Jocko Podcast - 392: Life, Death, Darkness, and Light. "OUTLIVE" with Dr. Peter Attia

Episode Date: June 28, 2023

>Join Jocko UNDERGROUND<Peter Attia, MD, is the founder of Early Medical, a medical practice that applies the principles of Medicine 3.0 to patients with the goal of lengthening their lifespan and simultaneously improving their healthspan.He is the host of The Drive, one of the most popular podcasts covering the topics of health and medicine.He is also the author of the #1 New York Times Bestseller, Outlive: The Science and Art of Longevity.Support this podcast at — https://redcircle.com/jocko-podcast/exclusive-content

This is Jocko podcast number 392 with Kerry Helton and me Jocka Willink. Good evening, Carrie. Good evening. The truth is, we died together once before. We died together once before. So says the character Thomas Shelby in the series Peaky Blinders. He's speaking of himself and his brothers who had served as British soldiers in World War I. He and his brothers Arthur and John as well as three of their friends

Danny whizbang Jeremiah and Freddie Thorne were in the field and they were cut off from the British retreat As the British left the battle they couldn't get away They had no bullets left simply waiting for the Prussian cavalry to finish them off and while they waited they decided they should sing the old hymn in the bleak midwinter and they waited to die whatever reason fate or Providence or chance or destiny the enemy never came and so they lived Thomas Shelby says at the end of this story that we all agreed Everything after that was extra and that attitude that perspective that perspective It permeates in the way that the Shelby brothers lived. And the way many veterans live after war,

this is something that war can do to a person. If you've accepted death, then the rest is all extra, a bonus. And so how do you live? What do you do? Are you taking risks, reckless risks? Are you taking advantage of every second that you have? Are you living to honor the ones who didn't make it home? Or are you guilt-ridden that you do?

did make it home. Are you trying to remember or are you trying to forget? Are you trying to leave a mark or just trying to leave some of my friends do some of those things or all of those things? I've done some of those things. My friend Peter Atia told me a story once and I've probably morphed it in my mind over the years. But it was something like this. He was an ER doctor at the time of this story and there was a teenage girl who was brought in by her mother and this teenage girl had broken up with her boyfriend or experienced some other kind of adolescent drama and She tried to kill herself by taking an overdose of Tylenol and Some time had passed and the young girl realized that this wasn't that smart and she didn't want to die and so she

apparently told her mother and her mother had brought the girl to the hospital where the girl's mother politely told Peter the ER doctor what had happened I can hear the conversation in my head you know the kind of casual home I daughter she broke up with their boyfriend and you know she took a bunch of pills and and I think she probably just expected Peter to give her the antidote or give her an IV or give her an injection of something or perform whatever simple routine medical procedure that would resolve the issue and then the girl and the mother could carry on happily with their lives having learned from this little innocent naive mistake by this young girl and Peter asked some questions and did some math in his head

and realized based on how long it had been since she had ingested the drug and how much she had actually taken as he ran that math in his head he feared it would be too late because with Tylenol there's a certain point of absorption in the blood where too much has been absorbed and the liver is poisoned and the liver fails and the body breaks down and you die and there is no procedure and so Peter quickly ran the necessary tests and his fears were connoisseur I was too late. There was nothing he or anybody else could do. I've thought about that story a lot.

From the girls' perspective, from the mother's perspective, from Peter's perspective. And I think about that story and how it relates to my own experiences with death, which, because of the war, those experiences have been too often and too close. And I wonder sometimes, do we realize the value? of life when we have it doesn't encounter with death bring fear or does it bring comfort and what do we do do and how do we act when we realize it's all going to end because there's no escape no one gets out of here alive days months minutes or years we don't know how much time is left but the clock is ticking like Thomas Shelby and his brothers we are all caught all from the retreat we will run out of ammunition we'll be waiting for time come and finish us off

winter now strangely or I don't know maybe not so strangely I thought about all of this as I was reading Peter's new book the book is called outlive a much more positive title than the subject matter I just addressed but it's a book that should be required reading for everyone and really it is it at least touches upon or borders upon being a textbook a textbook where Peter does his best to teach us what he's learned about health and about happiness and about disease and diets and drugs and about life and about death and Peter's been on this podcast before I think it was 2000 2016 episode number 56 and is a privilege to have my friend Peter back here again to discuss

Well to discuss all these things So Peter thanks for coming thanks for coming by thank you for having me back in the bleak midwinter how close am I on that story One small detail off one large detail off and the large detail is a good one to be off on so I wasn't the ER resident I was the surgical resident so So I wouldn't have been the first person they encountered. But the good news is she was one of the lucky ones in that while her liver did fail, we managed to get a liver transplant for her in time. Oh, she lived. She lived. Oh, that wrecks my whole story.

It actually makes my story a happy ending. It does, but it's the same point because I was the first person that she saw when she woke up. So most people in that situation die because the liver, unlike other organs in the body, you don't have a way outside the body to support it. We call that extracoporial support. So if you take a drug that destroys your kidneys, you could be put on dialysis for a period of time, years in fact, until you got a transplanted kidney.

Even the heart is true in that way. If you took something that was so toxic to the heart, you could be put on a ventricular assist device or something like that until a heart transplant came along. The liver, we have no option for that. So you've got, got in the case of this girl, if I recall, you probably have about a 20, a 36-hour window to get her a liver. And that's not big odds. So there's a decent chance that you just die.

She was one of the really lucky ones. So she got a liver. And I, you know, I just remember taking care of her when she's, you know, in the ICU. And, you know, I think it's a very, I mean, again, she was very young, right? So she was probably late teens, early 20s, probably an unbelievable feeling of shame. And, you know, I'm sure you read these accounts of the few people who have survived jumping off the Golden Gate Bridge. Yeah. And they all say the same thing, right?

I mean, there's only a handful of them that have survived. And the two things they all say are they can't believe how long it takes to hit the water. It's technically about a three second fall, but they describe it as taking like minutes. And two, they, again, it's a small N, but they all say the second they jump, They can't believe how much it puts in perspective, whatever it was that made them jump. Sketchy. That's crazy. I was looking at statistics on the Coronado Bay Bridge.

And I think, I want to say like 10 people have survived. Is that too big of a number? How many people did you say survived San Francisco? It's on the order of 10 or so. And I'm trying to think, like the Golden Gate Bridge probably averages. to a month. Yeah. I don't know about Kornado.

Kornado is a similar number. It's a similar number. It gets shut down all the time because people are jumpers are up there. All right. So you wrote this book. We're going to get into it a little bit. And you've also done a bunch of podcasts about the book.

The book, you did the audio book of the book. I'm going to try not to read too much of the book, but you know me. I probably will read more than I should. It starts off with this. Going to the book, the intro of the book, once again, the book is called Outlive, the Science and Art of Longevity. And it's a lot more than just that. In the dream, I'm trying to catch falling eggs.

I'm standing on a sidewalk in a big, dirty city that looks a lot like Baltimore, holding a padded basket and looking up every few seconds. I spot an egg whizzing down from me from above. And I run to try and catch it in the basket. They're coming at me fast, and I'm doing my best to catch them running. all over the place with my basket outstretched like an outfielders glove but I can't catch them all some of them many of them smack the ground splattering yellow yoke all over my shoes and medical scrubs I'm desperate for this to stop where the eggs coming from there must be a guy up there on the top of the building or on a balcony just casually tossing them over the rail but I can't

see him and I'm so busy I barely even have time to think about him I'm just running around trying to catch as many eggs as possible and I'm failing miserably Emotion wells up in my body as I realize that no matter how hard I try, I'll never be able to catch all the eggs. I feel overwhelmed and helpless. That's the opening of the book. This is a very similar, like military dudes, like me, we have a dream where the enemy's coming and we're running out of ammo. It's kind of like the Tommy Shelby thing. Like we're running out of ammo and then you run out and you're looking for other magazines.

The enemy's closing on you and you know what's going to happen. And that's when you wake up, drenched and sweat and you're all happy. You know, you're like, oh, I'm just in bed. We're all good. But this was the, this is how you viewed what medicine was doing. What you call in the book, Medicine 2.0, which is here's a problem right here. Let's fix it right now and not try and figure out where it's coming from. That's the impact that this dream had on you is to, to make you.

think of medicine in a different way. Yeah, although not at the time, right? It's only in retrospect that I put two and two together. At the time, yeah, it just seemed like, I mean, it's amazing to me that it wasn't obvious what that dream was about at the time because it's so obvious in retrospect. Oh, so what you thought it was about at the time was you needed to get better with the basket and be able to move quicker and be able to catch more. Just some stress, just stress.

Like it was just some dream about internalizing stress. How often do you remember your dreams now? Oh, you know, it's funny. If I'm really deliberate about thinking about it first thing in the morning, I would say probably more than half the time. Are your dreams good or your dreams bad? Very rarely do I wake up and think that they're significant about, oh, I don't know, maybe a little less than half the time that I do remember a dream.

I can at least say, I bet that's me ruminating on this fear or this concern. But I would say that the valence of my dreams tends to be negative. It's rare that I wake up and think, oh, I wish I was still sleeping having that dream. It's usually, I'm glad that's over. That could be some kind of a bias, though, because if you're having a bad, bad dreams seem to wake you up more than good dreams. I bet we just like happy, good dreams, you keep sleeping. I can always tell when I've had like a bad dream because I wake up just drenched and sweat and it's nasty and my wife is like you are as disgusting and I'm like yeah I'm sorry but it's always like you're running for ammo you're doing something you're trying to catch someone like something's going on like that it's weird that you physically sweat even when you're not moving yeah for sure I mean it's still there's still huge sympathetic you know nervous system is activated.

I mean, it wouldn't know the difference, right? Yeah, I guess. Well, mine doesn't. That's for damn sure. All right, I'm going to fast forward a little bit and read another chunk of the book. I'll never forget the first patient whom I ever saw die.

It was early in my second year of medical school, and I was spending a Saturday evening volunteering at the hospital, which is something the local school or the school encouraged us to do, but we were only supposed to observe because by that point, we knew just enough to be dangerous.

At some point, a woman in her mid-30s came into the ER complaining of shortness of breath. She was from East Palo Alto, a pocket of poverty in that very wealthy town. While the nurses snapped a set of EKG leads on her and fitted an oxygen mask over her mouth and nose, I sat by her side trying to distract her with small talk. What's your name? Do you have kids? How long have you been feeling this way? All of a sudden, her face tightened with fear.

And she began gasping for breath. Then her eyes rolled back and she lost consciousness. Within seconds, the nurses and doctors flooded into the ER bay and began running a code on her, snaking a breathing tube down her airway and injecting her full of potent drugs in a last-ditch effort at resuscitation. Meanwhile, one of the residents began doing chest compressions on her prone body. Every couple of minutes, everyone would step back as the attending physician slapped the defibrillation paddles on her chest and her body would twitch with immense jolt of electricity.

Everything was precisely choreographed. They knew the drill. I shrank into a corner Trying to stay out of the way But the resident doing CPR caught my eye And said hey man can you come over here and relieve me Just pump with the same force and rhythm as I am now Okay

So I began doing compressions for the first time in my life On someone who is not a mannequin But nothing worked She died right there on the table As I was still pounding on her chest Just a few minutes earlier I'd been asking about her family A nurse pulled the sheet up over

her face and everyone scattered as quickly as they had arrived. This was not a rare occurrence for anyone else in the room, but I was freaked out, horrified. What the hell had just happened? Do they give you any heads up at all? Are they talking to you about this, any of this from a psychological perspective when you are going through doctor school? Certainly not when I was there. I don't know what it's like today.

but you know it would only go from bad to worse right i mean i went to medical school at Stanford where that's often how you saw somebody die but it you know in residency i was at Hopkins which was more of a war zone so there what i saw as death was penetrating trauma for the most part and car accidents as well but but i would say the majority of the people that died well um you know right in my hands would have been trauma victims um and you you know you you certainly saw people die post-surgical procedures, you know, somebody dies after cancer surgery or heart surgery, but they usually didn't die right while you were watching them. The ones who die when you're standing there pumping on their chest and trying to do something heroic were

usually trauma victims. And that was just very, that was a very common occurrence. And no, I don't think that was ever, yeah, there was just, there was no, there was no sense of how do you process this? And I don't know that I did a great job of it. I mean, I probably, in terms of, internalized it more than was healthy. I feel like, yeah, there were many times when I, right after that person would die, I would do something like I'd take their wallet and look through it and like find a picture of them or something like that.

And it's, you know, I mean, I'm sure your audience can handle it. But like I remember the first time I saw somebody literally whose brains had been blown out. We use those terms very loosely, right? But you know what that's like. I mean, when you see a person with an entry wound yay big and an exit wound on the other side of their head, yay big and their brains are on the gurney.

That's not what they looked like 10 minutes earlier, an hour earlier. There's not what they look like in their driver's license photo. And yeah, I just think, I think that is something that we would be better prepared to, or we would have been better off if we'd had some sense of, how do you compartmentalize that? Yeah, I can tell you that I don't think the military does a good job,

of that kind of stuff. At least it didn't when I was in. We didn't talk about it. In fact, it's interesting. We even talk about like, hey, if someone dies, what do we do? What's our replacement plan for that individual? Are we going to get another guy? I was like, oh, no, that won't happen.

It was so far from our heads of thinking it could happen that we didn't even have some kind of a replacement plan. You know, you talk about World War II. They had replacement plans. In Vietnam, they had replacement plans. Oh, here's what you're going to get for replacements. We have another platoon full of stragglers that they're going to come in on the, you know, the fourth wave and they'll fill in whoever's whatever spots are empty we didn't have that so

that means you're not even thinking about it so now you're not thinking about it it's like okay what what goes on what goes on what how do people how are people supposed to handle it so it's interesting that even in medical school where you are 100% going to see people die you're not giving any sort of prep for that now listen it's also like oh you're going to be inundated with that and we've been doing it for however many years 100 200 300 300 300 years, there's been people going to medical school and people figured out. So we're good. Yeah, I mean, I think that I think the disadvantage of that approach in medical school is that it produces a level of callousness that I think all of us experienced to some extent, which is you

tend to retreat from from death. Now, when it's acute death, you don't have a choice. You don't have time to retreat. I mean, when that patient comes in who's been in a horrible car accident or who's been shot or stabbed, you're going to be there and do your job and they're going to die. that's that. But you do tend to retreat from their family. And, and, you know, you have an enormous obligation, I think, to the family of someone who dies under your watch. And in trauma, it is especially difficult to wrap your head around this. Because by definition, the last time that family member saw them, they were 100% normal. Like, their kid left the house today, totally fine and got teaboned in a car accident and now they're dead. Who should be the one to talk to

them? I think that the physician has to be there. Now, it's true that hospitals have social workers and have people that can come in to help with that, but I think that the doctor needs to be there. And we don't, we didn't certainly get any training in that. And I think a lot of doctors don't want to be there for that because they don't feel equipped. I was on my first deployment to Iraq and I'm not going to go into the details of what happened, but essentially we had ended up recovering a body of an American soldier. And we put this individual, you know, he's in a body bag, he's in the back of our vehicle, in the back of a Humvee. And one of my friends was in the back seat. I'm in the front seat. And it was, yeah, we're driving and the body, the bag started to leak.

And my friend who is in the back seat, like he's all of a sudden, the blood is kind of going on to his boots. It's running down a seat or whatever. And he's yelling at me. He's yelling at me and yelling, you know, fucking pull over. We're fucking, you know, he's, he's, he's, he's mad. He's irate. And we can't, like, pull over. You can't just, like, stop in the middle of a convoy. Or we could, but, like, well, now what additional risk are we incurring?

And he's yelling. And this guy's a dear friend of mine. But it was one of those things where I'm thinking, this is going to leave a deep mark on, and this was a, this was a soldier that we didn't know. This was a soldier that we went out and helped recover. And so we didn't know this, this soldier at all. And yet my friend is in the backseat. He's got his, you know, this guy's blood is leaking into the way a Humvee set up.

It's sort of like you're in a, you know, I guess a way to describe it would be, you know, the lunch, the school lunch trays that you have that have like a little dish version. Yeah. So you have like the division for your seats and there's a place where your feet go and it's all one big molded thing. And so that is what kind of tracked blood into my. my friend's feet. And I could hear in his voice, he was just, you know, yelling at me. Like, fucking stop, man, we got these, fuck this.

And he, I'm like, hey, bro, we're going to be okay. We can't stop right here. Come on, man, we can't stop. And, yeah, again, that was, he probably hadn't thought about that at this juncture in his career in the military. And, and you know what? I did when we got back, nothing. I didn't pull him aside.

I didn't say, hey, bro, or UK. I didn't do any of that. We just like, hey, what's our next mission? You know, so it's another case where, sure, and you know what he did? Got ready for the next mission. You know what I mean? That's what he did. But it functions, but as you mentioned, it's definitely not the optimum way to go about

dealing with this kind of thing in life. Listen, this book is big. and 410 pages of actual book, and then I think it's got a little more after that. Obviously, I'm not going to read the whole thing, and you read, I listened to the sample of the auto book. You read it. You did an outstanding job,

and I think you realized how hard it is to read books. It was the hardest thing I've ever done. It's a challenge, for sure. But get the book, get the audio book, and you've done a bunch of podcasts. You've been on Rogans, you've been on Hubermans, you've been on Peterson's. You've been a you've done a bunch of podcasts around the book and there and there's a lot there's a you guys deep dive in a bunch of different stuff

Um So I'm feeling like I'm getting a little bit getting a little bit tangential in this with what I'm gonna be talking about or what I want what made what the book makes me think about that's outside of the normal stuff You say in this section book I think about health span and and it's deterioration in terms of three categories or vectors the first vector is Of deterioration is cognitive decline our processing speed slows down we can't solve complex problems with the quickness and ease that we once did our memory begins to fade our executive function is less reliable our personality changes and if it goes on for long enough Even our sedient self is lost fortunately most people don't progress all the way to Frank dementia But many people experience some decline in their cognitive capacity as they age our objective is to minimize this The second vector of deterioration is the decline and eventual loss of the function of our physical body

This may precede or follow cognitive decline there is no pre-term Determined order but as we grow older for fraility stalks us we lose muscle mass and strength Along with bone density stamina stability and balance until it becomes almost impossible to carry a bag of groceries into the house Chronic pain prevents us from doing things we once did with ease at the same time Inexorable progression of disease might leave us gasping for breath when we walk to the end of the driveway to fetch the newspaper or we could be living a relatively active and healthy life until we fall or suffer some unexpected injury that tips us into a downward spiral from which we may never recover my patients rarely expect this decline to affect them and when i read that we had a guy on the podcast a guy named dean lad who's in the united states marine corps in

world war two and he had done i forget which island can he did multiple island assaults with the Marine Corps in the Pacific and he was on I think it might have been his second but he had already done one or two island assaults in the Pacific and so he's going into Tarawa and as he's going into Tarawa I was asking him I said hey were you know were you scared and he was like no because in his mind he's this is what he said on the podcast he's like in my he said I none of this stuff could happen to me. Like it was going to happen to the other guys. I'm sure the other guys must have been scared because maybe they thought they were going to get shot. Maybe they thought they were going to get blown up. But I wasn't scared because that wasn't going to happen to me. And he

ended up actually getting gut shot 800 meters off the beach and only by the disobeying orders of two other Marines that dragged him back to a boat and threw him on. Did he live? But what do you think that is? What do you think it is in human beings? Myself included, 100 percent, I, by the way, believe that if I'm on a commercial aircraft and it blows up in the sky, I'm going to survive. So what is that and how does that, how do you have to try and convince people that they are actually part of this? Well, the first question is the hard one and also the one for which I just don't think I have an answer. I mean, there's probably some evolutionary reasons for it. I think there are, I think it stems from a broader problem.

I don't know if you've read Oliver Bergman's book, 4,000 weeks. No. It's a fantastic book. And I've had him on the podcast as well, although by the time this one comes out, it might not yet be out because I just interviewed him recently. But he talks about sort of one of the most important issues with respect to the human condition is our inability to cope with finitude. Like we simply can't accept the finite nature of our lives. And that's why he really uses this 4,000 weeks thing. It's a very jarring thing.

I keep a calendar in my office on the wall with one block for each week. So it's got 52 blocks per row. And it's got 88 rows, you know, assuming I'm going to lift 88, which, of course, there's zero guarantee I will. And every Sunday I color in a block. So, you know, I'm into like the 51st row of coloring in those blocks. Those rows are looking lead, boy. Well, there's no denying.

I'm more than halfway done. My kids every day, they come and they look at this thing. And even they're starting to figure out, like, daddy's more than halfway through life. And so I think there's something important about putting that in front of our face. Now, I have an advantage that I think the average person doesn't, which is I've spent a lot more time observing the end of life. This thing I call the marginal decade. So the marginal decade is just defined as the last decade of your life, which, By definition, nobody knows the day they enter it.

Like, nobody knows that. Including people who die of natural causes, they don't know the actual day they are standing 10 years away from the end of their life. But most people know when they're in it. You know, most people have a sense of, I've got less than 10 years to go. As someone I once spoke with about described it to me, he goes, I'm on my last roll of toilet paper. and I'm going to be very careful about how I use each square. No more gratuitous toilet paper using around here. Every minute counts.

Of course, if we could apply that principle at the beginning, that's a different situation. So I suspect that this is such a painful concept for us that we just simply irrationally block it out and say, that's not going to be me. Like, you know, and also it's so, you know, it occurs over a relatively long period of time that you think, well, all right, look, I'm in my 50s today.

And I mean, I can do anything. Like, there's nothing I can't do. It's not like I'm going to wake up one day and not be able to do all of these things. So when we ask our patients to go through this exercise, which is a part of the marginal decade exercise, which is define, we define your centenary in decathlon. So we give them a list of like 50 activities. Some of these are activities of daily living. Like, do you want to be able to carry a piece of luggage up an escalator that's broken?

So 30 pound luggage carried up two flights of stairs functionally. Some of these are, you know, very recreational specific. Like, do you want to be able to go and hike? You know, this many miles at this speed over this type of terrain. And we show people this list of 50 and we're like, pick the 10 that matter most to you. The ambition that people come up with is remarkable. Oh, I'm going to be heli-skiing in my marginal decade. And they're very serious about this.

They're very serious about this. Because they can heli-skiy in their 40s, which is when I'm asking them to do this. And in their mind, there's no reason they shouldn't be heli-skiing 50 years from now. And I don't want to tell them they're not. I just want to show them that the amount of strength, eccentric strength, concentric strength, cardiorespiratory fitness, like we march through the measurable metrics. The amount of things you need to do that are here. If you want to do this when you're 85 and we know the rates at which these things decline, this is where you need to be at 45 in terms of those metrics. And you're only here.

You're well below that. So you're still above the threshold to do them, but nowhere near above the threshold given the inevitability decline. In other words, you're telling me that you want to your glider to be able to fly another two miles, but you're only 500 yards in the air. If you want to go another two miles, you need to be a mile up. The deterioration is inevitable. The decline is inevitable. Decline is inevitable. We have some control over the pace of it.

We do. So in other words, the first derivative is absolutely negative once you reach a certain age. But you have a lot of say in the magnitude of that derivative. So you got this chapter in here is called Centarians and you look at a bunch of people that are over a century old, which is pretty awesome, which is pretty awesome to be, oh, how old you? I'm a century old. That's pretty awesome. And you got a bunch of different examples in there. And of course, you cite a bunch of examples where the people are drinking whiskey and smoking cigars. And you go through all of that. When I was reading this,

You know, I've written some books and the fiction books I've written, which are one adult fiction book and a bunch of kids fiction books, story needs an arc, right? You kind of have a story arc. And sometimes I look at a lifespan of 80 years or whatever you said, 88 years, 70 years. Like, that's a pretty good story arc. You can fit a good solid story arc in there. How long is long enough? in terms of lifespan? Yeah.

Well, I mean, look, there's a lot of cliches and ways to look at this, right? It's not about the length of life. It's about the quality of life. It's not the number of years. It's the life in those years. Look, I think there are extreme examples that we would all agree are not ideal. Okay? So I think we would all agree that if you take someone who has the greatest quality life,

they're the greatest person, they're living life to the, fullest and yet they die prematurely at 50. They're struck down by an accident or by a cancer diagnosis. They didn't live long enough, right? They should have lived longer. I think we would all agree on that. I think similarly, we would agree that a person who lives a long life from an actuarial perspective, you know, someone that lives into their 90s, right? Remember the median life expectancy today in the United States for a male is probably hovering around 80 or just slightly below. So you take somebody who outlives that by 15 years, but, you know, since they were in their 70s, they've been in a stage of such fragility that they haven't really been able to

enjoy anything. Or they've been physically totally fine, but cognitively they're in such a state of decline. Or both mind and body are fine, but they're miserable sons of bitches, and they have no meaningful relationships and contribute nothing to the world. Well, maybe that's too long. You know, So I just don't think we know the answer to that question. I think it's a complex integration of lifespan and health span. And that's why I think this health span concept is so important. And it's something that for understandable reasons, because it's not as objective, especially on the emotional side, is largely ignored by the medical community.

The medical definition of health span is freedom from disability and disease. That's a broad definition. And in my view, not a helpful definition. Because are you as free from disability and disease as you were when you were 20? I mean, you are. But if push comes to shove, the jocco of today couldn't physically do what the jocco of, you know, 30 plus years ago could do. You don't have the recovery capacity, right? Now, you have other things.

You have more wisdom, right? I would bet that you're emotionally more competent. So health span has to include these more nuanced ideas. It can't be just about disability and disease. I have two comments on this. Number one, my mom, I think it was last year, my mom was talking to me. I was talking on the phone and she said something along the lines of like, you know, it's been a hard. Again, you know, my mom's, my mom and dad are getting in their 80s, late 70s, 80s.

And so their friends are all late 70s, 80s. And my mom was saying, you know, it's been a really hard. three months, four months, whatever, because this person died, this person died, this person died. And I said, hey, mom, I have gone to, like, so many funerals of guys that were 27, 32, 41, 29. And all your friends lived a full, happy life. I mean, I get it.

It's sad. but be thankful. That's part one. The other thing I wanted to say, which is on a lighter note, I have a friend who had sleep apnea. And so he had the big machine, and he was in an unhappy marriage. And he would rip the machine off at night,

because he's a very aggressive, hostile, you know, a seal friend of mine. He would rip the machine off at night. And his wife one time was, was trying to put it back on him in the night he's batting her hands away. And they woke up in the morning. And she said, you know, you need to let me put my machine on. You know, put your machine on.

You need to keep that on. And he says, if I take it off, just leave it off. And she says, what do you want me? You want me just to leave it off? That's what you want me to do? You don't want me to do anything? And he goes, no, just let me die. Just let me die.

So that's the other end of the spectrum. I guess if you're in an unhappy marriage, that can be a, that can be a, real bummer. You know the other thing, have you ever seen the show? By the way, I want to go back, I want to go back to the first point you made because I really, I've been thinking a lot about that lately. Just to take it back to Oliver Bergman's book, that's one of the framings that he talks a lot about. And it's this idea that, okay, we're really struggling with this idea that we're only here for 4,000 weeks. Like, we as a species, because we have, Because of the sentient nature of our consciousness, like we can really process that in a way that animal can't.

Right. So they're not tormented by their finitude. We are. And he said, look, you know, if you think about it through the lens of cosmic insignificance, one, none of us matter. Right. So let's just, let's accept that none of us matter. But another framing is the probability of any of us being here is infinitesimal. It can't even be calculated.

It is so small. Like on the day you were created, like the probability that that was the day that your parents had sex and that one sperm and that one egg managed to meet to create you. Because if it was a different sperm and or a different egg, it would be your brother. It wouldn't be you, right? So the probability of your existence is so remote. We can't put a number on it. It's functionally zero. And he said, you know, look, you think about this.

Another way to imagine this is how great. grateful are you to have any number of weeks? And again, I still would argue that just the way we're wired, I think sometimes it's too short, right? I don't think that the 29-year-old at the funeral, no matter how much they accomplished in their 29 years, you're still mourning on some level. But, you know, if you make it to 80 and you die, it is sad. And I just saw somebody, I sort of know reasonably well die at 83. And he was one of those guys you never thought could die. It was a little, just, it was just upsetting in a way that it would be more so than just anybody dying. But, you know, how amazing is it that any of us might get 4,000 weeks?

Be stoked. Yeah. Have you ever seen the show True Detective? Mm-mm. Okay. I watched the first one. Did you watch the first one? Is it like a Netflix series or something?

I don't know what's on. HBO series. It's done two, three? I think they've got three out, but three out. The first ones were, it's like three seasons? Yeah. Three seasons. The first one is really, really good, especially the first, the early episodes.

Anyways, cops, mayhem going on. But there's a character in there called Ruscoll who's, it's just an unbelievable, unbelievable character, amazing character, just a really smart, cynical, guy who's going through life and and at this one point he's being investigated for crimes there's a whole plot but he's being investigated he's sitting down interviewing there's there's cops that are interviewing him and he goes on this speech which you can go watch on YouTube but basically what he's saying is he's talking about looking at db's dead bodies he's talking about looking at db for 14 hours and he's going through pictures and he's saying

It doesn't matter if you're looking at pictures or if you're looking at real or if you see them just before they die or just after they die You'll see that in that last moment They realize they they're okay because they realize that everything that they've loved and everything they've hated and everything that they've lived and everything that they've worried about and everything they've been sad about everything they've been happy about I Think he says it's just a dream that they have in their own head and they can just let it all go. Just let it all go. What do you think about that? I don't know if everyone goes through that.

I don't know if everybody experiences that, right? And again, it might depend on the time scale, right? It might, if that's a statement about the milliseconds prior to expiration, maybe there is something to that. And we also just really don't understand death. I mean, it really is a vexing problem. Like we don't understand the neurochemical process of death. We don't, you know, when you, you know, I'm sure you've heard like all of these people that have near-death experiences come back and basically say the exact same thing.

It's kind of hard to believe they're just making this up or something, right? Like, there's clearly something really profound that's occurring neurochemically in that, in those final moments, you know, presumably for the people who aren't like decapitated or something like that where it's an instantaneous surprise death. But what I find interesting is that, you know, like there are some people who I hear talk about it. So look, we're all dying. We're all terminally dying. So we're all, we all have a terminal disease. But there are some people for whom that terminal disease is so apparent. So I'm sure you've heard Sam Harris talk about the hourglass.

Have you heard about this? This is, I find this to be a very powerful way to think about life and death. So all of our lives are represented by an hourglass. So when you're born, there's, you know, You know, all the sand is in the top, none is in the bottom, and then immediately the sand just starts flowing. But the hourglass is opaque at the top. So you never actually know how much sand remains in the hourglass. So we watch the accumulation of sand in the bottom with clarity.

That's the years we're living, but we have no idea how much time remains. Now, some people, you know, let's say someone gets a cancer diagnosis, and it's a very bad cancer diagnosis. So it's, you know, you have pancreatic cancer and it's spread to your liver. This is as close to a certain diagnosis as possible. You know you've got six to nine months to live. What that means is now there's all that opacity starts to become transparent in the upper bulb. And you see that there's actually very little sand there. And as those days get closer and closer to the end, it becomes more and more clear.

And I would say that there are very different reactions that people have to that. And maybe I spend a disproportionate amount of time thinking about that and wondering, you know, what's my reaction going to be? Because I've seen many people in that final stage of sand, and I've seen very different reactions. But I would imagine that, yes, virtually everybody, if they're being honest with themselves, realizes that many of us, certainly I would be the heavyweight champion of this, probably spend time worrying about. things that don't justify worry. I have a really, I had a really weird, kind of horrible comparison to this. I was thinking of people that quit. People that quit.

Whether they're quitting, you know, in seal training, whether they're quitting like you're training with them and you see them just quit. And you can see, sure, there's a, there's a moment of, they end up with the shame and the, you know, should I have stuck through it? but there's also like a split second where they rationalize with themselves and they say I don't have to do this anymore that's what I think of when I when I think of that like someone getting that just life is upon them and it's the weight and you can't keep it together anymore I'm good I hope I don't feel on my deathbed like a quitter I really hope I don't

That would send me And I just wouldn't appreciate that. I don't think at all. All right. I'm going to fast forward. Again, the book is 410 pages long. Get it. Get it.

There's so much good. So much incredible information in here. It's, to me, it's like a textbook as well, right? It's a textbook because it is so filled with knowledge and information that, look, there's a bunch of great stories in it, but it's a textbook. to teach you this stuff and a reference back to. Unless you're a medical doctor, you're not gonna read this thing one time

and be like, or like, you know, it's cool for me because I've been listening to you and known you for a long time. So I've heard you talk about these things a lot. So I get to read them and now I get, oh, that's that definition I've been missed. So get the book. Going a little bit here.

Autophagy represents the catabolic side of metal, and again, I'm fast forward. This is a totally different section. Autophagy represents the catabolic side of metabolism when the cell stops producing new proteins and instead begins to break down old proteins and other cellular structures into their amino acid components using the scavenged materials to build new ones. It's a form of cellular recycling, cleaning out the accumulated junk in the cell and repurposing

it for or disposing of it. Instead of going to Home Depot to buy more lumber and drywall screws, the cellular contractor scavenges through the debris from the house. He just tore down for spare material that he can reuse. either to build and repair the cell or burn to produce energy. Autophagy is essential life. If it shuts down completely, the organism dies. Imagine if you stopped taking out the garbage or recycling,

your house would soon become uninhabitable, except instead of trash bags. Trash bags, this cellular cleanup is carried out by specialized organelles called lysosomes. I said that right? Lysosomes. Lysosomes, which package up the old proteins with other detrius, including pathogens and grind them down via enzymes for reuse. In addition, the lysosomes also break up and destroy things called aggregates,

which are clumps of damaged proteins that accumulate over time. Protein aggregates have been implicated in such diseases as Parkinson's and Alzheimer's. So to getting rid of them is a good thing. Impaired autophagy has also been linked to Alzheimer's disease-related pathology, Parkinson's disease, and other neurodegenerative disorders. Mice who lack one specific autophagy genes succumb to neurodegeneration within two or three months. By cleansing our cells of damaged proteins and other cellular junk, autophagy allows cells to run more cleanly and efficiently and helps them, and helps make them more resistant to stress. But as we get older, autophagy declines. Impaired autophagy is thought to be an important driver of numerous aging-related phenotypes and ailments, such as a lot of.

as neurodegeneration and osteoarthritis. So this is, how long have people known about autophagy? This is something, look, I went to high school in the freaking 80s, right? But I remember some stuff from biology. I don't remember a damn thing about autophagy. Well, I mean, I think, we'll put it this way, the Nobel Prize for the genetic elucidation of how autophagy works was awarded relatively recently. so long after you and I were in high school.

So in that sense, it's a little more recent of an understanding. It's, you know, the million dollar question, because you can't read what you just read and not ask, okay, how do I make sure this is happening? What do I need to do to make sure I'm in the right balance? And of course, there is a balance. Very few things in biology are just a straight line or a monotonic increasing or decreasing function.

They're usually use or inverted use. Not always, and we'll talk about some exercise. potentially. Fitness is an example of one where there's no you or inverted you. It's just a straight up. The more fit you are, the longer you live on average, period. Higher your VO2 max, longer your lifespan. But with autophagy, there's a Goldilocks principle. You want to have the right amount. And the most important things that are required to signal to autophagy are generally reduction of nutrient in one form or another. Now, the two obvious ways to do that. One is obvious, I guess one is less obvious. The most obvious way to do that is fasting.

Right? So when you are fasting after some point in time, and most people are surprised to learn, we don't know how long that is in humans. So we know in mice very well how long a mouse needs to fast before it, you know, has a sufficient amount of autophagy going on. But the metabolism of mouse is so much faster than ours that we can't extrapolate. So, you know, in humans, we can. probably say that a day is not long enough, five days is probably long enough, no idea where the balance is. But what's interesting is at the cellular level, exercise is a really important tool for autophagy. Because at the cellular level, when you are exercising, the cell is actually

experiencing enough of an energy deficit that it triggers this process. So this is why exercise and fasting would probably be the two most important tools we have. Outside of pharmacology, there's one drug that may also be used for this purpose, but again, it's a little too soon to say, at least in humans. And so that's where we want to point people. This is another thing, and I think I'm going to get to this later, but you talked about the chances of us being here is so small.

This freaking system that we're rolling around in is a damn miracle. I mean, you think about this stuff going on inside your body, something you've never thought about before that we'd even know what's going on until pretty recently. It's insane what our body is doing all the time to be here, to be sitting here, surviving, living. Yeah, my kids right now, you know my boys, they're young, of course, and you know them well. They're going through that very predictable stage that five, six, seven, eight-year-olds go through, which is total obsession with dinosaurs and sharks. So pretty much all we're doing is watching everything there is to watch.

watch on YouTube about dinosaurs and sharks. And the oldest of them, who's eight, like he knows every fact about these things. Do you know that if a spinosaurus lost its spine, he would still be able to survive because I was like, I didn't even know what a spina. Like I knew what a T-Rex was and a triceratops.

Like I just didn't, I don't have any recollection of this. He knows all of them. And, you know, if you think about it, like how many millions, you know, let's just say, like 30 million years ago,

you had these things roaming the earth with their little tiny pea brains. and to think that like we're here today. Like this is unbelievable. And I love talking about evolution and natural selection with them. Like I really enjoy talking about it. Yesterday, my son was debating with me. And he might be right.

I think he's wrong. But he was trying to convince me that the great white shark has evolved from the megaladon and the megadon did not really go extinct. And I'm like, I don't think that's true, buddy. I think the Megalodon is extinct and maybe the Great White, you know, but but these things are kind of unbelievable. And even at the simplest level, I still can't believe it works. Like just at the level of a Great White Shark or, you know, never mind something that's as sophisticated as we are. Yeah.

When you got all this act, just sitting here thinking about your kids, right? And I was thinking about Jiu-Jitsu the other day. Jiu-Jitsu is evolving. It's so much faster right now than it did. 30 years ago and it's because more people participating but it's more because the information is just readily accessible So you can go on YouTube and you can learn all this stuff and I heard an interview I think it was I think Lex Friedman was interviewing

The chess player the greatest chess player Gary Caspar? Yes, he was interviewing Kasparov and he asked Kasparov if he could meet if he could be Magnus Carlson and Kasparov said no but what was interesting there's two things that he said number one he said because I thought you could beat him of course because you've been playing longer and you're like the guy he said I can't think as fast as I used to so there's the greatest chess player in the world and he's saying no I can't do what I used to do which is crazy because there's no physical thing we this was such it was like one of the first times I ever accepted the fact that the cognitive decline is a real thing that was number one number two he said he he he said

Magnus he has all my moves and he's had all my moves and so he didn't have to create any of my moves he just got them and so now he's creating he's building on what's already there so when we advance in medicine let's say are we advancing at a faster rate now than we did 50 years ago because everyone's just the information's all there I I mean, now we've got AI that can pull up all this old information. You could do studies. Are we getting better? Are we getting faster?

Yeah, in some ways, I mean, the concept, of course, that you're describing is the most important concept of our evolution, right? And I think one fun way to think about this. Actually, Leif was over a couple weeks ago, and we were having dinner and sitting around, you know, our job was making sure that none of the food got burnt on the grill. So while we were sitting there, I posed this thought experiment to him, which was, which I'll pose to you now. So you know what you know. It's 2023. This is everything you know.

I'm going to put you in a time machine and send you back 2,000 years. Let's make it 5,000 years. We're going to send you back 5,000 years. How much can you bend the arc of civilization with the knowledge you have now? 5,000 years ago.

Yeah, well, that depends if I don't just get, you know, die. Let's assume I put you back in the appropriate part of, you know, the 5,000 years ago I'd have to put you in Egypt to be in the center of civilization, right? So I'm going to put you back in Egypt. I'm going to color your skin the right color. I'm going to make you look like you're Egyptian, right? So you're not going to have the knowledge that I have currently.

You have the knowledge you have now. But let's be clear, you don't have any more than the knowledge you have now. Right. So you know what 2023 looks like and you're in 3,000 BC. can you bend the arc of the universe? In some areas. Where? Let's talk about it. Well, I can tell you straight up.

Because I'm sitting here thinking, if they want, I would probably provide little to no value in medicine. Now, look. There's one area you could, though. I could say, like cleanliness, right? Exactly. Sanitation is the only thing I can think of

where if you put me back in time, I could make a difference. Now, that assumes people listen. Because remember, and I write a whole chapter or not a, I write a whole section about Semmelvi. he came up with this idea first, and they put him in an insane asylum where he died. So you also have to assume people would listen.

But outside of that, man, I got nothing to offer. Imagine you standing there. You'd sound like a prophet. We're going to have these things. They're going to be called iPhones. And we're going to have this thing called the internet. Like, what? I mean, the point is.

Connecticut Yankee and King Arthur's Court. You remember that book? No. Yeah, it's like this guy goes back from Connecticut Yankee. He goes to King Arthur's Court. One of the things he does, he knows when the eclipse is going to happen. And so he's like, I'm going to blot out the sun. And oh, my gosh.

But, okay, sorry, continue. Yeah, so my point is, like, all of the modern nature of the world we have today is all predicated on knowledge transfer. It's codification and transfer of knowledge. And until that happened, like, we were in the dark ages for hundreds of thousands of years. And then the reason I think we're, you know, technology is increasing exponentially is due to that. And these have fed off each other, right? So the more we can codify knowledge, presumably starting with the printing press, the more we could get to the point where we could

generate knowledge that could do all these other things. So to answer your question, I think it's nonlinear. I think there are some spikes. So I'll give you an example. You know, most things that people think about, most people understand Moore's law, which is kind of like the pay, you know, it's about an 18-month doubling or halving, depending on how you look at it, you know, semiconductors. You know, so sort of chip size and incapacity. Well, there's actually been one thing in medicine that has taken a step function faster than Moore's Law and its genetic sequencing.

So when the first human genome was sequenced in about the year 2000, the cost of sequencing went down at a Moore's Law rate until about 2006, and then it just went, boom, just dropped to nothing. And now it's continuing at Moore's Law rate, but from a way lower base, line. And that big drop was high, high throughput sequencing, next gen high throughput sequencing. So,

like, that's one example where there's been a step function change in recent years in the past, you know, 15 years that has made at least genetic sequencing, you know, completely transformational. But, you know what? It hasn't translated to a huge impact in health. So it's been a big scientific breakthrough that hasn't really translated to a huge impact in health. I think there are other areas where I think we are starting to see areas where I'm optimistic. So in cancer therapeutics, I think it's been largely pretty unsuccessful for 75 years. And then in the last 10 years, there's been a pretty big improvement in harnessing the immune system. Now, we're we're we're still in totally nascent days, but I would say, and this is probably a conservative estimate,

8% of people who would have died even 25 years ago are living today with metastatic cancer. And we made zero progress from 1950 to 2000 on metastatic solid organ cancer. And so now we've, you know. So we're moving. We're moving. Yeah. That's good. your initial question about what I would do

5,000 years ago and I was like, well there's one area like I know Jiujitsu and you don't need anything for that because like look I know about weapons but I couldn't I don't know how to make the metal to make a weapon right right I know there's I know you can take like bat guanu and make freaking gunpowder somehow right but I wouldn't be able to pull it off but I know Jitsu I'd be I could I could jack some people up

I put together an army we'd take over the world I can say that Well, what kind of weapons were they using 5,000 years ago? What did the Egyptian armies use? My guess is spears. Spears. Yeah. Show the trebice. Yeah.

I don't know if I could show the trebice. There's something. We could start if they didn't have, I guess if they didn't have bow and arrow yet, we could get the bow and arrow out, start using that. Crossbow. Yeah, crossbow. But again, like, figure, I'd have to go through all the procedure. So the broader concept here is that military advancement would be the most important thing that we could bring to us as civilization. Well, that's the most important thing I could bring.

I think you would be a much better person to send back in time. I would make things much worse. It would be much smarter to send Peter and Tia back, not jocco. We'd just end up in some weird warlike, freaking dystopian time right now. But, you know, so let's say you sent me back, right? And let's say by some miracle I could convince people to wash their hands. That would have an enormous impact. But you know what I couldn't do?

I couldn't build a microscope. Yeah, I was going to say, you couldn't build a scalpel? It wouldn't be as much value They would probably already have it It's the anesthetic I wouldn't be able to build ether I wouldn't be able to make ether And that was the big breakthrough

And by the way, that didn't happen until the late 19th century Can you believe they used to cut people surgically Until just 140 years ago Without If I'd call 150 years ago You would undergo surgery

Like white knuckle in it Yeah Damn They were hard back then, huh? Did people just pass out Or you think they just got through it So it's totally, it's really interesting when you go back and read about surgical what was prized in a surgeon pre-anesthesia versus post. Pre-anesthesia, the only thing that mattered was how fast you were.

Damn. Like literally, it didn't matter how accurate. It was like, can you operate fast? They used to operate in front of crowds. Yeah. That was actually not, that was, you would even see operating theaters that exist probably in up until the 1940s or 50s. Who's going? Usually students and other people.

People there to observe. But it's not just like Friday night. It's not the riffraff. Yeah, yeah, yeah. No, it's like the medical students. Okay, well, then that makes sense. They still do that, right? I mean, not in a formal theater.

Okay. You know, not, but you're probably watching videos. Yeah, look, when I was in, when I was in medical school, I'd have VHSs of procedures that I would watch. So that I, you know, I didn't, I didn't want to go in and try to, like, assist on my first one without having watched it a bunch of times. Yeah, that's crazy. There was a guy. in Ramada, army captain, awesome guy. And he would sit back, like, go out on ops,

and he would run a camera the whole time, a video camera from Zahumvi, and then he'd go back and just sit there and watch, and he'd be like, oh yeah, he would know that little, what that door looked like, what that courtyard looked like. That's squared away, you know?

That's the, why would you not do that? Frigan awesome. All right, I'm gonna fast forward a little bit. In the 1950s, a surgeon in Topeka, Kansas, named Samuel Zellman, was operating on a patient whom he knew personally, because the man was an aide in the hospital where he worked. He'd known for a fact the man did not drink any alcohol.

So he was surprised to find out that his liver was packed with fat, just like one of my patients decades later. This man did, in fact, drink a lot. A lot of Coca-Cola. Zellman knew that he consumed a staggering quantity of soda, as many as 20 bottles or more in a single day. These were the older, smaller Coke bottles, not the supersized we have now,

but still, Zellman estimated that his patient was taking in extra 1,600 calories per day on top of his already ample meals. Among his colleagues, Zellman noted he was distinguished for his appetite. His curiosity piqued. Zellman recruited 19 other obese but non-alcoholic subjects for a clinical study. He tested their blood and urine and conducted liver biopsies on them, a serious procedure performed with a serious needle. All the subjects bore some sign or signs of impaired liver function in a way that eerily,

in a way eerily similar to the way. known stages of liver damage seen in alcoholics. This syndrome was often noted but little understood. It was typically attributed to alcoholism or hepatitis. When it began to be seen in teenagers in the 1970s and 80s, worried doctors warned of a hidden epidemic of teenage binge drinking. But alcohol was not to blame. In 1980, a team at the Mayo Clinic dubbed this hitero unnamed disease.

unnamed disease non-alcoholic stadio hepatitis. Am I saying that right? Stieto hepatitis. Steadio hepatitis or Nash. Since then it has blossomed into a global plague more than one and four people on this planet

have some degree of Nash or its precursor known as non-alcoholic fatty liver disease. How disturbing is that? Yeah. It's a hidden epidemic. They thought initially that kids were just binge drinking and that's why they had this fatty liver, but it was

just because our freaking diet was heinous. Yeah. In fact, I think I opened this chapter talking about a patient that I, you know, this is when I was an intern and I was assisting on a procedure. This was a patient who had colon cancer. He was there to get the right part of his hemicolon removed. And, you know, my job was to pre-op him. So that meant I had to go. I had to and ask him all the mundane questions. Among them is how much do you drink? And that's relevant from an anesthesia perspective, right? So you've got to know if somebody's a big drinker.

He claimed to not drink at all, so fine. So we get into the OR. And again, my job is to pretty much just retract and suction. That's it. I'm a lowly intern at this point. And we open him up and like the biggest fat liver just pops out of this guy. And the attending surgeon is upset at me thinking, Clearly I didn't even do the one thing I was supposed to do, which was figure out if this guy was a drinker.

And of course, it turned out he wasn't. And, you know, none of us really thought much about it at the time. But, you know, this was more than 20 years ago. And we now realize today that Nafaldi and Nash are the leading indication for liver transplant in the United States. And this chapter is called the Crisis of Abundance, because this is just too much Coca-Cola, too much crap, which is crazy, right? Like, that's where we're at. That's what's going on. Yeah. I mean, let's start with the positive spin going back to our evolutionary discussion. Well, okay. Mr. Positive Peter Tia, I like it. All right. So you talked a minute ago about how amazing it is

that we're here. And I assumed you were mostly referring to humans. It's obviously true of all species, but it is true. Like we are, we're in a league of our own. But what puts us in the league of our own? Is it our strength? No. Even your strength, right? No. Is it our speed? No. I mean, it's, it's one thing that catapulted us out of the swamp and passed every other species pre or current, and that is our brains. Our brain is the defining feature of our species. And we pay a price, if you will, to have a brain like ours, and it's a metabolic price. So your brain takes up 2% of your body weight, and yet it consumes 25% of your metabolic rate. 25% of the calories you eat go to feed that 2% of your body weight.

So how could we possibly get where we are without evolving a very elaborate system to make sure you never run out of energy? And that's what we had to do. Right. And so, and by the way, if you look at primates today, right, these would be our nearest evolutionary relatives. They don't have this capacity. Right. When you overfeed primates, they get more muscular. When you overfeed humans, we get fatter.

And again, in light of all we're going to talk about, that's not a good thing. But from an evolutionary perspective, it's important because muscle is a lousy source of energy. Fat is not. Fat is a wonderful source of energy. So basically, we were like the only electric car to show up with a huge battery. Everybody else basically had an electric car with a mini battery. And that meant they couldn't drive very far. We were the only ones that could drive all over the place.

So if you think about it up until a couple hundred years ago, those tens of thousands of years of evolution served us really, really well. We were incredibly active. Food was incredibly scarce. We didn't have natural, we didn't have unnatural light. And we didn't really have chronic stress. We only had acute stress. So you've got acute but no chronic stress.

no, you know, unnatural light, scarce food, and you're active as hell. And by active as hell, I don't mean we were like running marathons a day. But like, but you're more active. Gathering, you're moving around. Yeah. And we conserved energy. Like, it's a bit of a myth to say that humans were like constantly hoofing it. We looked for every reason to not move an inch because of the scarcity problem, right?

Like, you never wanted to wait. But you put all those things together and we were in perfect energy balance. And then, you know, a hundred years ago or so, all that started to change when we tried to solve a problem. So the problem was, hey, we don't want to be in farms anymore. Like, we want to do other things. We want to set up a society where people can do things other than be in charge of growing their own food. So we're going to centralize that. We have to be able to scale that problem.

So we have to be able to grow food at huge scale. We have to be able to preserve food to be able to ship it and distribute it. We should really make it taste good as well. You know, start to get into the hedonic side of this. And you basically arrive at this thing called the Standard American Diet. And it, you know, none of those things I mentioned that were part of the optimization state involved make it not harmful. Like that was neither a goal nor a thing to be avoided. It was just it wasn't considered.

It was how do you make it cheap? How do you make it abundant? How do you make it non-perishable? And how do you make it taste good? Those were basically the criteria. And so what we have today is the standard American diet. And so when you take our genes and superimpose them on the standard American diet, it's the crisis of overabundance.

And for most of us, that requires being deliberate. Because if we just let our brains run rampant, I mean, for most of us, we end up in an unhealthy state. Yeah, because part of the evolution that we made was to want to eat all this stuff that tastes good. And that's just you have to fight against that. Absolutely. I mean, if you think about it, like, you know, it's not an accident that we like sweet things. I mean, that was a very important characteristic to have, right? I mean, we, depending on which ancestral tribe you look at, I mean, some of them got up to 20, 25% of their calories from berries and honey.

I mean, we were, we really wanted to know what sweet was. That was a very important trait. In fact, I think I write about it very briefly. You know, one of these things I'm sure you can relate to this, Jaco, is you're writing a book. You sometimes forget the first version versus the published version because it's been hacked down. Yeah. So like the first version of this book was 200,000 words. What people are reading here is 120,000 words.

which is still, to your point, a very long book. It's a big book. But the 200,000 word book, that was a treatise. And I think some of this got, I think there was a much longer section I wrote about the evolution of an enzyme called Euricase and how basically there was a period of time in which we also couldn't get very fat. By we, I mean apes that became us, right? So these apes basically left Africa, went to Europe.

Ice Age comes and they're only the subset of the apes that developed a mutation to preferentially store fat out of fructose. Survived. Because they could eat enough fructose in this fall to fatten up for the lean times during the winter. And the ones who couldn't develop that mutation died off. The surviving ones came back to Africa. they basically became the precursor to us as humans. So again, very valuable set of mutations up until, you know, the last 0.001% of our time on this planet.

That's an amazing system. This freaking flesh bot we're running around. It's really hits nuts. Speaking of that, I'm going to fast forward here. Scientists have been exploring the medical mysteries of the human heart for almost as long as poets have been probing its metaphor. It is a wondrous organ, a tireless muscle that pumps blood around the body every moment of our lives. It pounds hard when we're exercising, slows down when we sleep.

Even micro adjusts its rate between beats, a hugely important phenomenon called heart rate variability. And when it stops, we stop. Our vascular network is equally miraculous, a web of veins, arteries, and capillaries that if stretched out and laid end to end, would wrap around the earth more than 20. twice about 60,000 miles if you're keeping score. So that's each individual human. So I have that. Yep. Are these like microscopic?

That's why? Yeah. So if you think about it, like coming out of your heart is one huge artery called the aorta. And then it immediately splits. So it comes, it has three things that hop off it. Okay. So they're major arteries. But if you trace the major arteries, they become smaller and smaller arterials that become

capillaries, that become veneries, that become venerial. that become veins, tiny veins, that become bigger veins and bigger veins that become the two major veins that flow back into the heart. So what it's saying is, yeah, you take all of those things. Because once you're at the capillary level, you have a whole bunch of these things in parallel. It's not just a serial process. So it's take all of that out.

And, yeah, it's insane. Each blood vessel is... By the way, not to just harp on this idea. This is one of those things that I don't think gets enough attention in terms of, like, how that even works. Like we, like the best and brightest engineers, material science engineers on this planet can't come close to making materials that can do this. Because if you think about it, how does something that small stay patent? It shouldn't.

Like we can't even figure out a way to make an artificial coronary artery. Like if someone needs a coronary artery bypass, we can only use their native blood vessel from somewhere else. And that's an artery that's like a millimeter and a half wide in diameter. It's visible to the eye. We still can't come close to making something that small, let alone the microscopic stuff. Going on same path through each individual blood vessel is a marvel of material science and engineering capable. Expanding and contracting dozens of times per minute, allowing vital substances to pass through its membranes and accommodating huge swings and fluid pressure with minimal fatigue.

No material created by man can even come close to matching this. If one vessel is injured, others regrow to take its place, ensuring continuous blood flow throughout the body. And it's interesting. My note here was F1 engineering is, F1 car engineering is like a miracle. But compared to the human hand, the human heart, to the human brain. Like, it's just not even, it's nothing.

It's a joke. Yeah, it's pretty amazing how our bodies managed to work. So my other note here was what is what is it that we, do we know what we don't know? What is the spark that makes life? Because we can't create an amoeba right now, can we? Do we know what we're missing? Can we, can we identify what it is that we don't know? Well, I mean, I should clarify this.

There are some ways to create synthetic life at a very, like an algae or something like that. There is some type of synthetic biology that can be done. So we can take no algae. We can take the material that is in algae. No, I shouldn't say that. Here's what we can't do. So going with algae, which is really simple, right? So what makes algae special or makes plant special for that matter is photosynthesis.

We can't in a black box make photosynthesis. In other words, we can't in a black box make something that takes carbon dioxide and light and fixes carbon atoms and spits out oxygen and water. Like we can't do that. You know, it depends. Okay, so your question's a bit difficult to answer because we can, you could argue we can take an egg and a sperm and merge those together using in vitro fertilization and we can grow that out. Yeah, I get that. But we're starting with the perfect genetic material at the outset. Like we're starting with a perfect egg in a perfect.

sperm and we inject them. And both those things are alive, right? When you say they're alive? I don't know. I mean, I guess that's a bit of a semantic question, right? What, I mean, how do we define alive? It's not bad. Meaning, if you take an egg and you put it out on the shelf and hit it with a hammer and

put it in the sun, it's not going to work anymore, right? That's right. Same thing with a sperm. Yep. So there's something, there's some attribute that they have that I believe we would call life. it's alive versus it's dead. Yeah, I mean, I guess you could say it's cellular respiration would probably be

the definition or the line. I think cellular respiration would be the cellular definition of life. So which is metabolic, right? So it's a metabolic definition of life. And we can't create that. No. Do we know what it is that what we're missing? Do we understand that is a chemical thing?

Well, I mean, what we understand why it's happening. We don't, like we can't make. a mitochondria. Yeah, that's what's so freaking crazy, right? Yeah, we can't make the engine that drives cellular respiration. Is someone working on that? I mean, we're not even working on that. What we're working on is how do we minimize the damage to our mitochondria, right?

Because if you think about aging, there are hallmarks to aging. I list all nine of them in the book, right? And I think one of the most important or significant hallmarks of aging is mitochondrial dysfunction. mitochondrial dysfunction. So as we age, our mitochondria become less and less functional. So as interesting as it would be to see if we could make mitochondria, I would settle for, can we figure out how to stop or decline, stop the decline of and or reverse the decline of mitochondrial dysfunction. And then the good news is we have some interventions that do. Exercise does, right? Like exercise

clearly blunts that effect. And if you take a person with type 2 diabetes, which would be kind of the hallmark state of mitochondrial dysfunction, and you get that person exercising like crazy and their diabetes goes away, like you've improved the state of their mitochondria. Absolutely full stop.

So we have functional tests that are usually exercise based to determine mitochondrial health. But shy of that, like it's not like we've got a drug that we can give somebody to tinker with that system or to take an 80-year-old and give them 20-year-old mitochondria.

Just not happening. Not yet. We got a long ways to go, don't we? I think very long. And in a way, that's kind of what, like, you know, there's an entire topic I don't touch on in this book. And it's a very deliberate decision, right? And it's basically the entire topic of the sci-fi of anti-aging. Right.

So in some ways, I'm sure there are some people who will read my book and come across and come to the end of the book and go like, where's all the cool shit? Oh, you mean like cryo? Yeah, or just like where you freeze yourself? Yeah, or like where's all the, you know, cellular engineering stuff and where's all the, you know, the highfalutant, really cool ideas that are, you know, we're going to become immortal. And the reason I don't write about that stuff is, one, I think enough other people are. But more than that, I think that I'm trying to write the operating manual for what you can do today. And if nothing else, even if any of those other things come to be viable in our lifetime, and I don't think they will, this would still be your hedge. Right.

This is the what you can do today. Like, why does exercise matter? Why would exercise add a decade to your life? and more importantly, even if it didn't, even if, you know, I often said this, I think I even make the point in the book, even if you told me exercise was going to shorten my life by a year, it would still be worth it based on the dramatic expansion and quality of life. And if you're, I think most people, if they really think about it, they don't care as much about length of life outside of those extreme states.

Nobody wants to die at 50, no matter how good their life is. But if you say to somebody, do you care if you live to 78 versus 88, if you told them that the 88 was going to be 15 years of poor quality and the 78 was going to be six months of poor quality, I'm not sure I know anybody who wouldn't take the 78. So as bringing it back to the mitochondria, like we might not know for a very long time how to rebuild those things,

but we sure as hell know how much exercise will give you better mitochondria, more of them and better ones. Mm-hmm. Speaking of high school science, I was taking my high school science class. And I remember it was in, I think it was in chemistry. And, like, we finally got to something

where my teacher was like, well, we don't know why this happens. And it was the first time in my scholastic career. And I was like, well, you know, I was sitting there doodling or doing something. He's like, we don't actually know why this happens. And I was like, wait a second, what? He's like, we don't know.

It should have been the thing that sparked me to enter physics and become a scientist. But I said, I was like, man, that's messed up. You know, I was too knucklehead to try and think, I could go try and figure that out. Interesting. Fast forward a little bit. Kids are great for that, right?

I mean, the amount of stuff that like, you know, because kids are, they just don't care. They'll just ask questions and they'll keep asking and they'll keep asking and they'll keep asking. Have they asked you a question where you've gotten to? I don't know yet. Oh, yeah, tons. Tons. I'll ask you that stuff all the time.

Yeah, especially the boys, right? Because they're at that age where they're, my daughter now just doesn't ask me too many questions. She knows that you don't know anything. She's just like, it's that guy. But the boys love asking, like, you know, all those kinds of questions. Yeah, that's good. All right. Fast forward a little bit.

Richard Nixon declared a national war. Again, I'm skipping through, like, massive chunks of this book. Go get the book. And I don't even think I'm doing a good job of skipping parts. I think I'm skipping too much. But anyways, that's what we're doing. Richard Nixon declared a national war on cancer in 1971. Initially, the hope was that cancer would be cured within the next five years.

years in time for the bicentennial. You want to talk about some presidential promises gone wrong. Good job. Yet it remains stubbornly undefeated in 1976 and still by the time I finished medical school in 2001 and today for all intents and purposes. Despite well over 100 billion spent on research via the National Cancer Institute plus many billions more from private industry and public charities, despite all the pink ribbons and yellow bracelets and literally millions of.

published papers on the PubMed database, cancer is the second leading cause of death in the United States right behind heart disease. Together, these two conditions account for almost one in every two American deaths. The difference is that we understand the genesis and progression of heart disease fairly well, and we have some effective tools with which to prevent and treat it. As a result, mortality rates from cardiovascular disease have dropped by two-thirds since the middle of the 20th century. but cancer still kills Americans at almost exactly the same rate it did 50 years ago. So cancer, horrible. That being said, I read one time that nurse, they surveyed nurses.

You know, how would you want to die? And the nurses chose cancer. Hmm. And I guess it was what they said was you have time. You can say goodbye. You can set things up correctly. That's what they thought. I had a friend die of cancer, pancreatic cancer.

How old? 48, something like that. Very fit, very fit, triathlete type guy. And I remember I didn't, I googled. But it was early internet. So this was probably, well, it was not early, but it was like 2010,

2011, 2012, something around that. And one of my other friends called and said, hey, we just got, he has cancer, he's got this kind of cancer, pancreatic cancer.

I Google it. Pancreatic cancer, survival rate after two years, zero percent, something that, maybe a survival rate after five years. If it spread, yeah. Zero percent.

Overall, it's like, less than 5% for everybody. Yeah. It's the most lethal cancer along with a certain type of brain cancer. He died four months later. I mean, it was, he must have not known about it until late, which I know you get into in the book.

But yeah, it was awful what it did to this incredibly healthy guy in a very short period of time, which is what surprised me when these nurses said, I think cancer would be the best way. But I guess you have that time to make things right. I'm really, I don't know why you telling that story really reminds me of another one of these memories I have from residency. So I was doing a rotation in the ER. So as a surgical resident, you will do typically one month a year as the surgical lead of the ER.

So you're in the ER taking care of everything that walks in, but they're driving to, to you the surgical cases. And so that means, you know, anything that needs to be stitched up, sewn up, drained, pus, this, that, and the other thing, put a chest tube in, you're kind of doing all those things. So I'm in the, I'm in the surgical wing of the, of the ER at Hopkins. And this young girl comes in and, God, she was, she was, she was probably 21. She's, her mom brought her in.

and she was just complaining a back pain. And it had been like pretty significant. It sounds like it been going on for weeks. And she finally, you know, they just came to the ER, which again, it's kind of an unusual place to go for back pain. You normally would go and see your doctor or go and get a referral to PT or something like that. And, you know, I examine her and she's really in a lot of pain.

And I remember, there's a handful of things you just sort of remember. And I remember, like, just beautiful, beautiful, completely healthy looking. 21-year-old. But there was no question that as I pressed on her spine, like it was really quite tender. And so I suspected maybe she had a fracture. Like it's possible. She didn't report any trauma. And who knows? Like I just assumed, look, either she's got some fracture there because there's some tenderness or, you know, more likely, maybe she's, you know, really had some serious disc disease. And so, you know, for a fracture, the test you want to do is a CT scan. not an MRI. At the time, it was too, it would take too long to get the MRI. So I figured,

look, let's do the CT scan. If nothing else, we don't see a fracture. We would probably just admit her for pain. And then, you know, she would get it, you know, she'd go to the, you know, orthopedic floor or something. They would do an MRI and figure out, okay. So anyway, to make a longster's just right, do the CT scan, she's got metastatic pancreatic cancer. And it's spread to her bone. And that's why she's in so much pain. And I mean, it's, Again, it's just one of those moments where, like, I can't believe this is happening. And how do I go and tell this girl and her mom? And her mom looks like she's, you know, 45.

Like her mom's a young woman. And at that point, she's going to be admitted to not a surgical floor, because this is not a surgical case when the cancer has spread. She's going to be admitted to a medical service, to a medical oncology service. And, you know, they're going to, they're going to, they're going to, palliate her at this point. They're probably, and they might give her some ineffective chemo, but it's mostly palliation. And I just, you know, I just remember not wanting to let her go. Like I just had this sense of like, God, I wish I could admit her to a surgical service,

which of course was made no sense at all, right? But, you know, pancreatic cancer is awful. I mean, it is awful. It's, you know, it's, it's one of those cancers that, gives cancer a bad name. And it's interesting that there's a subset of pancreatic cancer that is curable. So most of them are what are called exocrine pancreatic cancer. So the adenocarcinoma of the pancreas. So the pancreas is made up, just broadly speaking, 5% of the pancreas is endocrine.

That's the part that secretes insulin and glucagon and these peptides. And then 95% of it is exocrine. it secretes the digestive juices. That's where the majority of cancers arise. And those are the cancers that are essentially uniformly fatal. But every once in a while, someone will get a pancreatic cancer of the endocrine system, like a glucagonoma or an insulinoma. Believe it or not, those cancers are almost always survivable,

provided you don't let them fester forever. Do you know who died of a pancreatic endocrine tumor unnecessarily? No. Steve Jobs. How'd that happen? So he was diagnosed with a tumor and for reasons I don't, I was never involved in his care. Of course, I didn't, I never knew the guy. But based on everything I've read, he just decided he was going to beat this treatment. He was going to beat his cancer with juice and stuff like that. So he went way too long without getting treatment. And by the time he did get treatment, the cancer, the cancer, head spread to his liver. It was a bit too late. They treated him, but ultimately he needed a liver transplantation, which is a very unusual procedure you would do. You normally would never do a liver transplant for cancer that has spread to the liver, but you could do it for this type of cancer. But even then, it was too little too late, and he ultimately died as a result. So it's sort of one of the great ironies, right, which is you have this person who, you know, had such a remarkable impact

on the world gets diagnosed with a cancer, but gets really lucky in that he gets diagnosed with a cancer that is survivable. But, you know, for reasons of his own, just felt that he could sort of beat this without traditional treatment. But, you know, the people I've spoken to, and I do know people who were involved in his care, and they've all said that had he undergone the standard treatment for that immediately, you know, he'd probably still be alive. Is this just crazy ego? I don't know. I mean, again, having never met the guy knowing nothing about him, you know, literally only having read a bunch of his biographies, you know, his biographers would certainly speculate.

And they have. But I don't understand. Yeah. And at a certain point, your doctors are telling you and then you're, you know, I'm sure he went and got a second opinion and a third opinion and they're all like, hey, bro, you need to get this taken care of. He's like, no, I'm good. Pass me the carrot juice. Yeah. Damn.

That's insane. I did not know that. Fast forward a little bit important to bring this up. The final and perhaps most important tool in our anti-cancer arsenal is early aggressive screening. This remains a controversial topic, but the evidence is overwhelming that catching cancer early is almost always net beneficial. Unfortunately, the same problem. encountered in residency applies today. Too many cancers are detected too late. And after they've grown and spread, very few treatments work against these advanced cancers in most cases outside

of the few cancers that respond to immunotherapies. The best we can hope for is delay is to delay death slightly. The 10-year survival rate for patients with metastatic cancer is virtually the same now as it was 50 years ago. Zero. We do, we need to do more than hope for novel therapies. when cancers are detected early in stage one, survival rates skyrocket. This is partly because of simple math. The early stage cancers compromise fewer total cancer cells or sorry, comprise fewer total cancer cells with fewer mutations and thus are more vulnerable to treatment with drugs that we do have, including some immunotherapies.

I would go so far as to argue that early detection is our best hope for radically reducing cancer mortality. Where does the resistance come from? I think it comes from an overly simplistic view. So let's take a step back, right? You alluded to kind of Medicine 2.0 earlier. And one of the first chapters in the book is kind of devoted to explaining the difference between Medicine 2.0 and 3.0. And by the way, that's the underlying, that's the underlying theme of the book, is that Medicine 2.0 is, hey, we treat what hits us.

Medicine 3.0 is, or sorry, medicine 2.0 is we catch the eggs that are dropping from the building. Medicine 3.0 is we go and find out who's dropping these eggs and we get them to stop. So it's prevention, interdiction, early interdiction, early detection. That's what medicine 3.0 is. Yeah. So as you go deeper and deeper into that, you realize that one of the hallmarks of medicine 2.0 is an appropriate reliance on randomized control trials. So again, if you take a step back and go into the medicine 1.0 days, which was basically all of human history up until the late 19th century, we were just making stuff up.

Like everything was just sort of made up. Everything was a story, right? I mean, if you go back and really think about it, like that's how we made sense of the world around us. We are storytelling creatures. And we had to make sense of the sun, the moon, the stars. darkness, bad things happening. Every, you know, why is Johnny sick? It must be the bad humors.

It must be the bad air. It's getting dark and then light. Clearly these things are revolving around us, right? So you can't fault us for doing this. But once the scientific method was really developed, and this happens in the sort of middle of the 17th century, um, you fast forward a couple hundred years.

and we now start coming up with this idea of doing experiments. And this becomes very, very important. In fact, it becomes the cornerstone of Medicine 2.0. And these experiments, which everyone has heard of, called randomized controlled experiments, have an area where they work really well, but they have blind spots. So they work really well when the interventions are simple.

And when the out-examined. outcomes are going to occur relatively quickly. So a good example of a randomized control trial is, you know, does giving kids, you know, this vaccine for measles prevent measles? And, you know, even that's too complicated. Let's take something simpler. Like, does using this antibiotic when you have an ear infection reduce the risk of perforated eardrums and long-term complications?

You would take a bunch of kids and you would randomize some of them to the antibiotic and some of them to a placebo and you would follow them and you would very quickly see that there's a difference. And because they've been randomized, you've eliminated the bias. This is the magic of randomization. It takes out bias. We otherwise can't eliminate bias fully. Randomized control trials don't work very well in nutrition because the intervention is way too complicated. It's very difficult to tell a group of people to go and do something nutrition-wise and have them be perfectly compliant for five years and come back and compare it to another group of people. We can talk about some examples of where that's work, but nevertheless, it's challenging.

There's that time course. So even with the best of intentions, the randomized controlled experiment has a problem, which is it's only giving you average information. So you put N people into the system. They're all different. You run an intervention and you get an average outcome. That's valuable information at the population level, it's not very valuable information at the individual level. Any individual that went into the computation of that average could be quite distinct. There's quite a variance to that. So bringing this back to cancer screening, the real issue with cancer screening is the technologies that are typically debated, all have strengths and weaknesses, all have.

limitations, I'll have blind spots. And if you look at this in a very simple way and you factor in dollars, you might make the case that, you know, the only way it's justified to catch a cancer is if it saves money in the long run. And that's kind of true in a way, but it's based on a couple of problems that I'm not really here to write about. So I'm I'm only here to write about the individual. I'm not here to write about the policy. And the reason being is I think the policy side is broken. So we have artificial costs associated with health care in the United States.

So none of the dollars that we talk about in the U.S. are real dollars. It's just funny money. They're made up numbers. And it's gotten a lot worse in the past 12 years. So 12 years, the U.S. government made a deal with the devil. And the deal was you promote the Affordable Care Act. We will never negotiate with you on price again to the drug companies. So we just pay much more for that.

Furthermore, we have this two-tiered system of for-profit, not-for-profit in health care. So all of a sudden, unlike everybody else, we have a for-profit health care system, which just drives up cost. remarkably. So, you know, that's a whole separate discussion, which I'm not interested in at the moment. I'm actually asking the question, what should you do? What should your wife do to maximize their odds of not getting cancer? Or if you get cancer, beating it. So in that situation, we have to stack screening modalities. So let's take breast cancer as one example. And then we'll take prostate as another example and use those two,

because those are the second and third leading causes of cancer deaths. So it's lung, breast and prostate, colon pancreatic. Those are the top five. Those five cancers are responsible for more than 50% of cancer deaths in the United States. So the standard, you know, thinking on breast cancer historically has been mammography. And a mammogram is a decent test, but it's not a great test because no single test is a great test.

A mammogram has like a roughly 90% sensitivity and 85% specificity. So sensitivity means how likely is it to see cancer if cancer is present? So the answer is about 90%. The 85% specificity means how likely is it to say no cancer is there if indeed no cancer is there, 85%. That might sound okay. It doesn't sound okay to me at all, bro, honestly. Yeah, it doesn't because when you start. start to factor in the relatively low prevalence of cancer, which might be one in 10, your positive

predictive value and your negative predictive value are horrible. So this is how mammography got a bad rap. And this is why some people say, well, you know, mammography is like, yeah, you should do it, but, you know, we don't need to do it that often. Or, you know, you've got all these reasons for not doing it. And what I would say is, yeah, mammography is really good at some types of cancer. it's good in women typically post menopause because postmenopause, their breast tissue is much less glandular. So it's easier for the x-ray to see. It's also better when cancers have some degree of calcification in them. But it's not good for glandular breast tissue. It's not great if the cancer doesn't have any calcification in it. So instead of just thinking about

mammography, we should be thinking about how do you combine mammography with either ultrasound or MRI, which are far more sensitive. Now, again, a lot of people are just going to say, who's going to pay for that? Well, I'd argue that's where we should be spending money. We shouldn't be spending money on drugs that we're going to put people on when they have metastatic cancer for cycle after cycle after cycle after cycle after cycle. It's much better to spend the money right now when you treat something that's very small. Similarly for prostate cancer, I mean, the PSA test has basically become persona non grata. So basically, the thing is, the thing is, you know, the thing today is there is no official recommendation on prostate cancer screening, despite the fact that it's

the second leading cause of cancer death in men. There is no actual recommendation on screening. And the reason is, people say the PSA test is neither sensitive nor specific enough. And that's true. And in particular around the specificity. It has very low specificity. But that's if you take it in isolation. In other words, if you say, look, we're only going to care, we're only going to trigger, you know, an awareness if a guy's PSA is over four. And if you do that, you're going to be doing a lot of unnecessary biopsies. You're also going to miss quite a few prostate cancers. And I just think of that as like, I don't know, paint by numbers, right? Like, yeah, paint by numbers sucks. Like, if you want to be a real artist, you can't have lines that you color in with numbers. Like, you have to go beyond that.

And to do that, for example, you should be looking at the velocity of PSA. So if you check a guy's PSA every year, you should be not just looking at the number, but what's the rate of change? If that is over 0.45 per year, even if the absolute numbers are low, that's a reason to be concerned. Secondly, you should be looking at PSA density. So not just looking at the PSA, but dividing the PSA by the size of the prostate. So you're looking at how much PSA is coming out per unit size of prostate. and the bigger that number, the higher the concern. And if you have any man that's high risk,

and there are lots of different things that easily would tell you somebody's high risk, you should be doing other tests, such as a 4K test, and if any of those other things trigger, you would do a prostate MRI. And if you do all of these things, you could say, oh, well, gosh, the cost is a little bit higher.

Yeah, but it's a fraction of the cost and the morbidity that comes with missing that and waiting until that cancer has spread to the bone. because, again, once prostate cancer is spread to the bones, there's no going back. There is no effective treatment. It's a terminal condition. So all of these things come down to just understanding the basics of the following observation, which is every cancer that gets treated at an early stage when compared to the same cancer being traded at a late stage,

even when they use the exact same drugs, has a dramatically different survival profile. And we don't need very, very fancy drugs to treat these early stage cancers. So does the hospitals just run the numbers and think, well, we got 100 patients. If we give them all this screening, that's going to cost more than what it's going to cost to give? It's not the hospitals. It's the payer. So, you know, it's a really complicated system our system is. And, you know, it's funny.

We were talking about this before the podcast started that I'll never write. another book again. And that's largely true because there's only two conditions on which I would ever write a book again. One is I'd have to have enough time to do it and that's not going to happen for like a decade. And two, there would have to be a topic I'd be willing to go deep enough into to spend five years doing it. One of the few topics that would at least trigger that is this topic, right? Which is, and I don't know if I could ever do it, right? Like I just, I don't know if I could in just five years wrap my head around this if I totally immersed myself. But how would you structurally fix our system.

And one element of that problem is you have the wrong people owning the risk, right? Like we should actually own the risk for our lives. We would make better decisions. You want someone with skin in the game owning the risk. Hospitals should not be profiting off disease care. Like there's all these things that are totally broken. But it's it's the payer that's making the calculation that says, saying, look, I mean, we don't want to do these things.

And the payers primarily the insurance companies? Mm-hmm. Or the employer. So it depends on the size. So usually for a company more than 50 people, the employer is the insurance company. So, you know, if you're, you know, if you're General Motors, you are insuring your employees. You do it through someone that looks like an insurance company. You do it through Etna or Blue Cross or whatever, but you're the one that's footing the bill.

And you're the one that's, you're the actuary, basically. So, but they're doing what I said, which is they got 100 people or whatever that number is, and they run the numbers and say, look, it'll cost this much money for all this different screening. Or we just roll the dice and usually the dice come up that we'll lose a couple people. Or they just look at lousy studies, right? Like there was a study that got so much attention last year by all of the anti-screening advocates. And it was a study done in the New England Journal of Medicine. So, again, very prestigious journal. It might have been JAMA, but I think it was in England Journal of Medicine.

And it was a study done in Europe and it was testing the hypothesis, which is, hey, what's the efficacy of colonoscopy for colon cancer screening? Now, I mean, I don't know how many pages in this book I devote to the reasons why colonoscopy is one of the most important tool we have. Because of those five top cancers that kill, colon cancer is the only one that we could completely prevent. Meaning it's the only one that we can definitively look at and stop in its tracks. Yeah, you say that so every, every colon cancer starts as a polyp. That's right. And you can see the polyps and you can get rid of them. That's right.

This is like just the facts. Yep. So here's this opportunity. This is a cancer that you can basically eliminate. That's right. You could eliminate that. I can't say that for breast completely or prostate or lung or pancreatic. Those are more complicated cancers.

Obviously not smoking would get rid of 85% of lung cancer. So, you know, that's a given. But 15% of lung cancers are coming in non-smoking. And if you took all the smokers out of lung cancer and just looked at the non-smokers and never-smokers, lung cancer would still be the seventh leading cause of cancer death. That's how devastating it is. So back to this question. So this study, and I believe it was done in a Scandinavian country, but I'm blanking on exactly which one, if it, in fact, it was in Scandinavia. It was a 10-year study that if you read the headline, you would come away thinking, yeah, it's not worth doing colonoscopy. because the headline was in the group that was randomized to get a colonoscopy versus the group that was randomized not to. The reduction in colon cancer was only, I'm going to sort of, it's, I've written about this briefly, but I'm going to butcher it.

It was small. It was like a couple of percent. And so the argument put forth by the anti-screening advocate would be all those colonoscopies, the cost of doing those wasn't worth saving a couple of percent of people from getting colon cancer. But again, here's where you have to be a good consumer of science. You cannot just rely on the headline. You have to look finer. Okay, so the first thing is the study was very poorly done. The study tested taking a group of people and telling them to do nothing and telling a group

of people and recommending they get a colonoscopy in the next 10 years. Now, I don't remember the number, but it was less than 40% of the people who were told to get a colonoscopy actually did, get one colonoscopy. in that 10-year window of time. So to me, a more interesting study if you're really trying, so in other words, all that study told us that if you tell people to get a colonoscopy in 10 years, and it might have been less, it might have been like, it might have been 25% of the people actually did it. One in 10 years, yeah, you're not going to make that much of a difference. Because in the book you say it should be, it's not once every 10 years.

So this thing can progress. What do you recommend in the book? Every two, three years or something like that? no definitive answer to this because no one can do the full math on how long it truly takes for a polyp to develop. But in our practice, we're typically looking about every three years for modest risk, normal risk individuals, higher risk individuals. So someone who gets a colonoscopy and you find a cessal polyp, which is a higher risk polyp, or someone who gets colonoscopy and they didn't have a complete bowel prep. So the endoscopist couldn't visualize the complete colon. We're going to repeat that in a year.

But let's just say all things go well all systems are go you go and have a colonoscopy They pull off a couple of pedunculated polyps that turn out to be nothing Yeah, we'd recommend two to three year repeat as aggressive as that sounds But again in this experiment they did 10 years We recommend you get it and then they actually use this as a reason to not get colonoscopies That's right that's insane How does it how does somebody publish something like that? Well, again, you know, it's people would look at that and say, I mean, it was a big, randomized control trial.

But again, there's a big confusion. I mean, I think even in the medical establishment, there's a very big confusion between what is efficacy, which tests how well something works if done perfectly versus effectiveness. How well something works based on how you're told to do it. Both of those things are important. They're not the same. You have to know which one you're testing. Okay. Okay. So there's cancer. Damn. And I'm thinking as I as I am going through this and as we're doing this podcast, I realized like I would I would have been much better off to have laid out kind of the way you lay the book out. And I didn't do that. So I apologize because you hit these topics, you know, and the next one that you get to is Alzheimer's. You say this Alzheimer's disease is perhaps the most difficult, most intractable of the horseman.

Diseases. And you talk, that's what the book, that's another main theme of the book. Tell us the horseman diseases, the four horsemen. Yeah, these are the main four diseases that are the result of chronic death, the chronic diseases. So cardiovascular disease, cancer, neurodegenerative disease and dementia. And then the fourth one is kind of the foundational one, which is all of those metabolic diseases like non-alcoholic liver disease and type two diabetes.

Yep. So you hit these, and at this point in the book, you're talking about the most intractable of the horseman diseases. we have a much more limited understanding of how and why it begins and how to slow or prevent it than we do atherosclerosis. How do I say that freaking word? Athroschlorosis. Yeah, that. Unlike with cancer, we currently have no way to treat it once symptoms begin.

And unlike type 2 diabetes and metabolic dysfunction, it does not appear to be readily reversible, although the jury is still out on that. This is why, almost without exception, my patients feared dementia more than any other consequence of aging. including death, they would rather die from cancer or heart disease than lose their minds, their very selves. I had, I watched a close friend of mine, actually a couple of close friend of mine, their father, um, got Alzheimer's. And it was way more rapid than I envisioned. And he was a very active, very physically healthy individual.

and this came on very quickly and it was horrible. He was angry, he was confused, he was violent. This is horrifying. And another important lesson that was passed on to, well, I passed this on to everyone is they didn't try and get him into a home until he was, too far gone mentally where it could not be explained to him what was happening. He didn't accept it. You know, you can go and if you can make that transition while you're more mentally aware of what's going on and you make the decision and now you are in a home.

But like good family is trying to do, you know, we don't want to take you. You want to put you in there. You know, you stay out here and he didn't want to go in, right? And by the time they got him in, he got kicked out. got kicked out of the home. Like he was too, too violent. It was absolutely awful.

The only blessing in all this is that he did die. He died relatively quickly after it got really bad. The weird thing about this is, like you say we lose our minds and their very selves. Who are we? Like, who are you? Who am I? What makes me, me?

and if I behave a certain way, when am I not me anymore? Yeah, it's an interesting question. And again, it's a human question, right? It's, I don't think we can, I don't think we can think about this through the lens of any other animal. You know, a meditator would say we are not our thoughts, right? I mean, I think that would be,

that would be one of the tenets of mindfulness-based meditation is learning to create distance between our thoughts. But, you know, on some level we are, right? I mean, I think on some level, we are, we are our consciousness, we are our thoughts. I think those two, I don't think those two are mutual exclusive, I guess is what I'm saying. I think we can, I think it's very valuable to be detached from our thoughts, and it's very important to understand that they are things that pass through our minds. and that that but at the same time you know there are certain things about me that would cease to make me me if it if they didn't exist I had a woman on this podcast a friend of mine her name is Sarah Wilkinson her husband was a seal

elite seal great reputation and she they got married when you know when he I think they got married actually before he was in seal training and then she spent his spent her his career with him and he he killed himself while he was on active duty and what she said was the guy she married was not the guy that killed himself like it was a different person and look what was it was PTSD it was explosive breaching like all those things that the brain gets exposed to and that's why I've been I've been thinking a lot about that idea lately is You know, what makes you, you, and at what point are you not you anymore?

And I guess there's a lot of second and third order effects that go into that. You know, do you say, hey, if I no longer remember these things and I'm not me anymore, then put me in a home, let me, you know, put me on, put me out to pasture. The Alzheimer's disease, the way it's described in the book, when it's like, it sounds like spider webs kind of in the brain. Is that what it is? That's what it appears to be. Yeah, I mean, it's basically...

You use the word dental. You like, that's the word used. There's a word dental to describe what the brain looks like. Well, there's... I was thinking of floss. That's the only thing I mean. You know, there are these proteins that get folded. And amyloid is the protein that's most associated with Alzheimer's disease.

And if this amyloid protein gets misfolded inside the... the, inside the neurons, it's, it's an inflammatory process. And then you get these other types of neurofibulari tangles called tau. And they're kind of these structural tangles around the neurons. So, so there's very much a physical process that's actually happening in the cells that are destroying the cells. And one of the challenges is that we don't have a direct way to measure. those in an early stage. Now, as of right now, we do have some pretty interesting advances where there are certain blood tests that can look for things that correlate very well with those findings, both the amyloid and the tau. So we are just now starting to do this type of

stuff where we can use a blood test, or if you're willing to be a little bit more aggressive, you could use a lumbar puncture. So do a spinal tap on somebody and look at the cerebral spinal fluid. We don't do that in clinical practice, but they do that in research studies. And you can identify beta amyloid and tau in people who are still normal.

And we can use that. And you might say, well, what's the value in that? I'm going to say, can you do anything with that? Yeah, I think the value in that is we can start to reverse that. And we are seeing that. Now, again, this is still too early to tell because it hasn't been, you know, studied in a large, rigorous fashion. So anecdotally, all I can tell you is we do see that making positive changes,

and we can list what those changes are, can take people who are pre-clinical. So either they don't have any signs of cognitive impairment, or they only have mild signs called MCI of cognitive impairment, and we can pull those people back. What I don't think we can do is take people in, frankly, dementia and make a difference. Well, speaking of what we can do about these things, and I'll give myself a little reprieve here in saying that this next part of the book that you write, part three of the book,

is the basically what we can do about it, part of the book. And you go through a section talking about thinking tactically versus thinking strategically, which is a great thing to put in a book, especially from my military perspective. strategically, obviously the big picture of what we're trying to accomplish overall and tactically, how do we actually make these things happen? And you say this in medicine 3.0, which I think we've described now, and I apologize for not describing that more clearly out of the gate. This is us trying to prevent things from happening. Medicine 3.0. We have five tactical domains that we can address in order to alter someone's health. The first is exercise, which I consider to be the far most potent dominant in.

a potent domain in terms of its impact on both lifespan and health span. Of course, exercise is not just one thing, so I break it down into components of aerobic efficiency, maximum aerobic output, VO2 max, strength and stability, all of which we'll discuss in more detail. Next is diet or nutrition, or as I prefer to call it, nutritional biochemistry. The third domain is sleep, which has gone unappreciated by Medicine 2.0 until relatively recently, the fourth domain encompasses a set of tools and techniques to manage and improve emotional health. Our fifth and final domain consists of various drugs, supplements, and hormones that doctors

learn about in medical school and beyond. I lump these into one bucket called exogenous molecules, meaning molecules we ingest from outside the body. And the beautiful thing about those is we can control. All those different things, we have some level of control over. which is awesome. Chapter 11. Exercise.

The most powerful longevity drug. I never want to fight in the ring. I always won in preparation. Muhammad Ali. This gives good background here. Several years ago, my friend John Griffin pinged me with a question about how he should be exercising. Should he be doing more cardio or more weights?

What did I think? I'm really confused by all the contradictory stuff I'm seeing out there, he wrote, behind his seemingly simple question, I heard a plea for help. John is a smart guy with an incisive mind. And yet he was, even he was frustrated by all the conflicting advice from experts, touting this or that workout as the sure path to perfect health. He couldn't figure out what he needed to be doing in the gym or why. This was before I'd gotten back into full-time practice of medicine.

At the time, I was immersed in the world of nutrition research, which, if anything, is more confounding than exercise science, rife with contradictory findings and passionately held dogmas backed by flimsy data. Are eggs bad or good? What about coffee? He was driving me nuts, too. I remember those days. I started typing out a reply and kept on writing. By the time I hit send, I had written close to 2,000 words, way more than he asked for. The poor guy just wanted a quick answer, not a memo.

I didn't stop there either. I later expanded that email to a 10,000 word manifesto on longevity, which eventually grew into the book you're holding in your hands. Clearly something about John's question triggered me. It's not that I was a passionate devotee of strength or training over endurance or vice versa. I'd done plenty of both. I was reacting to the binary nature of his question. In case you haven't figured it out by now,

I'm not fond of the way we reduce these complex, nuanced, vitally important questions down to simple either oars, cardio or weights, low carb or plant-based, olive oil or beef tallow. I don't know, must we really take sides? The problem,

and we shall see this again in the nutrition chapters, is that we have this need to turn everything into a kind of religious war over which is the one true church. Some experts insist that strength training is superior to cardio, while an equal number assert the opposite. The debate is as endless as it is pointless, sacrificing science on the altar of advocacy. The problem is that we are looking at these hugely important domains of life, exercise, but also nutrition, through far too narrow a lens.

It's not about which side of the gym you prefer. It's so much more essential than that. More than any other tactical domain we discussed in this book, exercise has the greatest power to determine how you will live out the rest of your life. There are reams of data supporting the notion that even a fairly minimal amount of exercise can lengthen your life by several years. It delays the onset of chronic diseases pretty much across the board, but it also is amazingly effective at extending and improving health span. Not only does it reverse physical decline, which I suppose is somewhat obvious. But it can slow or reverse cognitive decline as well. So if you adopt only one new set of habits based on reading this book, it must be in the realm of exercise.

If you currently exercise, you will likely want to rethink and modify your program. And if exercise is not part of your life at the moment, you are not alone. 70% of the US population is like you. Now is the time to change that right now. Even a little bit of daily activity is much better than nothing, going from zero. from zero weekly exercise to just 90 minutes per week can reduce your risk from dying from all causes by 14%. It's very hard to find a drug that can do that. Thus, my answer to questions like the one my friend John Griffin asked me is yes and yes. Yes, you should be doing more cardio and yes, you should

be lifting more weights. Yes. I was so stoked when I was reading this part of the book because I finally felt like I was doing something good because I work out very religiously. And that was awesome. So I should have had you read that chapter. Oh, don't you think? Yeah, yeah. Like, don't you think a guest reading, how did we not think of that? That would have been cool.

Yeah, that would have been cool. A guest reading by Jocko. Yeah, I could have thrown in this little chapter here. I would have had to get somebody to help me, you know, put the phonetic pronunciation for some of the words. So that was weird 77% of people that don't exercise I am so If you were to ask me that question

I would have said it was probably got to be at least 15 or 20% of people in America That don't exercise Like that's how that's how much I mean obviously I own a gym I do jiu jiu jit-to I do CrossFit Like everything that I'm doing

I'm around to people that work out And people that come up and talk to me All over the world they all work out. So 70% that's crazy. With your patients, is there anything that stops

your patients from exercising? When you get that patient that's like you give him the program and three months later he's like, well, you know, next month I'm really going to start for real because he hasn't done anything yet. What holds him back? Yeah, I think there are probably a number of things.

So there's probably a subset of people who genuinely don't enjoy it. And I try to be sympathetic to that because I acknowledge that I genuinely do enjoy it. Now what's not clear to me is do I enjoy it because I just started it at such a young age and it's always been a part of my life and I've done it enough

to appreciate the short-term and long-term benefits of it. You know, one of the things I try to explain to people is that all of these things that we're talking about, but let's use exercise because I think it's the most important, have an advantage over of them that saving for retirement does not. So it's not like rocket science that you would tell somebody when they get out of college and start their first job. Like you got to put some money away, right? You got to save money for when you're going to retire. And there's value in that, and we understand that. But we should also acknowledge that when you ask somebody to do that, there's no short-term gain that comes from that. So if you're making $1,000 a week and you want to set aside $150 a week, there's lots of long-term gain to that.

But let's be clear, you get nothing in the short-term for doing that. you're just $150 lighter every week. It's $150 you could be spending on anything and you are not. But almost everybody would agree that there's value in doing this. With exercise, I can point them to all the long-term data. And I can make a more compelling case for this than I can for anything else. Again, I can't restate this enough. Right?

Like, is it better to be fit than to not smoke? Yes. is it better to be fit than to not be obese, not have diabetes, not have high blood pressure? Nothing compares to extreme fitness in terms of lifespan with respect to all-cause mortality and health span. I can give them all of that. That's like saying you can save that $150 a week

and I'm going to give you the greatest rate of return. I have an investment vehicle that's going to give you the greatest rate of return such that that $150 a week is going to be $10 million in $450. 40 years. That would require a great rate of return. But I can say that, guess what, you also get something in the short term. Yeah, you do. Like, you get something every single day that you do it. And that's why I mean by exercises, this really potent drug. And we can't replicate it because it's not just one molecule. It's doing so much every single time you pound it, right? You're getting an endorphin rays. You're getting an immediate response to your vascular system. It's changing your

energy levels. It's allowing you to do things here and now that make you better. There's a psychological component when you do something that is difficult in the gym or on the track or in the pool or wherever you choose to get your exercise. And you develop a sense of fortitude. Again, saying any of these things to your audience is dumb, right? It's sort of like, what's the expression? It's like telling. Singing to the choir. Yeah, singing to the choir or saying something about the Pope, right? So I don't need to go through all of that. But, but, but, If someone's never done it and they've never experienced the short-term benefits, the inertia can be really hard. So again, I think this is an argument for, I think, why we want kids to be active.

I think it's very important that kids are active because I think this is a very important lifelong skill. And so again, I'm sure you've been asked these questions. Like if you could, you know, change one thing in the world today, what would it be with respect to? your particular issue. And I think for me, the one thing I would probably change is institute a much more rigorous process of physical education and exercise from basically the time kids are born. So it's just take all those movements that kids do perfectly, which they do. They're all perfect when they're born and just never let that go away.

And everything should be built around movement. Everything. Education should be built around movement. Isn't that crazy gone in the complete opposite direction? Like they don't they have schools with no PE now and and when they do have PE it's like nothing. No, it's funny you were saying this way I don't need to tell your audience this, but you actually when I wrote Discipline equals Freedom Field Manual I sent you speaking of chapters I sent you the chapter on physical fitness and I was like hey I got and on diet. I was like hey man here's what I'm here's what I'm putting out. How am I doing? And you're like freaking good to go because which meant I basically had already been listening to you for a while. So so that's cool. But. Oh, I was. I was going to say, oh, I was going to say this.

This reminded me. You talk about like putting money in the bank physically. I remember when I was going to join the Navy. And I was like, damn, you know, this is like 20 years a long time. But I remember thinking to me as a 17-year-old, hey, when I join, I'm going to be in such good physical shape that when I get out, I'll still be like, good to go. And I was right. Like it teaches you a lot about physical fitness.

and it becomes a physical culture of life. Is there anything? So if you get one of these clients of yours, one of your patients, by the way, you have a practice where you help people with longevity. Again, I'm skipping all kinds of stuff today. When you have someone that doesn't want to exercise, have you found anything that helps them? And I have to preemptively say this.

People ask me all the time, like, well, how does someone get through seal training? And some people say, like, you know, you've got to have something, like, really meaningful. The fact of the matter is, there's guys that, like, having a girlfriend that dumped them in high school, I'm going to show her. I'm going to be a seal, and they make it. There's someone else that, you know, told his dad that I'm going to do this, and that's enough. There's, like, and there's someone else that's like, they told me I couldn't do it at the recruiting station, so I'm going to do it just to prove them wrong. And there's some people like, oh, I just want to serve my country. I want the people have an infinite number of reasons that they just make it through this program and it doesn't really matter

It doesn't really matter which one you have some people you'll I I see people on like Online will comment like you'll never make it through if you don't have the why or if you and I'm like bro you don't know This dude just like wants to prove his older brother wrong and he makes it like that stuff happens Have you figured out a way to coerce that out of people so they understand the value that they'll get if if they freaking exercise 90 minutes a week? Yeah, it's a combination of things and it's different for everybody. But I definitely do a little bit of carrot

and a little bit of stick. So the stick is usually showing them what the end looks like without it. Damn, it's going straight, scared straight. Well, it's marginal decade reality, right? It's like, okay, so let's talk about the inevitability of decline here. I don't know what you told Laf Babin,

but I called him today and he's like, he's like breathing hard. And I'm like, oh, what's going on? He's like, I'm just getting on finish up a workout. I was like, oh, I'm getting ready to record with Peter Atia right now. And he goes, yeah, why I'm here right now. We're talking about that marginal decade, man. I'm not on the path right now, which is funny.

You know, he's been hanging out with me for freaking 17 years, but it wasn't until he looked at his marginal decade from you where he's like, I better get my ass in the gym. So there you go. Good job. Yeah, and look, part of it is we're all victims of what works for us. And for me, that's a very motivating thing. Like it's really motivating for me to think about that last decade.

I'm now old enough that some of the things that used to motivate me don't. Vanity motivates me less. Okay. I'm going to be honest. Like the first time I stepped foot in a gym, it was for a totally different set of reasons than the reason I lift weights today. You wanted them guns. Yeah, you just, you didn't want to be, you didn't want to be this grannie kid anymore, right?

You wanted to show everybody how strong you were, how tough you were. And sort of none of that stuff means to me today what it did then. So now I have a different point of view. But I will say this. Look, that's the stick part. The carrot part is, and this has come with more years doing this, is realizing that I just want someone to get a win. Because once they get a win, they're going to get addicted to the win.

So when I start with that patient who's doing nothing, I don't, I hate when they say Peter, What do you do? Because I'm like, wrong question. Like, for me to tell you what I do is just going to make you feel worse and make you feel like this is not, you know. Achievable. It's not achievable. So let's forget that.

Who cares what I do? I've been doing this since I was a fetus, basically. What do we want you to do? And I will say something like, hey, if we can get you working out three hours a week. Well, actually, I'd take a step back and I go, how many hours are you willing to give me of your time? time. And they might say 90 minutes and they might say three hours and they might say five hours, whatever it is. But let's just say they say three hours. I say great. And I point them to the data. And I say, look, with a three hour, if you gave me three hours of your time and I could do whatever

I wanted with you during that period of time. And I promise we're not going to hurt you. Right. We're going to take this incrementally. You know, this is how much we're going to extend your life potentially. And we're talking about years. And this is the difference in quality of life. So I get them to buy into that. Okay, then I say, all right, here's the formula. Half of that time, we're going to do cardio. Half of that time, we're going to do strength training. And what does the cardio look like?

I show them what it's going to look like. And it's not crushing. We're just not there to crush anybody. They don't have any aerobic base at this point. So all I want them doing is really easy, peasy stuff. And it's just about habit building as much as it is about the stuff. And it's like, hey, like, this is a great time for you to listen to podcasts, listen to audio books, listen to music, whatever it is. In the weight room, we're not, I don't care what you

do. If you're someone who wants to go to a gym and work out on a bunch of machines because they don't look intimidating, that's great. But if you want to do something a little more complicated, let's just get you carrying things. Can you, you know, and again, it's a bit more nuanced because I want to make sure they can do it safely and all these other things. But it's like, what does step-ups on a box look like? What does carrying look like? So they might have this idea that they're walking into a crossfit gym and they're going to be doing cleans and they're going to be squatting and deadlifting it's like no no no you're not going to be doing any of that stuff anytime soon and and and I think if people give you three to six months of that I'm still waiting

for someone who at the end of that period of time says I don't feel better and if they as long as as long as you get there you're your your home run and you're good yeah the chapter goes I mean the chapter's all kinds of good detail in their zone two VO2 max strength training grip strength, concentric and eccentric loading. You cover all kinds of stuff in there with in a clear language that helps people understand what they need to do. So go get the book. Next section here is the gospel of stability.

Chapter 13. Relearning how to move to prevent injury. This is like a journey that you had to go on. And what does it mean to you? When you want to explain to people, what do you mean by the gospel of stability? Yeah, I mean, this is a, I think it's one of the most complicated chapters in the book. And it was definitely the hardest one to write from a technical standpoint because I think stability is something people kind of understand. But it doesn't really have a great definition.

I mean, I define it in there in the best ways I can. But I think the easiest way to think about it is, you know, a stable body is a body that transmits force to the outside world. without dissipation of force and energy leak and it's one to which force can be applied without internal collapse and dissipation of energy or injury. So, you know, just an example thinking about that, right? Like, you know, if you're walking up a flight of stairs or you're carrying something heavy up a hill and your knees hurt or you're walking down a hill and your knees hurt, that's an energy dissipation, right?

And you can really go through what's the same? the path of force from the point of contact, which virtually every time we're making contact with the outside world, it's our hands and our feet that are doing the contact. And how is that force moving from your hand or from your feet into the center of your body? Because that's where it's always going, right? So your feet are transmitting force through your ankles, your knees, your hips, into your pelvis, et cetera. And, you know, stability really comes down to, you know, creating an exoskeleton that allows that force to be transmitted safely. So the injuries that we have, many of which are chronic, but even the acute ones are

usually acute on chronic weaknesses. So, you know, when somebody tears their ACL, that wouldn't necessarily have happened. You know, if you took 10 people and exposed them to that same force at that same moment, maybe seven of them would have torn their ACL. Three of them wouldn't have. And a lot of that can be attributed to different types of strength. So stability in the knee, for example, lateral strength in the knee. Stability within the back explains a lot of why people have, you know, as I did, lower back injuries

and why, you know, failure to generate sufficient intra-abdominal pressure can lead to energy leak. So to me, this concept of stability goes so hand in hand with strength because a big point. part of health spam is not just being strong and having, you know, good cardiorespiratory fitness. It's also being free of injury. It's being relatively pain free. And I think that a very important part of this journey for me personally has been learning how to manage the sins of my youth from an injury perspective.

I often get asked about like, you know, this kind of stuff, especially with jiu-jitsu people. They're like, oh, you know, you're, what injuries if you're. had and I'm like I'm pretty good to go you know I'm pretty good to go and I think the reason that I'm pretty good to go again knock on wood a thousand times is because I I work out and I work out religiously so I think that when you you know you put your foot down you put your arm down and you get injured because that's what happens we we have a friend that just towards ACL like just taking a step literally like he's doing jiu jit-to but he wasn't getting heel hook

He wasn't no nothing dynamic. He was taking a step. He's actually taking a step backwards, felt a tweak, falls down on the mat. Like holding his knee, torn ACL from nothing. Scary. But I feel like working out lifting, squatting, doing pull-ups, doing dips. I feel like those things, I feel like I have pretty good stability. At this juncture, I need to work on my flexibility again.

I worked on my flexibility several years ago, and I got flexible and I felt good about it. And then I, I'm the worst. I'm the worst. Like, give me an example of something that is suboptimal for you. My shoulders are really, really inflexible right now. They're really inflexible. And I've lost a lot of mobility in them. I've just started getting it back, started proactively doing the stretches that I did for.

I just, I just showed a shoulder that hurt me one time. And this was probably 15 years ago, maybe even longer than that. Yeah, it was probably 15 or 20 years ago. I had a shoulder that was constantly hurting, constantly hurting, constantly hurting. And finally, I did, like, religious stretching and the pain went away. And the mobility increase, and it felt great. So I'm going to go through that protocol again and get it back. But those are the kind of things where I know.

And another thing, you know, I had to, you know, Bert Soren, Soren from Sorenx? Anyways, I have as... Oh, builds gyms. Yep, it's built my gym. But we were having a conversation and it's really easy to have an exercise that you, for whatever reason, can't do for whatever period of time. For instance, a pull-up, right? You could say, oh, I hurt my shoulder, can't do a pull-up. It's very easy to never do a pull-up again in your life.

And that's not good. So what I told him is like, I don't even... whatever I try and keep the exercises that I've been able to do before and continually try and maintain them. And if for some reason, like I got an arm injury by Dean Lister, my friend, my coach, he's showing a jiu-jitsu move. He's never hurt me while we were training in 20-something years. He was showing a move and like really hurt my arm. And so for six or, seven months, I couldn't do an overhead squat because I just could not, you know, you've got to kind of lock out your arms on an overhead squat.

I could not do it. And when I finally could extend my arms again, I could, I just didn't have the strength anymore. And I could see, I was like, oh, that's what happens to people. What happens to people is they go, well, I guess that's gone. And I said to myself, I will not submit to this. I will give me the PVC pipe. Let's start again.

Let's go and slowly started building that strength back. So I think that's what happens. And I know we've got a section in here about, or maybe we already covered the section, but you talk about the fact that you see people get derailed. Matter of fact, one of the stories you tell in here is one of your friends' moms. She was healthy, doing well.

She fell, broke hip femur or something. And then all of a sudden you can't work in the garden. You can't walk around anymore. everything falls apart. That's why here's some great piece of advice. I don't know if you have this in here. This is from me because I get asked this question all the time. I hurt my arm. I hurt my back. I hurt my whatever. I'm sick. What should I do? And this is such a good answer. I'm going to give it to you. Do what you can. You do what you can. Look, you used to be able to do 20 pull-ups and now you can only do a negative and only on one arm right now because your shoulder's hurt

your other arm cool do what you can oh you can't run anymore because you got your knees tweaked cool but you can go on the hand bike cool do what you can and then try and get back trying to aggressively go back not too aggressively but go back and and retake those exercises retake I was I was building a house and while I was building a house I was living in another house. My house that I was living in had a garage where I put my garage gym with whatever, seven foot ceilings. I couldn't do muscle ups in those. And I didn't think much about it. It wasn't like I was injured or anything. I just, oh, you know, and it took 18 months to build a house. So for 18 months, I would, wasn't really doing muscle ups. Didn't really think about it.

Again, you know, you just couldn't go up that high. So it just wasn't doing it. Didn't think about it. I was really excited. I got back to my new house. I have 20 foot ceilings in my garage now. So like I can do muscles, rope climbs, everything. But I did that first muscle up workout. And I was like, oh, oh, you got weak in this.

Look, I did dips the whole time. I did pulse all time, but I got weak. And then I just had to rebuild. That's a good thing is if you've had to rebuild before from an injury, you realize that you can rebuild. You had the shoulder surgery. Yeah, so I had, I tore my labrum probably the first time in boxing. Anytime you, once you dislocate or sublux your shoulder, you're going to damage that labrum.

And so I had multiple subluxations in my, in my teenage years. And then swimming, you know, as an extreme distance swimmer, that sort of made things worse. So by about 2012, it was sufficiently bad that I knew surgery. You know, I knew I was going to need surgery. But I met, you know, some really good folks who rehabbed me to the point where I was doing awesome. So in 2020, when we came to Austin, I, you know, met this awesome. Well, actually, I'd met him many years before, but he happened to be in Austin. He was an orthopedic surgeon that split his time between New York and Austin named Alton Barron.

And I went to see Alton having a little shoulder pain. And he said, well, let's do another MRI. It's been, you know, eight years since your last one. And it's like, yeah, it's horrible. Like, dude, you're, you don't have a labor. It's just, it's all hanging off there. And more importantly, that explains your symptoms, right? The MRI by itself doesn't actually tell you the whole story.

It's, let me examine you and see where your pain is. And he's like, yeah, I mean, luckily, you do so much other stuff. Like, your rotator cuff is an amazing shape. It's so strong. but your rotator cuff is stabilizing your shoulder. And not your labrum is what should be holding that in place. So I said, so do you think I need surgery now? He goes, no, I wouldn't do it until you can't take it anymore.

Like, let's see how far you can milk this. And I was like, great. And then finally in one day in 2022, January 2020, I was driving my car at the racetrack. And there was just something about the way I was getting in and out of the car that day that just finally tipped it over the edge. And to make a long story short, we were like, yep, okay, now it's time to do the surgery. So we did the surgery in March of 22.

And I actually put a video up on Instagram of him examining me under anesthesia on the table because that's the only time he could ever fully demonstrate how loose the shoulder was because I had to be under general anesthesia for the rotator cuff to relax. And it's one of the most gruesome videos you'll ever see. It's like, I'm sitting up intubated. Oh, I remember this. Yeah, yeah, yeah. And he's just going, want, and I mean, it's like, he demonstrates like, if there was any doubt that you needed this surgery, we just erased that doubt.

So I have the surgery, and it's so funny to hear you talk about, you know, what you just said, because these are all my fears, right? It's like, you know, grip strength is such an important part of my existence. Like so much of what I do is predicated on being able to carry things, being able to hang, being able to do pull-ups. You know, the dead hang is one of my favorite tests. It's not a regular part of my training, but it's a test set. Twice a month, I will do a dead hang for time. And that's something we do with our patients. And, you know, my goal was to get to five minutes.

You know, five minutes is generally considered the gold standard. Like if you can dead hang for five minutes, you're really special. I'd never got there, but I was at like four minutes and 36 seconds or something. How big of a bar? Probably like a oh you know I do it on a 45 Like a regular like Olympic bar So a little skinny bar Okay yeah

So I put that up on the pull-up bar Can it rotate while it's there? It doesn't Okay Yeah it's sort of locked in Cool cool My wife by the way First time she ever did a dead hang

Went 308 Dang Like that's ridiculous For anybody but for a woman That's really strong So I knew that post-surgery, like it was going to be, and again, this is not true for every shoulder surgery, but because of the nature of mine, I knew it was going to be six months before I could deadlift. I knew it was going to be six months before I could carry anything very heavy.

So I knew how much my grip strength was going to decline. So I did as much as I could around it, right? So it's funny, the day after surgery, I was in the gym in a sling doing leg extensions and leg curls. And within three days, I was even. able to do this other machine where you strap a belt to your waist and you do like, you know, sort of like deadlifts, but without holding the bar. So it's right. But I'll tell you what, here we are today, 15 months post-surgery. I still can't get to four and a half minutes. Like, and I'm working at it. But that's like, I tell this story to say, when you lose it,

it can take a while to get it back. And why this matters is the most, important rule of working out is don't injure yourself doing it because once you get to a certain age anytime on the sidelines is going to just make it harder and harder to get back. So you alluded to the broken hip story, right? I mean these statistics are so important to understand for two reasons. One is, so let's just state the stats, once you're 65 and up, If you fall and break your hip or femur, depending on the study, there's a 15 to 30% chance you're dead in a year. The one-year mortality of a broken hip or femur for those age 65 and up is 15 to 30%. What's equally tragic in my mind is of the 70 to 85% of people who don't actually die, half of them will have a full level reduction.

in mobility, meaning if they were able to walk easily before, they will require a cane for the rest of their lives. If they were walking with a cane before, they will go to a walker. If they were in a walker before, they will go to a wheelchair. That's called a full reduction in functionality. What if someone's a freaking stud and they're 72 years old and they break their femur doing jujitsu? They're more likely to survive than someone who's not, right?

Because, I mean, again, there's a lot of. of acute things that can go wrong. You know, you can have a fat embolism. You can have a, you know, a pulmonary embolism. There's a lot of stuff that can go wrong in the perioperative phase. But a big part of why those people die, if they don't die immediately, it's the inactivity. It's, you know, once you reach a certain age, it can take six months to 12 months to put on the amount of muscle you'd lose from 10 days of inactivity. Think about that for a second, Right. Like 10 days of inactivity is not a lot for someone who gets injured. That's like, oh, you went on vacation and decided, oh, you know what? I'm just going to relax and you didn't work out.

Well, it's funny you say that. I mean, this is one of the things we talk about a lot with our patients is we've got a lot of patience. And at the end of a year, they're not making gains. And what we're realizing is, you know, you're in a visa for a month. Like, you undid all the work you did. Now, again, you're not killing it for those 11 months, but you're doing good enough for 11 months. but you just undid it in a month. What is that when you're 23? I don't know, but it wouldn't be as dramatic. It seemed like when I was 23, doesn't just nothing matter?

Yeah. It was just like nothing mattered. Just do whatever. You're still going to crush. Yeah, yeah, yeah. But, you know, the experiments that are done are done in, you know, 60, 65 year olds. And as you get older, you become more anabolicly resistant. Meaning, literally, it is harder to experience anabolic function.

you require more protein to make the same amount of muscle. Good, more steak. Let's go. So, yeah. Can you hear how much denial there is over here on my side of the table? Like, I'm like, hey, the guy I was talking about earlier, that won't happen to me. That's me all day long. That's my attitude.

It's freaking jacked up. Or it's really cool. I don't know. What do you think, Kerry? I think it's good to go. More steak, more milk, more jiu-jit-to. Just keep it rolling, now. So again, the chapter, and go ahead.

Oh, no, I was going to ask you. Tell me a little bit about, I mean, Jiu-Jitsu fascinates me. I don't do it. I've never done it. My boys both do it. They love it. I'm so happy to see them doing it. It seems especially the younger ones still, you know, you just have a hard time getting his attention sometimes.

But the older one who's eight, like, it really is the thing he loves. I can really see him doing this as his thing. He loves it in a way that he didn't love. any other thing he tried. Yes. And so, you know, like, do kids get injured doing this? I mean, like, what are the, what are the, what are the things that a parent needs to understand as their kid is doing jiu-jitsu?

Kids are going to get injured in jihitsu. Same likelihood, soccer, basketball, whatever else. What are the main injuries? Are they head injuries? Are they shoulder injuries, knee injuries? Knees, shoulders, elbows, just sort of like they're playing basketball. For kids more resilient? They just

Friken bounce back so much quicker. Kids, honestly, my kids didn't get hurt doing Jiu-Jitsu. Like, they were doing Jiu-Jitsu seven days a week from the ages of zero, no, from the ages of five to like, for the girls,

five to 12, and for my son, five until current time. And they never had any kind of serious injury. My daughter that did gymnastics, got injuries from gymnastics, My daughter that did ballet got way worse injuries. Ballet is crazy.

So I don't think there's like huge. For kids, I think it's great. And what about the opposite end of the spectrum? Like what are the oldest people you have coming into the gym? 60. Yep. But no one in their 70s and 80s? There's people that compete at 70.

They have a master's division at 70 and up. It definitely, you know, depends on the person. you can do it. I mean, Elio Gracie, the founder of Gracie Jiu-Jitsu, he was doing jiu-jitsu and rolling until, you know, he was in his 80s, 90s, still doing it.

So you can do it. I think it can be a lifelong sport. I think it could be a lifelong sport as much as, as much as tennis or golf or, you know, people play pickup basketball. I mean,

it just depends on what you do with yourself. And if you let those little movements slip away and you don't say to yourself, hey, I'm going to get that movement back. You know, if you don't do that, it's going to go, if you don't use it, you're going to lose it. That's an accurate statement. So the other thing that's great about jujitsu is, you know,

they're going to get cardio basket work, they're going to get strength training, they're going to get flexibility, all from one big thing. So that's kind of nice too. Not to mention, they'll never get beat up, at least not in school by someone their own age, right? Can there be a 16-year-old when they're, they're 12, yeah, but generally speaking, 16 year olds don't beat up 12 year olds, like generally

speaking. They might bully them, they might push them around, but you usually have peer or near peer bullying situations, and so they're not going to get bullied, which is amazing. They're going to be able to protect other people. And what's interesting, they generally speaking, will not become bullies because they understand what physical confrontation does, to people and they don't like it and they recognize that it's not a way to get power over people. So it's beneficial across the board. Across the board. Freaking awesome.

Do you have an occasional like catastrophic injury in jiu jitsu? Yep. Competition. Yep. With kids competition they generally hopefully have referees that will stop the match. If, you know, a kid gets in an arm lock and he's not tapping because little kids, they won't tap. They want to win so bad.

They won't tap. And so a good ref will stop the match. You win. You know, the other kid wins. Sorry, you shouldn't have gotten caught in that position. I always coached and reffed like that. Hey, I don't care if you weren't going to tap. You were caught in that position.

You lose. But they also are pretty safe the way they do it in terms of they don't allow certain submission holds at certain ages because you don't have the maturity. to tap out. There's moves in Jiu-Jitsu. There's a move called the heel hook, which is putting torsion on the ankle, but what it ends up doing is it's very strange. It's very different than other submission holds

because it doesn't hurt until it injures you. So you can see a lot of people, they don't want to tap, they don't want to tap, they don't want to tap, they don't want to tap. And they don't want to tap. They know they're in the heel hook. They know they're in the heel hook. Generally.

But they're just thinking I can get out of this. I can get out. I can get out. Can you get out of it? You can. Yes, you can. You can't get out of some heel hooks. And that's what they're trying to do.

And I always, we know, we as instructors, instructors in general, always saying, hey, listen, this doesn't hurt. On arm lock, it hurts before you're injured. A choke, you just go to sleep. A straight knee lock, it hurts before you're injured. But the heel hook, I mean, you tell me, you're the doctor, like, you don't have. have nerves inside your knee by your ACL that's telling you there's pressure there, right? That's just there. And what would the purpose of being, they're being nerves there?

I guess there wouldn't be any. So. And the heel hook manipulates the knee, but it's the, the pressure's coming from the heel and the foot. Right. So with like any straight arm lock or anything like that, the pressure is directly on the joint that you're manipulating. This one's like, you know, the next one in the chain that's actually getting the pressure and the damage. Yeah. There was just, my kids just sent me a video of someone getting heel hooked.

And luckily for the person that didn't tap, you could see that it broke their tib-fib. It just broke the bones, which is great because then you're fine. You know, you get four weeks later, it's stronger than it was. You know, that ACL is a lifelong you're dealing with. Yeah. So, yes, Jiu-Jitsu, safe and beautiful for your children. The most important thing you can give children even more important than love. You've got a whole chapter about that stuff.

Stability. You go into nutrition here and you kick it off with, you say potato, I say nutritional biochemistry, which is classic. Then you got a quote from Feynman in here. Religion is a culture of faith. Science is a culture of doubt. Very important to understand. And you tell a story in here. I'm not going to read it.

It's the same story that I freaking had with my wife who used to be like, you're not allowed to talk about nutrition with my friends. And this was in the, I guess it was in the 2000s where I was pretty fired up about nutrition. And of course, my wife's friends would go crazy at the table with me. You know, oh, you're giving your kids a poison. That's cool. That was how I'd open up the conversation. And then you say this. Actually, you say, I am no longer a dogmatic advocate of any particular way of eating,

such as a ketogenic diet or any form of fat. It took me a long time to figure this out, but the fundamental assumption underlying the diet wars and most nutrition research that there is one perfect diet that works best for every single person is absolutely incorrect. More than anything, I owe this lesson to my patients whose struggles have taught me a humility about nutrition that I never could have learned from reading scientific papers alone. So that's what you figured out. People are different. And again, perfection can often be the enemy of good. And so we want to be careful that we don't lose sight of what is known and what is speculated. And what's a first order term versus a fifth order term.

And I think what's abundantly clear are the first order terms. Give me an example. Don't be overnourished and don't be undernourished. consume sufficient enough protein to support the anabolic activity of muscle, derive sufficient micronutrients from your food, vitamins, minerals, things like that, avoid toxins in food. That's about it. So good advice.

I had a friend here at this gym, and he got pretty chunky. We might go so far as to say he got fat. He was overnourished. He was overnourished. And then, you know, six months later, he's back to his kind of fighting weight. And I said, bro, you don't even cut some serious weight, huh? I said, yeah, yeah, I did. I said, what did you?

Like, what did you do? He said, I stopped eating like an asshole. And I was like, everybody, that's probably a great diet. Stop eating like an asshole. Because we all know what that means. And you don't have to read a freaking book or be a scientist to know what eating like an asshole. Donut, asshole. We can go down the list.

Like, how much. spaghetti can you possibly I can eat it all if I'm an asshole to myself um yeah it's it's I found it very helpful that you are explaining to people and then you go you go into you know you talk about everything in this chapter um and and and you hit the dietary yeah I mean that's kind of the irony of this I wrote two chapters on nutrition it's a 17 chapter book and Exercise gets three chapters. That's insane. Nutrition gets two.

Everything else gets one. And, you know, there was a part of me that wanted to do a very glib chapter on nutrition, which would have been a paragraph basically just stating the kind of stuff we're talking about. Don't eat like an asshole? Yeah. It's like, look, be an energy balance, get enough protein, avoid the toxins, get the right. But of course I go into the detail, right? Which is you have to be able to answer three questions about yourself or anybody else

if you're in the business of trying to treat this. And again, it's really easy to get the answers to these three questions. Are you overnourished or undernourished? Are you adequately muscled or undermuscled? Are you metabolically healthy or not? When you know the answer to that question, then it's just a matter of understanding. Do you need to increase intake, decrease intake, maintain intake, go up or down on protein? And what do you need to do with exercise, sleep and all the other things that factor into that vis-a-vis metabolic health?

health. For most people, the answer is you need to eat less, you need more protein. So you need less total calories. You need more protein calories. And that's what brings it full circle to strategy versus tactics, right? So there are basically three strategies to reduce energy intake, dietary restriction, calorie restriction, time restriction. So once you identify your strategy, then you can get into all the tactics. And the tactics is where the relationship. happens. People get crazy. It's unbelievable.

You were kind of crazy. Yeah. Bro, you were doing, I went out to dinner with you in New York. It was like you, me, Tim, like just a bunch of dudes and we were out having a good time. I still remember the restaurant. Yeah, it was freaking delicious, but you wouldn't know. I would not. Because you sat there with an empty plate in front of you because you were in the middle of a four-day fast, five-day fast.

Five days into a seven-day fast or something. thing yeah oh that was awesome I that you really missed out that night though that steak I got was amazing I've been back since to that place you tripled down so look again I just have a note here that says get the book because this is a textbook this is going to help you do an assessment it's going to help you answer those questions and then guide you in in a direction of which of these strategies and tactics you can utilize to sort your nutrition out the next Section is the awakening. Your favorite section.

Yeah, and you know what? I figured this was going to happen. So I broke out my book, Discipline equals Freedom Field Manual. And here's what it says. Sleep is a necessity. Humans need sleep. Failure to get enough sleep has serious side effects.

Lack of sleep can cause negative hormonal changes, interfere with the metabolizing of glucose, increase blood pressure, and suppress the immune system. Less sleep also means less human growth hormone your body, which means less muscle mass and weaker bones. Mentally, the brain is impacted as the ability to pay attention and concentrate begins to diminish and problem solving and basic reasoning become less acute.

Furthermore, over an extended period, there are psychological effects like paranoia and even hallucinations. So that's me. You're on it. You got it. That's me. I wrote that. Now, I don't know, people think, I wake up early.

I've always waked up early. I've always woken up early and people think I don't believe in sleep or that you need sleep and I'm not like that. I actually understand that people need sleep and quite frankly other people need more sleep than I do. That's just the way it is. I'm not bragging. It's been like that my whole life. I don't need a lot of sleep and that's the way it is, but I've never told anyone like, hey, you need to sleep less. I've never told anybody that.

Let me confirm. I don't think I've ever told anybody that. I've never told anybody, hey, you need to sleep less. And you go into some pretty great detail in this book about sleep. And it actually, you know, I'll just read this section. Old Man Blood. Scary as it can be in some situations, the short-term harm done by a night or three of poor sleep pales in comparison to the damage that we do to ourselves if this situation continues. Kirk Parsley, who's been on this podcast, observe this.

when he was a physician to the seals. He was also a seal. Outwardly, these men appeared to be prime physical specimens, finally honed in their rigorous training, but when Parsley analyzed their blood test, he was shocked. Many of these young guys had the hormone levels and inflammatory markers of men several decades older than them. Old man blood, Parsley called it.

Because their training exercises and missions often began at odd hours of the night and required them to stay awake for 24 hours or more at a stretch, they were chronically sleep deprived, their natural sleep wake cycles utterly disrupted. When Kirk told me the story, I experienced a jolt of recognition too. I, too, had had old man blood during my not thin Peter phase, and this is an earlier part of the book where you were not in good shape, swimming freaking to Catalina Island, but you were also a metabolic disaster and not looking as lean as you should.

according to your wife who said you should try to be a little less not thin a little less not thin with elevated insulin high triglycerides and a testosterone level in the bottom five percent of men in the united states i'd always attributed my poor health and hormone imbalance to the point of my at that point to my lousy diet and diet alone but i had also spent at least a decade in a state of severe sleep deprivation in residency and afterward belatedly i realized that not sleeping had actually caught up to me as well. It was probably even evident in my face. Studies have found that people who sleep less chronically tend to have older looking flabbier skin than people their same age who sleep more. Now I recognize that sleep, diet, and risk of long-term diseases are all intimately connected

to each other. Knowing what I do now, I would bet that a few months of perfect sleep could have fixed 80% of my problems back then, even on a crappy diet. Sleep. And I, you know, just to make sure people understand why I make such a bold statement there, because I was exercising 28 hours a week. In other words, I look back at that and say, how is it that with so much exercise I was still in the state I was in? And I think that there are extreme cases with extreme sleep deprivation where, you know, because the old saying, the old adage is, can you out exercise a bad diet? And the traditional thinking is no. The truth of it is you could if you can exercise enough. Like when I was growing up, I could clearly out-exercise a bad diet because I had the world's worst diet

and I was probably 6% body fat and fit as a fit. Like, I mean, I looked like a specimen. And you also had freaking like high testosterone. Of course. Absolutely. So there's clearly a scenario when you can't. But the difference is like I couldn't exercise that much today of my life depended on it. You know, I mean, I asked this question of a couple of our mutual friends, right, who were former seals who live in Austin now. And one night we were. having dinner. This is probably like a year or two ago and I was like, okay, I get from having talked to enough of you guys that like getting through buds is mostly here. Like, you know, I get that. Well, you guys are no more mentally, you guys are probably at least as mentally strong today as you

were then. Could you get through buds today? And every one of them said no. And the reason is they said, we don't physically recover the way we used to. Like we couldn't do that volume of suffering today in our late 40s and early 50s. And so that's why I just think the strategy of I'm going to out-exercise my bad diet, like that strategy will not work beyond a certain age and that age is pretty young. Sleep introduces another wrinkle to that, which is really bad sleep and really bad diet. There's no out-exercising that at any point either.

Yeah, I think when it comes to females going through seal training, I think one of the things that's going to be very problematic is the ability to recover quickly enough because they just don't have like the testosterone. I don't think they have the hormones to recover because you are getting a beat down. You are getting annihilated. And it's hard for it. Buds is six months, right? Six months. Yeah.

And what I think would happen is I think that what would happen was if you took an extremely fit person, which, I had a actually was Laif, Leif and I were having a discussion, this discussion, as a matter of fact, and Tia Claire Toomey, who's a CrossFit champion. I mean, just an incredible specimen of a woman, just badass. And I was saying, I said, you know, I mean, you take someone like Tia Claire, I mean, I said, she got, she can deadlift more than me. And he's like, no, she can't. And I was like, bro, she's like a professional athlete.

Of course she can. Blah, blah, blah. And he's like, no, there's no way. And I'm like, I bet she can. He's like, I bet she can't. And we looked it up. And her deadlift, I think it was, you know, 405, you know, which is a freaking outstanding for a girl.

But for a man, that's pretty normal. Right. Right. It's pretty normal. But so, so, but it's still, like, so she's in the, she's in the ballpark, right? She's in the ballpark. But if you, um, I think what would happen with a female in seal training is that,

like, they give you the weekend. to recover. But you're barely recovered on Monday morning, barely. And then you go another week and you have to recover again and again and again. And I think what would happen is a someone has been. Is Bud's the worst of it? As far as the physical demand and the recovery or lack of error of. No, it's not.

It's not. It's not because you'll go overseas and you'll be in some situation where you'll be getting crappy nutrition and even worse sleep or just as bad sleep and you'll be nervous. And like, it's going to be worse. It's going to be worse. So that's what I think what happened is I think, I think they would need recovery time. And they just wouldn't have, they wouldn't be able to keep up over. They'd probably, they'd probably be in the top 20% on the runs and swims in the first week.

They'd be in the top 40% in the runs and swims in the second week. They'd be in the bottom, 50% in the third and fourth week. And then they just would continue to go down. And what was the, at the worst of your training, I assume Hell Week was the biggest sleeped deprivation you've ever experienced in a training not in not in real life it is and is hell week 30 years ago the same as hell week today in terms of sleep deprivation pretty damn close okay yeah yeah yep it's it's for yes it's the same it's the same they'll sleep they sleep a couple hours and usually why they put you to sleep is to get people to quit because on you know you've been

awake for Sunday and then Monday and then Tuesday and then they'll come and say like hey listen We just got in trouble with the commanding officer and he says we've been too hard on you guys and he's now told us that you guys need to you guys are going to get six hours of sleep and you have to get dry. So go put on dry clothes and you guys will see you in six hours. And then you're like, oh, you put on dry clothes and you crawl into bed and then 20 minutes later, an hour later or 40 minutes later they're in there with Bowen sending you right back to the surfs on a bunch of people are like, I'm out, dude, I'm not getting back into this game. And they do that a couple times. They do that or something like that. So that's why they let you sleep. They let you sleep so that you have to wake up and go back into hell.

So that's a transitional period that some people don't make it through. How much use is there of stimulants? What kind of stimulants? Modafinil, you know, ridolin, things like that. None. Did they check guys for that? I mean, in your day and age, those things weren't popular. But today those are very popular drugs that any high school kid could get a hold of.

Do you have any idea if they're... They drug test the shit out of these kids. They do. So you're getting drug tested during hell week. I don't know if they drug test them during hell week, but certainly after hell week. And prior to hell week, you're getting drug tested a lot. How much do you eat during hell week? As much as you want.

You eat a ton. Well, yeah, you eat a ton. You eat a ton. That's the... So you're not limited on nutrition. Nope. You're basically... And then...

Coffee? You can have coffee? I don't know. I didn't drink coffee. I still don't drink coffee. And I don't know if you could drink coffee. I don't think you can. I don't think you can drink coffee during a week. I don't know. By the way, there must be a real difference between if you get your if you're doing your hell week in January versus August. There's a big difference. Is the dropout rate significantly higher in January? It's higher. It's higher for sure. I mean, it's you know the deal. It's San Diego. It can be 37 degrees. You know, can be 37 degrees. The interesting thing is, what is it? In winter hell weeks, the cold, so you'll get more quitters. In summer hell weeks, they'll get more chafing and more swelling and more disease. But more people will make it because cold is it. What month did you do it?

Spring, I think May, late May. And here's the other thing. Like when it's wintertime, they check the water temperature. They put you in that water until someone's getting hypothermia. Oh, so you'll spend less time in the water in January. 100% January 100%. So that means in the wintertime, you're running more. You're doing more.

And depending on who you are. Because some people that did cross-country, they don't care if they run. They'll run all day. Some people that did water polo that'd rather swim. There's some people, when you go to a pool evolution, it's a rest for them. I was very comfortable in the water.

Any of the pool, not the swims, but not tying pool comp. Well, I failed pool comp, but life-saving. those kind of things, drownproofing, they were like a break for me. Some people were absolutely horrified of those things. Some people, you know, you take a kid that ran cross country in college,

he's doing a four mile time run. There's no doubt that he's going to pass and he's going to be fine. A guy that swam in college or played water pole, he's going to pass those swims really easily. So people, depending on what your strengths are, you'll have some time where you'll get a little reprieve.

But they'll find your weakness too, because no one is, Good well just about no one is good at everything and even and you will get some studs you'll get some freaking guys that are complete and utter studs and occasionally make it and sometimes they quit Sometimes they quit because they lost something for the first time you know they never lost a brace before and that's too much for them they never failed pool comp like I did you know I'd failed all kinds of stuff my life so I failed pool comp was like cool what I need to do to fix it But the sleep deprivation thing You know some people have bad hallucinations and stuff and I didn't really have have I had like one hallucination you know as we were paddling our boat and I looked across the ocean I found us on a traffic light and I was like and I knew it I was like well there's we're in the

ocean so there's no traffic light I'm just hallucinating and it wasn't that big of a deal I recovered from hell week pretty quickly and like I said I've always been I'm I'm very functional without sleep as well very functional like when I hear Matt Walker and he'll say you know if you've had less than five hours of sleep, you cannot, you're basically, it's the equivalent of four beers or it's equivalent of whatever. That is just not true with me. And it's not true with many of my friends, too. It's not true with many of my friends, or at least a decent amount of my friends.

I just went out to, I was, I did an event in Las Vegas, got on a red eye, slept two hours on the red eye, arrived. at my next gig and was speaking and interacting and answering questions for eight hours. Like literally no factor. Literally no factor. And so I don't know. I think there's some, a little bit of exaggeration or something with that. I don't know.

Am I wrong? I mean, I don't know exactly what the stats are. I kind of forget, but it's, I don't think it's four beers. I think it's, is it four hours as equal to a blood alcohol of, 0.08 maybe that sounds about right yeah but yeah there's no doubt there has to be there has to be personal variation what you get some alcohol with me I'm a different man you want to see some changes bro and it can be no sleep lack of sleep it's going to be get me on the sauce get me on the fire water and I'll burn you'll meet a different jocco

all day when did you stop drinking basically when I retired so that was in 2010 and I didn't like consciously like yeah just all of a sudden I wasn't hanging around with a bunch of my friends anymore and I just stopped and then I looked up and I was like well no point in doing that anymore I mean and I at the World Cup I had a I had a Guinness you know I I don't like the taste of alcohol anymore at all I don't have any desire for it and man I've seen it just destroy so many people that I just can't I can't get on board I can't give money to that industry I just can't do it I'm I'm I'm becoming more and more anti-alcohol every you know every moment of life now and and look I've been kind of giving the caveat that you know I but had a lot

of fun and bonded with the guys and I've started to just like kind of kind of think about that too and think well how much fun would I've been having if I wasn't drinking what if I wasn't doing that what would I have been doing what did I miss out on so I'm even starting to revoke that caveat a little bit as I get older and and you know the culture was very strong for alcohol in the whole military and it was even stronger in the SEAL teams and you're a frog man. That's what we're doing. And I was like, cool, that's what we're doing.

I'm here. I'm here to be a frog man. Let's go. That's what we're doing? I'm in. And I'm going to do it hard. So watch this. But thankfully, I, you know, I always also, you know, some people have the, they say, oh, I

have an addictive personality. And it's almost like a humble brag. Like, I have an addictive personality. I think you actually do have an addictive personality. To some things. Yeah. I don't think I have it. Like, I'm like, oh, okay.

Cool. I don't, yeah, I, I, I can stop doing something. Maybe Jiu-Jitsu is a little bit. But, you know, I go times where I can't train and I don't freak out about it. So I don't think I have an addictive personality. And it scares me when I think about people that do have that. It scares me to think about what it must be like to want to drink alcohol or do whatever thing so badly that you can't control it. That's, that's very scary to me. I think I have a little bit of, I think I have a little bit of I like to be in control of what's happening and which is weird because when it comes to leadership I don't have that at all. I don't need to be in control and everyone that works for me will tell you like, oh yeah, Jocco is like, he's crazy. You let me do whatever I want.

Because I had somebody say something to me about that about me wanting to, you want to control stuff. I'm like, actually, I don't care. Talk to anyone that's ever worked for me unless they were an idiot and I had to micromanage them, which is a very small category of people. But most people, they work for me. They're like doing whatever they want. And I'm giving them free reign and backing them up and supporting them. But for my personal life, I don't like to feel like I'm going to lose control or feel like I can't control something that's happening. So that's what scares me about the, it doesn't scare me, but the psychedelic, you know, voyages that people are going on.

Because, and the way I explained it to some of my friends that have been on these voyages and it's been very helpful for them. And I've said like, well, I feel like I'm driving down the road at 80 miles an hour in my vehicle. I don't think I need to stop, pull over to the side, take apart my engine, put it back together again and like hope I got it right. It doesn't seem like a worthwhile risk to me. And I don't feel like I have, you know, that. I don't feel bad or feel good. I'm happy. So there, there's my, my thoughts.

But sleep, back to sleep. The other thing is you can only the short sleepers, the genetic short sleepers, which I don't know if I'm one. I don't think I am because it sounds like it's so rare that it could be impossible that I could be one. I used to think it was genetic because one of my kids is like the same way, doesn't need to sleep. One of my kids, my oldest daughter doesn't need to sleep. My middle daughter, go pull her out of bed. You know, my wife, pull her out of bed. my son somewhere in the middle my youngest daughter pull her out of bed so I thought okay well that

makes sense we've got different genes but then I hear how rare it is that you're actually really a short sleeper I'm like well then it can't be me but I can survive for sure on a pretty small amount of sleep without really much inhibition and I don't think that's cool in fact I want I want to sleep more I want to like let's go uh But to your point, what you explain in great detail in the book, there are all kinds of negative impacts to not sleeping enough. And you've got a section in here about, again, get the book. Go get the book. But don't drink alcohol.

Don't eat anything less than three hours before bedtime. Obstained from electronics for at least one hour before bed. Avoid doing anything anxiety-producing or stimulating, such as reading, work email, or God help you. you checking social media for the folks that have access to a sauna or a hot tub go getting that before bed room should be cool ideally in the mid-60s I hate to sound like one of those people that I guess I am now but I have a sauna and I have a bed cooler thing and that bed cooler thing is legit yeah that's amazing it's freaking legit it and when I had it's cold and so like I don't really have

like the crazy sweat nightmares anymore. I guess they're more in Arctic environments, but it works out good. Give yourself enough time to sleep. You call it sleep or scientists call it sleep opportunity. Fix your wake-up time. Don't deviate from it even on the weekends. This is where I feel really lucky because my boys,

especially the middle one, he's like, this kid is on a clock. He cannot sleep past 6 a.m. So we don't sleep past 6 a.m. Yep. So we don't sleep past 6. say him you don't doesn't matter if it's a holiday doesn't matter if it's a weekday

doesn't matter if it's a weekend it's we're always up at six and there's something good about that right you you you don't get into what's called social jet lag which is when people try to you know short change their sleep during the week and then make up for it on the weekends it doesn't work that way yeah or you or you do the opposite this is what I've always advise people oh it's Friday night so I'm to go out a little later I'll sleep in okay so now you wake up at eight and now it comes to 10 o'clock at night. You're not tired because you had more sleep.

So you stay up until midnight. And now you're next sleep until until 10. And now you can't go to sleep until 1 o'clock in the morning. And now you're getting up early on Monday and it sucks. So there you go. Get your sleep, everybody. From me, get your sleep. Definitely from the doctor here.

Get your sleep. Chapter 17, work in progress, the high price of ignoring emotional health. And this was the surprise chapter. On Tuesday, July 11th, 2017, at 5.45 p.m., to be exact, I had received a call from Jill, my wife. She was in an ambulance with our infant son, Ayrton, on the way to the hospital.

For some reason, he had suddenly stopped breathing and fallen unconscious. His eyes were completely rolled back in their sockets, and he was lifeless and blue with no heartbeat. Only the quick reaction of our nanny had saved him. She rushed him to Jill, who is a nurse. Her instinct took over. She immediately put him on the floor and began performing CPR rhythmically, but carefully pressing her fingers on his tiny sternum as the nanny frantically dialed 911.

He was barely a month old. By the time the firefighter stormed into the house, about five minutes later, Erriton was breathing again and his skin was turning from blue back to pink as oxygen returned to his body. The firemen were stunned. never see these kids come back they told Jill to this day we still don't know how or why it happened but this is likely what occurs when babies die suddenly in their sleep they choke for a moment on their own saliva or some other insult occurs and they very and their very immature nervous systems

fail to restart their breathing when Jill called me from the ambulance I was in New York in a taxi on 45th Street on 54th Street on my way to dinner after she finished telling me what The story, I just said without a shred of emotion, Okay, call me when you get to the hospital so I can talk to the doctors in the ICU. She got off the phone pretty quickly, and of course, it's obvious why she was upset. Our son had nearly died and the right thing for me to say. The only thing to say was that I was getting the next flight home. Jill stayed in the hospital with Erudin alone for four days.

She pleaded with me to come home. I called in daily to talk to the doctors and discuss each day's test results, but I stayed in New York with my important work. Eritin's cardiac arrest happened on a Tuesday, but I did not come back home to San Diego until Friday of the following week, 10 days later. Even today, just thinking about what happened, I feel nauseous about my behavior.

I can't believe I did that to my family. I can't believe what a blind, selfish, checked out husband and father I was, and I know I may never fully forgive myself. for as long as I live I must have been giving off very troubled vibe during this period because around then my close friend Paul Conti a medical school classmate who is now a brilliant and very intuitive psychiatrist began urging me to go to this place in Kentucky I looked it up and it seemed to be a place for addicts this doesn't make sense I told him I'm not an addict he explained to me over several

months of gentle discussion that addiction can take many forms not merely to drugs or alcohol. Often he continued, it's an outgrowth of some trauma that has happened in a person's past. Paul is an expert in trauma, and he saw that I displayed all the behavioral signs, anger, detachment, obsessiveness, a need to achieve that was fueled by insecurity. I don't know what it was that happened, but you just have to trust me on this, he said. He was relentless.

I agreed to go to Kentucky, but I was still looking at. for any excuse to get out of it. In early November, a woman from the bridge, which is the rehab place in Kentucky, called to do my intake interview. It was a long, tedious conversation, and my patients finally expired when she asked, have you ever been subject to any kind of abuse? I got so angry, I yelled, fuck you, and hung up the phone. After this call, I decided to cancel my plan's day.

What was wrong with these people asking such idiotic question? That Thanksgiving weekend was still a blur. It's the only thanksgiving in our life together when we didn't go to dinner with friends or family or host one ourselves. We just stayed home alone. On Sunday night Jill begged me to go to again to go to Kentucky. I just can't go off the grid for that long, I said. My patients need me and you need me to help with the kids. This was total bullshit and we both knew it. She replied point blank, you're of no help to me in fact you're hurting me and your kids very badly confronted with the brutal truth i knew i had to go so you go out to this place in kentucky um you get out there you are you know trying to keep a low profile i thought it was funny that you had called out that you wanted a private room you know because you're so important and know you're going to get a roommate i'm going to fast forward a little bit after four or five days I could no longer remain silent, which is what you had done for your first several days. They're not telling anybody anything. They'd set aside almost an entire day when we were

all supposed to tell our life stories from the beginning. We had an hour each and we were supposed to prepare. So I was finally telling my life story for the first time to this group of perfect strangers. Not even Jill had heard the whole thing, but I was telling it in a way that was very matter of fact. This happened when I was five. This happened when I was seven and so on. Some of it was sexual. Some of it was physical. But it was not all bad, I explained. These events, terrible as they were, had led me to take up boxing in martial arts at age of 13.

I got to punch bags and people, and that channeled my anger. I learned how to protect myself, but I also gained discipline and focus, qualities that proved invaluable. When around the age of 19, I pivoted from pugilism to mathematics, terrible as it was. My past was also what set me on the path to becoming a doctor.

I continued, growing somewhat defensive. Throughout college, I volunteered to shelter for sexually abused teenagers, and I became close to many of them over four years, including one young woman who had been abused by her father. When she attempted suicide, one of many attempts, I went to visit her in the hospital. I was a senior by then, and I had already applied to the top PhD programs in aerospace engineering, but I wasn't really sure it was my calling. Spending so much time in the hospital with her helped lead to the epiphany that I was meant to care. for people not solve equations. So you see, I concluded, parts of my past may have been bad,

but in a way, they also ended up setting me on a course towards a better life. Some of the kids I grew up with and boxed with, meanwhile, were getting arrested for armed robbery and getting girls pregnant in high school and all kinds of other stuff. That could have easily been me. So in a way, I said,

my abuse may have actually saved my life. I don't really even need to be here. Right then, one of our therapists, Julie Vincent, cut me off. there are many rules at the bridge and one of the most important ones was no minimizing You are not allowed to minimize anything that someone else is saying and you're especially not allowed to minimize your own experiences But she didn't flag me for that Instead she asked a simple question you are five years old when this happened

First to you right that's right I replied and your son Reese is almost five years old right now right? I nodded So you're saying it's okay that this happened to you and you You were his age, but would you be okay with people doing that to Reese now? Another rule at the bridge is you're not supposed to hand anyone Kleenex when they're crying. They're supposed to get up and fetch it themselves. Now it was my turn to stand up and walk over to the Kleenex box. It all came pouring out of me. And finally, I was able to embrace why I was there and begin the hard work of unpacking the last 40 years of my life.

When you're going to this place and you show up. there you know they say like uh someone that's going to seal training when you when you go there you know if you're going to quit or not like deep inside you actually know do you think you knew what was going to happen when you went to this place no no I mean I was just I was just I was just so angry you know I don't think you know I wasn't really there on my choice you know I mean if I didn't go I was leaving the house right and never coming back. So I think I just, you know, I just had so much anger that I, I wasn't thinking about anything other than just trying to get through the day. And this place is wonderfully awful, right?

I mean, they deprive you of everything. They don't, you know, you don't, you don't have a phone. They take your books away. There's, I mean, I think I mentioned there, the only thing they let me indulge in was exercise. You know, I could get up at four, 30. and they had this janky little universal machine somewhere in the basement that like, you know, I could go down and use and run in the woods. Like that was it, right? So aside from that,

you're stripped of every defense mechanism you have. But no, I had no idea what I was in store for. Now, I've felt like talking about combat, which I've done. I mean, basically because I have a podcast, And I, you know, I've said that when my friends have died, I've often been the guy that's giving the eulogy. And matter of fact, I have a SOP now. If someone I know dies, I'm immediately writing because I don't know if I want to get the call or not, but I'm going to be ready.

And I found that to be very, I think that's very helpful. And so is this the first time where you were able to, like, express these things that you had gone through growing up? Yeah, it's more than that, though, right? I think stating them as facts is not really the issue. It's understanding, it's not justifying them anymore, right? So I think, again, it wasn't like I didn't know this had happened. It wasn't like I blocked this out. It was that, you know, bad things happen to everybody, and we come up with adaptations.

This is a normal, healthy, important thing. If we don't adapt to bad things, we're hosed, right? Like, that's the end of our species. So the only issue is how many of those adaptations are positive, how many of those adaptations are negative? And what I don't think I ever appreciated was that all of the attributes of my personality that were positive and negative were actually quite linked.

and they all kind of stemmed from a coping strategy around these issues of my childhood. And I think the first sort of thing that I had to kind of realize in that moment was that the, you know, in this place in the bridge, they use a model, right, where you have kind of, you know, you're born as a young, healthy child, and then you suffer some sort of insult. And they talk about this thing as the trauma tree, right? So the trauma tree has branches and roots. So the branches are the things you see. They're above the ground, right?

So the branches are addiction, codependency, you know, all the things that we think of as, you know, habituated survival strategies. The roots are the things beneath the surface. That's the trauma. So that can be abuse, neglect, enmeshment, witnessing tragic events would be traumatic. And the thing to figure out is how do we go from sort of the young, healthy child into an adaptive child into a maladaptive adult? And like, what does that transition look like and what adaptations are serving you well and which ones aren't? And I think that was really, you know, a big part of the takeaway, right? Which was many of those adaptations have served me incredibly well.

but some of them haven't. Some of them have been very destructive. And, you know, we were talking earlier about alcohol. Well, I feel very fortunate, but like you, I mean, I can't actually relate to somebody who drinks alcohol through addiction. So there's very different chemistry in people's brains. There are some people for whom ethanol triggers a pleasure center in them the way I can't relate to. So, you know, drugs, alcohol, gambling, these things have never resonated with me. Those aren't my addictions.

It just so happens that my addictions are very socially acceptable. I mean, work is a very socially acceptable addiction. Perfectionism is a very socially acceptable addiction. Anger can be tolerated, provided you can sort of keep it in check, which I mostly could. But again, you know, as the story you read at the outset displays, I mean, it can get to a point where you're so detached and you're so addicted to, you know, work and, you know, your own sort of narcissistic beliefs that, you know, the destruction is just enormous around, you know, to those who are closest to you. Again, it's not visible to the outside world, but it's absolutely visible to the people closest to you. So you go here. You get, I would say from what you write in the book, it sort of moves you in the right direction.

It does, yeah. I leave early. I only stay for 14 days. And most people believed I needed to be there for six weeks. But I begged to go and they they relent. Fast forward a little bit here. We're into COVID times, 2020. As March bled into April, it became clear there was no end in sight.

One day in late April 2020, I was on a routine morning call with my practice manager when I couldn't take it anymore and started venting. I've lost control, I told her. I can't keep my patient's stories. anymore was it patient X or patient Y who just last week told me about his daughter's struggle at school was a patient A or patient B whom I needed to reach out to that evening about an issue she was having she tried to soothe me saying I was doing the best I could under the circumstances and that our patients were grateful but the more she talked the angrier I got and just like that I spun into a radical self-destructive episode

one like I've never experienced before or since even remembering it now was terrifying I threw a table across our living room I tore my t-shirt to pieces I screamed in rage and pain my wife begged me to leave the house for fear I would harm her or the kids I thought about driving myself into a bridge abutment or some other structure fast enough that I'd be killed I was convinced that I was broken defective when they autopsied my brain they would discover just how screwed up I was I was beyond fixing nothing could make it right. I ended up hold up in a motel on the phone with Paul, Esther, and Terry. They insisted that I needed to go back to a place like the bridge. Now, true to form, I stubbornly disagreed,

claiming that I could fix this with just a little more time and support. If only I could get home and get some rest. After pleading with them for 48 hours, I finally relented. In the middle of the night, I drove myself to Phoenix, Arizona to be admitted into a place called psychological counseling services or PCS. Terry had been telling me about PCS for nearly a year. He said it was a place that worked miracles, healing wounds that seemed beyond permanent. I asked how he could be so sure. He said I just needed to trust him. So you head out there. Fast forward a little bit on my second day. I was assigned to write a list of 47 affirmations representing one positive statement about myself for each year of my life. I made it to about five or six before I got completely

stuck. For days and days, I couldn't come up with anything good to say about myself. My perfectionism and my shame did not permit me to believe anything nice about myself. I just couldn't do it. Finally, on the 19th day, a blistering hot Wednesday morning, it happened. One of my therapist, Marcus, was pushing deeper and deeper into a story I had told him earlier about how it stopped wanting to celebrate my birthdays when I was about seven. In fact, I revealed, I would keep my birthday a secret until well into my 20s. His question made it clear that this was not something a healthy child would do, and it likely masked something more deeply wrong. He just kept digging and would not let it go. That recognition pushed me into an emotional freefall. It had been two and a half

years in the making, but I finally was able to let go and accept the truth about my past and how it had shaped me without any excuses or rationalizations. All that I had become good and bad was in response to what I experienced. It wasn't simply the big T traumas either. We uncovered many, many more little T traumas hidden in the cracks that had affected me even more profoundly. I hadn't been protected. I hadn't felt safe.

My trust had been broken by people who were close to me. I felt abandoned. All of that had manifested itself as my own self-loathing as an adult. I had become my own worst enemy. And I hadn't deserved any of it. This was the key insight. That little sweet boy did not deserve any of it. And he was still with me.

Once I had accepted all of this, it was easy to write out the 47 affirmations. Went through this with these people, with these therapists. What happens? What's going on? I literally don't know what this looks like. Explain it to me if I never seen a boxing match before. What is going on with these therapists? I know you get into the dialectical behavior thing.

therapy, DBT. What does this look like? Well, PCS is set up as about 80% individual therapy, about 20% group therapy. You're doing therapy from seven in the morning till seven at night, every day, 30 minutes for lunch, basically, seven days a week. Most people go there for one week. I was there for three. So I was there for 21 straight days, which meant I went through, I went with three different groups. So I basically did the same thing effectively,

but with three different groups of people. But I had the same individual therapist. So we were kind of going deeper and deeper and deeper and deeper. And again, you know, I didn't want to stay for three weeks. But I also knew from the last time, like I'm going to surrender a little bit on this one. And I'm going to stay as long as they tell me I need to stay this time.

And so at the end of that second week, I really thought I was there. And then my friend Paul called me the night before I was supposed to leave and said, we think you need another week. And I was like, I can't do another week of this. Like, I just can't do any more of this. And, you know, he just said, like, you got to trust me. And I did. And it made sense because of what happened in that last week.

Like that, you know, there's the, there's a quote in there about, you know, the stone cutter hitting the stone, right? And it's like on that 101st, you know, hit, the stone breaks. And it looks like, well, he did nothing for the first hundred. No, the first hundred were just as essential to that one. So even though I think kind of everything really came together for me on that 19th day, it goes back to two and a half years earlier in Kentucky

and all the work that had happened in that two and a half year period of time. But it really, it just, it really came together on that one, one, that moment. And through, you know, Marcus's real probing and it was more into the little T stuff, truthfully, right? It wasn't into the big, obvious stuff at this point. What's a little T look like? Yeah, I mean, it's, it's, you know, it's, in my case, I think it was, was more around not not having a dad around probably was was the most formative thing that I had just never assumed mattered.

I just didn't think that that meant anything. And I think I finally came to accept the fact that you can't use a totally rational brain of a 40-year-old to try to explain what a 2-year-old, a 3-year-old, a 4-year-old, 5-year-year-old experience. they don't process things that way and I think once I came to understand that I just stopped making any excuses you know I think there was always still some lingering excuses

and they were really standing in the way of doing this kind of work that needed to be done so would an excuse be well I get mad but this is the way I was treated well as a kid so that's just the way I am is that the type of excuse we're talking about Um, no, I mean, no, so, so an excuse, I mean, yes, that could be, but that what, so it would more be, um, hey, you know, I might not have had this kind of attention as a kid, but it doesn't matter because, you know, I wasn't getting beat to a pulp every single day. Like there was always sort of a way like it wasn't that bad. It was, you know, um, or another excuse could be, um, um, And so that's an excuse towards what's happening to you.

Another excuse could be like, you know, I have a horrible temper, but like I don't hit my wife or my kids. So therefore it has no effect on them. Right. Like, yeah, they see me like screaming at a driver or pulling a guy out of his car and almost killing him. But I mean, like I'm not hurting them. And not realizing, of course, how, you know, illogical that is. I guess it's because COVID was going on. But like I remember exactly when this was happening

because you and I were talking all the time. Like, yeah, and it's weird for me because like seemed normal. And you told me like, I can't remember if you told me before or after you, you went. I don't remember if you told me, hey, I'm going somewhere. Or if you told me after, I just got back somewhere. But I remember you indicating that you had gone. And you said something along,

lines of like, hey, I'm not addicted to anything, but I need to get some shit sorted out type thing. That's the thing. And I was like, okay, cool. But the reason I'm saying that is because from, just to just to your point that from the outside, I didn't have any, like, look, did I think, like, Peter gets pretty pissed when he, you know, misses a shot, whatever? Sure. But, you know, whatever. I didn't think that was a, any kind of like deep issue, you know. So from my perspective again to be aware of your friends and pay more attention so that you can help out is a good thing to do and obviously in the veteran world we need to do that but clearly it's not just veterans that go through trauma big T trauma little T trauma whatever and might need some

freaking support sometimes and who knows like you know like to talk a little bit about you know if You see someone that's doing this kind of stuff, like losing their temper or they're doing things that you think, that's a little weird. That seems a little strange. Like, just to be like, dude, what's going on? Are you good? I don't know. I feel like a bad friend, you know, to not maybe just be a little bit more proactive.

Yeah, I mean, I don't know. I mean, look, I think, you know, Paul Conti was able to see that because he's literally one of the smartest psychiatrist on the face of the earth. Like I just don't know that a normal, smart, a normal otherwise smart person could, could sort of put those patterns together. So I, you know, I just feel lucky that, that, you know, and again, Paul, I remember him saying this,

he's like, you just live your life like a trauma victim. And I was like, what the hell are you talking about? I'm not a trauma victim. And he goes, okay, but I'm just, I'm just, telling you, like, you walk like a duck, you quack like a duck, it's possible you're a duck. You're like a functional alcoholic, but you're a functional trauma because you're freaking highly functional. I mean, damn, you know, like you're just kicking ass across the, in so many different aspects

of life for extended period of time. You know, like, hard to see. How often are you around Paul Conti? Quite a lot, right? because Paul and I shared an office in New York. Okay. So I probably saw Paul more than any friend, you know, during like a five-year period of, you know, 2015 to 2020. And but again, he knew me in med school.

Like he's known me forever. He understands, yeah, he just understood the perfectionism, the rage, the constant need to prove myself. And again, I think it's, I'm not here to suggest that like striving isn't good or any other things like that. That's not the point here. The point is at what point do these things become maladaptive, right? And you could take someone else who's working just as hard as me, who's, you know, just as committed to excellent work, but it's not coming from this place of insecurity.

It's coming from a place of love. And it could be a totally different experience. And it's not destroying their life. I mean, the point here is it was destroying my life. That's the point. That's the only thing that matters is. And that's why, again, this chapter is not written as like, you need to do this. It's not a you need to do this.

It's, this is a story that I hope lets you examine yourself. Because there is no question in my life that I was, like there was just a trail of body bags around me. If you wouldn't have gone, gotten this help or you, you're getting divorced, your wife wasn't going to see you anymore. She was going to get custody of kids. you were going to get pissed off, you were going to stop working so much, everything is going to fall apart. That's the trajectory we're on.

I mean, I don't think I would be alive today. Because shame is really the problem here, right? Shame is the thing that kind of underpins all of this stuff, right? And that's, so every time you make a mistake, at least in my case, every time I would make a mistake, I would hammer myself harder for it. Right? So, for example, let's go back to when I come home,

from that trip 11 days or 10 days after my son is almost dead. Do you think I'm acting better or worse as a result of that? Like the logical person would say, oh my God, you must have been bending over backwards to be a better husband after you were such a dick. But that's the logical person. No, no. The reality of it is you feel the shame for how you've behaved. So you come home and you act worse. Again, shame is an awful thing.

How do you act worse? Like, what do you do? You're just more aloof, more distant, more of a dick, more gruff. Less helpful. Probably went back on the road three, four, five days later. Are you in your mind thinking, well, I'm just like such a beast of a human that I just, this stuff doesn't phase me and I'm just carrying on? You know, it's funny. I wish I knew, I wish I could go back and find out what lies that guy was telling himself.

Probably your job is to provide, like your job is to be the financial provider. Not to do not provide any emotional support. So this is the you you you explain this story. I'm you know obviously like I said get the book, but what is a beautiful thing is it says this One section. It says if you take nothing else from my story take this if I can change You can change and you know this is you're talking about this specific kind of emotional side of it, but it's really all aspects of health end of life and that idea right there. If I can change, you can change. And by the way, you have health issues earlier in the book. You have metabolic issues earlier in the book.

You have opiate. Do you talk about opiate in this book? I don't know if you do. No. No. But you talked about the last time you were on my podcast, like you have been through really bad spots in just about every aspect.

or potential way a person can be in bad spots. And yet you've figured out that you can change. This one's the hardest. This was the only one I really thought couldn't be changed. I always had confidence the others could change. I always felt like I could bend the arc in anything else. This was the only one where I was like, this is truly unchangeable.

I've never had a stronger belief in my, life stronger than the belief in gravity that I could not change this the set of traits in myself that these these were hard wired into my motherboard at birth when's the last time you lost your temper well never in a destructive way in since 2020 now I won't like let me be completely clear three days ago is the first time in In three years, I got mad at another driver and honked at them and yelled at them. Was this in traffic or is this on the race course? No, no, no.

It was just, we just, it was a, I was at the airport in San Diego and I went to get the car and I'm driving back to get, pick up my family, and a bus cut me off. And I was like, all right, so I pull out of the way. And then I go to go around them the other way. And then the bus like almost smashed me into a wall. So I pull out. And I'm like, I mean, I just got super pissed in that moment. And, you know, I'm like literally laid on my horn for 30 seconds, right?

Like, how do you not see a vehicle? You literally almost put me into the wall. And that's the first time I've had, like, road rage in three years. And what was your debrief to yourself after that? I went through kind of like, okay, what, what else was that? was what else was really bothering you that day because you've been cut off a thousand times in the last three years and you've never cared. So what is it about that day? And secondly, did you figure that out? Yes, I think this is the, this time really was almost really resulted in an accident. Like it's a, there's an asymmetry when a bus is almost cutting you off. Also, this sounds dumb. And I don't know if this justifies any of it. But in my mind, it's like, this was an airport bus at the airport. Like you should know your way around the airport. You shouldn't be weed.

in and out of lanes with concrete on either side. Like there was sort of an expectation. Um, but regardless, it was on my mind, like for a couple days. I was really like examining this. And here's another thing I've learned. Like, you have to forgive yourself. Like I'm not, I'm not here to say I'm perfect, but I'm here to say that I'm not going to let one mistake spiral into 20.

So there, you know, I say this to my patience all the time. Don't beat yourself up if you mean. miss your workout for a day, but just don't miss it two days in a row. Just get back in the gym the next day. Don't worry about it. If you go on vacation and eat like crap, come back and start eating well. Don't let a mistake spiral into infinite mistakes. And so in many ways, it comes back to this idea of shame, right? It's really tempting for me to just berate myself in shame because of my misbehavior. But instead, it was like, you know what? That's like not a proud moment for me. Like I'm not proud of the fact that I laid on the horn and yelled at someone who,

by the way, doesn't hear me, but it doesn't matter. The point is, like, I'm not proud of how I acted and I'm going to do better next time. But just by doing that, I can do better next time. Right. That didn't, it didn't ruin. And I'll tell you what I was most proud of is about 30 seconds after that, I picked up my family and I was totally fine. Whereas, like, three years ago, that would have ruined the day. my wife would have got in the car I'd have been like you wouldn't fucking believe what just happened this fucking idiot

I'm gonna go find them but instead like to the state my wife might hear this podcast but she would otherwise have no idea what just took place so I was just like we're done with that so you know it's a little bit of a setback

but there's a victory I know that you posted the other day after you dry fired my boat and you're like I click on it you start off or something like This is progress. I was like, oh, no.

And then, and I was thinking the same thing. I was like, well, and then you explained it. You're like, hey, you know what? I, you know, it's really dumb and I just, you know, shouldn't do it. And you know what? It's okay. Yeah, I mean, like I had, I had, I had, I had fired a bow in April of 2021. It was last time I drive fired a bow.

And I mean, and I, that was after going through all of this. And I did okay, but I had to go jump into an ice bath. Like that. was the own and I still screamed I was so pissed when I broke it. But prior to that when I drive fire to bow like 2019, I smashed the bow after. Like so you know people listening might not understand what happens. When you drive fire a bow, you've already broken the string, the cams and the limbs. Well then I just broke the bow. I was like I'm going to destroy this bow. Everything is gone.

So yeah, like I think that's like literally the thing. If you say like what are the three things you're most proud of in the last 12 months? I literally would put that on those the top three. Dry firing a boat. And within three minutes, first of all, not yelling, not screaming, not throwing anything. And within three minutes being okay. It's so crazy that you're a freaking grown ass man. That's a doctor of.

this look at your life, incredible, and you do that kind of shit. It's like, or you did that kind of shit. It's like, it's kind of crazy, right? Isn't that kind of crazy? Yes. It's so hard to, like, picture that. I have a friend named J.P. Denell.

Do you know what J.P. is? I know you do. My friend J.P. D. D.L., he's in the SEAL teams with me. He was very young when he worked for me. And, like, he's, you know, had a bad temper. And at one point I was like, hey man, losing your temper is a weakness. And we broke it down, you know, like later, because we look at our dads, right? And you're like, oh, when my dad loses his temper, it's like a force.

It's like a thing. It's like no one, no, all of a sudden he kind of turns into like a weird Superman character because now everyone cows to cows down to his behavior and everyone gets out of the way. And it's just like, so you see that. You go, I'm going to get that superpower. And that was what JP grew up with. Like, oh, you know, that's a power. And I was like, hey, man, when you lose your temper, it's a weakness.

And that impacted him because he never saw it that way. And I don't even remember when I figured that out. I don't really remember when I figured that out. But I was in the SEAL teams and, you know, probably saw some idiot officer freaking lose their temper and start yelling and screaming. and everyone in the platoon going, what an idiot. And I remember thinking, I will never do that. You will never see me lose control of my emotions.

That's a bad thing. And then just never let that happen again. That's like, I think Echo Charles has a similar story where Echo Charles realized at some point that losing your temper, he read it in a book, actually. He read it in a book that losing your temper was a sign of, you know, insecure. That's what it was. For him it was he read in a book,

that losing your temper was a sign of insecurity. He was like, I'm never going to lose my temper again. And, you know, I haven't seen a heckle lose his temper. No. It's a long time. But that's just, yeah, it's just so weird to think about that and think about how negatively that can impact you. When you see your kids lose their temper,

how do you help them see the problems that it causes? And I guess how old are they? Just turned six and we'll be nine at the end of the summer. And Olivia's already 14. 14. So she's good to go. So yeah, six years old, they're kind of not quite there yet. But nine, it's like if you're losing your temper at nine, we can start discussing how that's going to impact you.

So do you have any conversations like that? What do when they lose their temper? Yeah, I mean, look, it's, you know, one of the great questions you can ask a kid when they're misbehaving in general after the fact is how did that impact the outcome, right? As opposed to just saying don't do that, right? It's like, okay, you made a choice to act a certain way. There were repercussions from how you acted. How did it work out for you? And that's one lesson I've taken away.

Another lesson that I think every parent knows is the most important thing to do when a kid is losing it. And this is not easy to do, but it's an important thing to do is to not lose it yourself. I get asked, like, what's your, hey, how do you discipline your kids? What's your favorite way of discipline? Do you, you know, do you beat them? Do you make them do burpees? Do you, whatever? You know, they got a bunch of, and I got asked that a while ago.

And I was like, I can tell you my favorite form of discipline with children. my kids my favorite form of discipline was asking them questions because when you say exactly what you did like hey do that make you feel better how's that how's that how's that help you how's that make you look what do you think everyone's thinking of you right now that you laying on the floor crying when you're seven or you're storming off the field when you're 10 or whatever the case may be asking questions is a powerful discipline disciplinary tool for children um like I said there's so much So you cover, which we didn't even touch on, we didn't cover the actual tools that you used,

that you got taught to handle this, to you have tools that you learned to utilize. Just like I could teach you how to shoot a bow, you got taught what to do when your temper starts to flare up, when you start feeling certain emotions. And it's all in the book, and it's so worthwhile to read that for yourself and for your family and for everybody around you.

There's tools that you can utilize to overcome those things. But you know what? I'm going to fast forward a bit and kind of close this thing out. I mean, we've been in here for, I think, approaching four hours. You write this. As my recovery progressed, I noticed my preoccupation with dying began to fade away. And my quest for longevity no longer felt like a grim, desperate task. Now the things I did every day felt welcome, necessary.

I was enhancing my life and looking forward to the future. My journey to outlive finally had clarity, purpose, and meaning. It brought me back to something my dear friend Rick Ailius had told me. Rick had been one of the 155 passengers on U.S. Airways flight that emergency landed in the Hudson River in January of 2009. As the plane was coming down, Rick and most of the other pilots, passengers were certain that they were going to die. Only the pilot's skill and more than a little luck prevented disaster.

If the plane had been going down, if the plane had been going a little faster, it would have broken a power on impact. A few miles per hour slower and the nose would have tipped forward and it would have sunk into the river. A handful of tiny factors like that made the difference between everyone on that plane living and many or most or all of them dying. That day changed Rick's outwe. look on longevity in a way that really resonates with me.

All that time, I had been obsessed about longevity for the wrong reason. I was not thinking about a long, healthy life ahead. Instead, I was mourning the past. I was trapped by the pain that my past had caused and was continuing to cause. I wanted to live longer. I think only because deep down, I knew I needed more runway to try and make things right. but I was only looking backward, not forward. I think people get old when they stop thinking about the future, Rick told me.

If you want to find someone's true age, listen to them. If they talk about the past and they talk about all the things that happened and that they did, they've gotten old. If they think about their dreams, their aspirations, what they're still looking forward to, they're young. here's to staying young even as we grow older so that's the book that's some good advice from the doctor and you give away advice all the time you're still doing that now that's what you're doing now what currently what are you doing tell us what you're doing where we can find you well my podcast the drive still comes out every week. So that's, you know, continue to be a huge joy. We're

about five years into that and we've come no closer to running out of topics to explore than we were five years ago. So I see no end in sight to that. And we have recently launched, well, we soft launched it. It'll be kind of rolled out a little bit more this year, a product called Early, which is sort of a digital, I don't know how to describe it other than kind of a masterclass of everything we do in the practice. So this is something that took us two years to build. And it's truly this is all you need to know to do all this. And it's, you know, it's, God, it's probably 30 hours of highly produced video plus tons of downloadable material and stuff like that. So we had a very limited release of it in April.

where we put it out for four days just to our subscribers. We're going to have another release later of the year and then probably open it up to the public in the beginning of 2024. Because your practice, we've mentioned your practice, but your practice is helping people have better health span and lifespan.

Yeah, but it's super small and it's effectively closed. I mean, at this point, it's sort of a friends and family. But this is a way for a normal person to say, all right, I read this book. Because look, what we covered today, I barely dusted on anything. that's in the book today.

Like it's freaking 410 pages of dense, awesome information. We barely touched on any of it. And once you get done with that book, you're going to say to yourself, I need more. So the podcast, you have a subscription version of the podcast as well. That's right. So it's one episode a month is dedicated to subscribers called an AMA. And then the show notes are for subscribers only. So yeah, we don't have any ads on our podcast.

It's all subscriber. You're on Twitter? Yeah, Instagram more. You're on Instagram the most. You have a YouTube channel. Yep. You have a Facebook. They're all.

They're all Peter Atia, MD. Peter Atia, MD. He got it done. He got it done. I let. Only because somebody had Peter Atia before I started. Oh, otherwise you're used to. Otherwise, I wouldn't have thought to put the MD on there.

It seems a bit douchey, but. Well, luckily, there was no other Jock Oillinks back when I got a hold of my stuff. Jocko Willink, MD. Definitely. Definitely not. That's for sure. Kerry, sir.

You got Echo's job right now. You got any questions? I got an echo question, actually. Oh, damn. So you talked a lot in the book about sleep and, you know, the effect that has on our ability to perform and things like that. I'm curious about your kind of opinion on mouth taping. Do you have an opinion? I do, yeah.

Okay. Yeah. It's really important for people who are mouth breathers to not be mouth-wethered. breathers. So when you're breathing through your mouth, be at awake or at sleep. I mean, you basically want to reserve mouth breathing only for when there is no other option, which should really only be when you're exercising strenuously. And so if you're sleeping in your mouth breathing, it is sending a message to your brain that your energy requirements are significant and you're in a more sympathetic state. So your sympathetic nervous system ramps up, your parasympathetic

nervous system goes down, your heart rate goes up, your heart rate variability goes down. So this is a physiological state you don't want to be in when you're trying to rest and recover. So again, once you address any structural issues that a person might have in their nose, being able to put on mouth tape for people is an awesome tool to teach them how to nasally breathe. Right on. And what are some of the benefits of nasal breathing? I know there are some. I'm just not a hundred percent sure what they are. I mean, everything actually started. I write a lot about sort of how so much starts with the breath, right? So your breathing strategy, and there were basically two major breathing strategies. Your breathing strategy determines your center of mass. Your center of mass

determines how you kind of exist with gravity in the world, right? So are you hunched over? Are you sitting up too much? Being in that high, sympathetic, low, parasympathetic state by itself is counterproductive to your health. So that's really why you want to be named. nasally breathing. Got it. Cool. Yeah, J.P.

Dinello and I both, we've been geeking out about the mouth tape. We both do it now when we sleep. And it's, it's been crazy beneficial for me. I used to wake up with headaches a lot of times

because my mouth was like gaping open when I was sleeping, I guess. But it's been super helpful. Awesome. Yeah. I'm glad you asked that question because that's the type of information

that you can get from, from your podcast, from the drive podcast, from the book, from the newsletter that you sent out, from everything. So I'm glad you, like, legit. I'm glad you asked that because I spent all my time talking about death and hell and all this other stuff. So that's what I did. But that's not what you do for a living. That's just the stuff I wanted to talk to you about, you know, as my bro.

Peter, you got any closing thoughts? No, guys. It's a privilege to sit down and be able to go deep into this stuff. Well, thanks for joining us once again. I can't believe it's been seven years or yeah something like seven years since you came on this the last time um thanks for what you're doing too last time i was on i was just starting to write this book put it that way wow crazy uh thanks for what you're doing for so many people you give away so much information and everybody is should be so appreciative of that thanks for your friendship over the years man um It's been very meaningful to me. But like your friend Rick said, after his exposure to death on that seemingly doomed plane,

I like to think more about the things we will do in the future, the hunting, the shooting, the driving. And the mystery mission. The mystery mission, which I got for you, which is going to be so freaking awesome. I got Peter's wife asked his friends to send a video. with some thing, some request, some event that we would do with Peter individually in the future, sometime in the future in the next five years. And I couldn't think of anything because what do you get, what do you do with Peter Tee? Like I was like, oh, we go hunting.

Oh, we go shooting. Oh, there's a bunch of stuff. I was like, yeah, blah, blah, blah. No offense to people that said that because it'll be awesome. But I got struck with a bolt of lightning of something that I know he could never guess. it's something that he's been preparing for his whole life but that he doesn't need to prepare for but that's something that he's never done before

if you can imagine all that. Do you remember how you worded it in the video? What I say. So you got to remember my wife, she asked me what do you want for your birthday and I said this is what I want. I don't want any presents. I don't want a party.

I want an experience with each of my friends. And so it's this two-hour video, right? Because every person's going to talk for a few minutes And it's amazing. And Jocco's is, I will call you with a pack list and coordinates and a time to meet. Freaking morning order on the spot. And by the way, he prefaced this with a beautiful, beautiful, a lot of really, you know. And the ask wasn't, what do you have to say to Peter?

But a lot of people did that anyway. It was very kind and meant a lot to me. But after Jocko had one of the sweetest things to say, it was, this is the gift. Pack list coordinates, time Be there. It's going to be like It's going to probably be three

days total with maybe a day of travel On either side or half day of travel So it's going to be awesome But that's what I like to think about Like your friend Rick advised I like to think about what we're going to do in the future We're going to do that We're going to do rock marches

We're going to do a lot of cool stuff in the future And I think as much as we can, we will do our best to stay young and outlive. And with that, Peter Latia has left the building. And well, freaking, I legit, I'm glad you asked that question at the end because that's kind of knowledge that he is freaking packed with. And go listen to the first podcast. I mean, the guy's life has been, he's been an overachiever's all, a whole life.

He just he is brilliant and he's been focusing on this stuff for decades and and he's willing just to give it away. So and I didn't do the best job of like bringing forth that information. That's what the whole book is filled with. Get the audio book. Like do you really want to hear me sit here and and read the scientific parts of this book? I was like, well, I could do that or you can go get the audio book and listen to the doctor himself read it. That's what we did. I'm glad you asked that question so people recognize how much information they can get from him, from his podcast, from this book, Outlive, the Science and Art of Longevity.

Yeah, you got an opportunity. You got Peter T. in the room, man. You got something cooking on the brain. Yeah, you've been taping that mouth, been taping that mouth breather up. Bro, me and J.P. Donnell, we've been geeking out about that, man. We both use the same, like, brand of tape or whatever.

And it's been crazy. We're getting your hostage tape on us. That's what it is, right? Yeah, that's the one we both been using. And it works, man. Not waking up all, you know, headaches. Bro, I'm glad because for so many years I've been running around telling people, hey, quit being a mouth breather, right?

Like, what's your problem? All this time. All this time. And I didn't know there was some scientific truth for it, right? But guess what? Doggle was right again, man. Quit mouth breathing, son. I'm glad you got that tape.

I was wanting to tell you to get that tape, boy. Close that mouth, boy. Oh, there was a guy that was a mouth breather in the SEAL teams, but somehow his nickname wasn't mouth breather was fart sniffer. Because it kind of looked like he was kind of had his mouth open like he was kind of like trying to sniff that fart. Yeah. Pretty rough nickname on my homeboy, but no, that's the way it goes sometimes. It's crazy too. I catch myself closing like literally I'll be breathing through my nose more throughout the day two.

And I'll just notice it like my mouth. I'm breathing through my nose. I don't know if that's, you know, a subconscious thing that's going on because of the mouth. That's a damn improvement, bro. I feel like that bad friend now that didn't tell his buddy, he had a bugger hanging out, you know?

I should have been like, hey, bro, your mouth breathing all along me, man. Step back. Shut you down. Shut your mouth, man. Shut your mouth. Well, your boy's on it. We're getting taken care of. Right, right.

There you go. Well, hey, that's one of the many ways we can try and become healthier and live. healthier live longer have a better health span a better life span all that stuff so that's what we're doing need to get the right fuel in your system by the way you might as well go get that jaco fuel 100% get that jaco fuel hitter what am I thinking about I'm thinking about mulk because because that's one thing Peter was saying you got to up that protein got to up the protein you might Let's get up that protein when it tastes good and it's, what is that word, satiating, right?

It fills you up. Crack that milk and get it done, RTD style. So RTD, if you're not in the industry, that means ready to drink. You can get some milk and just have it in your house. You can drink 30 grams of protein like a boss. Two minutes. Like a boss. It's amazing.

And tasty. And you know what's crazy? It's so, it's filling. You feel good. So get some of that. And look, I'm still old school with the pow-pow. Get the mulk powder. Because if you're feeling like you want a little bit more,

you know, like if you want a full-on meal, that's dessert. Milkshake action. You want milkshake action. Yeah. Go get yourself. Get some of the powder. Joint warfare, super krill, krill oil, vitamin D-3. We got it all for you.

Time war. Time war, man. You want longevity, bro. You want eyesight. Yeah. Uh, you get that time war. Get that time war. Time war is the subscriptions for Time War is crazy right now. Because when you, so when you go to joccofuel.com, you can, you can get it. And then if you like it, you can subscribe to it. So right now, like once people go on Time War, they're just hitting that subscribe button. Just send that shit to me, boy. Send it to me. I was, I was digging into the jaco system the other day. Because I was tooling around on Jocco Fuel. You know, I'm getting some stuff. And yeah, I was looking at, there's like the jaco system. and the ecosystem. And I was like digging around yours.

I was like, oh, okay, got the full stack. There's go like in that system too. So all the cool things we just mentioned, they're all like listed in order in that stack. So easy access. Yeah, Time War is one of them. I told you this before. Like I will take Time War until I die.

Just the way that what you get out of it from a, from a feeling good perspective to like the joints to the, and the eyesight thing was crazy to me. The eyesight thing was crazy. My eyesight got legitimately better. I must have been about to say. I have to look at what the muster was because that's when I noticed it. But it's crazy.

So anyways, go to joccofield.com. Get yourself some of that. If you don't go to joccofuel.com, you can go to Wawa. You can hook it up at Wawa, bottom right corner of that shelf. They kind of, we got to put, the squeak got put on us by the big imperialistic beverage companies you know who they are and you name them there's you know who they are trust me but they went paid millions of dollars to try and subdue the rebels try and take out the rebels we're out there on what planet we're on hawth or some tattooing tatooine right we're out there trying to be free

trying to offer people something that's actually good for them they're trying to they're trying to take us out with the death start you can't deny performance jamie cochran said that when she was on the podcast the other day man and yeah uh that's where i think about are people clear shelves? Like you can't compete with that. You know, you can't buy that away from us. That's the way it goes down.

Look, if not vitamin shop, G&C, we're coming into A-fees. So all those military commissaries across the world, be able to get your supply, be able to get it.

Hanifer dash stores in Maryland, Wakefern Shop, right, H-EB. H-E-Bs represent, all my people down in Tejas,

just rolling in there and just getting after it. Thank you. Appreciate it. You got a full supply at H.E.B. We're sending it as fast as we can. Meyer up in the Midwest. Harris Teter in there now, Lifetime Fitness in there.

Shields rolled into Shields, 300,000 square feet of just awesomeness. Go and check that out. And they also have Jock Fuel. They got everything you want, including Jock Fuel. And by the way, we're in a bunch of little gyms, small gyms, Jiu-Jitsu gyms, CrossFit gyms. We're in there. We're the, we're the energy drink of CrossFit.

So when you get done knocking out that any, knocking out that work out of the day, before you hit it, you can get that energy drink. After you hit it, you can get that milk hit or get that protein in you. If you own one of those gyms, you want to sell Jocko Fuel. Go to email J.F Sales. I know at joccofuel.com. We can hook it up. Get that wholesale account.

That wholesale account rolling. OriginUSA.com. We just launched workout gear. Hey, it took a while. I know. Trust me. I know. Trust me, I know.

But to reestablish a supply chain of American-made materials so that we could cut and sew it here in America, took a little bit of extra time. Then to design it properly, get the right materials. It took some time. But we got it now. RTX. Roll, train, execute, execute, execute, execute. You can get that.

You can get hunt gear. You can get, you know what? Hoodies, bro. Are hoodies American? Yes. 100% right. If you're in America, you wear a hoodie. Yes. Right? You have a hoodie. You probably got two. Get yourself one more. Get yourself an American made kilo hoodie. Get the kilo. Get the kilo. If you're in the northern part of the states, get the heavy. But the kilo everywhere else. I mean. You see you never lived in the northern part of the states. No. Because in the summertime, in the fall, you don't know. need you don't need that you the heavies for the cold weather you need that kilo that kilo that's all year round kilo hitter and look you live this is what we were talking I was just at a at a meeting with origin and jaco fuel and they're like well you know it's it's we're not gonna be selling many kilos right now because it's the summertime and I was like bro what are you talking about what

are he talking about in California you need a you need a kilo year round 100% back back back of the back of the Jeep I've got two key like two kilos, you know, after 7 p.m., you throw that little guy on, you can get. But California, but East Coast, same thing. Same. Yeah. I was in Maine when I was growing up in Maine. The sun goes down.

Guess what? You need to put that kilo on. That kilo. That kilo is a go-to piece of equipment that should be with you at all times. Now, listen, I'm not going to lie to you. I have a blue kilo. I have a black kilo. Blue kilo is what I work out in the morning.

Black kilo is kind of the wear around. I have a cammy I have a raptor kilo And look, do I wear it when I'm out in the woods? Yeah, do I wear it when I'm also rolling down The streets? Hell yeah Do you wear it rolling into the podcast studio every day?

Yes, yes, I do. And then I have a zip up on now too And I got one of those. What I found out about the cool about the full zip for travel. If you're traveling, you may want to have some variable warmth. Right? Mm-hmm.

So you unzip it. It may not sound like much, but you just unzip that bad boy and all of a sudden let that coolness in. Or a little chill, a little chill coming through, little wind, no problem, zip it up. We're good. Get that versatility with the kilo zip hoodie. Dude, I just invented that, right?

Hey, if you get hot, unzip it. I'm over here smart. Freakin technology. I'm giving Peter a Tia run for his money on Intel, on his intelligence. Because I said if you get hot, you can unzip your hoodie. Check it out.

OriginUSA.com. Go get yourself an American-made hoodie and wear it with pride. Help your, help the national security in this country and help your children live in a stable, free nation in the future. That's what we're doing. OriginUSA.com.

There you go. Also got jaco store.com. Damn, you had one job. I had one job. One job. Blue it on jaco store. It would echo here is that, Right there, bro.

He's going to give you. What did you say Jock's get? What? Let's give it a go. Let's give it a go. Here we go. Jocco store.com. Boom.

We got rash guards, t-shirts, trucker hats, beanie, hoodies. We got the shirt locker subscription. Echo's putting out a shirt every month, new design every month. This is one of the earlier shirt locker ones. This is still one of my favorites, though. We got the LMAD. And we got layers in every shirt. This one's got the 0-434 at the bottom.

No big deal. But great subscription. New layers. Layers. Getting deep in the layers. Layers. It's like the first time Echo said that, man. I was like,

are you kidding me? And now we say it. Now everyone says it. It's so true. People talking about them layers. Actually, we gotta go back. I don't know who said that first. I might have said that first.

Got to watch the tape. We got to go back to the tape, man. We'll check it out. Yeah, if you want to get some of those layers, jocco store.com, subscribe to the podcast. Also subscribe to jocco underground.com. got that going on and just in case all other forms of communication go down we'll be there on the underground jocco underground.com we got a YouTube channel subscribe

to that Origin USA YouTube channel Jocko Fuel YouTube channel Ashland Front you got some YouTube channels you want some you want to get some watch some videos watch some good ones psychological warfare on iTunes flipside canvas.com to Codomier just making cool stuff for you to hang on your wall got some books outlive the science and art of longevity by Dr. Peter Atia. Just get that book. It's a textbook for you on how to be a better human. So there you go.

I've also written a bunch of books. You know what they are. Final Spin, Leadership Strategy and Tactics, Code Warrior, or the code, the evaluations, the protocols, discipline equals freedom. Feel me. I mentioned it today. I had to quote it today because I knew Peter Tia was going to come at me.

He was going to come at me. You got to sleep. You got to sleep. It's good for you. Tate that mouth, son. Tape that mouth, boy. Way of the Warrior. One, two, three, four, and five.

Everywhere I go, those parents are thanking me because of what their kids are doing. So they're doing jiu-jitsu. They're doing pull-ups. They're doing stuff that Peter T. was talking about today. He talked about how you would change the way children are raised. His kids are warrior kids, by the way. Forgot to mention that today. But his kids are absolute warrior kids.

He posts the other day doing the warrior kid workout. They're in the game, bro. Get the kids you know that book. Mikey and the Dragon's About Face. Extreme ownership, the dichotomy leadership. It's all there. Eshlonfront, we have a leadership consult. We solve problems through leadership.

That's what we do. Go to echelonfront.com for details. Next big event. Let's say we get the council, which is sold out. We got a battlefield August 8th through the 10th at Little Big Horn. I think there might be a couple. tickets left. So if you want to come and check that out, come and check it out.

We got a women's assembly run by Jamie Cochran, our chief operating officer. What'd she say? You just quoted her? Can't deny performance. Yeah, yeah. There you go. Well, there you go. You want to learn about that activity?

Go to the women's assembly. What I think it's called the Women's Summit? So it's the assembly now. Oh, okay. Yeah. So they had a, you know, a little name change. but the women's assembly, it's a free live event that we host through the Extreme Ownership Academy. Got it.

And the summit is an actual live event. The assembly. Yeah. The assembly will be the in-person event in Phoenix. Okay. It's September 14th and 16th, Phoenix, Arizona. So go check that out if you want. We also have online training, Extreme Ownership Academy.

This is where you learn the jiu-jitsu of life. 100%. That's where you learn the jiu-jitsu. of life. And listen, if you don't understand Jiu-Jitsu, let me explain it to you. A person that weighs 150 pounds can beat a person that weighs 250 pounds. That's what can happen with Jiu-Jitsu. If you want to learn Jiu-Jitsu

of life so you can out-maneuver, out-think, overcome problems, lead, go check out Extreme Ownership Academy, Extreme Ownership.com. How much of your career would you say was relationship? relationships based like in the teams like percentage was 99% 99% right on 99% was 99% was relationship based I I will have to think about this I never and

matter of fact I just got done saying this to a company I never had to say hey like do what I told you to do which is not relationship big that's authoritarian base that's rank based never had to do that never had to do that very seldom and I can't think of any examples where my boss told me like hey shut up and do what I told you do no because I had a good relationship with them they wanted to know my opinion they wanted to take lead from me we were influencing each other we were listening to each other up down and across the chain of command so you want to talk about how to get through life in a better way build good relationships so we actually teach because there's this is you can't well if I asked you like right now hey

hey carry build me a uh uh a 44 foot gaff rigged schooner boat would you be able to do that negative no you don't know how no there's skills you would need yes sir it's the same thing with building relationships there's skills that you need there's things that you can do to build strong relationships and when you build a strong relationship you build a strong team when you build a strong team you get the results so that's what we're doing go to extreme ownership dot com and learn how to build relationships learn how to make decisions learn how to get better and learn how to lead that's what we're doing also if you want to

help service members active and retired you want to help their families want to help gold star families check out mark lee's mom mama lee she's got a charity organization if you want to donate or you want to get involved go to america's mighty warriors dot org she is doing all kinds of things to help our veterans and also don't forget about heroes and horses dot org that right there is micah fink's organization We just got a report in from the field. Did you get that report from the field? I did not.

Okay. I probably should have related to you. Currently, Micah Fink, he just actually had a wrestling match with a bear, and he was about to submit it when out of nowhere flew a bald eagle, and the bear got scared and ran away. So we're still giving it to Micah, undefeated, 100. 100% undefeated in the field he's out there getting after it no but seriously micah fink doing awesome stuff helping veterans first responders find themselves out the wilderness it's an awesome program if you want to connect with us on the interwebs peter attia is on twitter on the gram on youtube and facebook all of them at peter atia md and for us carry helton is at carry underscore helton didn't get that didn't get it huh still still haven't gotten that one resolved didn't get that care Hellton. Is there another Kerry Helton out there?

Somebody has that? There is. Yeah. Then, yeah. Hit him up. Try and try and say, hey, man. Oh, because he's not active? Negative. Yeah. Did he get it before? Yeah. Yeah, he's had it for a long time. I first hit him up a couple years back and was just like, hey, man, like, if, you know,

maybe we can work something out. Throw you a hondo, bro. No interest. Zero interest in responding to Kato. Yeah, it's some computer out there. All right. That's Carrie. carries at underscore helton and i'm at jocco willink just watch out for the algorithm and just

just please and uh thanks to all the service men and women out there who are on the front lines of defense around the world keeping us safe also thanks to our police law enforcement firefighters paramedics emts dispatchers correctional officers border patrol secret service all first responders thank you for keeping us safe here at home and a special thank you right now in honor of Peter Atia, thanks to all of you doctors, nurses. That's in honor of Peter's wife, Jill, and all the health care professionals out there who support us in our darkest hours.

And to anybody else out there and everybody else out there, just remember what Peter Atia said. If he can change, so can you. So can you. And that is so powerful. It's so true. Look, if you've been on the wrong path, if you've taken some hits, if you've been doing some things, you shouldn't have been doing, if you're not as healthy or productive as you should have been. And maybe you haven't been the best mother or the best father or the best husband or best wife.

Maybe you've been hyper emotional or not emotional enough. And maybe you've been lazy and gluttonous and just generally freaking miserable. You don't have to be. You can't change overnight, but you can change. You can do it. But in order to change who you are, you have to change what you do, how you live. And that is something you do have full control over. And there's no better time to start than now.

And until next time, this is Kerry and Jocko. Out.