four to six hundred milligrams  of phosphatidylserine these are things that you're   using to force yourself to sleep when you don't  want to sleep because sleep is really just a   it's just a balancing act between three things  melatonin adenosine and cortisol and we have ways   to kind of manipulate all of those interesting  yeah um yeah I've used melatonin magnesium tea   I don't know if that makes a difference um and and  sometimes CBD uh I found to be helpful um but the   the um um and and when you say get the room dark  I mean you talk about actually like putting tape   on you know little lights on electronics or how  far do they go yeah so it depends like back when   I sort of partially lived in New York um you know  it was more of a problem right because you know   I I had to get like really special blackout blinds  and stuff otherwise it was just like light all   the time you know where we are now in Austin  Texas we're kind of in the middle of nowhere   um like we don't have blinds on our windows and  that's okay there's a little bit of you know   light that comes in but you'd be amazed at how  bright people's rooms are sometimes when they're   when they're when they're sleeping um you know I  do have a clock beside my bed but it's on a very   low setting and it's kind of faced like I can't  really see it but I do you know if I get up at   some point I kind of like to know what time it is  um so yeah I'm not fanatical about this like I I   don't wear an eye mask unless I'm on an airplane  or in a hotel and I can't like sometimes in a   hotel I just can't get it dark enough um I'll use  an eye mask yeah I I got an aura ring about a year   ago and that has helped me quite a bit largely  because I think the most profound impact was   just seeing how much my heart rate was elevated  by drinking alcohol and also late late dinners   and consistency of bedtime was something I hadn't  been tuned into and and the the adjustment that I   made is I used to allocate eight hours for the  sleeping process I now allocate nine because I   realize that I'm off in 15 minutes late it takes  me 15 minutes to actually fall asleep and if I   what I've concluded is if I want to get eight  hours of sleep at night I need to allocate nine um and and how do you feel about  about sleep trackers for your patients   um I think they're valuable but also you have  to be a little careful that you don't get too   neurotic about them so we we are pretty liberal  with sleep tracker holidays when that becomes a   bit of a problem so they're good and that they  help us see what's going on so we're you know we   have a portal that allows us to see our patients  data um but I also I think the most powerful   benefit is the one you just described actually  it's a bit of a compliance tool and it's a bit   of a reminder like I woke up today and my heart  rate was 10 beats per minute higher my HRV was   50 lower uh because you know I had two glasses of  wine last night and uh which I don't regret by the   way you know one of my best friends from high  school was over I haven't seen him in 10 years   we just we had an awesome night and you know  our our wives hung out and we hung out and   it was a great time and but I got to say I got  a little reminder hey that's what happens when   you do that and would I do it again of course I  would would I do that every night absolutely not   yeah so this so so of all the data um I I  joke with friends that I have a file called um   scientific studies that support the life I want to  live anyway and I think I think we all have some   degree of confirmation bias when we're digesting  kind of health information and and for me the most   you know 10 10 to 15 years ago there was a broad  perception I remember reading an article in the   New York Times that you know one to two drinks  a night for someone of my body weight decreased   uh you know heart disease risk by 33 I I had it  framed and on the wall I mean not not literally   but in my mind I was like how oh yeah this is  like you know and uh you know so I was I was in   a rhythm of two glasses of red wine every night  and and then I just you know kept getting this   more and more data was coming in more and more  studies just showing that really any consumption   of alcohol had negative negative impacts um and uh  and so I have been uh very diligent in looking for   any kind of countervailing evidence of uh because  honestly I love a glass of wine or Bourbon and the   only thing I like better than one glass of wine  is two glasses of wine um and so I have cut back   meaningfully I I I've now cut back to like only  only when friends are over only in with company   um because we know that that's critical to  health right that human connection is critical   um and so I guess my rationalization in my mind  is here are my two justifications that you can   poke holes in them the first is that yes alcohol  is a toxin but so is excessive stress cortisol   in the bloodstream is you know it's like Drano  if you have and arguably it's the Lesser toxin   if it really meaningfully decreases your stress  throughout your week is is my rationalization   number one rationalization number two is we  know there are massive health benefits to   really connecting deeply with other humans  and there's a fair we had a guy named Edward   slingerland on this on the show who wrote  a wonderful book called drunk about the   co-evolution of humans and alcohol fascinating  if you haven't read it and um and he cited some   a number of studies showing some you know very  definitively something that most people wouldn't   be surprised by which is you take a random  sampling of people some think they're drinking   alcohol but they're not some think they're not  drinking alcohol but they are tested every which   way you get five strangers in a room and there is  way more human connection more eye contact more   laughter more trust when people whether they  realize it or not have consumed alcohol so so   I think it is effective in helping humans connect  and we know that's good for health so what do you   think I think it would be hard-pressed to disagree  with anything that you've said you know I think it   it comes back down to this discussion  of nuance again and and for for   everyone there's going to be a slightly  different answer to this question um so there are probably at least in the case  of red wine there are probably also some   some phytochemical benefits as well there's  probably some antioxidant properties of red   wine yeah that in and of itself from just from  a nutrient standpoint are probably beneficial   um everything you've said about the pro-social  side of it for many people is true but of course   for some people that's not true let's not forget  that there are many people for whom alcohol is   a bad thing so it's an antisocial of course  and there's a negative consequence of that   both to others and to themselves so I don't  want to I don't want to lose sight of that   what's unambiguous is that ethanol per se is  a toxin a carcinogen and a harmful molecule   so ethanol is the fourth macronutrient we have  fats proteins carbohydrates and ethanol those   are the four macronutrients I just want to make  sure everybody understands there's nothing about   ethanol as a as a macronutrient as a hydrocarbon  that is at any dose beneficial it's not a   linear response to toxicity it's probably more  exponential so meaning at low doses it's probably   you know if you the difference between one uh you  know between zero Tequilas and one tequila is not   going to be huge but one to two is going to be  more and two to three is going to be even more   than that and then with with red wine you have  this other issue where there may in fact be some   chemical benefits of the other constituents of  the of the alcohol I.E distinct from the ethanol   yeah and then of course there's everything that  you said right about you know the the benefits of   what it does and and how that's probably what the  epidemiology is capturing right the epidemiology   is probably mostly capturing the the the social  connection piece of it so then how do you bring   this back and reconcile this which is well we just  figured something out thanks to our sleep trackers   right which is yeah if I have two glasses of wine  at six pm and go to bed at 10 pm I slept pretty   well yeah if I have two glasses of wine at nine  pm and go to bed at 11 PM I sleep really poorly   well I mean there's pretty pretty obvious  implication here yes which is right right you know   you don't you can be mindful about how you use  this thing to your advantage without and and and   and sort of Shield yourself from some of the harm  of it um and and so to me that's that's like what   I would call sort of the nuanced approach to that  yeah this is expert middle-aged partying which is   start early right what are the things that we  learn and actually like an open question is   how much of the negative impacts of alcohol on our  health is due to uh negative impact on sleep right   because we know that we know that negative impact  on sleep has profound negative impacts right so I   I don't know how when we look at those studies uh  how we can tease those two those two things apart   I don't think there is a way retrospectively I've  talked about this with some folks who are kind of   interested in this question as I am and um I  think the only thing we've ever been able to   come up with is there you would have to study  this question prospectively to really tease   apart these different things um I don't know who  would fund such a study um but it's there's no   question in my mind we could we could really make  you know if you if you were if if an entity was   willing to put up the money to do a five-year  study we could really get some insights here   I I I think you might I know you sometimes find  funding to accelerate studies of of collective   interest I think there are enough people who  enjoy a couple glasses of red wine that that   there might be there might be appetite to find  that the I I was interested I listened to your   conversation with Dr Andrew huberman and and  I was interested in in his you know he made   the comment that he doesn't he's never enjoyed  drinking and clearly when he encounters a data   point the drinking is just categorically bad he  just fully accepts it and integrates it into it   whereas since you do enjoy a glass or two of  red wine uh you know you're you're uh I mean   it it seems to me that in a world within which we  never have total Clarity on the facts and we're   constantly building a point of view and a belief  system that that a little bit of confirmation bias   is not it is Perfectly Natural right that we're  right how do you know and it's really funny like   I didn't drink in high school I can count the  number of times I drink you know in college med   school a little bit more but even then it was  just dumb drinking right it was like you know   cheap beer at the bowling alley kind of  crap but I've never really like it it's it's   it's only in the last 10 years that I've really  come to enjoy alcohol for for the sake of like   what I'm drinking like really kind of getting into  tequila really getting into Moscow really getting   into you know a handful of mixed drinks that my  wife claims I make better than any bar she's ever   been to uh you know obviously certain types of  wine a couple of you know there's a couple of   beers I really like that are unfortunately  too too expensive and too hard to come by   um so you're right like I I  think um maybe I I would love to   I'm always looking for data to to make me feel  better about that but but you know truthfully   I've you know I haven't come up with a lot yeah  yeah yeah I love your comment though if you have   a sip of a glass of wine or something it doesn't  taste good you'll spit it out I did it I did it   two nights ago or three three nights ago we opened  a bottle that we had never tried before so it was   just like hey this kind of came recommended  opened it and it wasn't like it was bad but I   drank it and I was like I don't love this yeah I  know we just spent 40 bucks on this bottle but it   kind of sucks like let's catch it yeah yeah yeah  I've I've found myself doing that with a croissant   but you know I figure like it's really not  something I should be eating but if it's just   totally Transcendent and and you know I break  out in Goosebumps from The Joy I'll give myself   permission for certain kinds of experiences but  sometimes I'll you bite into something and it's   just stale and not so good and I think why am  I chewing on this this is this is coming out   um yeah that's my approach to gelato in uh in in  Italy it's like uh it's so good I'm gonna have   it twice a day every day for two weeks and  deal with the consequences when I get home   interesting yeah well this is a good segue  to nutrition uh and you say Peter that you   you hate being asked at dinner parties about  diet why is that I also hate being asked about   it on podcasts by the way I just I just hate the  topic I hate everything about it I yeah you know   um and that's that's a it's sort of a mean thing  to say the truth of it is there's a lot of times   people come up to me and ask me things at parties  and there's just a genuine confusion and curiosity   and and I can understand that um but what I what I  think I rail against is just again the the sort of   and social media has made this unbearable but it's  just the religious Zeal with which people try to   tell you that their diet is the one true diet and  um again the evidence is just overwhelming that   that is not the case um and nutrition matters  in terms of energy balance nutrition matters   as far as micronutrients nutrition matters as  far as anabolic building blocks I.E protein   nutrition matters you know in terms of avoidance  of um you know disease-causing agents like there   are some really obvious things about nutrition  that matters truthfully the only thing that's not   in the book about that you know because I as much  as I hate to talk about nutrition that it does   have two enormous chapters in the book so I have  a lot to say about it yeah even though it's not a   topic I enjoy the only thing I didn't include  in that just because time and space became un   um unyielding um was I do have a very growing  interest in soil and uh and plant quality uh   interesting and and sort of you know the cycle  of life right so what's the carbon cycle right   so you're if your soil sucks which unfortunately  most of the soil in the U.S now officially sucks   then your plants kind of suck the the nutrient  density of the plant sucks if the nutrient density   of the plant sucks the animal nutrient density  that eats it sucks so it's really that doesn't   really matter that much if you're gonna you know  be a vegetarian or an omnivore you're you're just   not getting optimal quality and this is actually  the thing I'm finding myself most interested in   now is understanding this world of regenerative  agriculture and understanding how soil quality   can have such a profound impact and you know we  have a garden here at our house and I just can't   get over the difference in how and unfortunately  it's not big enough that we can sustain ourselves   fully on it so we're still kind of going back and  forth between you know the best organic stuff we   could buy versus our stuff and it's night and  day different like the tomatoes that you know   my son grows in our garden how incredible and  the stuff we buy in the store even though it's   the the organic stuff which I think is better  than the inorganic stuff or energy non-organic you know uh so so so like if I had a second life  I I'd love to have a regenerative you know AG   Farm where everything from soil to animal  is is is is purely grown in this way and   um you know so to me that's the most interesting  topic in nutrition right now but at the level of   kind of our patients you know what are we trying  to do we're trying to make sure people are in   energy balance so if you're overnourished we got  to make you less nourished that's just a polite   way of saying you have too much fat in your body  and a lot of it is probably in the subcutaneous   space which isn't problematic other than the  obvious aesthetic component that people care about   but it's when it escapes that subcutaneous area  and it starts to you know coalesce around organs   as visceral fat within the muscle as intramuscular  fat around the pancreas the heart all these other   places that really metabolically toxic fat is a  very high priority for us to get rid of um and so   we juxtaposed that question with are you under  muscled or adequately muscled and most people   show up slightly overnourished and under muscled  so this is the big problem that's the majority of   people that are listening to us right now you're  overnourished but you're under muscled so you have   to reduce intake while increased increasing  protein intake intake and increasing strength   training that's the solution to that problem  more strength training more protein less calories   um yeah and it's hard the the um I and I imagine  as you say it's a there's a lot of tribal passion   around diets and nutrition one of the uh you talk  a lot in the book about about fats and and how   the body processes them and and cholesterol uh  and uh a lot of it was was new information for   me this notion that um you know for most for  most all people listening I imagine the word   cholesterol has a negative connotation there's  obviously people talk about good and bad with   your distinctions you don't love um but I I  think I I had not understood that cholesterol   is critical to the functioning of a healthy  body right I believe it comprises our cell   membranes uh and uh and that so so you know fats  are absolutely critical to our health it's more   complicated than we think and you can have extra  subcutaneous fat as you were saying effectively   belly fat or wherever it resides and still be  perfectly healthy as long as that fat has not   overflowed into your muscles your bloodstream  your kidneys right uh that's right you want   to speak more to that no you did a great  job explaining it um you know the greatest evolutionary LeapFrog we took probably came in  one way or another in response to our ability   to store excess energy so um there's nobody that  would dispute what distinguishes us from every   other species on this planet is our brain right  we're not we're not bigger we're not stronger   we're not faster there's you know you can always  find another species on this planet that is better   than us at any domain you can think of except  one and so we pay a price to have this brain is   one way to think about it another way to think  about it is we paid the price by being able to   store energy in order to have this brain so you  know your brain is a fraction of your body weight   and yet it's responsible for 20 to 25 percent of  your metabolic need and that would be incompatible   with our Evolution had we not figured out how  to store energy so this capacity to put excess   carbohydrate and excess fat into subcutaneous  fat stores is the thing that made us what we are   and in a relatively food scarce environment it  poses zero problems it only has posed a problem   in a relatively recent time frame I mean it's  like 0.0001 of our genetic past that this has   become problematic because we're now in such a  food uh uh dense environment you know we have   so much food availability and when you factor  in other factors that are working against us so   now we have natural we have unnatural light  which makes sleep much more difficult yeah   um yeah we have modernity that has rendered  activity optional so everything is working   against us chronic stress versus just acute  stress we used to be mostly about acute stress   now we are mostly about chronic stress so you have  chronic stress inactivity poor sleep abundant food   it's a catastrophe so this idea that we can store  adequate amounts of energy is out the window most   of us are storing far more energy than we need  and at some point it escapes the as I described   it in the book it escapes the bathtub that we  are you know that we have to house water in   and the water starts flowing out of the bathtub  and if you're as long as the water's in the   bathtub everything's fine water starts leaving the  bathtub your host right that's when it leaks into   the ducts and screws up the air conditioning and  you know God knows where it ends up in the floors   and stuff like that so once that fat gets into  those other places that's where metabolic disease   really escalates I mean that's what's happening  in someone with type 2 diabetes and that's   why there's a very strong though not complete  correlation between obesity and metabolic disease   so so you could have someone who had the right  genetic predisposition and exercise quite a bit   who had a beer God and yet was pretty healthy  like a sumo wrestler that trained quite a bit   and and had the right uh predisposition is that  true there are there are people uh and and by   the way it's about I mean there's a figure in  the book and I so I can't remember the exact   numbers but but you know roughly 2 I think it's  maybe 25 percent of people who are obese are   metabolically healthy and their health outcomes  are no different than uh a non-obese person   similarly about I can't remember the numbers  again I think it's maybe it's 10 percent of   people who are non-obese and in fact not just  non-obese but of normal BMI are metabolically   unhealthy their health outcomes paradoxically  are slightly worse than the obese metabolically   unhealthy individual these are people that have  really small bathtubs in other words like they   don't they don't have much capacity to store  excess energy so they very quickly start to   Vault it into these unwanted places and I love  this detail that that that when we eat fats that   that typically our bodies produce cholesterol  produce fats but that most of of the fats that   we eat are shot out or are not cholesterol not  fat cholesterol okay right yeah yeah right yeah   um most of the cholesterol that we eat  because it is um attached to another chemical   um group called an ester link um it's just  too big to fit in the transporter in the   gut that brings it into the cell so you know  the cholesterol that's in eggs or shellfish   or things like that it's just leaving yeah  it's leaving your body without ever entering   it so virtually all the cholesterol in our  body is there because our cells have made it so so the basic principles though of  nutrition that are non-controversial   I imagine are avoid drinking sugar water  right obviously like you know sodas but even   fruit juice Gatorade sports drinks like  sugar Waters kind of all over the place   um processed foods are generally a bad idea would  you agree with that what what do you think are   the are the non-controversial statements I  don't want to be like too much of a stickler   but yeah you know even the term processed  food is a bit complicated right because you   know processing food is what allows us to live  in the way that we live right like it would be   very difficult for for us to live if we could  only subside on completely unprocessed food   um because you know we're not all growing our  own food so it's true that if you're eating   something processed the probability that it's  bad is probably higher than the probability   that's good but look there were some processed  things that I eat that I think are really healthy   um so you have to you have to sort of  look at everything in a case-by-case basis   um so if we're looking for just broad Contours  it's it's all the common sense things for sure   um you know it's shopping in the outside  of the grocery store not the inside it's   you know always doing the grandma test like did  my grandma eat this if no I probably shouldn't   be eating this but again that's not a universal  truth right you know your grandma couldn't have   had a whey protein shake but there's a really  high quality whey protein out there that is a   great way to get additional protein if you  can't get it through all of your meals so   long-winded way of saying um one has to be  painting and not painting by numbers when it   comes to nutrition I think yeah and so fasting I  I've been I've been in the intermittent fasting   time restricted eating you know eating within  an eight hour window plan for four years now   um you are um are kind of uh uh it seems  like uncertain that that is the right path   well I just think it it's a it's one of the three  strategies we have for energy restriction so if   we go back to the framework are you overnourished  or undernourished if you're in the overnourished   camp regardless of what's going on in the under  muscled or over muscle or adequately muscled uh   you're going to be reducing intake you have three  strategies to do that uh time restriction is one   of them uh time restriction has the advantage of  being conceptually and operationally the easiest   one to implement yeah yeah it is a Mindless hack  okay you literally just need a clock that's it   and once you do it it's so easy so that's the  good news here's the bad news bad news is it's   very difficult with a very tight window of time  restricted feeding to get the appropriate amount   of protein consumed and spread out accordingly  over the over the course of the day the second   big limitation of time restricted feeding which  is by the way I'm not suggesting that you're doing   this but just this is a lot of people do this is  they tend to overcompensate when they are eating   by just eating a bunch of crap yeah um it look  you see the same thing in everything you know the   person who says I'm going keto or I'm going vegan  therefore I'm holy and anointed and they just eat   the crap version of Keto and vegan right so it's  like yeah congratulations you've done nothing so   um those are the two biggest issues we have to be  mindful of when people do time restricted feeding   um and there are ways around both of these things  but again you just have to be mindful and you have   to be very deliberate about it yeah yeah for me  it as you say it was much easier than and much   more appealing than other ways of restricting my  diet it caused me to drop another 10 pounds to   get closer to my college weight uh and I I feel  much more alert I feel I used to feel kind of   a little sleepy after lunch I I generally I like  the cognitive feeling of it uh and it also lowered   my LDL into a healthy range so it seems to have  worked for me however I am concerned having read   your book that I'm not eating enough protein uh  and and this is one of the most surprising uh uh   sections of your nutrition chapters is you say the  standard recommendations for protein are a joke   right so you're recommending two to three  times I think the standard protein consumption   recommendations yeah about about two to two  and a half times so the standard the the RDA   which is the um um God now I'm blanking  we're going to edit this out what is RDA   um it's um recommended dietary daily allowance  is it it's dietary dietary um okay I'll try   that again yeah uh yeah so the the RDA the  recommended dietary allowance for protein is 0.8   um grams per kilogram of body weight uh so if  you do the math on that so someone who weighs   80 kilograms they'd be you know recommending  65 grams of protein so that's you know   I mean woefully ineffective right that's enough  to not waste away uh if you were you know   starving on a on a ship wreck um but the reality  of it is if we're talking about putting on muscle   mass and maintaining muscle mass especially as we  age and as you age you encounter something called   anabolic resistance where as the name suggests  just as we have insulin resistance where the   muscles are less sensitive to the effects of  insulin the muscles also become less sensitive   to the available amino acids to undergo what's  called muscle protein synthesis which is the   process of assimilating and incorporating those  amino acids into growth so if you look at the   data it's clear you need probably closer to 1.6  to 2 grams of protein per kilogram of body weight   so that hundred and or that 80 kilo person who  weighs about 175 pounds if you convert it is   going to need closer to 160 grams of protein so  you know I just basically say whatever system   you're in you know it's either about one gram  per pound of body weight or about two grams per   kilo of body weight and that's that's going to get  you in the right Zone and then it's not just that   in total amount it's that those have to be spread  out reasonably so you can't have too much and you   can't have too little protein in one sitting or  you reduce the effectiveness of it so if you're   consuming probably less than 10 to 15 grams of  protein in a sitting you're not getting any of the   anabolic benefits of that protein that protein is  first the the liver always takes first dibs on the   protein and will undergo gluconeogenesis so it's  going to turn that first spigot of protein into   glucose and so you have to be kind of above and  beyond that so if you just you know ate 10 grams   interesting 16 times a day you'd you wouldn't  get the anabolic benefits you'd get some but   you wouldn't get yeah similarly if you ate it all  in one day uh pardon me all in one sitting yeah   um the the data would suggest that you can really  only use about 40 or 50 grams in one sitting so   you have to kind of spread that out interesting  and this is part of the challenge with with   intermittent fasting or time restricted eating  which is you say for me at 185 pounds to get to   you're you know the the recommended protein levels  I I'd need to have four servings of 45 grams and   45 grams which is six ounces of of chicken fish  or meat that's that's a lot to consume and if you   look at what that looks like I I just looked it  up because I was so astonished by these numbers   a cup of hummus contains about 19 grams of protein  a cup of almonds about 28 grams of protein which   by the way is very expensive almonds and and you  know and so we're talking about like nine cups   of hummus you want to be mindful of especially  if you're trying to cut calories while you're   doing this like you have to look at basically  pure sources of protein like I would never use   hummus as a protein Source because it's just come  in with way too many other calories interesting   yeah I'm consuming protein I'm I want to consume  the leanest source of protein I can get so for me   it's mostly venison elk bison salmon I mean that's  where I'm going getting the bulk of my protein and   um so so you know I'll easily have like when  we're done this podcast I'm going to go and have   50 grams of venison of protein in the form of  Venison and the total calories will be 250. and so   you would say that it's possible to get there to  you as a vegetarian or a vegan it's just difficult   that's right yeah it's just harder because  of protein quality um so protein density and   protein quality are lower without animal  products and and this protein consumption   these protein levels are critical to building  the muscle which we've we and we've described   how critical that is to long-term health yeah  um okay quick quick side question for you Peter   might you have an extra five or ten minutes or a  hard stop do you have a hard stop in six minutes   um maybe another five so maybe 11  minutes yeah excellent okay great   because I've I've got uh two two final  topics I'm excited about okay great   um so I have had a real interest in in longevity  research and I I read lifespan by David Sinclair   um and I'm what do you think about his information  Theory of Aging and I I I know you're not a big   fan of of the NAD booster NR nmn supplements um  what's your view of of the probability that we   will meaningfully extend the human lifespan  in the next several decades well I guess it   depends what we Define as meaningful but if  we're talking about basically undoing aging   um I I'm not particularly optimistic that that's  something that's going to happen in our lifetime and and and and what do you think of the of  this sort of notion that aging results from   an accumulation of errors in our genetic  code this this information Theory of Aging   this notion that that our our when our cells  reproduce the error rate and our our ability to   um to correct errors in cellular reproduction  as I understand it uh erode as we get older   uh is that does that uh make sense to you oh  absolutely it's it's a it's a Well understood   um Hallmark of Aging so there are nine Hallmarks  of Aging um that are well described and uh clearly   a subset of these involve replication errors  and accumulation of mutations another one of   them involves epigenetic modification to to  the genes even absent mutations and that just   is what happens when you get little what are  called methyl groups so little carbons with   the three hydrogens on them stuck onto the DNA  itself and that impacts the expression of those   genes so you have both accumulation of mutations  and then you have epigenetic overwriting of the   genes and these are both clearly a factor in  our aging I don't think that's in dispute I   think where I probably differ in my level of  optimism from maybe the most optimistic here is   um I think that's a much harder problem to solve  than than maybe is advertised so there's a very   famous idea proposed by a scientist yamanaka  who I believe was awarded Nobel Prize for this   so using these yamanaka factors there are four  of these factors and you you can basically turn   a cell back into its primordial stem cell  by uh adding in the four yamanaka factors   um the problem with this approach when applied  to an organism is complicated as ourselves is one   it's not clear how you would apply the factors  across the body right it's clearly not like an   ointment you're going to rub on yourself you  somehow have to decide which cells like well   is it the heart do we want to somehow take  a heart which is aging and has less ejection   fraction less contractile function than it had  you know when you were 20 and we want to take   it and make it become younger again so how  would we even get the yamanaka factors Into   the Heart secondly how do we know where to  tell it to stop because I don't want to turn   your cardiac myocyte into a stem cell because I  mean that's not going to work out too well how   do I even know it's going to differentiate back  into the cardiac myocyte that we want it to be   so so I I think that there are going to be some  applications for this this type of approach   um you know one obvious example might be with  cartilage you know can we take a person whose   cartilage is you know very much in the phenotype  of an arthritic State and can we you know   using localized therapy try to bring that back  to something that is a more youthful phenotype   again I'm still not convinced that a yamanaka  factor is the way to do this for reasons that   are probably too complicated for for the podcast  um but anyway I could say more about this but I   look I think this is a this is a very long and  interesting topic yeah yeah sure yeah yeah and   in terms of the supplements that you yourself  take I know rapamycin is is is one that you   are taking are there any other supplements that  you're personally taking in this area of of life   extension well I mean you know rap is actually a  drug it's not a supplement so it's um and it's you   know it's important to understand that this is a  very off-label use of of rapamycin and rap immune   and this is not something that we use liberally uh  most of our patients are not taking rapamycin I I   would argue that I'm you know I'm really taking  a leap of faith in in using rapamycin I've been   doing it for five years um but the unfortunate  thing with rapamycin in this situation which is   taking it as a zero protective agent so zero  protective meaning you're taking this not to   Target a specific disease but to Target those  Hallmarks of Aging that I referred to earlier   um the real problem with rapamycin and many  proposed zero protective agents is you don't   have any biomarkers for them and you got to  think like it's really complicated in biology   to take drugs where you don't have biomarkers  you know at least if you're taking something   to lower your lipids you have your lipids to look  at if you're taking something to lower your blood   pressure you can see your blood pressure if  you're taking something to improve your blood   glucose you can measure your blood glucose when  we give people rapamycin when I take it myself   I don't have a biomarker to point to so that's  the challenge with the Hallmarks of Aging is we   don't have great biomarkers for them um and  even things like methylation clocks at this   point seem so noisy so invalidated that they  don't seem to offer any insight meaningfully in   um in predicting what matters most which is  remaining life now I'm actually optimistic   that that's going to change so I do  think that that is the next Frontier is   being able to use epigenetic markings as a way to  come up with a better biomarker for these types   of interventions so that that is something that I  think is going to happen in a lifetime and that's   something I'm very excited about let's turn to uh  the last chapter in your book about mental health   um and as you point out all this effort to  extend our lives and and extend our health   span is not particularly worthwhile  if we're not enjoying our lives right   um and you do something really bold and I  would say generous in your final chapter of the   book which is you share some really significant  challenges you face in your childhood and young   adulthood and talk about how you adapted to those  challenges and the consequences in your adult life   um feel free to share as as little of that  Journey as you'd like or as much but but I   think it's uh I think it's a really inspiring  choice you made to get into your own your own   Journey uh with mental health uh and really  really helpful for readers and listeners   thank you um yeah this is uh of all the things  I write about in the book this is clearly   the area where I have the least professional  expertise I think in the rest of the book I'm   I'm bringing the reader along the journey as  the teacher and I think in the last chapter   I'm bringing the reader along as the student  um you know we didn't spend much time on this   podcast talking about the distinction between  lifespan and health span yeah but I think it's   also intuitive to to The Listener what we mean  by that lifespan is how long you live and that's   where we talk a lot about the horsemen and  the horsemen being a threat to your lifespan   um and of course implicitly we've touched on  healthspan which is the quality of your life   that's you know so much about what we talk about  in the marginal decade and um it's also inevitable   that gravity is working against us in everything  that we've just said right here your risk of dying   is increasing with every passing year regardless  of how much of this stuff you do um if you follow   all of these steps I think you'll live a longer  life but you know maybe it's a decade longer it's   not like you're doubling your lifespan and it's  certainly not that you're going to become immortal the only thing that doesn't have to  decline with age is your emotional   health and I do distinguish this from  mental health right I mean this is   um you know mental health really  is more about the pathology around   you know depression anxiety uh you know mental  mental health diseases like schizophrenia bipolar   disorder things like that personality disorders  but but I think emotional health is a broader   term that encompasses mental health but basically  speaks to pathology and not pathology so everyone   really should have a dashboard of their emotional  health and I think it is the single most important   piece of this whole puzzle and even though it  only gets one out of 17 chapters in the book   um it's it's a it's a very important chapter  because as you said without this nothing else   matters you see there are people who are in a  wheelchair whose mind is sharp as attack and   live a very meaningful life they might not be  able to physically do all the things they could   do before they were in a wheelchair but they  can have a wonderfully Rich meaningful life   and there's conversely many people who have  complete sound mind complete sound body and   they are miserable as hell and their life sucks  and their relationships suck and I would argue I   was one of those people and so in that sense this  is a chapter about how to address that crisis and   why I think it's the best news of all because  as we're kind of all going through this journey   basically just dying because that's what  we're doing I mean we're all just dying   um this is the one thing where we can become  better as we age we can become better people   as we move through life and even as we're  getting weaker and slower and Dumber yeah   and some of your discontent in your early life  was was motivating and drove you right to have   the level of intensity I mean your podcast is  called drive right to have this although it is   in reference to driving like it's the drive  like going for a drive okay okay but you're   not the first person to assume that okay right  right right but it's it's how do you think about   optimal contentment right because when you look  back at your own life your success is inextricably   entwined with your you know childhood and  young adult experience which drove you to   prove yourself and and this kind of extrinsic  extrinsic motivation of approving yourself to   the world now as we get older we we hope to be  more driven by intrinsic motivation and do things   for ourselves and families and communities opposed  to to prove something right but but clearly that   driver was critical to getting you to where you  are how do you think about optimal contentment not sure I I don't um again  I don't look at my past   um as as necessarily a negative thing it is  what it is I think the only regret I have   is that I didn't figure out sooner a way to  extract the positive things from my experiences   from the negative ones right so there are many  adaptations that come from negative experiences   I had a lot of really positive adaptations you  point them out but I had a lot of negative ones   too and I'm only in the last you know five  or six years coming to the point where I'm   now focusing on how to undo those negative ones  and try to preserve some of the positive ones   I wish I could have done that 20 years sooner  uh I wish I could have done that 30 years sooner   there there's a lot of uh there are a lot of dead  bodies in my wake and uh I wish I wish there were   I wish there were none well it's an inspiring  chapter and um and I'm sure we'll we'll be one   of the many parts of your book that that has a  profound large-scale positive impact uh Peter   thank you so much for taking time out of your busy  schedule your workout routine your your thriving   practice and your book tour to be with us uh I  now have a lot of work to do I've got some I got   to fill up my sandbags in my wrecking sack I've  got I gotta gotta hit the trainer at the gym um   and uh I really appreciate uh your time yeah thank  you so much for uh for for making the time to read   the book it was uh it's clear you've spent a lot  of time thinking about it and uh I appreciate it

Channel: Next Big Idea Club

Views: 13,464

Keywords: Peter Attia, attia longevity, book authors interviews, book community, ideas that will change your life, interviews with writers and thinkers, life-changing insights, longevity, longevity diet, next big idea app, next big idea club, next big idea podcast, nonfiction, outlive, peter attia exercise for longevity, podcast, smart talks, transformative ideas, world's great thinkers, peter attia podcast, dr. peter attia, peter attia md

Id: zWPuYERh4Ow

Length: 125min 20sec (7520 seconds)

Published: Thu Jun 22 2023