Modern Wisdom - #613 - Dr Peter Attia - The Health Metrics That Matter Most For Longevity

Episode Date: April 10, 2023

Dr Peter Attia is a physician, longevity expert, podcaster and an author. Working out what to actually do if we want to maximise our health and lifespan has become an increasingly difficult task. There are an unlimited number of wellness approaches available, but thankfully Dr Attia has spent his career assessing the most important strategies we all should be focussing on for fitness and longevity. Expect to learn how to best increase your chances of living longer, the role of fasting in longevity, the most important metric that predicts a long healthy life, the longterm effects of vaping and alcohol, how you can prevent cognitive decline, the vital signs that everyone overlooks, how to design a science-backed weekly workout regime and much more... Sponsors: Get 10% discount on all Gymshark’s products at https://bit.ly/sharkwisdom (use code: MW10) Get £150 discount on Eight Sleep products at https://eightsleep.com/modernwisdom (discount automatically applied) Get over 37% discount on all products site-wide from MyProtein at https://bit.ly/proteinwisdom (use code: MODERNWISDOM) Extra Stuff: Buy Outlive - https://amzn.to/413jYwH  Check out Peter's website - https://peterattiamd.com/  Get my free Reading List of 100 books to read before you die → https://chriswillx.com/books/ To support me on Patreon (thank you): https://www.patreon.com/modernwisdom - Get in touch. Instagram: https://www.instagram.com/chriswillx Twitter: https://www.twitter.com/chriswillx YouTube: https://www.youtube.com/modernwisdompodcast Email: https://chriswillx.com/contact/  Learn more about your ad choices. Visit megaphone.fm/adchoices

Hello friends, welcome back to the show. My guest today is Dr Peter Atir, he's a physician, longevity expert, podcaster and an author. Working out what to actually do if we want to maximise our health and lifespan has become an increasingly difficult task. There are an unlimited number of wellness approaches available, but thankfully Dr Atir has spent his career assessing the most important strategies we should all be focusing on for fitness and longevity. Expect to learn how best to increase your chances of living longer, the role of fasting in longevity, the most important metric that predicts a long healthy life, the long-term effect of vaping and alcohol, how you can prevent cognitive decline,

the vital signs that everyone overlooks, how to design a science-packed weekly workout regime, that everyone overlooks, how to design a science-backed weekly workout regime, and much more. I am a big fan of the approach that Peter has today. It is evidence-based, it is grounded in science, and it's very simple to apply. I very much appreciate the work that he does. Don't forget that if you're listening, you might not be subscribed, and that means you're going to miss episodes when they go up. It also supports the show, it helps me get bigger and better guests, and it makes me very happy indeed. So, go to Apple Podcasts or Spotify or wherever you are listening and press the subscribe button.

I thank you. But now, ladies and gentlemen, please welcome Dr. Peter Atia. would you say that you have a unique or different perspective when it comes to longevity. I don't know, that's an interesting question. Yeah, maybe in some ways I do, I suppose. It seems to me that you're focusing on not just lifespan, but also health span as well, not just physical health, emotional health, mental health. That more holistic view seems to be different to me. Yeah, and also I think kind of a somewhat low tech approach as well. I'm completely interested and fascinated by obsessed with all the high tech stuff

and the science that hopefully will come through in the coming decades. But maybe going back to my background and risk management, I really think everyone should always be hedging everything they're doing. So, you know, to just assume that we're going to come up with some amazing technological breakthrough that's going to, you know, start to defy aging while not doing all of the things that we can do with the technology

that exists today strikes me as unwise. What's that background in risk management? After I left my first stint in medicine in 2006, I went to work for the consulting firm McKinsey & Company, and though I was recruited there to do healthcare, I ultimately wound up in the risk practice because of my background in math. So I was doing credit risk and cool stuff like that. All right. Now, how does that inform the way that you show up for your work now? I think it's essential, right? I think everybody should be trained in some understanding of risk. Everyone should be trained in probability statistics. That's, that's to me the much more important stuff in mathematics.

And I think that understanding how to think about symmetric and asymmetric risk, understanding expected value, thinking about how to hedge risk, all those things are, you know, important, not just in, you know, thinking through financial instruments where banks are constantly making mistakes anyway. But as you think about your own life.

So I'll give you a very silly example. So two weeks ago, a friend said, hey, you want to come skiing. He's going to go to this amazing place in ski. And I said, no, he's like, how do you not want to do this? And I was like, well, I don't personally get enough pleasure from skiing to justify the downside. Right? So the upside for me to go skiing with you is this much.

The downside is this much. But that's my decision. That doesn't mean you shouldn't go skiing, right? Because for him, the upside is probably much larger. And maybe he's a much better skier than I am, so his downside is much less. But it's thinking through simple things like that. Every decision I make, I sort of put through that matrix.

That makes a lot of sense. I'm interested by this low tech approach that you've mentioned. And I keep on bringing this up, mutual friend, Andrew Kebeman, yourself, has really been sort of the forefront, I think. In Kelly Sturett's new book, he's almost sort of stripping things back a little bit. There was a movement, you know, 10 years ago, the sort of advent, the absolute, like, frontier of the biohacking, quantified self.

And it really seems like that's not being reversed, but being taken back to a much more simple set of rules for people to follow. Yeah, look, I think they're not mutually exclusive, and I'm certainly no stranger to all of those things. And I probably still do things that most people would consider excessive when it comes to tracking things and monitoring things and incorporating technology into what I do.

But the reality of it is, you know, having a very high VO2 max, being incredibly strong, that's going to do more for your lifespan and health span than any piece of technology or biohacking or manipulation of gut biome or any other thing that people are talking about. I mean, it's just not even within the same zip code. And you don't need a lot of technology to do those things. You just need to put in the work. It seems to me that one of the longest levers is compliance on whatever the program is that you're going to do. And one of the problems that I found,

certainly, I struggle tracking macros, right? I've always struggled tracking macros. So for me, learning what intuitive eating felt like actually meant that I adhered to my diet more effectively than setting the bar for compliance so high that I just constantly failed and then I didn't get any motivation from doing it. And I feel like that is a little microcosm for tons and tons and tons of ways where the

bar has been set too high for people to actually access these protocols. Yeah, everybody's got to figure out the system that works for them. I think using nutrition as an example. So as I talk about in the book, there's basically three ways to go about reducing intake. If you're overnourished, which is the way I describe people that have too much body fat, especially in places where you don't want it. It's not really the subcutaneous fat. We're worried about it's the visceral fat.

It's the intramuscular fat. It's the peripancreatic fat, perinephoric fat, all of those things that are metabolically destructive. So not the cosmetic fat that actually has no metabolic consequence. So let's assume you established that a person needs to, you know, me, I need to lose, I need to reduce energy intake. I can do it by calorie counting or tracking my macros. I can do it by dietary restriction, by sort of identifying things within the diet that I don't want to eat and limiting them, or I can do it via time restriction, just narrowing the window down in which I eat.

Each of those has its pros and cons, but what matters is that you figure out what kind of risk for you. So for me personally, dietary restriction has always produced the best outcomes. If I simply pick certain bogeymanes in the diet diet and say I'm not going to eat those things, everything falls into line. Whereas when I track macros, which by the way sometimes produces better results in the short term, it can be harder to maintain. Conversely, I have friends who can track macros all day long every day and they can do it automatically. They don't have to be in a happy way. I'm not built like that in the slightest. And that's okay. I mean, again, I think the point is I you know, sort of would want my patients, for example, to try all

three and figure out which one works for them. And as I always say, like, you're better off being seven out of 10 in performance, but doing it every single day, then being 10 out of 10 some days, zero out of 10 other days. And, you know, that kind of cyclic performance generally leads to worse outcomes over the long run. One of my friends, Alex mentioned to me the other day that most people have a bucket of perhaps between five and 10 meals that they typically eat. And he said that one of

the longest levers when it comes to altering your diet is to just look at those five to ten meals. Even forget about everything else. It's like, what do you eat the most? You probably have, for me it's like four recipes that I go back to very consistently. Okay, what's that constituted of? And how can you just tinker with that a little bit for it to be closer to what your goals are? I thought, holy shit, like that's such a low tech solution. And yet, in terms of what it does, does it grow any corn? Does it actually work? Probably super effective. Yeah, that's one of the things I enjoyed most about macro tracking when I do it is, you know, the app I use, which is called carbon has, you know, and I'm sure this is true of

any of the apps now. They're all so much better than they used to be 15 years ago when I started trying to pay attention to this. But you basically put in your recipes. So you're not necessarily going to pre-populated things. You're saying, look, when I make an omelet, I always do it the same way. It's eight egg whites, it's four yolks, it's half a tablespoon of butter.

I do it for 25 years. The exact same way every time. So just click, click, click, click, click. And now I can know, and you're absolutely right, there's probably no more than about six things that are constituting 80% of what I eat. Talk to me about the difference between slow death and long death. Ah, okay. So, I mean, as the name suggests, it really comes down to the rate of time between when the

onset of the illness takes place and when you demise. So if you think about the greatest successes in medicine, our current medical system, what I call medicine 2.0, medicine 2.0 is remarkably successful in treating fast death. So when you think about trauma, you think about the person who's driving down the street, car hits another car, and they suffer a significant injury that 100 years ago would have killed them. We now have remarkable capacity to save lives in that situation. Infectious diseases, of course, would be the poster child for this. Up again, up until 150 years ago, we stood no chance against most infections. And today, some of the most devastating bacteria barely touch the surface.

And by the way, viruses that once wiped out civilizations, we can now vaccinate against them all these things. So we've effectively doubled human lifespan, going from about 40 to 80 years by treating fast death. So big win for medicine 2.0. The problem is we haven't really made much progress against slow death. So slow death is what most people think of when they actually think of death now. When you think of cardiovascular disease, cerebral vascular disease, cancer, neurodegenerative disease, metabolic disease, those vascular disease, cancer, neurodegenerative disease, metabolic disease,

those are slow deaths. Even when a person drops dead suddenly of a heart attack, right, a person who's been asymptomatic their whole life and drops dead suddenly of a heart attack, that disease was killing them for 30 years. So unfortunately, we just haven't made much progress there. And as I argue, that's where we have to make progress. That has to be the transition if we want

to be serious about longevity. Why is that not a priority currently? I don't think it's not a priority. I think we just have the wrong strategy. So if you have the wrong strategy, you will fail. And I would argue that we don't have the right strategy for addressing those problems. So it's not due to a lack of trying. I think we've been trying very hard to eradicate slow death. And I would argue that the fact that we've had such little success, given the enormous resources that have been put in both financially and simply sheer effort, I think is proof positive that we need a different approach. We're going to go through a lot of insights today that people can apply to their lives.

Before we even get into that, how should someone think about building a framework of how they can take the tactics that we talk about today and actually use them? As we mentioned at the very start, compliance, adherence, you can have the best strategy in the world if you don't end up applying it, it means nothing. What is your best advice on how people can form a framework of tools that they can actually use. Well, I think you have to start with the objective. So, so everything I talk about, I've always talked about this way, or at least for more than a decade, and I certainly have written the book through this lens, which is you go from objective to strategy to tactics. So, we always want to start with the objective objective and I do think it's worth being clear

for any individual what their objective is. And I take a lot of time with patients going through this. So when you go to your doctor, that's not a common question. What is your objective? And again, it's not the fault of the doctor. I think it's the fault of the system. The system isn't really set up to ask that question. The system is more set up to kind of play a bit of whack-a-mole.

Is there a problem right now? Is there a symptom right now that I need to address? But if you're trying to play this sort of long game, you have to work backwards and say, okay, what do you want to be true at the end of your life. And the framework that I use for that is called the marginal decade. So the marginal decade is the last decade of your life. Everyone will have a marginal decade. And that's not a pleasant thought for many of us to think about, right?

I don't love thinking about the fact that I'm going to have a marginal decade, but I will. Now, you never know the day you enter your marginal decade. But many people know when they are in it. And the question then becomes, what do you want to be true in that decade? So let's play the game with you. How old are you Chris? 35.

Okay. So let's assume that, you know, fate will smile on you and, you know, God forbid, you're not going to have some premature death You know you're not gonna die in a car accident next week or be stricken with cancer and you know 10 years or something like that So let's just assume your marginal decade is kind of the ninth to tenth decade of your life What do you want to be true in that decade? I would like to still be able to move without assistance. What kind of moving?

I would love to be able to still walk. I would love to be a door dogs. So being able to take the dog for a walk, being able to throw the ball. A big a dog. Golden retriever. That big dog. Yeah. Big for a 90 year old. Yeah.

That's okay. You can be ambitious here. I am ambitious. Yeah. Big golden retriever. Okay. I would I would build a walk a golden retriever. Yep. How far? 30 minutes. 30 minutes a day. Okay. Yep. Maybe twice a day if I could. At best. Hills or no hills? Not so first about hills. Okay. Hills can go. But do want to live in a house that's got a balcony.

So we need to be able to go up and downstairs. Okay. Would love to still be able to pick up grandchildren. I have no idea whether that's realistic at 90 years old, but that would be something I'd love to do. Pick them up from the floor, from a crib. Both. Where? Okay.

Would love to have still a good quality of sleep. would love to have still a good quality of sleep. And would love to be able to have sex at 90? Yeah. Not something I've considered. Good question. Let's say yes, let's say yes, I'm still going at 90. OK. And probably most importantly, above all of this

is still have proper cognitive function. Like still, I value the quality of my thoughts more than anything on the planet. I still want to be able to learn, I still want to be able to satisfy my curiosity. You know, if I was still able to have conversations like this at 90, that would be just fantastic to me. I assume you don't want to be in pain. That would be good. Okay. So again, we could drill into this a lot further, but I think what would emerge, and by the way, this is an visival exercise, because I don't think a lot of people do this. But I think everybody needs

to do this and needs to go really far down the rabbit hole. And what you'll realize is, by the way, everything you've said is totally reasonable. Like I have some people when you play this game with them, you know, the first thing they say is I want to be hella skiing when I'm 90 and it's like, I'm not going to tell you that's not possible. But like that, that's the first thing you would say is a little odd, right? But everything you're saying is, is, is achievable, but is challenging. So for example, walking a golden retriever at the age of 35, you don't even have to think about it. But if you actually look at the force that's in that leash and the amount of balance and strength and lower leg variability, you need to not

fall over when that's happening. By the time you're in your 70s, that's going to be very difficult. So you have to build up an enormous reserve in those capacities today to cope with and anticipate the inevitable decline that's going to come in all of those. So that's how you start. You start with the objective, you reverse engineer what the implication of each objective is. And you, you know, you, you, you, you, we understand pretty well what the decline of those properties looks like. I need to stop you that. How realistic is it for some male in his 90s to still be able to have sex without any assistance? Well, it depends on you to find assistance. I think the use of like phosphatesterase inhibitors is probably going to be required. What's that? Like a drug like viagra or Seattle.

That's a stud. But otherwise, I think it is realistic. But again, like, think about what that comes down to. So a big part of that is going to come down to your microvascular system. So there's a reason that, you know, having type 2 diabetes, having atherosclerosis is an enormous cause of impotence. It's not affecting your brain. What it's affecting is the microvascular, or the blood flow of the penis. So there's an argument for being very metabolically healthy. I mean, I see this even in patients

who were in their 50s and 60s, who at one point are completely dependent on drugs like sealas, and then you get them metabolically healthy and all of a sudden they're like, oh, I don't need this anymore. I wonder how many men who aren't that concerned about getting overweight, who aren't that concerned about losing a foot, but if you told them

that penis would stop working, that would be the final motivation to look after the entire... Whatever it takes. Okay, so we've got objective. Yeah, then we have to think about what the strategy is, right, and this is where I think it's very complicated in this problem. Is this where people get lost?

I think so. I think this is the step that most people just skip altogether and go right to the tactics. So they say, okay, I hear you on objectives. Now, tell me how to eat, how to exercise, how to sleep, etc. And I think you can't skip this bucket. And there's a reason that those like chapters in the book that are devoted to this. If you're trying, if you're asking questions

that are straightforward, you don't really need a strategy. So if you said to me, Peter, my objective right now is not to get a sunburn. We don't need a major strategy. Like it's relatively straight. We can go straight to tactics. You're going to avoid the sun altogether. If you need to be in the sun, you're going to wear long sleeves and a hat, and then you're going to wear sunscreen and blah, blah, blah. And it's pretty straightforward. But when you say my objective is to live 10 years longer than I otherwise would and do so at a much higher function as evidenced by that list of things you just said, well,

I can't just jump to tactics. They're not obvious. So instead, I have to go through a whole bunch of indirect measures because I don't have what I really want, right? What I really want is I'd love to be able to rely on the gold standard, which is randomized controlled experiments that would give me the answer. But for reasons that are self evident and obvious and not worth explaining, we don't have randomized controlled experiments that answer all the questions that pertain to taking a 35-year-old and setting him up to be the best 95-year-old. So we have to have an option B. An option B really rests on a whole bunch of other pillars of strategic insight.

So one of those things is what are the inferences we can make from observational data of long-lived well-functioned humans? So looking at the centenarians, for example, who we very quickly figure out are genetically gifted. So their superpower was picking the right parents, but we can still learn a lot from them. We'll put that aside for a moment. The other thing we can look at is short-term human studies

that don't cover the hard outcome, such as the full duration of your life, but cover certain things. So for example, they might be hard outcome studies that look at heart disease or stroke or hard outcomes that look at performance and functional metrics such as strength, resilience and things like that.

We then look at animal literature or non-human literature, I think, to be more accurate that looks at the full duration outcome. I think we can look at some of those animal studies and get a pretty good sense of what's affecting lifespan and healthspan, but we have to be careful with it, like we do, with everything, in that we want to be very thoughtful that we're not just sort of zeroing in on one model.

This is again where we look at things that favor lots of models. So you know, something that's consistent across mice and worms and flies and dogs is much more interesting that something that is only going to work in one mouse model in one person's lab. Then we want to look at mechanistic studies. So how can we understand, for example, the benefits of exercise when we look at the cellular level, when we understand the, you know, when we look at proteomic, metabolomic changes of exercise, and how do, you know, what do those things tell us as an example about, say, exercise or sleep restriction or dietary restriction?

And then the final tool that I think we look at in our strategy bucket is Mendelian randomization. So sometimes you actually let nature do the randomized controlled experiment for you. So Mendelian randomizations are very elegant types of studies where when you can find genes that are responsible for phenotypes of interest, you can ask the question, as nature shuffles those genes, do we establish causality by the outcome? So when you put all five of those together, that's how you start to cobble together what your tactics are. And that's the final piece of it. So what are your tactics? You basically have five domains. You have all things that pertain to what you eat, all things that

pertain to how you exercise and move, how you sleep, all the drugs, molecules, supplements, hormones that you could possibly take, and then all that, you know, call it the bucket of things that you would do to manage emotional and mental health. When you break it down like that, longevity seems very simple, that you have these five key areas that you're focused on. Where are people focusing their attention in your opinion when it comes to both health span and life span longevity that have the shortest levers but people are giving

undue attention to. Yeah that's such a great question. I think what's what I find funny is that everybody and I'm sure oh my I'm not sure I know I've been guilty of this myself. It's it's very tempting to just focus on your favorite thing. There was a point in time where virtually all of my attention was focused on nutrition. I really felt that nutrition was the alpha and the omega of this entire equation, and all you had to do was sort of eat a certain way and everything was going to work itself out. Obviously, the medical establishment

is hyper-focused on the medicine side of this. As evidenced by the fact that's the only thing we learned in medical school and residency, right? It's not like anybody taught you how to administer exercise or nutrition. Even if you knew that those things mattered, you had no education in how to actually do anything about it. It would sort of be like an oncologist who knows chemotherapy is good, but doesn't know anything else. Like,

doesn't know which chemotherapy or what dose or what schedule or what biomarkers to use to track the progress of the chemotherapy in the, you know, in the tumor as it regresses. So so each each each entity I think just kind of has their own expertise. Where I stand today, I would say a lot of people are kind of majoring in the minor and minoring when the major, when it comes to nutrition, is sort of a belief that I have. I think, once you get beyond the real fundamentals of energy balance and protein intake. I honestly think a lot of people are spending too much time thinking about the finer details of it. And the evidence, at least at this point in time,

is not really there in an overwhelming way to say that it matters a whole heck of a lot once you achieve it. In other words, there are multiple different ways to achieve energy balance, to achieve adequate distribution of fats, macronutrients, and things like that. In other words, there are multiple different ways to achieve energy balance, to achieve, you know, adequate distribution of fats, macronutrients, and things like that. But the belief system that I once had and that I think many others have that, you know, this exact ratio of omega six to omega three is what's essential. If that's true, it's not based on any evidence as of this time. You've mentioned the protein intake. Very important. What are your thoughts on this current

movement at the moment, which is people avoiding and sometimes demonizing meat consumption because of activating the mTOR pathway? Yeah, I think there's a bit of a confusion between chronic activation of the umtorp pathway and acute activation. So we do need MTOR to be active sometimes, right? I mean, MTOR is the most important amino acid sensor we have in our body, and if we want to be in an anabolic state at sometimes, which we do, it's going to have to be activated, right?

In fact, I would argue that the three most important amino acids, leucine, lysine, methionine, will, MTOR is the leucine sensor, right? I mean, leucine and MTOR were sort of made for each other. This is very different from the metabolically ill person whose MTOR level is probably chronically elevated. There's also an issue with tissue specificity. And again, part of the challenge here is in humans, we have no way of measuring this. So we can measure this stuff in mice. You can sort of look at mTOR activation in muscle versus liver versus some other tissue. And humans, we can't do any of this. We don't have what David Sabatini refers to as an mTOR integrator, a signal integrator. So the sort of the way that hemoglobin A1c

is an integrating function of average glucose, right? It integrates glucose level over the previous three months, roughly. We don't have a tool like that to measure M-Tore activity. So, again, I think that the belief that we need to limit amino acids to limit M-Tore activity is it's kind of a backwards way to think about it. What that's really going to do is create a situation of sarcopenia with muscle, like loss of muscle as we age. Okay. Surely though, if people are consuming three to four servings of 25 to 50 grams of protein per day. Is that not

just going to continue to just spike m-tod? Is that not end up netting out at m-tod just being elevated throughout the day? Not necessarily. I mean, you have to remember the duration that, you know, free amino acid stay in your circulation is pretty low. You're also probably still spending 12 to at least 14 hours a day when you're not eating. Right? So even so, I'm someone who probably takes a lot of effort to consume, you know, 1.8 to 2 grams of protein per kilogram of body weight, and that's going to be spread out over 3 to 4 meals. But there's probably still 14 hours a day when I'm not eating anything.

And during that period of time, those amino acid levels are going to be really low. I heard about you doing some very extreme fasts over the last few years. Talk to me about those. Yeah, I don't do that anymore, but I used to do a lot of fasting for many years. I would, you know, do a seven to ten day fast quarterly and a three day fast monthly. That's intense. That seems intense. Yeah. I'm someone that's done intermittent fasting. I sat down with David Sinclair four and a half years ago, I think, in his office at Harvard. And, you know, when David first came onto the scene, which was the first time I'd really, really heard intimate and fasting as being pushed

as a longevity lever, I thought, well, this is great. You know, it's something that I can do. It's for the lazy among us. It actually makes eating food easier because we've managed to reword skipping breakfast as doing intimate and fasting, but I found it incredibly difficult to blend stang fit, stang muscular, and doing intimate and fasting. I really, really struggled to make that work. First off, why have you changed your approach to intermittent fasting, I know that you've gained a ton of muscle recently, and how have you worked in blending your understanding of intermittent fasting and its positive benefits with the fact that you want to look good, feel good, perform well. Yeah, so again, I still think going back to kind of one of the three ways that you can

reduce caloric intake. You can calorie restrict directly, So just track and reduce globally. You can dietary restrict, which is pick certain elements within the diet carbs, fat, whatever restrict, or you can time restrict, create a smaller and smaller window in which to eat. The biggest drawback of that final strategy, which again is a viable strategy, but the biggest drawback of it, in my opinion, is the reduction in protein intake. So this has been borne out in the literature. So we've seen clinical trials that have documented this, that first and foremost, the time-restricted feeding within that 24-hour period doesn't seem to produce any benefits above the caloric

restriction that it brings. That's a very important caveat. Okay. It's a very important caveat. Okay, it's just meaning there is nothing magical about the time restriction beyond the calories that are being restricted. Wow. Okay, so the hunger signal that people get, which is those of us that have taken like the the Sinclair Red Pill, this is a signal that I'm hungry, this is Hormise, this happening, this is discomfort, this is good for me, has no different impact than small amounts of satiation throughout the day with. There's nothing that has been measured or documented in any clinical trial that suggests that that is beneficial over the

Clarification. In other words, if you're going to eat 2,000 calories, spread out over 12 hours, or you're going to eat 2,000 calories, spread out over 12 hours, or you're going to eat 2,000 calories, spread out over six hours, where your time restricted feeding for 18 hours, we're not seeing any difference. Wow. Now, that's not, here's what's interesting. That's often not what happens. So what more likely happens is the person who calorie restricts, has an easier time, believe it or not, maintaining muscle mass than the person who calorie restricts has an easier time, believe it or not, maintaining muscle mass than the person who time restricts. Why? Probably for two

reasons, although this hasn't been fully teased out in the data because they're not tracking it this closely, but my impression is that when you time restrict, you're just less likely to eat as much protein. And secondly, as you kind of alluded to earlier, it's a delicate balance to get the right amount of amino acids into the muscles. You can't have too much and you can't have too little. So what you don't want to do is waste for lack of a better word, your amino acids down a gluconeogenic pathway where they're basically being used as glucose substrate. What would cause that to happen?

Either too much or too little. So I've watched too much and watched too little. Yeah, sort of 10 to 20 grams of protein, the liver is going to preferentially take that and use it as glucose, and anything over about 50 grams, the liver is going to say, I'm going to take that excess and also make a glucose. So let's just say your number is 180 grams of protein per day, eating 18 servings of 10 grams a day, not going to achieve optimal results, having one serving of 180 also not going. I've tried both. Yeah. So that person really probably ought to be doing four servings of 45. Right. So you're saying for most people,

it seems like roughly a sweet spot is 25 to 50 grams per serving. 45. Right. So you're saying for most people, it seems like roughly a sweet spot is 25 to 50 grams per serving. Exactly. Right. So in this regard, and that time-rescripted feeding guy has a really hard time doing that if he's going to be deliberate about that. How big is the gap? When does a feeding window stop? Great question. Probably about three or four hours. So it's basically impossible. For the time restricted feeding person, unless they're willing to eat protein outside of their window. Right. Okay. Which if you are a dogmatic around. If you're dogmatic, it becomes very difficult. Correct. But if you're if you understand that there and what we do with our patients who and who want to do time restricted feeding, because I think it's the easiest one to do. Yeah. Like you

should agree. It's the easiest one conceptually to do. it's the easiest one to do. Yeah. Like, you should agree. It's the easiest one conceptually to do. It's the easiest one to be compliant with. So what we would say is, look, it's just about the calories. So I still want you to have a low calorie protein shake in the morning, where you're gonna have 200 calories of a protein shake. That's basically just protein some cashew milk

and a few frozen berries. But at least you got that protein dose in. Yep. The other thing that I would say leads to what we experience clinically as a lot of people losing muscle mass when they do this is a lot of people exercise in the morning, but their feeding window is in the evening. So now they're creating a little bit of a gap, especially if they're untrained. It's less, less of an issue in a trained individual, but in an untrained individual, we do see some benefits to having the amino acids restored in greater proximity to the training.

How worried should we be about artificial sweetness? You know, I don't know. It would be the short answer. I think that this is another one of those things where people really love to demonize these things. But if you really just want to look at the facts, let's talk about facts, right? So aspartame, which is the original kind of the OG sweetener, everybody loves to demonize aspartame or neutral sweet. But the reality of it is, if there is toxicity to it, it's probably impossible to measure at regular doses.

This is a substance that at least the last time I checked had more data on it from a safety perspective than any other molecule tested by the FDA. You're kidding. No, it's just, because again, it's been around since the 1960s, right? So does that mean that if you consume the equivalent of 12 cans of diet soda a day, it's safe? Probably not, but we don't know, right? So where do I think these sweeteners potentially wreak the most havoc? You know, one is I think that they probably increase your appetite for sugar anyway. So if you're consuming them in an effort to avoid sugar, you have to be just mindful of the fact that am I robbing Peter to pay Paul? If you really want to eliminate sugar as one of your dietary strategies,

you might just be better off reducing sweet things altogether. And what you'll discover, because I've done this myself, I've had periods of my life where I've been very dogmatic about restricting sugar. I'm not that dogmatic about it these days, right? But when I have been, you know, what are the things I noticed was how unbelievably sweet things are that I used to not think were that sweet like berries, you know, like, you know, raspberries aren't generally thought of as the sweetest thing in the world. But when you completely eliminate artificial sweeteners and regular sweeteners, you know, after a few months, berries

become insanely sweet, you know, 85% chocolate becomes mind-bogglingly sweet, as opposed to what most people would think of it as kind of bitter. There was a recent study published that looked at one particular sweetener, Arithritol, and it was a pretty poorly done study, but it asked some interesting questions, which is, you know, is a metabolite of this potentially atherogenic? Well, it's atherogenic. Would it lead to or cause atherosclerosis? What's that? Cardiovascular disease, sort of the inflammatory disease of the coronary arteries and other

arteries. Again, I think the data are pretty underwhelming that artificial sweeteners are harmful, but I also think there's probably a class of differences between them. So my personal favorite of all of them is something called alulose. Alulose is, it's basically natural. It is an enantimer of fructose, meaning it's a molecule that's almost identical to fructose with one very minor structural change. What's unique about it is it has, in my opinion,

the best taste, because the thing I don't like about artificial sweeteners is I just don't like the taste. I actually like the taste of sugar. I don't like the taste of, you know, saccharin. I don't really like the taste of aspera tame. I certainly don't like the taste of stevia. I mean, that, to me, it makes me want to vomit. But alulose has the same taste, the same mouth feel as sugar, and

the only drawback is it's only 70% of sweet, which is not a real drawback because you could always dose it up if you want. It also has the added benefit of, it appears to actually reduce blood glucose a little bit. It appears to have an effect where it pulls glucose into the kidney and Here's to have an effect where it pulls glucose into the kidney and basically increases the filtration, the glomerular filtration of glucose. So it slightly lowers glucose, not as potent as something called an SGLT2 inhibitor, which is a class of drug that does that. But it's very interesting nonetheless. So, I guess if I were thinking about how I would consume it, I would probably consume more

allolose than other things. But unfortunately, it's still not that prevalent in foods. You have to just buy the allulose itself. So if I'm making something, I'll use allulose in it. What I like about this framing is it gets to one of the reasons why doing a randomized control trial for diet stuff is so hard, because how are you going to be able to control for the psychological training that having a sweet thing, even if it is a zero calorie sweet thing, even if it's a zero

calorie sweet thing with no downstream risks to your body unless you take it in the same dosages, how are you going to be able to control for what that does psychologically to people's expectations of the sweetness of their foods, of the frequency of having sweet things throughout their diet. I think that's a really nice little microcosm there. One of the things I'm wearing a whip band at the moment, some people are drowning in data now. We've gone from a world where we need nothing to where some people know a lot,

but I would guess on average, that even people who care about the health and fitness are still mostly not wearing a tracker. They're still mostly not getting blood panel done. They're still mostly not going and getting a full body MRI scan, et cetera, et cetera. What are the most important metrics for someone who is completely unindctrinated into the world of looking at vital signs within their body? What are the most important metrics for people to be looking at vital signs within that body, what are the most important metrics for people to be looking at?

Well, I mean, again, I have a pretty long list on that because we're holding ourselves to a pretty high bar. So the way I think about this is what are the inputs to what I call the longevity risk assessment? So there are basically about seven or eight things that are a threat to your length of life and quality of life. We've talked about them already, right? So cardiovascular disease, cerebral vascular disease, cancer, neurodegenerative disease, orthopedic injury, emotional distress, misery, like all those things, right? So how do we know how you're stacking up on all of those things?

What are the inputs to do them? So yeah blood tests, family history, selective genetic testing, colonoscopy, MRI, liquid biopsy, VO2 max test, zone 2 test, dexascant, I mean the list is long and I think in our matrix we have over 40 things that go into that, or over 40 inputs that go into our risk assessment. And then that risk assessment leads to outputs. So what do you do in response to the ranking of risk based on those things? Okay, run the matrix, go and do those things, and then let's come back and measure and do again.

So, it's hard for me to say what the most important is because it really comes down to an individual. So, if an individual shows up and they have a significant family history of cardiovascular disease, well, look, a CT angiogram is going to be very important. And a blood test that's measuring LP, little A, lipids, and APOB is essential because you have to know which of these things is responsible for that. Certainly a continuous blood pressure monitor or at a minimum, we would have patients checking

their blood pressure at home two to three times a day for a month. Again, super low tech, right? You might think, how is that interesting? Well, it's enormously interesting because blood pressure is one of the biggest risk factors for Alzheimer's disease and cardiovascular disease. So, again, people are obsessed with things like their sleep data, but don't forget the really less sexy stuff that we could have measured forever such as blood pressure. But knowing how to measure blood pressure accurately is important. And I think undiagnosed hypertension is an epidemic in this country. What do people get wrong when measuring blood pressure?

First thing they get wrong is they don't measure it. But assuming they do measure it, they're not stationary for five minutes before they measure it. They don't have the cuff on correctly. They don't have their arm in the right position. If your arm is too low or too high, you're going to get an inaccurate reading. Your arm really needs to be, the cuff needs to be right at the level of your heart. You have to be very close attention to where the cuff tells you to put it. You want to be about an inch above the brake in your arm and there's a good cuff will tell you where

how to line it up with the brake you'll artery in your arm. You don't want to have just had coffee right before you do it. You don't want to be sitting like I am with your legs crossed. Your legs need to be uncrossed. So there's a whole protocol for how to do this. And there's a very good study called the Sprint Study that really established the measurement standard for how to establish a proper measurement for blood reading, which was five minutes sitting stationary without doing anything stimulating you know, five minutes sitting stationary without doing anything stimulating, measurement, five minutes of, you know, doing nothing again,

repeat measurement, five minutes, repeat measurement. So 15 minutes to get three measurements, taking the average. That's a blood pressure. Now, we don't ask our patients to do that. We ask them to do it once, but two to three times a day. So you should even out any inconsistencies. Yeah. And you'll also notice trends. Like, are you normal in the mornings but elevated in the afternoons? And, you know, the data are really clear that anything above 120 over 80

has long-term risk associated with it. And so, when we see people that have an elevated blood pressure, we want to make sure we're addressing that. And there's lots of ways to address it before you have to go down the pharmacologic path. But if you have to go down that path, you're much better off going down it to protect your kidneys your brain and your heart what is Good and what is bad about different types of cuffs are automatic cuffs. Okay

Yeah, so the gold standard is of course a manual cuff So having an actual person yeah, who's who's got a stethoscope on the brachial artery and measuring your blood pressure. The problem is, unless you're, you know, you have, like for me, that's what I do, typically, because my wife can measure my blood pressure, even I can measure my own blood pressure. So marry someone who is trained of taking blood pressure, that's what you're saying.

But the automated cuffs are pretty good. In me, they run high. So across the board, automatic, automated cuffs tend to run 10 to 15 millimeters per mercury high, systolicly, and they're accurate, diastolicly. That's just a glitch. I have never been able to come up with a compelling explanation for why, but I'm not unique in this. We do see this in a number of people where the gold standard runs lower than the cuff. So the challenge of doing an manual cuff when you're at your doctor's office is the challenge of having your blood pressure checked at the doctor's office. For some people, it produces this syndrome like white coat hypertension where...

The moms got that. Yeah, they just, you sort of get, you know, and by the way, the other thing is, most of the time you walk into the doctor's office, they don't even adhere to this principle, right? Five minutes. Yeah, yeah, yeah, you sort of run in from the parking lot, run up the flight of stairs, sit down in the waiting room.

Last time you had a coffee. Yeah, yeah, blah, blah. So again, I think that blood pressure is a very difficult thing to accurately glean in the doctor's office for all those reasons. And that's why I just think everybody should buy one. I don't have any affiliation with the company that makes these things, but there's a brand that I like called Omron OMRON.

That's the one we tell our patients to get. You can get these things on Amazon. What are the most common lifestyle interventions? Let's say that someone does get to what that 120 over 80. Where should they go first? Would you think? Exercise is a big one. Arobic exercise is an enormous way to lower blood pressure as is weight loss. So weight loss is going to be mostly driven by nutrition and then arobic exercise. And sleep. So because I track my blood pressure pretty regularly, two of the most obvious things that show up when I'm not well slept is, you know, higher blood glucose

and higher blood pressure. I went to Medellin. I went to bio-accelerated down there and got a ton of stem cells for a week. Medellin is at altitude and they were coming in and testing my blood pressure three, four times a day, using that and I had a nurse doing it, which was nice to have the sense that a team's there for your health. That was, I really enjoyed that part and felt like I was being cared for, but at altitude and I'm a heavy guy, at altitude, my blood pressure was not happy. So I came back and I thought, I really need to, I really need to make a change here, I really need to, because even if it is at altitude, et blood pressure was not happy. So I came back and I thought, I really need to, I really need to make a change here, I really need to,

because even if it is at altitude, et cetera, et cetera, I was in there with Al Jermaine Sterling who is the current UFC 135 champ. And yes, Elite athlete, yes, best in the world, literally what he does, but he wasn't struggling. And I figured I probably could do with making a change here. So what's the altitude there? I don't know. I don't know. High higher than higher than I'm used to. I presume. And you were getting stem cells for what? So they reached out and suggested that I go

in and get a procedure. I've got two bulging discs, L3, L4 and L5S1. That's been an issue for a while. Although I managed to get it to a very manageable place now, which I'm very happy with. Little bit of Rotator Coffee. It just bro injuries. Sometimes my knees are a little bit achy. I had a full Achilles detachment playing cricket a couple of years ago, most British way that you can do it. So I went in and I had 110 million through IV, two separate ones. Oxygen chamber, twice, two sessions of that, a bunch of vitamin IVs, two intraarticular shots into the shoulder, quadriceps tendon above and below the patellar, and then straight into the shoulder, quadriceps turned in above and below the patella, and then straight into the Achilles. And then a intradiscal injection into L3, L4 and every facet joint as well,

done my number spine. Under general for the spine stuff, which was great, under nothing for the local injections, which were spicy. But that was seven, eight, seven, eight weeks ago now and three months is around about the time when this stuff's supposed to kick in. So I'm very much looking forward to seeing how that works. I enjoyed it. Psychologically, it was neutral, physically,

slightly difficult. The sort of is it's cytokine inflammation response is something to behold. For the next 24 hours it felt like anyone that's had dorms after a three-month break from the gym, imagine that kind of stiffness but exclusively in the tendons of the places that have been touched. Oh, God, it was so localized. And so I was laughing in for the next day, as I sort of totted around like a robot, it was very interesting experience. What about health metrics that people are overlooking? So we've mentioned, you know, even the stuff that you've given there in terms of top line,

probably, you know, VO2 max is your HIV, your resting heart rate, your blood, blah, blah, blah. Is there something that most people have? Well, think about how many people listening to us today, do you think know their VO2 max? Very few. Yeah, very few. Yet there is no metric that I am aware of that is more highly correlated with the length of a person's life than their VO2 max. Wow. Why?

Not even close. Why? Not even close. Why, why that particular metric? Well, there's probably two things going on, right? One, it actually does matter a lot. It's an amazing proxy for health. If you think about, have you had a VO2 max test done recently? Not recently.

I had one done last one was probably four years ago. Okay, so you think about how miserable it is, right? Like, what is it testing, right? It is testing your maximal consumption of oxygen. Well, to get to that level, we are stressing you to the highest degree possible. It is, as its name suggests, it is a maximal VO2 max test. So the higher that number is, the more oxygen your muscles can utilize, the more fit you are, the healthier you are, the more capacity you have to avoid illness.

So I think there's the biological reason for it. I think the other reason for it, as opposed to, say, your zone two threshold, which I think would probably be equally predictive, is that it's a metric that is so ubiquitous. It's very standardized. It's easy to test for conceptually, not necessarily physically. And so you have a metric that we can easily capture. So for example, it's better than like a deadlift. In deadlift, there's variability of form.

There's too much risk of people getting hurt. There would be a harder metric to track. So you have this metric that you can track, and then the having a high number tells you something about the person, right? To have that number, you must be, to have a high number, you must be exercising a lot, and we know the benefits of exercising a lot. Right. The person who has a VO2 max at the top 2% of their age, I mean, by definition, they're doing a lot of exercise and exercise has more benefit than probably any other single intervention we can do. So again, it's, I throw that out there because I say, like, yeah, we know those things, we know exercise matters, but when it comes right down to it, most people don't know if they're fit enough. Most people don't know their VO2 max, most people don't

know their ALMI, Appindicular Lean Mass Index. They don't actually know how much muscle mass they have. They don't know where they stack up for other people their age and sex, and yet that's also a highly, highly predictive metric of how long you're going to live. They don't actually know how strong they are. They don't know if they're in the top 25% of their age or sex for strength. So I think it just comes kind of back down to the basics, but we have to know these things. What gets measured gets managed. And if you're not measuring these things, I don't know what you're managing.

What is the best protocol that you have found for improving VO2 max in terms of training? It's two things, right? So you want to think of the way I think of cardio respiratory fitness is it's a pyramid. So you have a base to a pyramid and you have a peak to the pyramid. And you want the biggest possible pyramid. So the area of the pyramid is your total cardiovascular... But also wide.

Exactly. So the width of the pyramid is your zone two. That's your sort of aerobic efficiency metric. So if you, and your VO2 max is the height of the pyramid. So if you want a high pyramid, you also need a high base. So you have to do training that widens the base and raises the peak. So the base widening training is what we call zone two training. So you have to do training that widens the base and raises the peak. So the base widening training is what we call zone two training. So again, there's lots of ways to do that, but the simplest way to do it is to train at an RPE that barely allows you to maintain a conversation. So the way I describe it to people is I do my zone two on a bike on a trainer indoors, right?

I'm listening to podcasts and audiobooks. It's a it's a pace of training where I'm mostly able to breathe through my nose, but that just speaks to the fact that I have pretty good airways. A better metric is if my wife comes in and talks to me or if the phone rings and it's important and I pick it up I can carry on a conversation, but it's strained. The person absolutely knows I'm exercising. Well, it takes on the fusion. But I can speak. If I'm at the point where I can't speak, I'm outside his own too. I'm into zone three. What's a heart rate? Is that? Have you got any idea for you? Yeah. For me, it's typically a heart rate in the high 130s.

Okay, that's a little high than I would have guessed, but I might speak for you. But it's very, very basket-like. Well, but it also varies day by day. So yesterday, I was having such a lousy day, probably that didn't sleep really well, that ended up being a heart rate of about 131 to 132. So it varies, I've had it days where it's as low as 130 and days where it's as high as 145. How old are you? 50. Wow, that's still very fit. I'm going to guess that will speak to the fitness that you've got. Well, I think it just speaks to the bigger point, I think, is that it just speaks to

kind of the variability you have in heart rate between individuals. But then, to train the peak of the pyramid, I think the most efficient way to do that is, so VO2 max training is maximized between three and eight minute intervals. So, if an interval, you will train VO2 max if you're doing something harder than that. If you're only doing something, you can hold for 30 seconds or one minute that will still give VO2 max benefit, but not nearly as much as if you can push it closer to three, four, five minutes, etc. So for me personally, I mostly do that at four minutes. So I'll do four minutes very hard, four minutes of recovery, four minutes very hard, four minutes of recovery. So I do those also on a bike usually and I'll do those outside on a hill.

So there's a, I'll see your roads cycling this. Yeah. So there's a hill near my house that is up. It's a, it's just a straight hill that's not so steep, like meaning I'm in the saddle. I don't have to be out of this. I'm just in the saddle looking at my power meter and my heart rate and just going very, very hard for four minutes, getting to the top, feeling like I want to puke, going back down, doing it again, just repeat, repeat, repeat. Two sets? No, typically, do four to six.

Okay, how often puke? I just do that once a week. Okay, and that seems to be... Well, again, it's remember what I'm training for now. When I was training as a cyclist, I was doing those types of workouts three times a week. And they were much longer and much more grueling. But again, I was optimizing for a much broader array of fitness. But for today, for all I'm doing is, no, I'm just, you know, I'm just trying to be a good, I'm just trying to be fit as a person, not as an athlete. So yeah, once a week of doing a very hard VO2 max set, four times a week doing those

lesser zone two sets. How long on zone two? 45 to 60 minutes a session. Okay, so you're looking at what, 180 to 240 minutes, cumulative leap of week. Correct. So I'm basically doing four to five weeks of cardio training a week, which is, you know, depends who you ask. Like, for, by my historical standards, that's very, very low. Obviously, for some people that would still be considered a lot. I think, you know, I think it would be crazy not to want to capture

the benefits of something like exercise. So we do, you know do sort of sit down with everybody and say, okay, how much time are you willing to put into exercise? And then that's how we sort of think about how to allocate time across all endeavors, strength, stability, aerobic efficiency, peak aerobic power. We do take kind of a portfolio approach to that, but starting through the lens of how much time are you willing to put into it. So someone like me who's willing to put in 10 to 12 hours a week, that's, you know, but starting through the lens of how much time are you willing to put into it.

So someone like me who's willing to put in 10 to 12 hours a week, that's, you know, you can go through all of the bases as much as you want, basically. Absolutely, yeah. OK, so you've got four pillars. Strength, stability, VO2 max, zone two. Yep. Strength and stability.

Talk to us about that. So strength is probably the easier one for people to understand. You know, that's basically your ability to generate force. And of course, within strength, you have different areas of strength. So, I don't do a lot of maximal stuff anymore. So in other words, I'm rarely, if ever, I don't think I really ever go below three reps. So the heaviest I will go is five reps stuff.

So I'll do dead lifts. They're 5% ish. That's why you don't know you don't know you don't know you don't know you want to run because you're not doing it. But I can sort of predict it because I do use a velocity tracker. So have you seen these? Yeah, yeah, the boss speed things.

Yeah, yeah. So I do measure bar speed. So I can have a prediction of it. I can have a prediction of one RM. can have a prediction of 1RM. But yeah, usually I'm sort of in the five to 15 rep range when I'm training. So I'm basically, but what I'm always trying to do is make sure I'm somewhere between zero and two reps in reserve.

So that's, I'm really training off reps in reserve. Okay, that's my overarching principle of training is. So even if I'm at five, I'm really training off reps and reserve. That's my overarching principle of training. So, even if I'm at five, I'm probably training to one to two rep and reserve. If I'm at 15, I'm still one to two reps and reserve. Is the bodybuilders out there, the one to do super sets and drop sets to failure that are tearing the hair out at the moment? Yeah, I'm sure. And again, there are absolutely sets where I do go to failure,

but the truth of it is it's very hard to go to failure all the time. I think if people are being brutally honest with themselves, like, they still had another one or two reps left at the time. Yeah, I don't, I mean, I know what it's like to go to failure and you don't, you only have so many of those matches every day. So I don't even try to play that game. I just sort of say, like, I know, I've learned that I've got, if I stop now, there's only two more I would get before I would violate my form so badly that I would either injure

myself or, you know, just effective. Transcending ego lifting is one of the most difficult things that you can do. Forget about the consistency and all of that. It's transcending ego lifting. Strength, formulating a strength protocol across the week. What are you prioritizing? Are you prioritizing large lifts, are you prioritizing session length, et cetera, et cetera? Yeah, first of all, there's quite a bit of variability in my training, but generally I'm doing four days a week,

and not generally, I'm always doing four days a week, it's two days lower body two days upper body now I used to I've for years also done three days of mixed longer sessions but I prefer what I'm doing now I prefer doing two lower body days two upper body days and And yeah, I prioritize big lifts and I'm sort of working on, like so today I had 24 working sets of upper body. On Monday I had 18 sets of lower body, 18 working sets of lower body and probably on Friday it'll be a little bit more volume. It'll probably be 22 to 24 sets of lower body working in that five to 15. Yes, which is ish, up E eight eight eight and a half. Yeah, yeah, sometimes maybe as little as seven on some things. Especially if you've had the shit night sleep. Yeah, the night before. Yeah. What when you're looking at movements, for instance, what was your session this morning? Can

you remember in terms of exercises? Yeah, so I did floor presses. Dumbbells. Yep, I did pull downs. I did incline press. I did row. I did incline curl overhead tricep extension, and then a preacher curl, you know, it's not a true preacher bench,

but hanging over a bench, doing a preacher to create the same angle, and then laying tricep extension. And then always in between them, I'm doing stability work. So we didn't come to stability, but I'm doing, I do two dedicated days of stability a week. So Tuesday, Thursday, I do a full dedicated hour of stability training.

And then on the off days, it's not Tuesday, Thursday, I'm getting in at least 20 minutes of stability per day on either side of the exercise, like throughout the workout. So the stuff that we've gone through so far, the gym bros will still understand what cardio is. The cardio bros will still understand what lifting is. The cardio bros will still understand what lifting is. Nobody understands what balance training is. No one understands.

What are the principles behind this? No one's ever thought about stability training before. How do you integrate it into your workouts and then also what does a dedicated session look like? Yeah, it's very difficult to explain. It's actually, I think it was the hardest chapter in the book to write truthfully, because it's hard enough to show people in videos or to have friends over who want to work out with me and put them through the exercises.

That's actually very difficult. So I lead with an analogy in the book where I talk about the difference between streetcars and trackcars because I'm a car nut and I being on the race track is probably one of my favorite things to do. And so, so the analogy I give is this, which is if you took, if you take a streetcar with very high horsepower and you put it on a track and you let it race against the track car, which is lighter, less horsepower typically for a given engine size or for a given class size, slick tires on it, which one's going to be faster.

I mean, it's no comparison, right? The track car rips the street car into oblivion, even though, by the way, the street car will go faster in a straight line. So the example that I use in the book car into oblivion. Even though, by the way, the street car will go faster in a straight line. So the example that I use in the book is a real example. I compare at the time, this is, you know, seven or eight years ago, my street car at the time was like a, an actually a modified E92 M3. So I modified it, changed all the airflow.

That thing was putting out 475 horsepower. Big German beast. Yep. Yep. And at the time, my track car was a spec E30 M3. I'm sorry, not even an M3, just a spec E30. Okay. Right.

But everything stripped out, roll cages in, stiff as hell. Stiff as hell. 165 horsepower. Why engines in it? Oh, this is stock engine. Yeah, it's a six in line. Right. Okay. Yeah. Yeah. So, so you've got the the stock 165 horsepower engine. It's very light. The car weighs like probably 2400 pounds versus the M3's 3400 pounds. M3's got street tires on it. This one's I'm running, you know, probably handcooks slicks on it. But to your point, the chassis stiff as a button, suspension, super stiff. And yeah, I was going faster in the straightaways in the M3, but my lap time was two seconds

faster, which on a track is, might as well be a day, in the spec E30. And of course, what does it come down to? It's cornering speed. What is cornering speed come down to? It comes down to of the 165 poultry horsepower in that engine. Every little bit of it is making it where it belongs. Remember, what is the name of the game in driving a race car? It's all about friction. It's all about power loss. it's all about transmitting what's happening in the crankshaft to the tire, tire to the street, that's it. You only have four points of contact with the outside world, nothing else matters.

And so again, we're not talking about aerodynamics because these aren't aerocars, right? So in the street car, first of all, I have much more slippage at the tires because I've got, I'm not running slicks. Secondly, the chassis is so loose, right? So, allowing all over the place. I've got all this energy loss with energy leaking out of that car, not making it to the surface of the track. It's like having a laxity in a joint.

That's right. So, every time you're hurting your knee, you're hurting your elbow, something's hurting. That's an energy leak. So again, even if one doesn't care about performance, just from an injury perspective, this is something we want to avoid. We want to avoid it. And again, my introduction to stability only came the hard way. It's not like I was born out of the womb realizing this was an important thing.

I mean, I had to go through horrible injuries to finally arrive at this place where I said, you know, I'm tired of being in pain. I'm tired of the fact that my elbow hurts when I do pull-ups. And, you know, oh, like half the time I deadlift or squat, my back hurts, you know, my SI joint hurts the next day. Like it was just kind of tired of that. And then I got very fortunate and that I landed in the company of a guy named,

who I write about in the book briefly, his name's Michael Stromsness, and he's a practitioner of something called DNS, dynamic neuromuscular stabilization. And very first time I met him, you know, at the time I was like, my main complaint was basically my right SI joint and my right elbow.

I had tennis elbow having never played tennis. And he said, all right, take your shirt off and hop up on the bar and do some pull ups. So I did and rattled off, 15 pull ups or something, which I could do easily at the time. And he's like, oh, that's horrible. Like, those are, those are, and by the way, these are good form pull-ups.

I'm not doing like, bro pull-ups, where I'm like jerking up and down. I'm doing like full extension, like everything perfect. And he's like, yeah, you have no capacity to control your scapula. So your scapula is winged. And in doing so, you are transmitting all of that force into your elbows. You cannot retract your scapula is winged and in doing so, you are transmitting all of that force into

your elbows. You cannot retract your scapula. You don't have the control. You don't have the stability in the scapula. So you're leaking energy through your scapula in terms. So to make a very long story short, that, that, which started in 2017, just took me so far down the rabbit hole of not just DNS, but other other schools have thought.

I would later go on to meet someone named Beth Lewis through Michael who, you know, has her own expertise around other other disciplines. And we basically just started piece by piece rebuilding my movements. And by the way, that meant spending a year not doing pull-ups and not deadlifting as I relearned how to align my body again. And so today, I'll still spend two days a week working with a guy here in Austin named Kyler Brown, who's amazing, working on just dedicated DNS things.

And again, if you watched the exercises I was doing, you would be thinking, what is he doing? You know, like, why is he doing, and why is he in these baby positions, like moving in these odd ways? But a lot of what DNS is based on is the idea that up until we were about two years old, we all moved almost perfectly. Most of our movement patterns that are corrupt, which we all have as adults,

only started to kick in once we're about two. Maybe one, but generally about two. So there's a very predictable, you know, neuromuscular set of sequence of movements that are genetically programmed into us. The way a child reaches for something, the way a child rolls, the way a child stands, the way a child, you know, gets into a bare position. All of these things are basically hardwired into us. And the goal of this type of training is to basically provide a software update on the crappy software we've, you know, we've overridden that system with. Let's say someone doesn't live in Austin, doesn't have access to your very smart friend. There are lots of DNS practitioners

across the country. But you would advise doing this with instruction? I think so, yes. I think the complex and nuanced and you need to. I think DNS is very difficult to learn. I shouldn't say that. I haven't tried to learn it off videos and online and there might be ways to do it. But I think trying to find a practitioner is a good way

to start. And then once you have it going, it's always great to continue on your own. And there's a lot of stuff I do with my friend Kyler that's not DNS. I mean, one of the issues I've been having injury-wise, I have very flexible ankles. I think a lot of former swimmers do. And so one of the drawbacks of that is, when I do, I love doing box step-ups. We're both cut from the same cloth. I knew that you were a massive fan of these.

They're my favorite movement for the lower body. I absolutely love doing them in all regards. I love doing them very, very heavy. I love doing them very, very heavy. I love doing them very, very slowly, all of these things. Well, because my ankles are so flexible and I can really, really dorsiflex, I have a tendency sometimes, because I guess you know, when you wanna do a step up,

the real key to it is preloading the glute and the ham. Right. Not bouncing off the floor. That's right. So to preload, you wanna be able to shift forward and glide the femur back. That creates an enormous stretch, eccentric stretch, so that that front leg is loaded, boom, you pop up. Okay, well, in doing so, I often will drive my knees so far over my toes, because I

have the flexibility in my ankles, but sometimes I'll develop a little bit of discomfort there in the front. So one of the things I'm working on with Kyler is solius strengthening to actually counteract that movement. Bring it back. Yeah. And so the amazing exercises that he has come up with for me to do solius strengthening, which again, you have to be very deliberate about doing that.

It's easy to strengthen your gastrox. The soleus requires more effort. I learned this intimately during my rehabilitation. Absolutely. I overshot it actually, it's hilarious. So there's not a good time to snap any killies, but during COVID, it wasn't bad. And I overshot it on my right leg, which is the one that snapped. And I ended up having to then work on my left more aggressively to catch it up because I'd ended up building up a calf that was big.

I learned so much from that. The first thing was, I had a 13 day wait period because I was doing it on the NHS, although I managed to find one of the top three surgeons in the entirety of the UK through a friend who was on the NHS to come and do my reattachment, which was really, really great. It felt like being fitted in at the end of the day with a barber that needs to do the haircut.

And I was waiting around all day, all day, all day, and then it got to the very end. And he had to run it back, and I had to go back tomorrow. I'd been faster at all day, because I was going to go into general and I was like blah, blah, blah. Anyway, a bunch of the things that I learned from that coming out the other side were how important it is to be able to deal with not just strength but plio, especially for that ankle position. But what I'm thinking here when you're talking about your challenges with box step-ups, there's a guy called Dr. Eddie Joe PhD on Instagram. Now, he took a massive hiatus for like three years, but he did these really great

breakdowns of academic literature in infographics, which lend themselves to Instagram very nicely. I'll never forget this one from maybe four years ago, I think, and there'd been a study done looking at muscle fiber recruitment for glute exercises. And, you know, you look at the glute factory bum lab things for girls that want big glutes or me that's increasingly realized that my back gets better, the bigger that my bum gets. And glute bridge, donkey kick back, side raises, all manner of fantastical exercises that girls do. And he drank them by the amount of muscle fiber recruitment. The top five exercises were step-ups or step-up variations.

It's like step-up, cross-body step-up, like lateral step-up, something, something, something. And then maybe hex bar deadlift was in the sort of upper middle deadlift, another one. And then you get down toward like, glute bridge kickback, and it's at 25, and I think it's 95 on this particular scale of this number would step up. So for anybody that wants to improve like lower body power, I just, I absolutely adore that movement, and it's so easy to do. We, you know, in the first iteration of writing the book, I had intended to put so much detail in about instruction on like kind of the most important movements. In the end, I had intended to put so much detail in about instruction on like kind of the most important movements. In the end, it was getting too long. So what I did is I ended up

creating videos for a handful of them. And one of them is the step up. So there's a pretty good video on the like the book. I'll point people to where to go on our site to see it. And it's a pretty, I just watched it yesterday. It's a pretty good instructional video. Is it you doing it? It's me doing it with Beth and I talking through how to do a step up. Cool. Weighted, unweighted, low box, high box, the whole thing. E-centric, concentric. What are the pitfalls? How do you, you know, how do you unload the ribs to, you know, do the movement correctly and all that stuff? So beautiful. Yeah. I'm going back to some of the other, we've spoken about sweeteners. What about vaping?

If you had to look at any of the signs around vaping, it's kind of a little bit of a moral panic at the moment. If you look at certain areas of the ancestral paleo world on the internet, what's your thoughts on vaping and its potential, Daniel? Let's come back to the risk-reward matrix. Right? So again, I view everything through this two by two. So what's the risk-reward matrix. I view everything through this two by two.

What's the risk? Is it closer to getting hit by a tricycle or getting hit by a train? What's the reward? Is it picking up a dollar or is it picking up a gold coin? I don't think we have sufficient data to say that it's getting hit by a tricycle. I don't think the industry is standardized enough to be sure that what is being inhaled is sufficiently clean. Maybe it is.

Maybe some companies are better than others. I mean, we could talk about that all day long, but I'm not personally willing to put my trust in that market, in that infrastructure, in those companies, whatsoever. So for me personally, this would be a no-brainer. There's no upside in it to me. What would you be concerned about going into your body? It's not just the nicotine. It's the stuff. Oh, no. Well, first of all, nicotine, I love. I'm all about nicotine. How do you use nicotine in a safe way? I would chew gum or I would use, I use like a lazinge or I chew, there's like these little patches that you, you know,

kind of suck up. Zin pouch, what have you found is your favorite brand for those? Well, I'm blanking on the name of the brand. They come in a little round, colorful thing. I don't remember the name of the brand. Got you. Any using three makes, five makes? Unfortunately, that's the, maybe I don't remember the name of the brand. Got you. Any using three mix, five mix?

Unfortunately, that's the, maybe I haven't bought in a while from these guys. I bought so many the first time by accident that I'm still living off the last two years worth. I literally just like an idiot accidentally bought 10 times more than I'm like a prepa. Yeah. So unfortunately, they only come in sevens,

which is no way, dude. I would, you can't do it all at once. That would be in my mouth for 30 seconds, and then I would have to take it. Yeah, yeah. So I go in, out, in, out, in, out, in, out. I think they have a four as well. It's a little bit more manageable. Yeah.

But truthfully, I think two milligrams is sort of the right dose. One to two milligrams is probably the sweet spot. And then you don't need to dick about taking it in and out. Yeah, yeah, yeah. So to be clear, the nicotine is not the problem, right? It's just like with cigarettes. Nicotine is not the problem with cigarettes. Yes, there's an adequate component to it.

The problem is the toxicity of the vehicle that's delivering the nicotine in the form of tobacco. Well, with vaping, I don't have any sense of what's happening when you have a heated metal filament that is burning combustible products, some of which I may or may not be inhaling through a filter. Like, what I'm saying is not that I know there's something wrong with this, but I'm saying I have no confidence in that industry to regulate itself or our regulatory agency to regulate them. And therefore, because I don't know where it is on the risk parameter,

but I definitely don't feel comfortable saying it's getting hit by a tricycle. It could be getting hit by a small car. It could be getting hit by a train for all I know. It's just an unknown. And then, how would I justify it? Well, unless I felt that the reward matrix was picking up gold coins,

it just doesn't justify it to me. So, is that a moral panic? I don't think so. I think it's just saying, like, what's the risk reward trade-off for it? Justified skepticism, perhaps. Another revolution that's going on at the moment, which I've been the sort of front row seat of

has been alcohol and the reduction in the consumption of alcohol. I think people realizing it's no surprise that it's a really dangerous risk, but people who considered that one drink was okay, that two glasses of wine because there's some reservoir of troll coming from the red grapes, etc, etc. I was a club promoter for a very long time, so I was in the trenches partying hard for all of my 20s, which is why your 90th to 100th your estimation, I think is unfortunately going to be a little bit too generous.

But I went sober for six months, really loved it. Most to do with the lifestyle changes, cognitive improvements, what it meant in terms of habit, in terms of consistency, energy, money, time, all that stuff, came back to drinking, didn't like it, went back to sober for another six stuff, came back to drinking, didn't like it, went back to sober for another six months, came back to drinking for a couple of months, didn't like it, did a thousand days sober, I never had an issue with substances, but just really loved what it had done for me. And, you know, five years, hands, six years, hands now, the low and no movement, seems to be really, really gaining speed. Why is it so surprising?

Why is it that something that, ostensibly obviously wasn't that good for us is now only just beginning to kind of get some momentum of people thinking, oh, maybe this thing that makes me feel like a total pile of dog shit the next day is something that I shouldn't take all the time. I don't know, I can't speak to it. The only thing I could speculate is that with the with the rise of sleep trackers, I think you really have some objective data on the downside of Alpera. And I don't think anybody who's worn a whoop who doesn't look at their heart rate variability

pre and post alcohol consumption or the fragmentation of their sleep is not saying what the hell? It's insane. Why is it such an impact? For the uninductinated amongst us, let's say that you've got a heart rate variability of 70. If you were to have two glasses of beer or two small glasses of wine on an evening finishing at 9 or 10 pm and then go to sleep on the night, it wouldn't surprise me if from 70 your heart rate variability is down in the 30s or the 40s. What is happening inside of the body that's causing that to happen? So alcohol is metabolized into different elements, but one of the metabolic byproducts of alcohol is quite toxic. And I suspect, I don't know, but I suspect what's happening is the toxicity of that is changing the autonomic nervous system. So in what you want to be doing when you're sleeping

is in a maximally parasympathetic state, that the so-called rest and digest state. And that's really what heart rate variability is measuring, right? Heart rate variability, along with other things such as heart rate itself, and temperature, respiratory rate, are proxies for your autonomic nervous system. And anytime those things move in the wrong direction, so heart rate goes up, heart rate variability goes down, respiratory rate goes up, temperature goes up, all of those things happen when you drink. That, to me, is a very strong signal

that's something about the toxicity of the metabolic byproduct of ethanol is putting the body into more of a fight or flight response as opposed to a rest and digest response. It's so hilarious that the thing that a lot of people use and has been used for a long time, I can't get to sleep, I'll have a glass of whiskey. Isn't really dating with sleep is just sedating people. Yeah, that's the insidious thing about it, right? Is people confuse sedation, consciousness, and sleep. And I love to tell the glib anecdote, right? Which is like, if I hit you over the head with a baseball bat, you would lie motionless

for 12 hours. But of course, there is no confusion over the fact that you are not sleeping and nothing about that experience is good for your brain or your body in terms of rest and recovery. So yes, alcohol is very sedating, but it doesn't promote sleep in the way that we know sleep works in terms of its stages and its functionality in terms of healing. Let's say that no one has looked at Alzheimer's or neurodegenerative disease. What do we need to know? I mean, the first thing I think everybody needs to know, you're talking about from a personal

risk standpoint or just understanding the disease. Personal risk. Okay. Yeah. So the first thing I, you know, we want to know from all of our patients is tell us your family history. Right? There is a genetic component to this disease. So let's understand what your susceptibility is. there is a genetic component to this disease. So let's understand what your susceptibility is. Would you ask them that ahead of just saying go and get a genetic test? Oh, absolutely. Yeah.

Because I think the family history is more telling than the genetic test. Wow. Okay. Because remember, the genetic test we look at, we look at the most common gene, which is the gene that's easiest to test for, which is ApoE.

There are a dozen other genes that we look at, but they're much harder to sift for. There aren't really great commercial tests for them. And God knows if there's something looking that isn't part of this current paradigm of what we understand. Yeah, exactly. Did it show up? Yeah. If it showed up? Yeah. So right out of the gate, we want to know, is dementia in your family? If so, what type do we think it is? So do we think it's Alzheimer's dementia? Do we think it's vascular dementia? Do we think it's front to temporal lobe dementia? Do we think it's Lewy body dementia? Is there Parkinson's disease? When you think about just comparing Parkinson's disease, Lewy body

dementia, Alzheimer's disease, those are three types of neurodegenerative diseases that are on a spectrum, where Alzheimer's is the most cognitively destructive. Parkinson's is the most movement destructive. Lewy body is taking bits of both of their playbook, right? So Lewy body is destructive to both movement and cognition. Well, we want to understand exactly what pattern you may or may not be a part of. Well, so I want to understand age of onset. So tragically, there's a, fortunately,

very, very rare, but, you know, still, unfortunately, prevalent form of early onset Alzheimer's disease. These are people who are afflicted in their 40s and 50s. Is that what Chris Hemsworth's got? No. No. No. He realized something during that. Chris learned that he has two copies of the Apo E4 gene and the Apo E4 gene is the most common genetic, you know, the most common gene responsible for Alzheimer's disease. But it's not early onset.

It's not early onset. Right. It's a late onset predisposition. The early onset ones are called APP PSCN1, PSCN2. So again, those can be tested for. We don't normally test for those because it's normally so apparent from family history. Of course. Now, if we document that, we would, of course, test for it. Tragically, I think that's a variant of Alzheimer's disease that is, I think it's less clear

how much you can prevent. Lifestyle independent basis. Right. Whereas the one that Chris has and that 25% of the population has, if they have one copy of that gene, that's highly amenable to prevention, which really gets to why we want to know this stuff. You want to know this stuff because one, sometimes that's the motivation people need to take this seriously when they're 35 years old and young and indestructible because that's the time you want to actually act. And secondly, there are certain things that we know are even more important to

people with that genotype. So it would factor into what medications we might use to lower cholesterol. It might factor into how much omega-3 EPA and DHA we would want them to take. It might factor into other choices we might make around nutrition. And even in people who are exercise time limited, it might factor into how we prescribe exercise. What are the biggest prophylactics against mental degradation of a time? So I did recently did a podcast on this. It's an AMA on my podcast that is 100% devoted to all interventions that improve cognition and delay the onset of dementia. And I sort of broke it down into here are the things for which there is no ambiguity about the benefit. So enormous signal,

I'm not going to talk much about them because it's, I'll give you the basics on it. And then I spent the entire podcast talking about the gray stuff where there's probably a benefit, but it's harder to quantify. So you're asking, what are those things that I didn't really talk about? It's basically exercise, lipid management, not having type 2 diabetes, and probably sleep, having adequate sleep. Those are the no regret moves that have enormous impact. And it's probably in that order. So it seems like looking at what we've spoken about so far today, and you mentioned it earlier on, you thought diet was this unbelievably huge lever.

It seems now that exercise is one of the longest, if not maybe the longest. I think it is that you're talking about. I think it is, yeah. I think the data, certainly the data would suggest that, right? So in other words, you go back to, so a hazard ratio is a very, it's an important tool in statistics

to understand the relative risk or benefit of any intervention. So a hazard ratio of one means that this intervention has no benefit and no harm. A hazard ratio of 1.5 means this intervention is 50% riskier than the baseline. A hazard ratio of 0.75 means this intervention is 25% less risky. When you just go off those numbers, what's the hazard ratio of smoking? Well, it depends on the study bits about 1.4.

So what that means is, and that's for all cause mortality. So that means that if you compare a smoker to a non-smoker, all things equal, at any point in time, that smoker is 40% more likely to die in a given year than the non-smoker. Devastating, right? If you look at hypertension, it's about 1.2, 1.21. So having high blood pressure means you're about 20 to 21 percent more likely to die in a given year than someone who's identical to you in every way except they don't have high blood pressure. If you look at somebody with, you know, atherosclerosis, so advanced cardiovascular disease,

it's about 1.25. If you look at somebody with end stage kidney disease, so someone who's on dialysis, it's like 2.75. I mean, so 175% more likely to die in a given year than someone who's not in end stage renal disease. So now start comparing all of these other interventions I'm talking about. Well, let's go back to the VO2 max.

If you take somebody who's in the bottom 25% of fitness, which by definition, 25% of the population are, and you compare them to somebody who's in the top 2% for their age, it's a five, that has a ratio of five. It's a five, the hazard ratio is five. So that means it's 400% difference in mortality. If I take somebody who is in the bottom quartile of strength and compare them to the top quartile of strength, it's about three as a hazard ratio. So when you go through these metrics of exercising or muscle mass or strength or cardiovascular

fitness, it just dwarfs everything else, including diabetes, including smoking. So, and again, this isn't a zero-sum game. Like the goal is, get as many things on your side as possible. Be of normal weight. Don't have diabetes. Be sleeping well. Don't smoke. But be strong as hell. Have a high VO2 max. I mean, you want, you want to stack the odds as much

in your favor as possible. There's no guarantee in life. And this, there's still an enormous stochastic random bad luck component to life. I could walk out of here and get hit by a car. But I'd like to control what I can control. Hot disease is the biggest killer on the planet at the moment? Barnum. Why are our hot suffrage? I mean, actually, I would argue they're not, right? If you consider what your heart is doing, right? You know, it's like this amazing organ that is beating nonstop without any instruction from you consciously and has this remarkable

capacity to respond to your autonomic nervous system on demand, right? Someone runs through this door and startles us. Our heart rates are going to skyrocket instantly. We don't even need to tell it something bad is happening, right? I, you know, you go to, you know, get stem cells at elevation. Your heart rate knows to get jacked. And so, so, so, so this thing is in a remarkable muscle. But it has, it has a narrow blood supply, you know, so, and it doesn't have a remarkable capacity to revascularize itself.

That's probably its biggest drawback. Other muscles in our body haven't much easier time undergoing angiogenesis. So if you suffered an occlusion of a small blood vessel in your leg, it wouldn't cause as much trouble because you'd have an easier time creating collateral flow around it. But in the heart, that's less the case. And of course, the stakes are much higher. You probably wouldn't notice it if a silver dollar sized patch of your quad stopped working. It wouldn't wreak as much havoc as if an equal size patch of your left ventricle stopped working.

So the problem is that evolution didn't really care about atherosclerosis. That's really the problem. So atherosclerosis. That's really the problem. Atherosclerosis is driven by factors that evolution wasn't at all caring about because they didn't interfere with reproductive fitness. Smoking, high blood pressure, and high APOB are the main drivers of atherosclerosis, and none of those things were on evolution's radar. In fact, you could argue high APOB for a period of our human history would have been beneficial. APOB, being the lipoprotein that wraps around LDL and VLDL, would

have played an important role in a scarce nutrient environment, which we were in up until a few hundred years ago. And today, of course, it creates a problem, right? Today, those APOB particles, those LDL particles are carrying cholesterol into our artery walls and our immune system, which, by the way, is doing the best job it can, like the little train that could, is treating that as though it's a foreign invader and mounting an enormous immune response. And it's that immune response that's actually leading to the creation of plaque that ultimately

results in a heart attack. So when it comes to heart disease, it seems like there's two broad elements here. One would be restricting the things which cause risk and the other would be improving yourself from baseline. What are the big buckets in either of those? You mentioned smoking. Smoking blood pressure in APOB. So if you just took those three things off the table, it's very hard to imagine how you can get atherosclerosis. So if you don't smoke, if you maintain a blood pressure at or below 120 over 80, and if your APOB is maintained

at the physiologic level that kids have, you can't get arthroscarosis. How does someone know about the rapopie? Simple blood test, cost about 12 bucks. Okay, and how often do you need to get that done? I mean, I probably check mine three or four times a year. I probably check mine three times a year. And if it came back and said this is high, then you would try to ask the question, why is it high?

How much of this is gonna be fixable by diet? How much of this is going to be fixable by diet? How much of this is going to be fixable pharmacologically? Truthfully, to get to the levels that are necessary to eradicate atherosclerosis for most people does require pharmacologic intervention. This is probably, in my opinion, if antibiotics represent the biggest win of medicine 2.0, anti-lippid therapy would be the second biggest win. Okay, that's stopping the bad.

Yep. Improving the good for the heart. Yeah, so again, exercise, not surprising. And probably more so the benefit on cardio here, probably you're going to see more of a, the data would certainly suggest that cardio is the more important exercise of the two, but again, I always caution people. You're not just feeding your heart. You got to worry about your brain.

You got to worry about your body. So we're never going to get into a cardio or strength paradigm. It's always going to be end, but just to be clear, the cardio training probably has a better impact on the heart. Sleep. So, you know, poor sleep has devastating impact on the heart, probably through sympathetic overtone, hypercortisolemia, things like that. So stress becomes another thing that really matters. It's kind of, it's one of these sort of fuzzy terms that kind of seems like,

oh, yeah, I stress, I'm sure. But I think the data are very clear that high levels of cortisol are really damaging to coronary arteries. And then, again, nutrition kind of factors in probably to the pharmacologic strategy. So there's no question that for, you know, if you're, if you were saying, what would be the most draconian nutrition step I could take to minimize my lipids, you could take that step, but you're probably creating three other problems in its wake. Right? So if you went on like a 10% fat diet, you would probably drop your lipid levels to, you

know, very healthy levels. The problem is what other problems would you create? How do your hormones look? Yeah, how do your hormones look? How does your muscle mass, all these other things? And so what you call it, you've lifelike only having time to some fat and you die. Right. So the way I think about it is, so if I can use pharmacology to solve a problem without creating another problem, that's a far better use case than using nutrition to solve a problem that creates a whole bunch of other problems.

Because you can be more targeted. Yeah, understood. That's interesting. What about motivation? What do you think about motivations? We're talking here about all of these things that we could do and should do and potentially need to do.

But there's other competing goals that people have got as well in here. What have you found, given that overwhelming number of things that you get exposed to, ready to be good if I added this into my routine, you could get to the stage where there is no life left in your life. How do you map your intervention threshold and then try to stay adhering and compliant, given

all of the stuff that there is to do? Well, I mean, I think everything has a season, right? So there's been periods of my life when I've been far more disciplined and far more regimented than others. And again, I just, I kind of always want to remind myself that I never want to be in this situation where everything is off the rails. So if I'm really feeling stretched thin,

if I'm really feeling like I can't do it all, then I have to start prioritizing. Then I have to start, you know, if you're on a lifeboat and you can only take so many things, this is where it really matters to think that you know, if you're on a lifeboat and you can only take so many things This is where it really matters that you think about what you need and so if You know if if for example when I was you know finishing the book and under You know unusual amounts of stress based on the demands of the book the demands of my practice the demands of the podcast all these are the things I just made a very clear, unilateral decision,

like there's certain things I'm not gonna care about, and one of them is gonna be eating, like I'm going to indulge and kind of eat whatever the hell I wanna eat, but I'm not gonna compromise sleep or exercise, because I know that those two things factor far more into my productivity, my cognitive capacity, and my mood, truthfully.

And yeah, in an ideal world, I would be firing on those cylinders plus eating perfectly. But I was like, look, sometimes I will, sometimes I won't. And if my assistant manages to be able to get me a great salad for lunch today, that's awesome. But if she can't, and I feel, and I'm starving, and I just want to go and have a bowl of cereal, so be it, I'm just going to have a bowl of cereal. Like I'm not going to beat myself up over this or let it bleed into some other areas. And of course, you know, I hope that that's not something

that I endure as forever. And of course, you know, it doesn't. You know, you just have to remember that you gotta remember why you're doing this, right? So I think, I don't know that motivation is the right word. I think it's sort of purpose that matters. I don't really know what motivation means. At least for me personally,

I'm sure for some people that word has meaning, for me kind of purpose is the thing that matters. A more accurate word for me to have used would have probably been something like consistency over a long period of time for this because we're looking at longevity by definition up until the end of life. You began this conversation asking,

what do I look like when I'm still having sex on M90? Which means that you're making decisions in the now, which are very different to if you only have a five year or a ten year, even a 20 year timeline to what you do. You know, your training protocol, which the risk to reward, it may be fun to do this particular training style. It may be, what's the injury risk and what would the downstream costs of that be in 30, 40, 50 years time? So it's...

I don't have great advice for how to get somebody there. I mean, I just know that I've crossed that threshold probably in the last five years. And I'm really happy about it. It's actually created a much greater sense of calm in my life. It's less hurried in a way. Yeah, and also just less harsh. It used to be that every day, I used to say this, every day you have to burn at least one match. And a match for me being burned was a physical exertion to the point of wanting to puke.

I had to do that at least once every single day. There was no workout, seven days a week that didn't at least produce that once. So even like if I was out on a recovery ride, I would still have to close the ride. There was, I used to live at the top of a hill and it was a one kilometer hill and it would always be a one kilometer sprint to the death where I was always trying to hit a PR or every, if I went into the weight room and the goal today was to deadlift, it was like always going to try to PR. And I mean, I am so far from that mentality today that it's sometimes, you know, like I'll

go in and I just don't feel right during the warm up. Like it just doesn't feel good. And I'll say, you know what, I'm gonna abort the deadlift today. I'm gonna go and do some safer exercises where the stakes are a lot lower. And if I make a mistake, I'm not gonna get punished for it, the way I'm gonna punish if I'm doing deadlifts and I don't have my form just right.

And so yeah, you've got to be able to play the long game, I think. And I don't know what to tell somebody to get them there other than anchoring them to the marginal decade. Because if you know what you're training for, then of course you wouldn't take that risk, right? Like, and I'm gonna say, I think what we have an epidemic of is people who don't know what they're training for. Like, you know, if you really stop them and ask them, like, are you doing this because you want to look good on the beach?

Are you doing this because you want bragging rights? Are you doing this or the other guys at the gym look at you? It's okay to say that the answer to those questions is yes, but at least be deliberate about what you're doing and why. Because if you are doing this to look good on the beach or to have bragging rights, then you might have to compromise some of your long-term goals. But at some point you got to decide like what matters the most. What sacrifices did you need to make whilst writing this book? It's been a very long labor as far as I'm aware. There was a draft at some point that essentially just got totally burned.

Two. Two drafts. And that essentially just got totally burned. Two. Two drafts. And it's not a small book. I mean, it's like a, it's a, it's a, it's a big boy. What did you have to sacrifice as someone that likes to get things right, like swap to mice? What did you have to sacrifice in order to? Well, I mean, I think I had to learn to compromise a little bit truthfully.

You know, I had a co-author, I have an editor, and I think I had to learn that sometimes they would have a point of view that was different from my point of view, and I had to make concessions. And I actually think that in the end, those concessions were valuable. So one of the biggest conflicts early in the writing process, so I wrote the first version by myself and nobody liked it. So everybody was like, this is way too technical and there's no story. There's no story.

It's just a technical treatise on longevity. And I was, I really rejected their suggestion that this book needed to have part of me in it. I was like, that's going to be, that is going to have no credibility. It's just going to read like, you know, pop fiction garbage, like, blah, blah, blah, blah, blah, blah. Well, when I look at where that book is now, I realize, no, it had to have part of me in it. This is partly my story, and it's the story of my patience. And it's basically a very technical book that is weaved together between the stories of people.

And, you know, there's a saying, right? Like, never make a point without telling a story, never tell a story without making a point. You know, This is something I really, really rejected in 2016, 2017 in the first iteration of that book. There are countless other examples of things where I was adamant that it needed to be done a certain way, and luckily people around me who are smarter than me said, no, I don't think that's the way to do it. I think we need to cut this down a lot. And that's a hard thing to do when you're writing. When you're writing, there's this sort of thing that's called you learn to kill your babies.

And that's a really hard thing to do. I had there were chapters of that book that were literally twice as long. And I thought they were really good. And that left on the cutting room floor. They're gone. And they're better now, shorter. It's okay that I didn't say everything that needed to be said. A bunch of things that we haven't spoken about so far today are heat, cold, sunlight, grounding, meditation,

reguative practices, social connection. How do you map these onto the discussion about longevity? Recently read a book by Robin Dunbar, friends, sorry, the social brain, his new one, and in it he says, one of the biggest discoveries that we've seen over the last decade has been the unbelievable power on health and longevity outcomes to having a social group has with us.

Where do you fit all of this stuff in the heat, the cold, the sunlight, the grounding, the friends? How does all of that work? I mean, I put them in different buckets, but I would agree with that. I mean, I think that, I mean, we are evolutionarily so wired to be social creatures. And that doesn't, like, I'm an introvert, but which means, like, I don't like really being around that many people, and I certainly don't like being around strangers. But I would die if I was alone. So, you know, people who are introverts don't necessarily aren't immune from this either. And by the way, I love playing thought experiments, right? So, you know, one of the thought experiments I would play

with myself when I was sort of wrestling with this was, if you could have everything you wanted, you could achieve everything, right? You could be the most physically fit, you could have the most knowledge, you could have the most cars, race cars, and race tracks, and blah blah blah blah, but you live alone in this planet.

All of your needs are met by robots that do everything else, right? So the robots are, you know, pulling the oil out of the ground to make the gasoline for your race cars and they're building it and they're farming your food or whatever it is. Like, but you're alone. Like, think about that existence. You can't fathom an existence alone regardless of how good everything else is in your life. In fact, that would be the closest thing to hell that I think I could ever imagine. We certainly know at the extreme end of the spectrum that loneliness is an enormous predisposing factor for suicide.

So suicide is just the most extreme form of emotional death. But I think there are a lot of people who never get close to suicide, but who then enter kind of the second orbit around suicide, which we would call parasyuicide. So engaging in behaviors that are ultimately reckless enough that they cost you their life. I mean, you would argue that smoking is parasyuicide. Excessive drinking is parasyuicide using dangerous illicit drugs that unfortunately nowadays are so often laced with fentanyl is parasyuicide. Is driving a strip back three series with a V6 engine and roll cage parasyuicide? I don't think so. I think driving to the race track to do those things is basically Paris suicide. No, it's so funny.

I actually brought my daughter to the race track for the first time two weeks ago. Coatta? No, I went to Harris Hill. So I would love to bring her to Coda. I wanted to start her at Harris Hill. It's a smaller track. You don't get nearly as fast. And she was so reluctant for like a year to come.

How old is she? She's 14. Okay. And I was like, she's like, well, how, what happens if we hit something? And I was like, well, I'll leave you the way they design racetracks. It's like, it's anticipated that you're going to lose control of the car sometimes. So everything is designed to minimize that. Plus the cars are in company safe. So then of it, she finally came. I have a GoPro on the dash filming us driving. It is hilarious to watch her head like moving around and stuff because the, you know, she's, you know what a Hans is? Yeah. Yeah. So the, the belts came off her Hans. I don't think my coach strapped her in tight enough. And so pretty soon she's like, you know, she's still strapped in there,

but she's not like I am. Like when I'm in there, like my Hans is like, and I showed the video to him on my buddies. He goes, she looks like one of those monkeys they used to put on rocket ships. You just see a big helmet head bubbling around. It's hilarious. But anyway, no, I would not describe that as perassueous. I would describe that as, no, when I describe skiing or other sort of risky sports,

I just think you have to decide where they are within your risk behavior. But then you go even beyond that and I think there's you know, behaviors that that aren't going to kill you, but they're just going to make your life so miserable, right? Like having horrible relationships with people. That degrades the quality of your life. And while I do think that that does shorten your life ultimately, I do think that there are biochemical ways that that impact probably through stress hormones, probably through greater activation of sympathetic,

an imbalance between sympathetic and personal sympathetic flow, I think those things absolutely do impact our immune function, our cardiovascular function, all these things. Even if they didn't, what's the point? We just think about the enjoyment of life. Yeah. And we can break things down into an objective list of metrics and how does it impact

the things that we can measure that are going on. But what's your felt sense of life like? Yeah, so go back to what you said in your marginal decade. And I think most people, when you ask them about their marginal decade, none of it's in isolation. It's, you said picking up grandkids, being able to walk your dog, which is a companion,

being able to have conversations with other people. That's the cognitive piece. So I think when most people really think about this, they can't escape the fact that their quality of life is inextricably linked to interaction with other people. We haven't spoken about emotional health as an individual at the moment. It might surprise people to think about

when you have the discussion about longevity, you're talking time on the planet, bone density, muscle mass, cardiovascular risk, et cetera, et cetera. What about emotional health? How should people even frame that in the discussion that we're having? I think it has to be top. I think it's right there with those other things.

I don't think it's something that should be thought of as an afterthought. It matters just as much. Again, long life with poor emotional health is probably a curse. What? Rejuvenative practices do you find best? We tend 12, 14 hours a week of sometimes punishing, sometimes sub punishing workouts and yeah, usually sub punishing, right?

So call it 12 to 14 hours a week of exercise is very important for me. I do sauna four days a week. I tried to do four days a week. Session link. Minimum 30. So 30 to 60 at 196 to 200. You taking a break, but those you must be. You're taking a break? Who does? You must be.

You'll straight through on that. I can. I usually will go 30 and then a quick break though. 60 at 200 would be. I've never done 60 at 200. I've done 60 at like 194. It's hard. Okay. Right. So full times a week. Yeah, four to five times a week.

And by the way, that's doubly regenerative for me So, full times a week. Yeah. Four to five times a week. And by the way, that's doubly regenerative for me or rejuvenative, depending on you, because like, I'm, again, I never do that alone. Right. So, I'm going to do that with a friend. I'm going to do that with my wife. Yep.

And that's always just an awesome time to be, like, last night, talking about talking about, you know, my wife and I spent the whole time talking about, you know, a session she had with her therapist and how, you know, how much she learned and it was just so wonderful to have stacking multiple things on top. It's just it's just being able to do multiple things at once that are both really beneficial. I like rocking. That's something we didn't really talk about. I don't really lump that into my exercise bucket of time, though it is, it is obviously a great type of exercise, but because of the way that I'm doing it, which is I'm not taking any electronics with me and I'm not multitasking when I do it,

it really is just as much about my brain as it is my body. So rucking, of course, just for folks who don't know, it's basically walking around with a very heavy backpack. So sweet spot is about a third of your body weight. And, you know, so I'll go and do about three, three, three and a half miles with as many hills as I can find. And I'm not taking anything. I'm not listening to podcasts or books or anything. I don't have my phone with me.

So it's really just something that's unusual for me. Because usually, I mean, they're working or if I'm exercising in the gym, I'm listening to to music if I'm on my bike. There's always multiple stimulus going on. Yeah I'm listening to a podcast or something like that but here it's truly just observing thoughts. What's your divisive choice for Rukin GoRuk? Yes, absolutely.

What does it go? Is that, do they do anything that isn't, because they do the thing that's like a big penis coming up of your back way, you can literally plate load it, right? I'm gonna guess you use a more. I have a pack, so there's an actual pack that has pockets in it, so you drop the plates in it. Cool.

And you've got what's like 60 pounds? Seven pounds in there? 60, and I have several packs, so I have one, my wife has one, we have one for anytime friends come over, and I've just got, like, we've got tons has one. We have one for any time friends come over and I've just got like, we've got tons of weight. So we go, yeah. So it's like I like to do rocking meetings with friends.

Okay, yeah, cool. So, Solna, Sanna, cold, you have a cold plunge, love that as well. What are you aiming to hit per week then? Again, it depends, probably also about four times a week.

And again, that's something I like doing with my wife, even though she's tiny, she can actually take the cold almost as much as I can. I have a lot more insulation than she does. Worst for conversation than a sauna. Yeah, not as much. Usually the conversation there is how much longer. Yeah, yeah, yeah, yeah, yeah. Okay. And, and then truthfully, I think the most sort of rejuvenating practice is playing.

Like I, I'm really lucky because I have, my daughter doesn't like to play as much, but we still play, like we, you know, we play volleyball. She loves volleyball. So anytime I can be out on the court with her playing volleyball, I'm teaching her how to drive stick. So that's something that she loves doing.

She'll be like, can we go and drive? And it's like, yep, getting the pickup truck, go to the parking lot, and, you know, making her start on steep hills and stuff like that is awesome. And my boys are eight and five, and so all they do is play, and so I get to play every single day. You're down on the ground. You're probably going to be on grass. Playing Lego, jumping on a trampoline, goofing off. I like doing Lego myself. That's another super enjoyable thing for me to do. What is your...

I saw... Did you post something saying that shares of Lego had increased by 25% at some point and your wife had accused you of being single-handedly responsible for it? Controvuding to it. You moved the Lego market. Yeah, yeah, yeah. Wow.

I got sent by a very good friend, Tim Bishop, from Australia, a Colosseum Lego set. Yeah. This one of the three biggest Lego sets. Yeah. So he sent me this. Where's you one of the four? So the, yeah.

Well, look, tell me what's the first biggest? The first biggest, I think, sucks. It's the world map. Lane. It's so lame. Right. Second, third. Second is the Eiffel Tower. Less lame. Lane. It's so lame. Right. Second, third. Second is the Eiffel Tower.

Less than I do. The new Eiffel Tower. There was an old one. Right. The new one is really cool. If you did not one. We have not. My boys want it.

My boys are just finishing the Titanic, which is the third largest, and the Coliseum is the fourth. Right. And it's funny. My boys, I was putting them to bed last night, and we were playing the rank order game, which one would you want? And I said that I think the coolest is the Titanic followed by the Coliseum. Okay, well, I've got that.

Have you done it yet? No, I haven't even opened it up. Tim sent it to me with a letter about the man on the stadium floor. Yeah, yeah, he was a little bit of a Teddy Roosevelt. Yeah, which was very meaningful. And he shipped a thing from Australia. Oh, maybe he hasn't. Yeah, he must have done because it had the note in it. God, yeah, so he shipped it across the planet. Yeah, you was very meaningful. And he shipped a thing from Australia. Oh, maybe he hasn't. Yeah, he must have done because it had the note in it.

God, yeah, so he shipped it across the planet. You can do it. I mean, I find that I love doing Lego. I do that. My favorite of the Technic cars, so I have all of them. OK. Do you do this? I'm going to get, because one of the other things

that I had Kelly stare on the show yesterday, no, Monday this week. And there's this big movement at the moment for being on the ground. Spending as much time hips below knees as possible. Do you consider that as well? Are you Lego-ing? No, I do Lego on a table,

because it's so complicated. I have multiple plates laid out with all the different pieces and stuff. Your workstation needs to be optimized. I can tell you a surgical with your leg creation. But my, I, you play on a floor with kids, because kids play on the floor. Understood. Yeah. And that's also something that factors into how you think about this last decade of your life, which is if you want to play with grandkids,

like you'll be able to get down the ground, you have to get to their level. And that's why, by the way, I think the step up is an amazing exercise. The step up is the movement that tells you you can get up off the floor. So you won't think I haven't brought it up yet today. I've been playing around with a Vitruvian at home, which is kind of like a tonal, like magnetic drive training thing. They sent me one, two or three months ago. Did this thing so much fucking fun? It's so cool. So you can imagine a, like a step, a, like one of those Reebok things that ladies in aerobic class would use, a little bit bigger than that.

Flat on the ground, magnetic drive, two cables that come out of it, two nylon cables, tons of attachments that go in. You can belt squat by slotting something between the two. They can be a long bar that goes between the two. You can use all these different bits. There's a bench as well, and the bench has got one leg is shorter than the other so you can go flat or you can flip it and then it's an incline. It's so much better. Is it working? Is it magnetic? Yeah, okay. So you can have time and attention. If you start to fail on a rep, it'll do it'll dial the weight back and then as you get to the top it'll turn it back on.

So it can do eccentric only training and it goes up to 440 pounds of weight, and doing step ups with that, or doing my favorite movement with that is a front foot elevated split squat. So putting up onto that handles in either hand, it's so much fucking fun. And it feels so... How much room does it take up? Not just literally just the size of a

like the Reebok step. Yeah, that's it. And there's no more room to eat. How much are they? Three grand. And three, three, three and a half. And if you get like the looks, sweet of additional things, the nicer handles, the bout squad, etc. You're probably looking at all in,

including shipping, probably like on the three and a half, something like that. They're not a sponsor on the show, but they sent me this thing. And if you had a thousand square foot, 500 square foot apartment in New York, you could slide it, but it's got little wheels on it, put it up against a wall, it would take up no room and do this thing fucking crushes you. It absolutely destroys you. And there's the app as well that they've done. There's something else that I thought was really cool. You can do not only individual workouts, where there's a video and the person does it and it tells the machine what you're doing. And it gives you time in between for rest or to change the things over and you change it over

with the guy or the girl. But it can do entire programs where it pings you and says you need to do lower body today and then you press it and then away you go. I trained in the gym for nearly 20 years now and this thing is really fun and I really, really enjoyed the variation that it's added into my training. So you know thinking about Lego, thinking about getting down on the ground, thinking about stuff like 10 years ago if you'd said, oh you're going to love box step ups. It's a fuck off.

I'm not going to enjoy box stepups. All of these different training modalities are great. Pickle balls, great. I'm really enjoying, and I think that you mentioned it as well, like transitioning the goals that you've got. What are my aims? What are my priorities here? The first time I spoke to David Sinclair, I guess I four years ago, just after a first time he did Rogan, I thought, wow, this is really interesting.

I learned about NMM and all this shit. And I went to go and see him and it still sounded to me a lot, the longevity movement generally halfway between like something for other people because I was made of rubber and magic and 30 years old. And just it was, it was something over there, whereas now it very much feels like, I really need to take a heed of this. It's not just about learning it and teaching it

to other people, it's like, okay, fuck, like how do I start to integrate this into my life? And I think that a lot of more people are feeling that as well now. Yeah, well, I mean, the interesting thing is the relationship between the age of an individual and when they start to pay attention to these things. The younger you are, the greater your advantage in terms of the compounding benefit of the

changes. This is all about daily practice. This is all about day in and day out adhering to these things. The drawback of being young is that marginal decade is a very abstract concept. Less motivating. Yeah, so it's harder for you to stay focused on a goal that's so far away. Conversely, when you look at people in their 60s, they're already on the downside. They've watched their parents go through this. They've watched people live and die through horrible marginal decades.

They have all the motivation in the world if we want to use that word. They just have less room to alter the course if they're really far off. So I'll never know what the perfect time is to begin other than right now. You know, the perfect time is to begin other than right now. You know, the perfect time was yesterday. The next best time is today. But it's always interesting to observe that difference between the extremes of age.

Did you become chronically aware of your own mortality? As you went to the beginning of your 30s, I think it's just it's the first time where warmups take a little bit longer, where hangovers feel, they never felt that good, but they feel, start to feel really, really rough. And it does, it, it's a very strange situation, especially as a guy, especially as a guy who's taken a lot of pride in the way he moves or looks or is fizzy and stuff, to start to kind of at the top of a rollercoaster you go, this isn't going up anymore. I'm kind of weightless at the top, and maybe this is the biggest or the fittest

or the strongest that I'm ever going to be. And realizing that is like, oh, fuck. I need to think more carefully about this. But another side, when we're talking about motivating young people to consider in your 20s or whatever, to think about longevity, one of the prescriptions that you've got is you have like a 15 to 30 minute window for sleep and for wake and like try and lock

that in. If you do that throughout your 20s, you're not going to have a massive number of life experiences. Now that being said, it's not a prescription you're still fine for you to go and travel and change time zones and all the rest of it. But there is a degree of like, just go and live life. And perhaps part of the reason that you're able to deal with that when you're younger is that. And perhaps part of the reason that you're able to deal with that when you're younger is that it is more indicative of the kind of lifestyle that you're going to live. And then as you do get a little bit older,

things are going to be routineized. Kids will be need to be taken to school. Work will require you to be at a place at a particular time. You can't just piss off and do a season in a beathor or like move to Hawaii for a couple of months or whatever, right? And I think, I like the journey. I really enjoy the arc that I can feel happening

with my training, with my fitness, with the way that I look at stuff. And thankfully, your friends grow with you, and you tend to be friends with people that are your age. So you're all thinking about the same things. You're all thinking about like, dude, if you drink the wrong amount of water on a nighttime, do you have to get up and go out of the bathroom

in the middle of the night? Like, fuck yeah. Right, I feel like we need to do a bit of research on this. You know what I mean? Yeah. Peter, I really appreciate you. I really appreciate your work. I think the book's fantastic. It's a labor available for over a half a decade for you. If people want to check out all of the stuff that you do, where should they go? I think everything is under my Peter Atia MD. So the website, we have a newsletter that comes out every Sunday that's, I think, pretty good. And then the podcast, the drive.

Thanks, Peter. Thanks for this. you