Feel Better, Live More with Dr Rangan Chatterjee - How To Live A Long & Healthy Life with Dr Peter Attia #389

Episode Date: October 3, 2023

Imagine yourself in the last decade of your life. What would you like to be able to do? I’m talking about the simple stuff, such as walking up a flight of stairs without losing your breath or picking up your grandchild. How about being able to stand up unaided, after sitting comfortably on the floor? Or simply being able to get yourself on and off the toilet with ease? It’s so easy to assume these everyday movements will still be easy when we’re old. But my guest this week wants us to get real to the fact they probably won’t – unless we take action now. Dr Peter Attia is a medical doctor and founder of the Early Medical Practice, a private clinic in America, which helps patients lengthen their lifespan and improve their ‘healthspan’. He is the author of the New York Times bestseller: Outlive: The Science and Art of Longevity. In our first conversation (Ep 356) Peter explained how years of research have shown him that physical activity is the number one predictor of longevity. In this new episode, we unpack what that means and what strategies you can use to live a long and healthy life. Peter explains a concept that he calls the Centenarian Decathlon – a novel, but specific way of thinking about the various forms of movement we might require IF we want to be strong, fit, and active in our later years. He explains you need to be a good generalist with a high peak cardiorespiratory fitness, a wide aerobic base, functional strength, and good levels of stability, and why each of those metrics is important and how we can start improving them. If you’re in your 30s, 40s, 50s, or 60s – then training today for your twilight years might seem too distant a goal to feel motivating. If you’re active now, it’s easy to think you’ll be fine by then. But, Peter says, you’re kidding yourself if you think that your day-to-day function will not decline, as you get older. And, so he wants to empower us and demonstrate what we need to do today, to ensure we will have the life we want later. We also cover resistance training, Zone 2 training, grip strength, and foot strength, training for teenagers, training for women around menopause and so much more. This is an insightful episode, full of practical advice and wisdom. I hope you enjoy listening. Support the podcast and enjoy Ad-Free episodes. Try FREE for 7 days on Apple Podcasts https://apple.co/feelbetterlivemore or via https://fblm.supercast.com. Thanks to our sponsors: https://www.vivobarefoot.com/livemore https://www.calm.com/livemore https://drinkag1.com/livemore Show notes https://drchatterjee.com/389 DISCLAIMER: The content in the podcast and on this webpage is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor or qualified healthcare provider. Never disregard professional medical advice or delay in seeking it because of something you have heard on the podcast or on my website.

You know, if you're listening to this and you're a person who doesn't like exercising, that's fine. But just understand that there's a huge responsibility that comes with living in the modern world. Our ancestors didn't deliberately exercise. If they saw that there were things like gyms and treadmills, they wouldn't fathom what we were doing. But all of this is a construct we've had to create to compensate for the fact that the modern world has taken the need for all movement out of our lives. Hey guys, how you doing? Hope you're having a good week so far. My name is Dr. Rangan Chatterjee, and this is my podcast, Feel Better, Live More. Imagine yourself in the last decade of your life. What would you like to be able to do?

I'm talking about the simple stuff, such as walking up a flight of stairs without feeling breathless or picking up your grandchild. How about being able to stand up unaided after sitting comfortably on the floor? Or simply being able to get yourself on and off the toilet with ease. It's so easy to assume that these everyday movements will still come easily when we're old, but today's guest wants us to get real to the fact that they probably won't, unless we take action now. Dr. Pisa Rattia is a medical doctor and founder of the Early Medical Practice, a private clinic in America which helps patients lengthen their lifespan while simultaneously improving their healthspan. He's also the author of the New York Times bestseller,

Outlive, The Science and Art of Longevity. Now in our first conversation a few months ago, back on episode 356, Peter explained in detail how years of research, observation and analysis have shown him that physical activity is the number one predictor of longevity. And if you've not yet heard that episode, I'd highly recommend you give it a listen at some point. In today's episode, we start off there, and Peter explains a concept that he calls the centenarian decathlon, a novel but specific way of thinking about the various forms of movement we might require if we want to be strong, fit, and active in our later years. Like all decathletes, he explains, you need to be a good generalist. That means having high peak cardiorespiratory fitness, a wide aerobic base,

functional strength, and good levels of stability. He explains in detail why each of those metrics are important and how exactly we can start improving them. Now, I completely understand that if you're listening to this podcast and you're in your 30s, 40s, even your 50s and 60s, then training today for your twilight years might seem too distant a goal to feel motivating. If you're pretty active now, it's easy to think that you'll be fine by then. But Peter says you're kidding yourself if you think that your day-to-day function will not decline as you get older. So he wants to empower us and demonstrate what we need to do today to ensure that we will have the life we want later. We also cover resistance training, zone 2 training, the importance of grip strength and foot strength,

training for teenagers, training for women around the menopause, and so much more. But before we actually get into the conversation though, I want to say a few words about Peter's approach. A few of you, I imagine, may feel that some of his recommendations are unachievable, especially in the context of a busy and hectic life. Please do not let that put you off. It's really important to remember that any movement is better than none, and generally speaking, the more you move, the better. Also, even if you think you are unable to do as much movement as Peter is advocating for, I still think that Peter's framework and ideas have incredible value and will help you think more broadly about the types of exercise you are currently doing

and whether you might benefit from broadening your approach. This really is an insightful episode full of practical advice and wisdom. I thoroughly enjoyed my conversation with Peter. I hope you enjoy listening. So the starting point is exercise is the number one factor for our longevity. exercise is the number one factor for our longevity. Recently, you were asked, I think it was in the Q&A you guys published on your show, that a chap who's playing tennis twice a week and basketball twice a week, is that okay? And I think your answer was, it's probably not optimal. To the person on the street, I believe if they heard that someone was playing tennis twice a week and basketball twice a week, they would be thinking, wow, that guy's crushing it. So I wonder if that's a good way of explaining your model for exercise

and why we need this broad approach to movement. So maybe I'll explain what the centenary decathlon is and then I'll come back and your questions are an interesting one. So the centenary decathlon is a model that we use to anchor the marginal decade. So again, the marginal decade, last decade of your life. So what we want our patients to be able to do is identify, again, in great specificity, physically what they want to be able to do is identify, again, in great specificity, physically what they want to be able to do. And the physical manifestation of your marginal decade, we just describe as your centenary in decathlon. So you might have lots of goals in that marginal decade. They might, you know, you should hopefully have some cognitive goals. Hopefully you have some emotional goals,

goals vis-a-vis relationships. But when it comes to the physical goals, we want you to be very specific. And we start by saying, look, we have a menu of options and we want you to at least be able to identify 10 that you want to be able to do. And again, these are very, very specific. And I think there are some of these that many people would have on their list. And there are others that are unique to individuals. So there are some that are on my list that most people wouldn't care for. Like what would you say? I'm sure most people wouldn't care that, I want to be able to pull a 50 pound bow back. I love archery. So, and currently I draw like a 75 pound bow, but I want to be able to still draw a 50 pound compound bow. I still want to be able to drive a race car to within about 5%

of how fast I can drive it today. You know, Paul Newman up until a few months before his death was still driving at this, you know, almost at his best times. So, you know, those are some really kind of weird esotericals for me. But then I also have much more generic goals that I think make sense. Like I still would want to be able to walk up five flights of stairs uninterrupted. I want to be able to walk down five flights of stairs. Those require very different types of strength and integrity of the musculature. I want to be able to get up off the floor. I want to be able to sit on the floor for 20 minutes and I want to be able to get up on my own power. Again, how often do you see somebody in their 80s that can do that? It's very, very unusual.

You know, I want to be able to pick a child up out of a crib. I want to be able to pick a child up off the floor. So there are many of these other goals that I have. Now, how does one go about doing that? Well, again, I think if you are listening to this, scratching your head a bit, thinking those sound really, really easy. How can those be goals? You probably haven't spent enough time around people in their 80s or 90s. Those are staggering physical feats. So let's think about what decathletes do a decathlete is an athlete who performs 10 different

activities and the decathlete is not the best at any one of those activities right like when it comes to the 110 meter hurdles or the 200 you know yard meter dash you know they're not the fastest but no one is faster at doing all 10 of the things that they do, which encompass both the track and field events. And they're generally regarded as the best athlete in the Olympics. And they train as a generalist, but with great specificity. Yeah. And so I think we have to apply the exact same model to ourselves as we prepare for those events. We have to be great generalists. So we have to have high peak cardiorespiratory fitness, wide aerobic base, high levels of strength, great amount of stability, all of these things.

And we also have to be able to train very specifically to achieve those things. So now let's go back to the question that you asked at the outset. So is playing tennis twice a week and basketball twice a week sufficient to prepare you to be the most robust 85-year-old? you to be the most robust 85 year old? And I said, believe it or not, I don't think the answer is yes. Yeah. Because as wonderful as those sports are, they don't cover all the bases that I just described. They're not building a very wide aerobic base, nor are they building a very high cardiorespiratory peak. Those are both very intermittent sports, start, stop, start, stop. They're interval training and that's great. Interval training is a very efficient way

if you had no other time to get bits of both, the aerobic base, the anaerobic peak. But it's no substitute for having a really wide base and a really high peak. Also, they're not doing a lot for your strength directly. They're not doing a lot for your stability. In fact, they're challenging your stability. So if a person says, I love doing those things, I say, great, keep doing them. If a person says, I want to be able to do those things in my 80s, I say, great, I think that's doable. But you will

need to train to ensure that you have the strength, stability, and the endurance to do those things well. Yeah. It's such a wonderful framework to look at aging. And I like this idea that you specifically get your patients to write down, what are 10 things I want to be able to do in my marginal decades? Now, I've heard you say once that a couple of people will say, I want to be able to do in my marginal decades. Now, I've heard you say once that a couple of people will say, I want to be heli-skiing. Does that person in their 40s, let's say, really want to heli-ski when they're 95? Or is heli-skiing a way of saying, I want to be independent and be able to enjoy the mountains and nature. Whether they do or not, the point is by you knowing that, by them articulating it, it means they can develop a specific program with you

and your team to help them meet that. Oh yeah, completely. And the other thing is these things can be malleable. I mean, if you'd asked me this question 10 years ago, I don't know that there might not be many things that overlapped 10 years ago. Because 10 years ago, I probably would have taken for granted so many things that I don't understand today and they wouldn't have even made the list. And there would have been other activities in the list that aren't as high a priority to me today. So for example, now in my marginal decade, I would be happy to swim, you know, half a mile. I think that's one of my things is to be able to swim half a mile in 20 minutes. How have you, where have you got that from?

Well, you know, swimming used to be very important to me. Yeah. So, you know, again, if you'd asked me this a decade ago, I probably would have wanted to have swum 10 miles. And I would have really over-indexed swimming and being able to swim really, really long distances. Whereas now swimming is much less important to me. So it's mostly just about being able to still enjoy the water. And if it's swimming half a mile now, that would be sufficient. It's, you know, can I tread water? You know, one of the things I have now is can I get out of the pool on my own? Again, without a ladder.

Could I push myself up on a pool deck and get out of a pool? So it's just less focused on the time in the water. But you're right. If you go after heliskiing, and when we have patients that say things like that, I mean, I'm not going to discourage somebody from that, but I'm also going to say like, that's going to require an astronomical amount of strength. And you're going to have to be a lot stronger in five years than you are now to appropriately catch the glide rate down to where you're going to be at that point in time. And by the way, if you miss, if you fall short, you're still going to be able to do a lot of great things. But let's go for it. Yeah. No, I love the approach. You bring a specificity to something that is otherwise vague. I just want to be well while I'm older. Well, what does well

mean? Like well for what? Yeah. That's the thing that I, we really try to get people to understand is no one, no athlete. And you have to think of yourself as an athlete here. No athlete has ever achieved anything great without specificity. I mean, like pick any athlete doing anything today that's exceptional. Do you think they're just out there willynilly going, meh? You think Djokovic is like, yeah, it would be great to win Wimbledon. I'll just play tennis a bit each week. I'll just play a little bit of tennis each week. I mean, no chance. I mean, no chance. And again, we live in a world where sports science has made it really clear as to what it takes to achieve these physical things. So there shouldn't be any difference when you're thinking about the activities you want to be able to do in the final

years of your life. There's a real irony about that sports science, because if I think about humanity as a whole, on one hand, we're now seeing just incredible feats that we've never seen before. Let's say Kipchoge running a marathon in under two hours, something that was deemed physiologically impossible maybe 10, 15 years ago by certain people. It's not possible. The human body will self implode or whatever, right? So he's shown that that's possible. We're seeing world records left, right, and center going down. We're seeing, you know, Premier League footballers playing into their 40s. You know, things that we didn't think was possible.

Yet at the same time, so the elites, it seems are getting the benefits of all the latest sports science and are, you know, pushing new limits, what humans can do. Yet it feels like the baseline of what the population is able to do is going down. And I don't know if you saw this, there was a study recently, I think it was 25

million kids in 28 different countries. They basically observed that I think it's compared to maybe 30 years ago, the average speed it takes a child, and this was between the age of seven and 17, the average speed it takes to do a mile has gone up. Slower, they're 90 seconds longer. They're slower, they're 90 seconds slower. So there's a certain irony there, isn't there? That's a great point.

Two things you said, Peter, which I think are really important. Number one is the point you made about if you think you're going to be okay, you probably haven't spent much time with people in their 70s, 80s, or 90s, or if you're going to be okay without doing anything. And unfortunately, in my own life, there's been a stark realization this year. I won't go into all the details, but my mum, who lives five minutes away from me, Christmas day evening, she'd had a fall. She got admitted to hospital. She was in for three weeks. There wasn't enough sat to take it out of bed. I'd go in and do my own rehab. I know how quickly one can decondition.

bed. I'd go in and do my own rehab. I know how quickly one can decondition. And unfortunately, since mum came home three weeks after being in hospital, she has not been the same. She has not recovered to anywhere near her baseline. So first point I wanted to address was, if you haven't seen it, you may not take it as seriously as it needs to be taken. And then the other point related to that, and I kept this page open in your book, it's in the chapter on Training 101. But the graph that you have pulled from the Jason Clifford and Brigham Young University, I spend so much time looking at that graph. I think everyone should look at it. This is figure 11. Figure 11.

Yeah. This is the VO2 max decline. It is utterly remarkable. The central point I get from you is that decline is inevitable in your physicality. It's going to happen. You've said before that we understand at what rate it is likely to happen. And I think it's genius this way that you go, if you want to do that in your 90s or your 80s, whatever that point is, you have to account for the decline. And therefore, you have to be able to do some specific things in your 40s. Now, many people who listen to this show, Peter, do parkrun, community events every Saturday where you run or, 5K. Right. So I don't know if you're up for a little experiment here, but this graph basically has, well, maybe do you want to explain the graph? Because you're probably

better at doing it than me. Sure. Yeah. So the graph, it shows, I could probably do it from memory, but it shows three lines. So these lines are placed on against an X and Y axis. So the X axis is your age, and it's obviously increasing to the right. And the Y axis shows the VO2 max. Now, I can't remember how much we discussed VO2 max on the first. We didn't. So let me explain this first. So VO2 max stands for maximum ventilation of oxygen. So what is ventilation rate or minute ventilation rate of oxygen? It means how much oxygen you're using at any point in time.

So ventilation rate is defined in liters per minute. in time. So ventilation rate is defined in liters per minute. And you and I sitting here right now having this discussion are probably at 0.3, 0.4 liters per minute, maybe 0.5 liters per minute because we're a little animated in how we're speaking, right? So we're at 500 cc per minute of oxygen consumption. If we were to stand up and walk around this room, that would maybe increase to one liter per minute. If we were to go outside there and jog back and forth, that would increase to two and a half liters per minute. And eventually, if we kept forcing ourselves to exercise at ever increasing pace and demand, we would reach a maximum. And that can be tested for in a laboratory. So it's done either on a bicycle or on a treadmill,

stationary, because you have to have a mask put over your face and the mask is what is able to measure the amount of oxygen you're consuming. And this is one of the more important tests that's done by elite endurance athletes. And so if you talk about the most elite endurance athletes, they're typically going to be cyclists, cross-country skiers, runners. And so whether it's Kipchoge or Taddy Pogacar, these people have astronomical VO2 maxes. So the higher it is, the fitter you are. This is your peak aerobic capacity. It's normalized by weight. So ultimately the numbers that you're used to seeing are reported as a number, say 50, and it's converted into milliliters. So 50 milliliters per minute per kilogram. Okay. So the higher that number, the fitter you are. And so,

you know, we have tables that tell us, and I think I put one of those in here, that tell you by sex and by age where you rank by percentile. Now this graph is showing something different. It's showing people in the top, I think 5%, the middle of the pack, so the median or the 50th percentile, and the bottom 5%. And it's showing over time how those three lines decline. They all decline. They all decline. That's the key, isn't it? In fact, the rate of decline is actually steeper for the fittest people because they're starting at the highest point. But even though it's steeper, they still have- They always remain higher.

They remain higher. That's right. So you always want to be on the top line. What this graph also does that I find interesting, and the reason I included it in the book, is it shows various activity levels and what they correspond to in terms of a given VO2 max so that you can observe when various people cross over. So at this point, I've lost my ability to memorize it. So I'll just kind of turn to the graph. So for example, briskly climbing stairs requires a VO2 max of approximately 32 milliliters

per kilogram per minute. It doesn't matter your age, right? If you want to go briskly upstairs, whether you're at 30 or 90, you require. You need to be at about 32 milliliters of oxygen per kilogram of body weight per minute. Okay. Now, here's what's interesting.

People in the 50th percentile of the population at the age of 25 have a VO2 max of about 44. So they can do that pretty easily. By the time they reach 50, they've descended to that level. So a person who is my age, who's 50, at the middle of the population's fitness level is just at the point where they're going to lose the ability to briskly climb a flight of stairs. And it's only going to go down from there. Now, interestingly, someone in the bottom 5%, even at the age of 25, is below that level. Wow. Okay. Now let's look at someone in the top 5%. Someone in the top 5%, who, by the way, at the age of 25 is at about 62. In terms of that VAC? In terms of their VO2 max. They don't hit that level of being right at their threshold until they're 75.

So one of the things about this graph that I find interesting is it stops at 75. So one of the things about this graph that I find interesting is it stops at 75. So one of the reasons we show this graph to our patients is to say, oh, and by the way, the reason we hold you to a higher standard than this graph, we hold our patients to a standard of being, it's aspirational, but this is what we want everyone to be at. We want everyone to be at the top 5% for someone 10 to 20 years younger. And the reason for that is we want you to actually be able to thrive into your final decade of life. And you have said, Peter, before, there is no reason that most people cannot be in the top 25%. Absolutely not.

There is simply, I mean, you would have to have a mitochondrial disease to not be able to reach the top 25% of your age. So this is really empowering, I think, for people that no matter how old you are, of course, the earlier the better, you want to give yourself buffer room. So let me just summarize to make sure I've got it right,

make sure everyone's following along, that essentially your VO2 max is a super important metric. It is going to get worse as you age in a relatively predictable fashion. Therefore, if you want to be doing something like briskly walking upstairs in your 80s, we know what VO2 mats you need in your 80s, and therefore we can say what VO2 mats you need today. And it's such a logical and beautifully simple way of looking at it, and it makes it very, very tangible. The reason I brought up parkrun, Peter, is because one of the things it talks about in this graph is jog six miles per hour on flat ground. Right. So six miles per hour is roughly 10 minute mile pace. Right. A 5k, so a parkrun. For anyone who does parkrun, I appreciate some people walk, but that is

roughly a half an hour parkrun. I think a lot of people, I know a lot of people my age or 10 years older who are in great shape, but they can do a 30 minute 5k, right? So what's really interesting to me is that, I mean, it's just, it's brutal, this graph. It's utterly brutal, this graph. It's utterly brutal, right? If you are about 37 years old, right? Give or take a year. I haven't got exact lines going down. So if you're 37 years old, you can barely walk up a very gentle hill at three miles per hour. Yeah. If at 37, your limit is just being able to run that 30 minute park run, at 75, you're going to have a very difficult time getting around. So in other words, at 37, you need to be hammering through that park run. You need to be running it in 21 or 22 minutes if you want to make sure that when you're 85, you have no physical impediment.

I mean, the way I describe it to patients is I'm not so deluded to think that at 80, I'm going to be doing what I am today. But what I want to know that I can do when I'm 80 is take a train through Europe and take my own luggage with me. And I pay attention to what that means now. I pay attention to how quickly I sometimes need to move through a train station with my luggage. And even now I know like, like you have to hustle sometimes. So like, now it's not the limit of my ability today,

but if I'm banking on that being the limit of my ability when I'm 80, I know what level of fitness I have to have when I'm banking on that being the limit of my ability when I'm 80, I know what level of fitness I have to have when I'm 50. Yeah. And it's way higher. It's way higher. The decline is inevitable. So you need to give yourself buffer room.

And again, just to be clear, look, I get not everyone's a runner, right? So it's not that you have to do a 30 minute 5K or be some equivalent version, whether it's. Yeah. I'm not, I'm not a runner either. So, but it can be other things. So I do most of my cardio training on a bike or on a treadmill or, and if on a treadmill, I do it on a steep incline or on a stair climber. Yeah. And I've just decided like, and I still go back and forth. Sometimes I want to get back into running cause I used to be a runner, but I'm like, you know what? I'm not going to do it. I'm going to save my joints. I'm going to let

it go. But there are lots of things that I still need to be able to do on my feet. Just taking a quick break to give a shout out to AG1, one of the sponsors of today's show. Now, if you're looking for something at this time of year to kickstart your health, I'd highly recommend that you consider AG1. AG1 has been in my own life for over five years now. It's a science-driven daily health drink with over 70 essential nutrients to support your overall health. It contains vitamin C and zinc, which helps support a healthy immune system, something that is really important, especially at this time of year. It also contains prebiotics and digestive enzymes that help support your gut health. All of this goodness comes in one

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five free travel packs to 10. And these packs are perfect for keeping in your backpack, office, or car. If you want to take advantage of this limited time offer, all you have to do is go to drinkag1.com forward slash live more. That's drinkag1.com forward slash live more. I love being outdoors. So I ruck a lot. And that's a great way for me to add the conditioning element. And for people who've never heard that term ruck, would you mind explaining it? So it's walking with a very heavy weighted backpack. So I walk all over our neighborhood, which because I live in Austin, it's all hills. So it's up and down very steep hills with a weighted backpack. And depending, you know, sometimes I will go with 60 pounds, which is normally what I do. And there are other days when I really want to push it,

I'll do a hundred pounds. And that, you know, I'm walking, but it's still the most taxing thing you can imagine when you're carrying that much weight to walk up a hill that's 15% grade with more than half your body weight on your back. So you don't have to be a runner, I think is the point to test this system. And the other thing that is important to understand is it does all at the end of the day come down to what you can do on your feet. So being able to walk on an uneven surface, being able to walk up a hill, those will become the rate limiting steps as you age. I want to go back to something you said earlier, and I'm sorry to hear this news about your mom, but it actually is a sad illustration of a very important point. Now, I write in the book about the fact that the mortality from a fall, if you're over the age of 65 and break your hip or femur, is as high as 30% at one year. And most people, myself included, when I first learned of this literature, because I did a whole AMA on this topic. And initially,

when the analysts, because I have a team of analysts that helps me with everything, initially, when they were pulling this literature, I was like, guys, come on, this is nonsense. Use your logic here. There's no chance the mortality can be that high. And they kept showing me paper after paper after paper. And this is often the case. The analysts just keep showing me data and I'm not willing to believe it. And I'm like, guys, come on, you're being stupid here. Like, yeah, I love that. Use your logic guys. It's like, wait a minute. Yeah. And it's like, oh, they're actually right. You know? So, you know, it's like, I would say a very conservative bracket is 15 to 30% of people, once they reach the age of 65, if they fall and break a femur or hip, they're not going to be alive in a year. But here's a stat that I didn't include in the

book and I wish I did because it's just as important. Of the 70 to 85% who are not dead in a year, 50% of them will have a complete reduction in level of function by one measure of unit. So for example, if they used to walk freely, they will now require a cane for the rest of their life. If they used to require a cane, they will require a walker. If they used to require a walker, they will be in a wheelchair. So in other words, there's a huge cost to this. And there's actually another graph in there that I think is very sobering, which shows the mortality associated with accidental death by decade. And appropriately so, we in the US are very fixated on accidental death due to opioid. Because this last year was the first year that that number of deaths eclipsed 100,000 in the US. So it's a staggering number. I believe it was 106,000 people died in the US last year due to opioid

poisoning. But at a population adjusted basis, that's nothing compared to what falls due to people over 75. And that's the graph I have in there, which shows deaths normalized per population basis. And all other forms of accidental deaths, of which the other two big ones are overdose and auto death, they're completely dwarfed by deaths associated with falling. So yes, the point here is most people in their 40s, in their 50s, I mean, it just wouldn't even occur to us that you could fall, let alone that a fall could be the end of your life, either in that moment or much more commonly in the coming year. Yeah, it's incredibly sobering hearing that.

Of course, I've seen that firsthand with my mum, a demonstration of that, this idea that, well, if it's what we've just been talking about, even though we may be talking about strength per se now, or a mixture of strength and stability, I guess, the principle of the VO2 mats declining, it's the same kind of thing, right? We're going to decline. And it is. It's strength and it's stability. And it's, same kind of thing right we're going to decline and and it is it's the it's strength and it's stability and it's um you know the point we're going to decline so we need the buffer room so that if we do fall and break our hip when we're 65 we don't want to be in that 30 percent bucket we don't want to be in the other 50 percent bucket of the ones who yeah are not dead right we want to be in the other bucket where we are i don't want to be in the other 50% bucket of the ones who are not dead, right? We want to be in the other bucket where we are, I don't know what percentage that is, where you get back to

your pre-fall baseline. That's what we want. And to do that, we need to build a buffer, right? So you have these four pillars of exercise or movement when it comes to being that generalist who's able to do the things that they want to do in their marginal decades. So you have strength, you have zone 2 cardio, you have VO2 max, and you have stability. And I really want to make sure we make this as practical as possible for people. But I wonder if it's worth just giving the broad overview at the moment of these four pillars. And I don't know if we can say this or not, but what percentage of time perhaps we should be allocating? We should allocate to each one? Yeah, so you've got it right.

Those are the four pillars. I will say that we have the most data, the most clarity around two of them, strength and VO2 max. So the data for strength and VO2 max are undeniable, meaning we just have so much epidemiology that is so uniform in its direction, so strong in its signal that, and I go through this at great length in the book because I want the reader to understand the difference between good epidemiology, according to the criteria of Austin Bradford Hill, and weak epidemiology. For example, what we see in nutrition, where the epidemiology has a very difficult time parsing signal from noise. But in exercise, that's not the case. And I go through

all of the criteria why. So when the epidemiology says having a very high VO2 max leads to a longer life, I mean, it's crystal clear. And by the way, we haven't mentioned that, so it's worth mentioning that. So everything we've talked about so far vis-a-vis VO2 max has been in the context of quality of life, which for most people matters more than length of life, but it should be noted that a high VO2 max is associated with a lower all-cause mortality

to a greater extent than any other health metric, including not smoking, not having high blood pressure, not having coronary artery disease, not having end-stage renal disease. None of those compare to the harm that they bring bring more than being unfit does. So the association, the hazard ratio for being in the top 2% of VO2 max compared to the bottom 25% is a hazard ratio of over 5. I mean, it's just, it's a staggering. It's almost as staggering when you consider having high strength. High strength to low strength is almost as potent. It's a hazard ratio of over three. And for people who don't know hazard ratio, Peter explained it in depth in our first conversation.

Yeah, yeah. So, okay. So let's talk about these things. Why is strength so important? Why is stability so important? And stability, by the way, there's a whole chapter on it because it is the most foreign

concept of those four. So it warranted the exercise component or section of this book is three chapters, but stability is by itself one of them. Stability basically is the capacity to transmit force from the body to the outside world and vice versa, stably and without injury would be the easiest way to explain that. So every time you're taking a step, you're transmitting a force to the ground. That's what propels you forward. But a force is being transmitted in the equal and opposite direction back to you. So what prevents your knee and hip

and back from hurting? It's stability. What allows you to do that efficiently is stability. So typically when an elderly person falls, it's due to a lack of strength and stability. Stability is, for example, what allows the foot to maintain balance. If you think about it and watch yourself in the mirror, if you're doing an exercise standing on one leg, let's say you're doing a single leg RDL or something like that. You'll notice that that foot is twitching like crazy to try to preserve balance. An RDL, Romanian deadlift,

for anyone who's not familiar with that. Yeah, but look, stand in front of a mirror and stand on one leg and watch your foot. Watch what it needs to do. And we think of that as balance, but balance is kind of like the readout state for stability. Yeah. Most people probably have heard of different types of muscle fibers, fast twitch muscle fibers and slow twitch muscle fibers. Well, the fast twitch muscle fibers, the type two muscle fibers, are the muscle fibers that give us power.

fibers are the muscle fibers that give us power. The slow twitch muscle fibers are the ones, and I'm oversimplifying a little bit, but they're the ones that kind of give us more endurance. So you can have strength in both of these fibers, but the explosive power comes in the type two muscle fiber. Well, that is the hallmark of aging is the atrophy of that type two muscle fiber. So hold on, Peter. So when we hear about fast twitch, some of us will go to, yeah, if I want to be a hundred meter sprinter, that's what I need. What's the relevance of that to when I'm 80 years old? Because when you're 80 years old,

if you lose your footing slightly and you, let's just say you're stepping off a curb and you lose let's just say you're stepping off a curb and you lose your footing, you need to be able to react with enormous force. And that's those fast twitch. The term fast twitch and slow twitch is unfortunately a little bit misleading. While it is completely true

that fast twitch fibers twitch faster, it really means, and the real reason we use the terminology is they are fast to fatigue because they are much more powerful. So a better way to think about it is you have high power, fast fatiguing fibers, and you have lower power, very slow to fatigue fibers. And unfortunately, as we age, we lose the former. And so much of the injury we see in people as they age is the direct result of the atrophy of that powerful, fast-to-fatigue muscle fiber. Now, if you train it, you can maintain it. Now, you'll never maintain, no 80-year-old is going to walk around with the volume of fast twitch muscle fibers that a fit 30-year-old has.

That's not going to happen. But a well-trained 80-year-old can still have the fast twitch muscle fibers of a 60-year-old. And that's what we want to have. We want to know that we still maintain some power in those muscle fibers. And that's why, for example, lifting heavy weights is essential for everyone at every age, be it men or women. So again, one of the big misconceptions is women don't need to lift weights. That's completely incorrect. One of the misconceptions is as you get older, you shouldn't be lifting weights. I mean, this is a complete misconception. So strength training is imperative for people as they age. And not only does it have an enormous impact on bone mineral density, but it has this enormous impact on these type two muscle fibers. We were talking about fast twitch and sprinters.

I just want to clarify, when you're lifting weights, does it need to be done with speed in order to really help that fast twitch fiber? Or does simply lifting a heavy weight slowly also count as a stimulus for that particular fiber? It still does. It doesn't have to be lifted quickly. So it really comes down to the weight. So you have to lift a heavy enough weight that the type two muscle fiber gets recruited. And if the weight isn't heavy enough, the muscle will simply recruit the slow twitch fibers to do the work. Yeah. If we just zoom out for a moment and think about a lot of the centenarians that we see being interviewed,

and of course that's not a scientific study, this is just observations of humans in blue zones or wherever it might be. What strikes me as very interesting is that very few of them were trying to work on their longevity, from what I can tell, right? It doesn't mean we shouldn't be. It also is pretty obvious that most of those people are living in environments whereby a lot of the things that you write about were being automatically covered. Let's say, I don't know, a farmer in Sardinia still herding goats in his 80s, right? Well, he's kind of going up hills a lot, walking, VO2 max, probably lifting things around.

I think it's always good to zoom out and go, okay, these guys weren't measuring every metric. They weren't looking at these decline graphs. I feel, and I wonder what you feel about this, is that because of the way many of us now live, we kind of need these frameworks to help us achieve what these guys are doing naturally. Yeah. Would you see it differently? No, I see it exactly that way. Do you remember in like the original Spider-Man story, you've got Peter Parker when, you know, when he, when his uncle Ben gets shot and, you know, right before that, his uncle says to him something, which is, you know, Peter with great power comes great

responsibility. And I kind of always have that in the back of my mind when I think about modernity. Do I like the fact that it's 2023 right now? Or is there any reason I'd want to go back to 1923 or 1823 if you gave me a time machine? The answer is zero chance. There's no chance I'd want to go back to 1923 or 1823 or 1723. So in other words, I fully buy the beauty of the modern world we live in. It's not perfect, but it's better than the world 100 years ago, 200 years ago, and 300 years ago. But it comes at a cost. Like everything. And we have to be very mindful of that cost. And by the way, I think that exercise and nutrition are probably the two greatest examples of where we pay that price. So, you know, we spent hundreds of millions of years evolving, depending on which form of

ours you're considering, but even if you consider just homo sapiens, right? Like just think of the last hundreds of thousands of years of evolution. What really gave us our superpower to leapfrog ahead of all these other species was our brain. And what enabled us to have a brain that was so energy demanding was the capacity to store energy. So in some ways, the human superpower from an energetic standpoint is the capacity for energy storage. We are very efficient at energy storage. very efficient at energy storage. That served us incredibly well until relatively recently. When energy became so abundant, energy, of course, in the form of food,

that superpower became a detriment. And now most people, certainly in the developed world, are overnourished and we're on the wrong side of the energetic curve. Yeah. Does that mean that we should all aspire to be hunter-gatherers again where we don't know where our next meal is going to come from? No, it just means we have to understand that with this great privilege came a responsibility. The same is true with movement. Our ancestors didn't deliberately exercise. If they saw that there were things like gyms and treadmills, they wouldn't fathom what we were doing.

But all of this is a construct we've had to create to compensate for the fact that the modern world has taken the need for all movement out of our lives. So we have to go above and beyond. So, so maybe if, if, you know, if you're listening to this and you're a person who doesn't like exercising, that's fine, but just understand that there's a huge responsibility that comes with living in the modern world to yourself. Yeah. And even though, you know, your ancestors, five generations back, wouldn't exercise, they didn't need to.

They didn't need to. Because of what they were doing. Yeah, and also, I mean, I love that line of thinking, because it also means, I think, yes, we need to take responsibility as much as we can within our means, within our, you know, what's possible in our environments. But I often say to patients, if your great grandparents were here today in this food environment, you know, we'd probably find 78% of them would also be overweight and obese.

It's not a moral failing. No, not at all. It was your superpower in a different environment. Now it's your Achilles heel. So it's definitely worth considering. And even this laziness to exercise. We've always kind of been lazy. We've always tried to conserve energy. One of my dreams is to go to a tribe. I wouldn't say it's a dream. Thought experiment with a treadmill.

I just wonder what they would think about. You're on a treadmill for an hour. You're not even going anywhere. What are you doing? It's such a ridiculous concept. And it's been done. I mean, anthropologists today, there are still a handful of remaining of hunter-gatherer tribes out there. And everything I have read says that they are in prime energy

conserving mode. So when they are not hunting or gathering or moving with deliberate purpose, they're conserving energy as much as possible. They're not, they're, you know, in fact, I think Herman Ponser wrote about this. I was going to say, in Burn, he writes about this. Yeah. And their total body energy expenditure is quite low. Yeah, it's really fascinating. So let's go back to these four pillars then, okay? So if we want to be well in our marginal decade, and we're thinking about exercise,

we need to think about four components. VO2 max, strength, zone two cardio and stability. We've touched on VO2 max, we've touched on strength. Before we move on from strength, you're talking about lifting heavy weights. So I guess I have two questions. One is, what qualifies as strength? The reason I ask that question is because, let's say you're a runner, right? And I personally think running's fantastic. It's a very innate human movement. You're interacting with the ground, you're putting load through your joints, through your tendons. If you're doing hills, that is a form of strength training for your legs, right? So if you're a runner, and yes, this is lower body, not upper body, if you do hill repeats regularly, does that qualify as strength training?

Probably not, because it's still a high enough number of reps that it's not hitting the type two muscle fibers. Okay. As evidenced, and by the way, even when i'm walking up a hill with a hundred pounds on my back up a 15 grade i'm still doing so many reps that i'm mostly fatiguing my type one fibers okay so even though it's you moving your body weight against gravity which is a form of weight yep it doesn't quite meet the threshold for working on that particular type two fiber that we are going to need when we're 70 or 80 stepping off a curb. Right. So a better example would be doing a box step up with weight in your hands. So getting a box and stepping up on it. Getting a box, stepping up onto it, up and

down, up and down, holding weight in your hands. And if you did that such that you could, you were literally, so we typically talk about doing these sets until you're at one to two reps in reserve. So you don't have to go to failure when you're lifting, but you want to go until you could only do one or two more reps and that would be failure. And if you're loaded to the point where you're getting eight to 20 reps in, but meeting that criteria, you're one to two reps in reserve at the most, by definition, you're now recruiting type two muscle fibers. You've fatigued all the way through the type one and your type two. And as a runner, you'll appreciate the difference in what that burn feels like versus the burn of running hill repeats. Again, there's a lot of benefit in

running hill repeats. And you're taxing your VO2 max and you're doing a whole bunch of other things. And by the way, as a runner, you'll benefit from the strength that comes from those box climbs. Okay. Fascinating. So that was one component. So hill repeats doesn't count. You're looking at something that's just one or two short of your maximum, which I think is very helpful, very, very specific for people. And again, in terms of making this accessible to people, in terms of making this accessible to people, that's a relatively, you know, a box step up, you know, it's kind of most people have access to that, right? Yeah. When it comes to lifting weights, especially if you're just starting out, I mean, the amount of equipment you need, you can do this at any hotel, you can do this at any, it doesn't have to be a super fancy gym,

you know, carrying dumbbells, doing what's called a farmer's carry, such an important form of activity, both for your grip. So most people will find when they initially do this, and we have standards for our patients when it comes to these types of exercises, whether it be box step-ups, farmer's carry. For example, for a woman, we want her ultimately, and we index this by decade, but say a woman in her 40s should be able to carry 75% of her body weight in her hands for a minute. So if she weighs 100 pounds, she should be able to carry 75 pounds, 37 and a half in each hand for a minute. And if she can do that, if she can, if she can, then she's been what it means that we are very

confident that by the time she's in her last decade, she will have the strength to open a jar. For example, do the types of things that we think really matter to people. Yeah. I love that. It's really specific because anyone, any female. Do the types of things that we think really matter to people. Yeah. I love that. It's really specific because anyone, any female listening to the show right now can actually go and check that themselves. See what am I able to carry? Now, if they cannot, let's say they go, okay, this sounds great. Oh, wow. I can only do 20% or 30%. Or I can only carry it for 20 seconds and then my grip fades out. Yeah. So what's the advice then? It means drop the weight. So say go to half your body weight until you can get to a minute. Go find a weight that you can get to a minute and then slowly advance the weight. That's brilliant.

Really, really practical. And for a man? It's your body weight for a minute. At what age again? In your fifth decade. So between the age of 40 and 50. So for example, if the man weighs 180 pounds, he should be able to hold 90 pounds in each hand and walk for a minute. Yeah, I love that. And again, a lot of people will not be able

to do that out of the gate. That's fine. Drop it down. Go to 70% of your body weight. Go to 50% of your body weight. It's interesting. A lot of people get put off strength training. They think it's, A, they may never have done it as a kid. They may be intimidated by gyms. They may not know what to do and think, oh man, I can't afford a personal trainer. I don't know what I'm doing. The farmer's carry is kind of something, I guess you've got to be mindful that you're not sticking your head out, that you've got a decent

alignment. And yes, you probably need some body awareness, but it's quite an accessible thing that people could try themselves, I think. Yeah, for sure. And I can't remember if we included the farmer's carry in the video for the book, but there are, there's a, there are a series of videos we made to go with the book. It's on your website, right? Yeah. Yeah. So, so it's, we, there's probably at least-

We'll try and link them in the show notes. Yeah, there's at least half a dozen of the exercises, including the step up where we show the correct form, because you're right. You can, you can cheat. You can do these things incorrectly. There's a lot of ways to do do this and we always have people start these things with just body weight for example in the step up you know before they move to any weight staying on strength let's talk about grip strength and foot strength the extremities of our body why are they so important maybe there's a lot of data on grip strength, but what's fascinating for me, and you'll explain the data I'm sure on grip strength, but that might indicate to someone,

I need to get my grip stronger. So I'm going to buy those little grip squeezes and just get really, really strong grip strength, which I'm not entirely convinced it's going to do what we want it to do. So maybe expand out on that if you can. Yeah. So I think the same reason that VO2 max is such a remarkable proxy for lifespan and healthspan is why grip strength always seems to be a remarkable proxy for both as well. always seems to be a remarkable proxy for both as well. And it comes down to what they are indicators of, or what I like to describe as integrals of. So you know how a hemoglobin A1c is, at least in theory, supposed to be an integral or summation of what your blood glucose has been like over the past three months.

Similarly, a very high VO2 max is an integral of very hard training for a long period of time. If you took an unfit person and said, I want you to train really hard for a week, they're not going to have a high VO2 max in a week. In fact, if you took a person at the bottom fifth percentile and had them exercise for three months, they're not going to get to the top fifth percentile. That's why a person at the top 5% of VO2 max, you can tell has years of training. That's what it's telling you. So it's such a good predictor of lifespan because it's reflecting so much more than we can ever get

out of a questionnaire. Tell me how much you exercise a week and how strenuous it is. Who cares? All those inputs are reflected in that number. And it can't be hidden. It can't be masked. It can't be cheated. The same is true with grip strength. Grip strength is an integral for overall strength. You can't be very strong without having a strong grip.

So think about being in a gym and lifting weights. You're always using your hands. I'm here in London right now. We're at a hotel. I was deadlifting yesterday and I sometimes bring liquid chalk with me because if you're at a gym and they don't like you to use chalk, you have this liquid chalk and I forgot to bring my liquid chalk. And so I had to deadlift without chalk yesterday. And it's just a stark reminder of how I become grip limited when I'm deadlifting. In other words, like I was failing because I couldn't even hold the bar anymore. So I actually ended up dropping the bar at some point,

not because my glutes and my quads and my legs were- Because that was a limiting factor. I was limited by my grip. And you start to realize so much of what I'm doing in the gym is driven by my grip strength. When I'm doing a pull-up, if my grip is failing, I'm failing. And that's why farmer's carry, of course, is such a good functional exercise. That's right. You're using your grip so often when you are strength training. And so it's true that it's an easy thing to measure. And that's also true of VO2 max. It's objective, scientifically measurable, reproducible. You can measure it here in London. You can measure it in San Francisco. You can

measure it in Delhi. It doesn't matter where you are. You can always measure this. Same is true with grip strength, leg extension, chest press. I mean, these are the things that they typically measure, but you're always gonna see the studies talk about grip strength. And I agree with you completely. It's a bit misleading because people think,

great, I just need to go get a little squeezer thing. And it's like, no, definitely don't get a little squeezer thing. And it's like, no, definitely don't get a little squeezer thing. Go pick heavy things up and walk around. Yeah, there's something about that, the extremities, isn't it? That's how we interact and carry things, but our feet are how we interact and-

That's the, these are, the hands and the feet are the force transmission to the outside. Yeah, and my, I was gonna say bias, but yeah, I was trying to be aware of my own biases. I personally have been wearing minimalist shoes for over 10 years now. They've been transformative for me. I've recommended them to so many patients over the years, not everyone, but many of them. And I've heard and seen so many improvements. Now, again, you've got to be careful. I'm not talking about going from wearing cushion shoes your entire life to suddenly trying

to run marathons in minimalist shoes. No, no. Let's be logical. Let's be rational about this. But I wonder what your perspective is on foot strength, how it relates to what you just said about grip strength and potentially where minimalist and barefoot shoes may fit into this part of the conversation. Yeah. I mean, I have the luxury of kind of, because I work out at home, I work out barefoot. Me too. So I do really enjoy being barefoot as much as possible. And I think that, look, the feet are very similar to the hands in terms of musculature. What I think most people would appreciate is we have much more dexterity with our hands than we do with our feet. And a part of that is the fact that our hands are never really restricted the way our feet are. So when we're in tight fitting shoes constantly,

so in other words, it's not just being in a minimalist versus a non-minimalist shoe, it's kind of like having your toes jammed together. Pointed toes. Yeah, you know, 12 hours a day, that creates for a difficulty in using the foot the way it was kind of meant to be used. So for people who have kids, look at your kids' feet. Yeah. You see what happens. Yeah. So anyway, long and new way of saying, I completely agree. I do think that the shoe

industry has kind of probably gone to a place where we're not making healthy feet. And many people, myself included, have had to spend a lot of time undoing the damage of wearing shoes too often and very tight shoes. And, you know, interesting, there was a study done at the University of Liverpool a couple of years ago. And to be fair, this study was done wearing Vivo Barefoot shoes. And to be completely transparent, they are one of the University of Liverpool a couple of years ago. And to be fair, this study was done wearing Vivo barefoot shoes. And to be completely transparent, they are one of the supporters of this show. And it was making clear that I was buying them with my own money for seven years before they started sponsoring the show. That being said, that study showed that

adults who were wearing these minimalist shoes over four to six months for just regular activities, going to work, going to the shops, going for a walk, not for running or not for going to the gym, just for getting on with their day, I think from recollection, the foot strength went up by over 60%, which I find remarkable because you're not actively trying to get a foot workout in, you're just wearing something that allows your feet, that results in your feet having to do more work than when they're completely cushioned, which is pretty incredible. So strength, I just wanted to, before we move on from strength, just touch on females. There are some unique pressures on women, especially postmenopausally. And so I just

want to speak to that. When we're talking about strength training, yes, it's very important for both men and women, but are there particular reasons in your view why women need to pay special attention? Before we get back to this week's episode, I just wanted to let you know that I am doing my very first national UK theatre tour. I am planning a really special evening where I share how you can break free from the habits that are holding you back and make meaningful changes in your life that truly last. It is called the Thrive Tour. Be the architect of your health and happiness. So many people tell me that health feels really complicated, but it really doesn't need to be. In my live event, I'm going to simplify health,

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of anxiety and depression. It's also been shown to decrease emotional stress, make it easier to turn new behaviours into long-term habits and improve our relationships. There are, of course, many different ways to journal. And as with most things, it's important that you find the method that works best for you. One method that you may want to consider is the one that I outline in the three-question journal. In it, you will find a really simple and structured way of answering the three most impactful questions

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all you have to do is go to drchatterjee.com forward slash journal or click on the link in your podcast app. In part, I mean, there are several, but in part, I think on average, women come in, for example, to our practice or in middle adult, middle age, they've done less strength training than men. Of course, we use nomograms that are sex specific. So when we're looking at metrics of muscle mass, we use something called appendicular lean mass index and fat-free mass index. So those are going to be normalized to age and sex.

But, you know, women are often coming in having done less strength training. So they're going to have less muscle mass. Is that a problem? Yes. Yeah. Strength and muscle mass are positively associated with lifespan and healthspan for men and women equally. And there's a big step up once you're at the 75th percentile. So in other words, the top 25% compared to the bottom 25% for muscle mass is a pretty significant difference in terms of risk of all-cause mortality. Okay. So let's just imagine two scenarios here. A teenage girl, or there's a parent listening, and they're concerned about their daughter, let's say, maybe their son as well, who's a teenager.

We've spoken a lot about the decline that happens in your 30s and your 40s. Are there things we can and should be doing with our children, with teenagers to insulate them even more from this decline? Absolutely. And I'm glad you brought that up bone mineral density has a strong genetic component. However, you achieve your genetic ceiling or your genetic potential by your early 20s. And so if you think about the implications of that, it means that people who are not doing the types of activities, and again, people who are not doing the types of activities, and again, strength training is the most important activity on the list. If you're not lifting weights as a teenager into your 20s,

you're not gonna achieve your genetic ceiling. And everybody, both men and women, are in a state of decline for bone mineral density from your early to mid 20s on for the rest of your life. So if you're before that, if you're listening right now and you're a teenager, or if it's a parent, we should be doing whatever we can to encourage our children or yourself if you're that teenager to be lifting heavy weights until at least 22, 23. Well, beyond. Beyond, but there's this beautiful window in which you can capture your genetic potential.

And again, everybody, male and female, will start to decline from about the mid-20s onward. Women have a much more precipitous decline at menopause if they don't go on hormone replacement therapy. So estrogen is the most important hormone in bone health for both men and women, and women lose their estrogen precipitously at about the age of 50 if they don't go on HRT.

So in that sense, women are more susceptible and it's not uncommon to see women at the transition to menopause who haven't been lifting weights, even if they've been very fit and they've been exercising, they show up with osteopenia. And I mean, we see this too often. Two things to comment on there. One is that makes me feel better about some of the disagreements my wife and I often have. If a new kettlebell delivery has come at home and I have them lying around and the kids

are picking them up and playing with them. And my wife's like, no, no, put it down. You'll hurt yourself. I'm like, hey, let them pick it up, right? Of course, there's injuries to consider. You got to be safe. I just think, you know what? Kind of let them do it and pick it up. It's funny you say that. I mean, my two boys who are, one just turned six, the other is eight, they've really become interested in coming in the gym with me in the past year. And I've just started them doing kettlebell lifts. So it's a deadlift basically with a kettlebell. So they're standing over a kettlebell and, you know, at first I just had them doing it with the lightest kettlebells

and they were really getting annoyed and they really wanted to start lifting heavy things. So I said, okay guys, on the condition that you can listen to me and you can do this properly. And actually it turned out to be really challenging to cue a five and six year old to do a deadlift because I can't cue him the way I would cue you. I can't tell him about intra-abdominal pressure and thoracic extension and stuff. It has to be much more simple. So the first thing I realized when I was watching him pick it up is he was doing it incorrectly. And I was surprised. I thought a kid will always pick something up correctly, but he didn't. He was using his back and not his legs.

And I was like, why is he doing that? And I realized, oh, immediately, like his arms are bent. If you don't have tension in the arms, if you don't have profound tension in your arms, you can't use your legs. If you have any laxity of tension in the upper body, and he was bending down so much that he was like grabbing

the thing this close and then trying to pick it up with his back. So anyway, it was a great exercise for me to learn to cue him correctly, but then to watch how perfectly they can lift things. And now it's like, okay, so he just comes in the gym and all he wants to do is pick up that kettle bell up and down, up and down, up and down. How old is he? He just turned six a couple of weeks ago. I love that. Yeah. I love that. And obviously he wants to do what daddy's doing and daddy's lifting stuff.

I want to do that as well. So we can harness that potentially. Yeah. But the point is, this is so important for teenagers. teenagers and um again you you may you mentioned something earlier that i think is a troubling and upsetting statistic which is you know that over whatever period of time i can't remember 30 years i think you said there was a 90 percent 90 second loss in one mile time you know unfortunately i'm sure there was a comparable statistic for loss of strength as well. So yeah. So basically with kids, teenagers, we want to be encouraging this early. Now, of course, many people- And the same is true with fitness. In other words,

like I feel very fortunate that, you know, even though I don't train at a fraction of the level that I used to, I think that part of the reason I can maintain a relatively high level of fitness is I maintained an absurd level of fitness as a teenager into my twenties. So in other words, I reached a genetic ceiling then that I think makes it easier for me to stay in shape now. And again, that shouldn't mean that anyone who arrives at 50, who's not in shape should be discouraged. You, in many ways they have more potential. They have a potential to be higher than they were before. I don't. I'll never be as high as I once was, but I'll probably be higher than that person on account of the fact that I had that capacity

so young. So again, to your point, if you're listening to this and you're a parent or a teenager, you really want to make sure your kids are fit. Yeah. When I think about your work, Peter, and when I think about the things that you're talking about in Outlive, a lot of what you're asking or, I guess, suggesting people consider doing in their lives requires them to make some quite significant changes sometimes. Now, over the course of my career as a medical doctor, I've changed my perspective on what really causes a patient to change. I used to believe that knowledge was all that was required. Knowledge is power. And I've realized that I

don't think that's the full story. Even with the knowledge, there's a lot of knowledge out there in podcasts, books. If knowledge was the answer, we wouldn't have a healthcare crisis. So my question to you is, in your experience, what are the common obstacles you find for people who are trying to make changes? I think it depends on the changes. So put that nuance aside for the moment. I think in some cases, the impediment to change is just inertia. I mean, sometimes it is difficult to say, you know, this is the way I kind of live my life. These are my habits. I want to create a new set of habits that requires sort of a willingness to, to, to do something different, which for some people, they don't want to break a habit. So I'll give you an example.

I think they realize that doesn't sound very clear. If you tell a person, look, you've got to go to bed an hour earlier, and it would really be great if you didn't fall asleep on the couch watching TV, because that hour of sleep that you're getting on the couch, then you have to wake up and go into bed. That's just lousy quality sleep. Well, that the impediment to change isn't that they don't understand, as you said, that sleep is important, but it's that they have a real habit around sitting on the couch and watch TV after, you know, to unwind. And you're now basically saying, well, you're going to have to come up with a new way to unwind. So you're now basically saying, well, you're going to have to come up with a new way to unwind. So it's the introduction of, you know, we're going to make one change, but it actually

requires several changes. And I, and I, I think that sort of underlies a lot of things. I also think there are, you know, certain things that people have to do that are not that pleasant initially. So for a person who's never exercised i think it's actually quite intimidating and initially unpleasant to exercise and you can tell them until you're blue in the face that once you get over kind of the initial challenge of this it's actually going to feel quite good you're actually going to appreciate the fact that it's not just beneficial for you in the long run which it is but even in the short run. But they do have to take a bit of a leap of faith sometimes to do that.

I think when it comes to changing behaviors, for example, such as food, sometimes realizing that changing the default environment of your food is very important requires a big leap forward. So it's one thing to say, look, I want you to, you know, stop eating this way and start eating this way. Isn't as simple as saying that it's well, your pantry needs to change and the types of places you go for lunch need to change because, you know, you want the changes to be requiring less willpower and more automated behavior. So I don't think I'm being very articulate when I'm saying this, but I guess what I'm trying to say is it's usually not one change. It's usually multiple changes that have to be set up to make the behavior of interest be more automatic? Yeah, I would say that very

much echoes my own experience. I guess what I often think about with patients, very similar to you, I think, is that all behaviors are therefore a reason. They serve a role in our lives. And I think often we try and change the behavior without understanding what was driving that. So is the sugar you're craving at 9pm on the sofa really physical hunger or is it emotional hunger? Is it that you've had a crap day? Is it that you've fallen out with your partner and that that bit of sugar is going to help you? Because if it is, then you might need a different strategy. Is it that you feel lonely? And instead of the sugar, maybe you want a phone call with your friends. Is it stress? Maybe you want a relaxing bath rather than that sugar or whatever it might be. And so I would say that's one of the key things I've learned

over my career is, yeah, you can change the behavior without addressing that, but it tends to be short-lived. Classically, new year, new you. Fine, spinning four times a week, every week for the whole year. Don't you do it for two weeks when your motivation's high, and then suddenly you've had that bad day at work, and you need to pick the kids up, and whatever. You know what? That's too hard. So is that something you spend time within your practice trying to understand? Because look, the behaviors are great. I want to talk about more of these behaviors that we want people to do,

but it's often not the behavior. It's the impediment to that behavior that I find I spend a lot of time with patients. I think we do as well. And I think that that is the biggest challenge. And certainly within a year of being in our practice, there's no patient who's at a loss for what they should be doing. Right. There's not much of a mystery. It might be a mystery when they come in. There might truly be some confusion about the optimal strategy around exercise or whatever.

be some confusion about, you know, the optimal strategy around exercise or whatever. Um, you know, one of the things that, um, we try to remind folks, I just think of it with the example you gave is, um, try not to have two back to back misses. Yeah. Right. So the, the example you gave there of, so you, for, for two weeks, you're doing your four spin classes a week and it's all going well. And then you have that bad day. I think that a lot of people get into a negative spiral when they punish themselves for that bad day and they feel ashamed that they've missed their workout, something that they set themselves to do. that they set themselves to do. And sort of that shame becomes the more dominant emotion as they are getting ready to have that next workout and it becomes easier to miss that next workout. And instead, what I think you want to try is say, look, you have that bad meal that you said you weren't going to have. You missed that workout. You do something that is kind of off your path. Just give yourself a total pass with no judgment and just say, yeah, it's really hard. Like if this was easy, you would have done

it last year or the year before or the year before, but just get it right the next one. Just make sure the next meal is right. Make sure the next workout happens. And I even find this as important myself. I mean, I, and I tend to, you know, people would look at me and assume I'm sort of a beacon of willpower, but it's not always true. And I still have to be very nonjudgmental and sort of remind myself when I slip that it's okay and let's just try not to slip tomorrow.

Is that a new thing you've had to learn? In general, absolutely. It's become more relevant as I've become older. So, you know, I think when I was younger and even more selfish, there were never reasons for me to deviate. But now with a family, with other responsibilities, there are plenty of reasons for me to deviate. And I deem those better uses of my time sometimes. And as a result of that, I do sometimes battle myself thinking, what's happened to you? Like, look at how much you're slacking off in whatever in you know whatever regard you're talking about but but yeah i think i'm much more compassionate with myself today than i used to be yeah snap i mean i i would very much berate myself in the past if i said i was going to do something and i didn't uh there was quite a lot of negative self-talk going on. And you realize it's just never that helpful if shame or guilt is that underlying emotion.

I just don't think it's sustainable in the longterm. It will always catch you out at some points. Certainly that's what I felt. By the way, that's a whole other, so going back to the, what are the impediments to the behavior change? I find that there's another phenotype that I see in my

practice, which is another manifestation of trauma, right? Which is basically the individual who's completely incapable of taking care of themselves or putting themselves ahead of others. So I see this phenotype more commonly in females. And I see this as often, you know, a mother who's, you know, doing a lot of heroic stuff. So probably working really hard in a job, probably puts her husband and kids needs ahead of her own, but she does so at such a detriment to her own health. And she keeps, you know, she, you know, it's like, so she sort of understands that her health is suffering, that her health is suffering, but almost feels like it's her place to suffer and she can't make that exception. And you'll sort of say, look, you've got to carve out an hour a day for yourself to do these things. And she says, yeah, I know I should, but, and then there's a string

of excuses, but you realize that deep down what's going on is there's a form of self-punishment happening. And I'm not saying that that's true of every mother who's out there working and busting her butt, but I'm just saying in the examples that I've seen in my practice, I really attribute this to kind of a maladaptive behavior around trauma. And that's another example of where, you know, I would describe that as sort of an emotional health failure that's cascading into physical health failure. Yeah. I would say that one of the things I've learned, and it plays into what you just said about this trauma piece, a lot of people these days have, I would call them low grade addictions, whether it be sugar or social media or online shopping or scrolling online, whatever, which gets in the way of other

behaviors. Because there's a lot of behaviors that people could do to optimize their longevity. But I think this is a really important piece. Why is it that people can't do those behaviors? Why do a lot of people perceive themselves to not have time? And I mean, I very much like Gabor Maté's definition of addiction, which is, again, if I butcher it slightly, please forgive me. But something, it's got these three components, any behavior or substance that you crave that either relieves pain or gives you pleasure that you are unable to stop doing or give up despite negative consequences, right? So through that lens of looking at addiction, I would say many of us, most of us, all of us have some level of addiction. And I'm interested, do you find that a relevant area to go into with your patients?

Do you see these low-grade addictions as getting in the way of them making potentially more helpful changes when it comes to their longevity? Yes, but I would take a step even further back from that and say, forget about the impact of these addictions on their capacity to exercise or eat correctly or sleep correctly. I would say, just talk about the impact of those addictions on their relationships. And I think that's kind of the interesting thing about trauma, which usually on some level underpins some of these behaviors. And by the way, I think that that term is so loaded and people think trauma has to be big T trauma, but really little T trauma can be just as impactful.

For sure. But not kind of dealing with those things and not understanding that most of those things produce really wonderful adaptations, but as collateral, they sometimes have maladaptive behaviors. Yeah. And failing to deal with those things can have the impact on the physical side, which we talk about, right? It's usually going to come in the form of failing to engage in self-care through those behaviors, those positive behaviors, but it can also be pretty disruptive to your interpersonal relations. And I think if your interpersonal relationships are compromised, your quality of life is compromised, your happiness is compromised, your joy is compromised. And honestly, I think that's just as problematic.

So to your question, I think the way to approach that with patients is probably to find out where they're sensing the discomfort the most. Yeah. And I think that varies by individuals. So I think there are some people who are sensing that discomfort the most vis-a-vis the behaviors that they're not engaging in correctly,.e i'm not eating well enough i'm not exercising i'm not taking care of myself in the physical sense whereas i think for others the the the way in which they're going to um face up to that is going to come through the the destruction or damage on their relationships be it with their spouse their kids their friends co-workers it's when you When you really delve into this area,

and I know you've been on a personal journey yourself with this, as have I, it's more and more about emotional health. I think it's not that physical health doesn't matter. Of course, it doesn't. Being physically healthier, of course, helps us with our emotional health as well. But I kind of feel that the emotional health piece, yes, it drives better self-care. Yes, it helps your relationships. But there's quite a lot of research now showing that, I've got to be very careful how I word this because I'm absolutely not putting blame on people. But there are strong associations now between people who hold on to negative emotions, who hold on to anger and resentment, who are unable to forgive, and the risk of autoimmune disease. And again, I'm not putting blame on people. There are associations in the literature. If I look at my own practice,

my non-NHS practice was largely filled with people with autoimmune disease, a lot of women. was largely filled with people with autoimmune disease, a lot of women. I would see these kind of personality traits a lot. I don't know if you're familiar with Fred Luskin's work at Stanford about forgiveness and the ability to forgive on blood pressure. Really, really interesting. And I guess I followed you for years, peter and so you strike me as someone who you you've you've openly shared things that you measure in your own life right for many years i often think about that that phrase that you know not everything that we measure matters and not not everything that matters can be measured. So yes, we can measure key metrics. And we spoke about some of them the first time you came on my show, but there were kind of some other sort of unmeasurables, which I find more and more

are impactful for health. I'm thinking about specifically to one patient. I think she was 48. She had mildly elevated blood pressure. I can't remember exact numbers, but I'm going to guess it was in the region of 135 to 140 over 90, something like that. And we, for six months, were trying to make changes with Elisa. She transformed her diet. She started exercising. You know, she started to prioritize her sleep. Yeah, I couldn't get it to budge. I couldn't help her get it to budge. And we measured it properly. We did 24-hour monitoring. And I thought, what am I missing here? Now, of course, some people are going to be resistant. Maybe it needs pharmaceuticals. But I just felt from talking to her that she was holding on

to a lot of anger. And it turns out, as I got to know her more, that she actually was, she had split up with her ex-husband who had cheated on her. And she couldn't let go, right? She absolutely just could not let go. And we spoke a bit about forgiveness and the importance of doing that and letting go. And I won't go into everything that we did, but essentially over the next few months, she basically learned the skill of forgiveness. She managed to let go of the anger she felt and her blood pressure normalized. Now that's an N equals one. I'm aware of that, but I'm sharing that with you because these things really teach me that there are all kinds of inputs into a human that manifest in their physical health. And I didn't learn that stuff at medical school. I've just kind of picked it up through just observing.

And then I go to the literature and see, well, that is supportive research. Now, do we have the same quality of evidence for that as we might do for a particular form of exercise for lowering blood pressure? No, probably not. But on an individual level, when I have someone in front of me, I'm always trying to think, which inputs here can I manipulate? What could I be missing here? And you're someone I respect incredibly. And so this feels like the softer side to medicine, but I feel it's just as important as the harder side. And I guess I just love your thoughts and perspective on areas like that. Oh, I would agree with that completely in every regard, right? Meaning that, do I think that that matters? Absolutely. Do I think that it's very difficult to quantify if

not impossible? Absolutely. Um, to me, the biggest question is, um, you know, how do you teach it? Right. So, so how, how did you get that patient, uh, who I think most people wouldn't fault her if she basically said, I'm going to carry this, you know, ax to grind for the rest of my life. Most people would say, understood. Yeah. Get it. So how, how did you work with her to, first of all, convince her that it was worth trying to, to, to, to forgive her, her ex. And then secondly, how did she actually go about doing that? Yeah. So firstly, I believe in informed consent. So I explained to her the situation. I explained the risks of not treating that blood pressure in terms of her long-term health. And I explained what the options were. I also built up a really good rapport with

her. I got to know her. This is one of the beauties that it's hard these days to be fair, but certainly a few years ago, there was still that continuity in primary care where you would, in the NHS here, where you would get to know someone, you would get to know their family, you would actually get to see who they were in their lives in a way that you don't always get with hospital medicine. So I built a really good rapport with her. She trusted me. So I don't go there with every patient. I just got a sense from her. So when the time was right in a consultation, when I felt she was open to it, I said, listen, you've done incredible work with all the changes you made to your lifestyle. I would have expected to see some change here. Not always, but usually. My feeling is I picked up a couple of things from you that I

think may be at play here. Would it be okay if I go through some of them with you? Are you interested? And I broached it. And the first time I broached it, you know, brick wall, she wasn't willing to go there. But I would like to see patients regularly, even though it's just 10 minutes, I would often get them back every few weeks. I like to follow them up and talk to them. And it got to the point where she was open. She goes, I said, look, we can put your medication and, or we can try this because I think this may help your blood pressure. But frankly, I think it's going to help many other aspects in your life as well. Like if you hold on to this, I understand. And I explained to her that forgiveness would be not for her ex-husband,

it would be for her. And I can't remember the exact exercise. I think I wrote this out on my third book, but it was a forgiveness exercise. It, just a four-step process of asking her, you know, what exactly, what was the emotion she was holding onto? What benefit that gave her? Is there a possibility that you can see it from your ex-husband's perspective? You know, what might have been going on in their mind? And are you willing to carry this for the rest of your life? Because you essentially, and I can't remember the language, you said, actually, that means your husband still has power over you today, your ex-husband. An act that he did, it still affects you in your day today. So again, I don't want to derail the entire podcast onto this case, but it wasn't just a quick fix.

It took time. It took trust. It took her trying it a little bit, coming back. I think I'll often refer to a psychotherapist. I don't think she wanted to. She built up trust with me. But the point is, is that yes, it was difficult. But my belief is that not only did that help her with her blood pressure, that's going to reap dividends in multiple aspects of her life emotionally and physically for years to come. I'm convinced of that. And I agree with you. I think there's a subtle point there, which is I think it's a better health outcome than just pharmacologically addressing it. So if you had just given her an ACE inhibitor or an ARB, you would have fixed her blood pressure,

but you probably wouldn't have fixed the underlying sympathetic tone, the hypercortisolemia that was still going to have negative health consequences. And I've done that for many patients, right? I've done what you did. I put them on the ACE, right? So I'm not trying to say I do that every time.

No, no, but I'm saying want you to, I put them on the ACE. So I'm not trying to say I do that every time, I don't. But I'm saying in her case, what I think is a win is the blood pressure got fixed, but that's almost a biomarker of the actual problem getting fixed. And with it, her risk of many things is going down that are accounted for by the hypercortisolemia and that increased sympathetic tone

and the increased blood pressure. Yeah. I just find that so fascinating. And then when I was thinking this morning, you know, what I'm going to talk to Peter about, you know, one thing that fascinates me deeply is your practice. It sounds like very few other practices

that exist maybe globally. Now, we touched on this briefly last time about our different experiences. You know, you in the US in a private system, me in the UK in a publicly funded system, and how that would affect our experience and potentially our viewpoints as doctors. And I'm fascinated as to what people come in to see you with, because typically in the NHS, we acknowledged last time that we're pretty bad at real prevention in medicine the current way it's practiced. Medicine 2.0 compared to medicine 3.0, as you outline in your book, right? But people in the UK, I would say, and in America, I'm sure, typically go to see their doctor with a problem.

Doctor, I've got pain here. This hurts. You know, they're coming in with a problem that they want you to solve. Are your patients coming in to see you and your team with a problem or are they coming in to say, hey, listen, I want to make sure my marginal decade is as good as it can be. Peter, can you help me? Yeah. So if you compare, I think maybe a note that you would write when you see your patient, it probably starts with a chief complaint, right? It would probably start with, Mrs. Smith came to see me today with a chief complaint of bloating or reflux or pain here or there. On our first meeting with a patient,

the note actually begins with their goals and we break the goals into two brackets. So it's marginal decade goals and goals for the next 12 months. Yeah, I love it. I think it's just a wonderful exploration of what might be possible, what might healthcare, real preventive healthcare look like. And yes, you say it's a luxury, but I guess you've created that. You've created the opportunity for people to go and experience that. And I guess you've learned so much through doing that and creating that because often we don't have the luxury, certainly in the National Health Service, of doing a lot of the tests you do, having access to that data.

What do you say? Because I was thinking, okay. I don't think the testing is the biggest limitation. Really? I don't. And we actually talk about this with our patients early on, like in the first month or so. In fact, the first time we do a blood test review with a patient, we review their bloods. I sort of give a soliloquy that every patient gets the first time. And the gist of it is something like this. Look, there are several metrics that we're going to be paying attention to in the duration of your time in this practice. So you might be in this practice for two years. You might be in this practice for 10 years. We don't know, but you're going to get used to a drill and a cadence with which we pay attention to things. And most patients are coming into this practice with an

over-indexing on blood test because that's kind of, you know, in their previous relationships with doctors, that's the thing that doctors are most paying attention to. And we say, look, that's fine. We're going to do blood tests and we're going to talk about that here today. That's what we're here to talk about. But you should understand that your blood test is only about, I don't know, one of 30 to 40 inputs that we put into our risk assessment model. So your family history, which we talked about last week, and the reason we sent you home with a 10-page packet to fill out is because we really want to know your family history.

And we're gonna do a movement assessment that's gonna take two hours and eventually a strength assessment that'll take a couple of hours and a VO2 max test and a zone two test and a DEXA scan and a liquid biopsy. Like there's a lot of things. And yes, we want to know your ApoB and your, you know, euglycemic, you know, we'll do an OGTT,

et cetera. So the labs are only one of, again, 30 things we look at. And by the way, the labs have huge blind spots. Like the labs are really good at helping us predict your risk of cardiovascular disease when coupled with understanding your blood pressure and a few other things. They're not really good at helping us understand your long-term risk of cancer, even your immediate risk of cancer. I mean, there's just a stochastic process to that, that outside of measuring metabolic health, this doesn't really tell us if you have cancer or not.

So we sort of almost de-emphasize the labs. And I think the biggest impediment from a time perspective is actually on the, is on the movement stuff, is on the exercise stuff, is on nutrition, sleep. It's, that's the challenge you'd have in 10 minutes, right? is on the exercise stuff, is on nutrition, sleep. That's the challenge you'd have in 10 minutes, right? That's why 10 minutes can't simply make that happen.

And people say to me, you know, Peter, why aren't you scaling this? Like, why aren't there a hundred other practices doing this? And I think that's the challenge. It's how do you scale those other pieces that do require the bespoke nature of interaction with an expert in that area. And we're doing some things. I mean, we're building courses and video stuff along that line, but it's just going to take other doctors saying, I want to learn this stuff well enough that I can

then be the conduit of this information. But I'll tell you, I mean, in the UK, you guys are further ahead of the US in that you already consider ApoB, for example, to be an appropriate metric for measuring risk for cardiovascular disease. You consider ApoB in the UK to be superior to LDL-C. The US is still backwards on that one. I think also what your model is showing is true prevention. And actually, without getting into policy and why the healthcare system is set up the way it is, big picture, if every patient had access to that, let's say, let's take the UK, every patient had access to that, let's say, let's take the UK, a government funded system, a tax funded system. If you actually were able to do this with everyone, despite the upfront cost, it's very clear, or I guess without running numbers, how can I say this? It would appear to be very clear that you will save a ton of money at the back end.

Well, it's just why, by the way, people always ask me, can we institute a system like this in the US? And I actually say it's much easier to institute this in a single payer system. Can you just expand what that term single payer means if someone doesn't yeah so a single payer system would be like the nhs where you have the government as the only payer the government is the insurer yeah and why is that the case so a single payer system by definition implies the government is paying we don't have that in the united states for everyone. We have something called the Center of Medicaid Services, CMS, that provides services to people over 65 and something called Medicaid for people who qualify for very low income. But the majority of people in the United States who have health

insurance have it through a private insurance carrier. And that private insurance carrier will only be insuring them for a short period of time. And it's actually, it's even more complicated in the US because depending on the size of your employer, sometimes the employer is the insurance risk bearer, but it's done through the administrative services of an insurance company. All of this is to say, they don't really have the incentive to pay money today when you're 25 and 30 to prevent complications when you're 60 or 65, because they won't be the ones insuring you then. You'll have a different employer or a different insurance company. So if you think about the NHS though, or any single payer system, there really is an incentive to invest wisely when people are young and healthy to spend a little bit more because

you still, as the single payer, in this case, the government, own the risk of that life down the line. So it's in many ways much more logical to consider medicine 3.0 in the context of a single payer system than it is in a multi-payer system. That makes complete sense. I guess one of the obstacles to that is that the National Health Service is such a political hot potato that really there doesn't appear to be this 20-30 year vision more there's an election in two years so what do I need to do with the NHS to make sure that I get re-elected which is fundamentally going to be problematic because decisions are always going to have a bias to short term as opposed to long term. And of course, these things require an upfront investment that is more painful in the short term. You reap the benefits in the long term. Just to finish off on your practice,

given that it is private, given that there's a cost element to it, presumably, and please correct me if I've got this wrong, presumably, it's only going to be people with a certain amount of resource who can actually access that. And then in a capitalist system, a lot of the people who end up with that resource, in my experience, are kind of type A personalities who have worked hard often, not always often, felt that there was something to prove, right? Which drives them to get incredible success in the system, which can reap rewards. I don't know if that's fair to say or not. Of course, every patient is different. But then if that is the case, are there certain patterns you see in those individuals?

And then I guess what can we learn from that? Because a lot of people like your show listen to this show who may not have those resources. So I'm always interested, this is a great model of a practice. What can we learn from that? Yeah. I mean, I think as a generalization, that's probably a fair characterization. Of course, there are many exceptions to it. So one has to take that with a grain of salt. And what's interesting is something that you alluded to earlier, right? I think that sometimes the most high achieving, hyper-performing people are doing it because they have something to prove. And sometimes that need to have something to prove comes with other baggage that can undermine your health, both directly and indirectly. And so I realize that statistically speaking, more affluence translates to more health, but that's not true beyond a certain point. In other words, it's true that having an income of 50,000 pounds a year will produce a better health outcome than having an income of 10,000 pounds per year. And maybe having an income of 100,000 pounds per year will give you a better health outcome than having an income of 50,000 pounds per year, possibly, I'm not sure.

But what's absolutely not true in my experience is having an income of 50 million pounds per year versus 100,000 pounds per year. I don't see any difference in health outcomes at that level. And in fact, the person with the multi, multi million pound income often comes with other problems. And so one needs to be careful what one wishes for. And I say that just as much to myself as to others. And I think one just has to accept the fact that you only have really responsibility and accountability for your own choices and your own behaviors. And I really think that time is the most important parameter in this game. It's really not about resources, financial resources, as much as it is about time. And that's an example of where, yeah, that person who's barely making it can often be in a situation where they don't have time either.

They're scrounging so many things together to make it work. But, um, but you know, you brought up exercise a moment ago. I mean, if a person could spend an hour a day exercising, I mean, they're going to be healthier than the richest person on the planet who isn't doing that. Yeah. than the richest person on the planet who isn't doing that. Yeah. Who has all the fancy doctors, who has all the fancy clinics, who does all the executive physicals. I mean, none of that stuff will matter

if they're not taking care of themselves. And I've seen people across the spectrum and the correlation is very loose. Yeah. Just to finish off then, Peter, you touched, and maybe we don't have time to really go into this in detail, Just to finish off then, Peter, you touched, and maybe we don't have time to really go into this in detail, but given that women have lower estrogen levels post-menopause, I know this

is quite a contentious area in terms of does every woman need hormones after menopause for brain protection, cognitive protection, muscles. Are you able to go to such a nuanced topic? A sort of quick overview summary. Does every woman need it, in your view? Well, it is a very complicated topic, and it's one I've devoted a couple of podcasts and a lot of writing to. It is contentious, very contentious. Certainly I found it to be. It is contentious. Unfortunately, it's contentious for the wrong reasons, meaning it's all predicated on bad information, right? So all of this controversy around hormone replacement therapy stems from a trial called the Women's Health Initiative that was published 21 years ago that very erroneously sort of permitted the media to misunderstand and misinterpret and propagate.

And basically, the conclusion of that study was that estrogen caused breast cancer. When in fact the experiment showed the exact opposite. So the Women's Health Initiative actually showed that estrogen was protective against breast cancer. But estrogen combined with synthetic progesterone did slightly increase the risk of breast cancer, but not mortality from breast cancer. And when I say slightly increased the risk, breast cancer, but not mortality from breast cancer. And when I say slightly increased the risk, I mean one case per thousand. There was one additional case per thousand of breast cancer,

zero additional breast cancer deaths associated with that. In the estrogen group alone, meaning women who didn't take estrogen with MPA, the synthetic progesterone, there was a reduction in breast cancer. That was both true when the trial was halted at five years and subsequently when the data were evaluated 15, 16, 17 years later. So again, just a grotesque misunderstanding of the literature. There are many reasons to consider estrogen. Some of those have to do with symptoms. So vasomotor symptoms. And I would argue that any woman who is experiencing vasomotor

symptoms, such as hot flashes and night sweats, shouldn't have to suffer through those. And therefore, I think hormone replacement therapy completely makes sense in that context. Where I think it gets a bit more nuanced is what about women who are not experiencing vasomotor symptoms? And what about women who are through the period of vasomotor symptoms? So let's say they went through menopause at 50 and they're now 60. If they stopped the hormone replacement therapy, presumably they would stop, they would not have symptoms anymore, but they would also lose the protective benefits

of estrogen on their bones. The truth of it is we don't have great data on that and we never will. No one will repeat the experiment to find out the answer to that. But at least in our system, I believe that it's much easier to screen for breast cancer than it is to treat osteoporosis.

And I think each woman has to be sort of, I mean, I hate to say it, it's such an obvious cliche, but each woman needs to be treated individually. And you basically have to look at what are the symptoms of estrogen withdrawal. And if they're trivial, if a woman experiences no issues with estrogen withdrawal, and she's really afraid of the consequences of lifetime estrogen, then that's probably the choice for her. Yeah. I appreciate your brief overview on a very complex topic. I spoke to Professor Anis Mukherjee a few months ago about menopause and issues like this. I hope to cover it again. So I think it is such

an important issue. And I think we're going to see, I would imagine we'd see more research on this, particularly to do with cognitive health and what it means, what that estrogen deficiency may mean for the brain going forwards. But again, that needs a proper nuanced discussion in and of itself. Yeah, the Women's Health Initiative didn't really answer that question for us. There were a lot of flaws in that part of the study. So we instead look at smaller experiments that have been done since that time, certainly some of which suggest the protective benefit of estrogen for cognition. It's possible that might only be in a subset of women,

for example, those with an APOE4 gene. Exactly. So it's still a TBD. In the remaining time, let's see if we can cover cardio, zone 2 cardio. Okay. What is zone 2 cardio for people who've never heard that term before, right? And I think there will be quite a few, although I think we often get seduced into thinking that our section of the internet is what everyone also sees. But we all consume highly curated feeds that feed us what we already know what we like. I'm pretty sure much of

my audience will not know the term. So why is that a key pillar of longevity protection when it comes to exercise for you? So this is a complicated one because it requires understanding a little bit about metabolism and how we make ATP out of nutrients. So there are basically two pathways that we have at our disposal to make ATP, ATP being the energy currency that is necessary for every physiologic function. So to be clear, ATP is a form of chemical energy, but it is made from another form of chemical

energy in the form of food. So when we consume food, and for the purpose of this discussion, let's just talk about two things, fat and glucose, since those are the most abundant energy sources. Fat and glucose contain energy in their chemical bonds. Those chemical bonds have to get turned into electrical energy, which then gets turned back into chemical energy. There's two ways to do that. There's a very, very efficient way to do that and a very, very inefficient way to do that. You might ask, why is there an inefficient way to do it? Why would you ever do it that way? It has to do with speed. It's the speed with which you need the ATP. If you need the ATP really, really quickly, if I said, I want you to stand up and give me 25 burpees, you know, or do something, you know, I want you to sprint all out for 30 seconds or for a minute. You are demanding ATP at such an accelerated rate that

your body is going to take you down a very inefficient way of turning glucose into an intermediate molecule called pyruvate and then turning that into lactate and generating a little bit of this ATP. If I gave you all the time in the world, if I said, I want you to go for a slow jog, your body, hopefully, if you're reasonably fit, will instead turn that glucose and maybe even fat, ideally fat, into smaller molecules that go into the mitochondria and make a lot of electrons that then get turned into ATP down the line. So again, I'm really oversimplifying, but I think the point I want to make is there's a slow, efficient way to do it that has no byproduct except for carbon dioxide and water. And then there's a inefficient way to do it when

there's a gun to your head and it doesn't make much ATP and it makes a lot of lactate. And lactate gets attached to hydrogen and the hydrogen causes your muscles to get stiff. Okay. Zone two is a term that is used to describe the highest level of exertion you can sustain while keeping lactate below a certain threshold, 2 millimole. Why? Well, once lactate gets beyond 2 millimole, it begins to start accumulating. it begins to start accumulating. Two millimole for most people is the level at which you can sustainably clear it while creating more of it. So the fitter an individual is, the higher speed they can run or the higher wattage they can put out on a bike while still keeping their lactate at or below two

millimole. And the difference is quite staggering. So you mentioned Kipchoge earlier. I don't know his numbers, but I would bet that Kipchoge could run a four minute 50 mile, a four 55, A four minute 50 mile, a four 55, certainly a five minute mile while keeping lactate below two. For many of us, that'll be beyond our max. If you, I, first of all, I couldn't run a mile in five minutes any longer. But even when I could run a mile in five minutes, you know, that I would be lactate above two. Yeah. Right.

So maybe even say in five. Yeah. Yeah. So, so the same is true in cycling. Like if you look at, you know, Tadeep Hogachar, he could make four Watts per kilo on a bicycle. And his lactate is below two. I could make four Watts per kilo for a few minutes before I'd be filling up with lactate. So the point being that this is working out in this specific zone is particularly working on a particular energy system that we need. Yeah. It is your maximum aerobic efficiency.

So if VO2 max is your maximum aerobic output, VO2 max produces lots of lactate, but it is the maximum oxygen consumption you have. It's your max aerobic output. This is different. This is max aerobic efficiency. The sort of metaphor I use with patients is a pyramid. The VO2 max is the peak height of the pyramid. The zone two is the base of the pyramid. And the goal of cardio training is to have the biggest area of your pyramid. So you don't want a pyramid with a high peak narrow base, and you don't want one with a wide base short peak. You want wide base, big peak.

So you want a very high zone two threshold and a high VO2 max. Yeah, thank you. It is a complex area. I will make one more point because the person listening to this might be like, what the hell is he talking about with lactate? Here's the good news. A person who then says, okay, how do I put this into practice? If Peter says, hey, we really ought to be trying to do three hours of zone two conditioning per week. It's true that the gold standard is achieved by measuring lactate, but the way that we can do this in real life is just on exertion, what we call rate of perceived exertion.

And this is the tell for when you're in zone two. When you're in zone two, you can speak, but it's uncomfortable and you don't want to, but you can still speak in full sentences. If you can do, if you can speak in full sentences easily, you're in zone one and you're not achieving that training effect. So in other words, it's not hard enough. So if you and I went for a walk right now, we would not be in zone two. Because we'd be in zone one. We'd be in zone one. Flat ground, having a walk, we'd be in zone one. That's right. If we went out for a run right

now, well, that would be a bad example because it would be easier for you than me. But let's just assume for a moment, we did something where we're both kind of comparably fit and we couldn't speak to each other. Or if we did, it was one word here and there, we would be in zone three, four, or five. Yeah. And there's benefit in zone three, four or five. And there's benefit in doing that, but not for this type of conditioning. You have to thread the needle to that sweet spot. And that's what you're basically doing is enhancing your mitochondrial efficiency.

Yeah, no, I love it. And I would say for me, for much of my life, I've neglected this massively. I was always drawn to intensity for a variety my life, I've neglected this massively. I was always drawn to intensity for a variety of reasons. Not really because I liked the feeling more because I've always felt quite time pressured. I've had a lot of caring responsibilities for parents throughout my adult life. But I was saying the last couple of years, completely changing that. And I'm spending a lot of time relative to the past in zone two. And what's weird, I think for me, and there's a lot of content you've put out online about zone

two that you've written it beautifully in your book. If people want to learn more, I'm going to cover it on the show shortly for sure as well. The beautiful thing about zone two is it's quite easy. It doesn't, you know, yes, you know, you're a bit out of breath as you say you can hold a conversation, but you don't want to. A lot of people get put off exercise. I think it's too hard. And I find one of the great things about Zone 2 is I really enjoy it. I can just think, listen to a podcast, listen to an album I haven't listened to for ages or whatever it might be. listen to it for ages or whatever it might be. And the recovery time is negligible. So actually, I feel it enhances my life. It enhances my cognition. And I know it's doing something for longevity. So I'm not sure how appreciated that is. So for people who are

scared of exercise and don't want that uncomfortable feeling of real high exertion, Zoned 2 can become one of your very best friends very quickly. And it's important even if you're the best in the world. So if you look at the Kipchoge's of the world, they're still spending 80% of their training time in zone two. And you asked earlier, can you think about a way of what percentage of your time should you spend in each of these zones? I mean, that's really what it comes down to. Exactly. It's about 80-20. So it's about 80% of your cardio time should be spent in zone two, 20% of your cardio time should be spent at a much higher intensity. But if you start to push that down, you're going to

risk overtraining, burnout, and injury. So if you say, I'm going to do 50% of my time will be high intensity and 50% of my time will be low intensity or zone two, A, you're not going to achieve as good a result, but more importantly, I think you're going to run the risk of that injury and overtraining. We don't have time to go into this in detail. So let me just summarize and please correct me if you think I've misinterpreted. And if it's a VO2 max workout, so to really that 20% of time, potentially where you're working on that part of your fitness, as opposed to the 80% at zone two, it's typically done with longer intervals. I know you do four minutes on, four minutes off. So four minutes really intense,

four minutes off, so you have full recovery. So beyond kind of the typical sort of HIIT workouts, again, that's a really quick summary because I want to be respectful for your time. Yeah, the sweet spot is actually three to eight minutes. Three to eight minutes of work. Of work with one-to-one work to recovery. So if you're exercising at such a level of intensity that you can only do it for a minute on and a minute off, that's great. There is VO2 max benefit in that. But just understand it's not optimized for VO2 max. You're not going long enough because you're going too intense. So Peter, then if that person is going, okay,

you've convinced me I need to get on my exercise train for my longevity, I can give you five hours a week, but that's all I got. How would you break up those four pillars into those five hours? It would depend on what their current deficits are now. So again, it's different if this is a person that's coming in, who's done a lot of strength training and never done cardio or vice versa, but let's make it really hard and say, it's a person who's never lifted a finger. So if it's, if that's the case, if it's a person who's never lifted a finger, I might do two hours of strength training, three hours of cardio. And in their first cycle, that three hours of cardio would all be zone two. I wouldn't even throw in any VO2 max. Or stability.

No, I would just say for three hours a week, I would do four 45-minute zone two training. And maybe in the last five minutes of each, I would pick up the intensity a little bit, but not even to the, just to get them a little acclimated to a higher workload. And then the two hours of strength training, I might have them do probably two 60-minute sessions a week where each session is whole body strength training. And it's really foundational fundamental movements. There's nothing terribly fancy. Some of it's probably going to be with just body weight. And then I would sort of reevaluate them at three months. And first question would be, hey, have you enjoyed this enough that you'd want to add a little more time? They might say,

I've enjoyed it a lot, but I don't have more time. Okay, great. So then we might say we're going to go to two and a half hours of Zone 2 and 30 minutes where there is now a dedicated VO2 Max workout. And we're going to probably get more advanced on the strength training. So it's hard for me to say exactly, but that's the general way I think through it. I appreciate it. It's very individual. It was more just to give some sort of guidance, huge apologies that we sort of rushed through a lot of these really complex topics like Zone 2 and VO2 Max. Of course, people can read more in the book or on your podcast.

Just to finish off then, Peter, final words, if someone is asking you, listen, I'm inspired by what you do. There's so much info out there. I don't know where to start. What do you say to them? Boy, that's tough. I guess I would say just sort of pick one thing. I mean, presumably the person asking this question has enough awareness to know where they are most efficient, whether it be, hey, I'm really

overnourished, I'm under-muscled, I'm sleeping four hours a night. I would say, pick the one thing that you're confident you could chalk up to a win and just do that for the next 12 weeks and really fix that pattern. Again, if it's your sleep, really fix your sleep. We haven't talked about that today, but again, there's lots to do there. If it's nutrition, just really get that because it's just as much about the confidence that comes from sort of addressing that pattern and making incremental changes that stick as opposed to trying to make massive changes that are harder to stick. So that's probably what I would advise.

Thank you, Peter. Thank you for all the work you're doing. I think you're inspiring many people around the world to believe that they can actually do something right now that's going to help them in their marginal decade. Thanks for coming on the show and enjoy your time in the UK. Marginal Decade. That's coming on the show and enjoy your time in the UK.

Really hope you enjoyed that conversation. Do think about one thing that you can take away and apply into your own life. And also have a think about one thing from this conversation that you can teach to somebody else. Remember, when you teach someone, it not only helps them, to somebody else. Remember, when you teach someone, it not only helps them, it also helps you learn and retain the information. Now, before you go, just wanted to let you know about Friday 5. It's my free weekly email containing five simple ideas to improve your health and happiness. In that email, I share exclusive insights that I do not share anywhere else, including health advice, how to manage your time better, interesting articles or videos that I'd be consuming, and quotes that have caused me to stop and reflect. And I have to say, in a world of endless emails, it really is delightful that many of you tell me it is one of the

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