The Megyn Kelly Show - Importance of Exercise, Effects of Alcohol, and the Science of Longevity, with Peter Attia | Ep. 286

Episode Date: March 25, 2022

It's Wellness Week at the Megyn Kelly Show. Megyn Kelly is joined by Peter Attia, longevity expert and founder of Early Medical, to talk about the science of longevity, the crucial importance of exercise (especially later in life, new ways of detecting cancer, how alcohol affects our longevity and our overall health and sleep, mindfulness best practices, how sauna use can lengthen our life, how to live a healthier and longer life, and more.Follow The Megyn Kelly Show on all social platforms: YouTube: https://www.youtube.com/MegynKellyTwitter: http://Twitter.com/MegynKellyShowInstagram: http://Instagram.com/MegynKellyShowFacebook: http://Facebook.com/MegynKellyShow Find out more information at: https://www.devilmaycaremedia.com/megynkellyshow 

Welcome to The Megyn Kelly Show, your home for open, honest, and provocative conversations. Hey everyone, I'm Megyn Kelly. Welcome to The Megyn Kelly Show. Do you have a goal of living well, and I mean living well, into your 90s or even 100s? It's possible, and you already have the tools to make it happen right at your disposal. Dr. Peter Otia is a physician who focuses on the applied science of longevity. He is with us today to explain how it's possible

to increase your lifespan while simultaneously improving your quality of life. And his life is fascinating as well. Peter, so good to have you here. Hey, yeah, great to be here. Thank you. Yeah, the pleasure's all mine. I'm looking forward to this greatly.

So let's just start a little bit with your personal story so people know the very weird, fun, interesting journey you took toward this place you're in, which is not only a medical degree from Stanford, a residency at Hopkins, a fellowship with the National Cancer Institute, but now your own fasting app, your own successful podcast, the Peter Atiyah Drive podcast, and a whole sort of wellness program that takes a look at this thing, longevity, which we'll get to. So let me just take you back.

I don't want to go too far, but you're Canadian by birth and you were raised there. And you, as my parents told me, didn't seem like anything so special when you were basically K through 11th grade. Yeah, that's funny that you know that. Yeah, I was not a particularly happy student. Didn't like school very much at all from about the fourth grade on. And my passion was boxing. So I wanted to be a professional boxer. And that was kind of the only thing that mattered to me growing up. And so if I were to talk to your eighth grade teachers about little Peter at that point, what would they say about you?

Well, I could quote one of them who said, Peter Atiyah, you are the biggest loser in this school. So that pretty much sums up what they thought of me. Wow. And so you said, I'm number one. Yeah. Can you imagine a teacher saying that today? No, no.

You should, you're, you're a gentleman not to actually name the person and shame them. I still remember his name too. Should we do it? I don't know. Nah, nah. We'll skip it. You guys probably not even alive anymore. So you're feeling kind of mediocre and you're thinking like, maybe I'll make boxing my thing.

That, that doesn't require great grades. It requires different skills, but I don't have to be, you know, valedictorian to become a great boxer. And you were going to drop out of high school in the 11th grade. And I love this piece of the story because, of course, anybody who achieves the kind of greatness you have, there's a turn. You know, there's the moment of the turn and your turn, um, was brought about in large part, thanks to a man named Woody Sparrow. Great name, Woody Sparrow. What's the story? Yeah, well, actually it was, it was 12th grade, believe it or not. Um, and Woody was my math teacher. Um, and it's funny, it's weird that I was still taking math because it wasn't a required subject beyond, I think the first three years of high school or something like that weird that I was still taking math because it wasn't a required subject

beyond I think the first three years of high school or something like that. But I was taking it and I liked him for some reason. I don't know why, but he was really kind of the first teacher I had in a while that I really liked. And I remember just wanting to be present in his class and wanted to do well. And little by little, I kind of started working a little bit harder. Um, and I don't know, somewhere in the spring of that year, he said, Hey, you know, Peter, can you come in a little early tomorrow morning? So I did. And he said, look, I I've kind of heard from some of the other

teachers. You're, you're not going to, you know, you're not applying to university. And I said, yeah, that's right. And then in my mind, I sort of thought, well, here we go. He's going to give me the big lecture about what a waste of time it is not to go to college and all that other stuff. And he said, you know, Peter, I got to tell you, I really respect the fact that you've got a dream that you're so passionate about. And he talked about how when he was young, he actually wanted to be a professional hockey player and that was kind of his life. But he said something that really kind of resonated that I think did change the arc of my life. He said, I think it would be sad if you didn't go on to university because I think you have a real gift for mathematics. And I think the world would be a better place if you put that to use. But that was it. He didn't give me any

guilt trip or anything like that. He just said, I think you have a hidden talent here that you don't recognize. Did that resonate with you? I mean, apart from being flattered and feeling good about receiving a compliment, did you think, I also believe I might have a secret math ability? I mean, I don't, I think I just loved, I mean, I guess it was the first subject I really found myself enjoying. Of course, as time would go on, I would enjoy many other things, you know, intellectually. But at the time, I saw a little bit of what he was saying, at least in terms of enjoyment. I don't think I necessarily thought I had something special. Although I will say this is kind of a funny side, but my parents are both from Egypt. So

they immigrated to Canada and we're Coptic. So we're kind of the minority of Egyptians. And of course the Coptics are the descendants of the pharaohs. And my mom used to always say this to me when I was doing horribly at school. She'd know, it's in your blood to be a scientist or a mathematician because, you know, you're a descendant of the Pharaohs and look what they did. They built the pyramids, they did all these other things. So I think like that was her kind of way of like trying to, you know, say, look, it, it really is something you should be good at. Um, but nevertheless, I think when, when coming from Woody, it meant a lot more, I think, you know, you sort of expect your parents to trick, try to trick you into doing the right thing. But, um, yeah, look,

I don't think Woody had any agenda. And I guess, um, uh, I, I sort of believed him and came to realize kind of in the first risk-based calculation I made in my life that the probability that I was going to end up as the middleweight champion of the world was pretty low. The probability of pumping gas with brain damage was pretty high. So I thought maybe I should give this other thing a shot. I love that. You came from the pharaohs. You're going to be great at math. You should consider science. It's in your blood. My parents were more like, you come from a long line of mediocrity and you are a chip off the old block. Oh, okay. All right. Nail. So nailing it. All right. So you decide to give the old math and science thing a try. Okay. That starts working out okay for you, I guess, as early as 12th grade. And then can you

explain what you did, the young, well, it must 17, 18-year-old you, going into college, you did decide to go, to sort of stay ahead in math and science? Well, I think once I decided that this is what I wanted to do, I think the one thing I had going for me, and I think it's something that is important for any kid in school today, in high school or whatever is, I think it's really important, even if you're not completely fixated on school, to be really passionate about something. And so whether that be music, the arts, sports, something like that, because when I did decide that, hey, I really want to do this, I had a lot of catching up to do. And I only had one year to do it. So I had that 13th grade of high school, that additional optional year in Canada. And I basically went from training six hours a day, which is what I was doing for boxing to applying that obsessive compulsive

nature to basically trying to catch up on all the things that had to do with math and physics and chemistry. Because by that point, what I decided to do was go to college, but study two things at once. I wanted to study applied math and mechanical engineering. And so you wound up buying, as I understand, a copy of all the science and math and maybe the engineering books as well prior to going into school. And you read them all

before you had to for class. Right. So after high school, I got all of the freshman books for calculus, algebra, geometry, probability, statistics, physics, chemistry, and actually hired a tutor. So I went and found somebody who was a graduate student and took the money I made working at the restaurant and sort of got through as much of it as I could. But I really needed a couple hours a week with a tutor to take my questions to and just kind of learned everything that we were going to learn in the freshman year. And then when we got to the freshman year, my technique was basically just when we're learning it for the first time in class,

I'm going to get to learn it for the second time and I'm going to get to go a little bit deeper. So, you know, if the professor assigns questions one through 30, um, I could do questions one through 60. Um, and yeah, that just, I think that what that did was, um, allowed me to more quickly get through the fundamentals. Uh, I had this discussion with my daughter who's 13 the other day, which is that one of the challenges of mathematics, unlike English, is it takes longer to learn the basics. So in English, you can learn the basics by the time you're quite young. You can learn how to read, you can learn how to write, you can understand sentence structure. And so very quickly, you can get over to the sort of creative

part of the language. You can write, you can read for pleasure, you can do all these other things. With math, it's harder. There's a lot more stuff you have to learn foundationally before you I wanted to make sure I could master all of the fundamentals of calculus and real analysis and all of that stuff until we get to complex analysis. And then you really start to get into really interesting mathematics. That's fascinating. I've never, I mean, I never got to the stage of life where I thought math was beautiful as opposed to just a constant stressor. But it's also not something most people do right before they go to sleep at night or while they're sitting on a train ride or, you know, I mean,

English reading that it's built into our lives in a way where it's celebrated pretty much universally, whereas math isn't. So I do think if you have that aptitude for it and the drive that you have, yeah, you can take it to places the average citizen is not going to wind up. So you do clearly have a big, beautiful brain, even though that guy in your elementary school didn't see it. And you wind up at Stanford Medical School, which is and then you're to your fellowship with the National Cancer Institute, where you studied immune-based therapies for melanoma. That was a particular area of research for you. Can we just stop there for one second? Because I'm fascinated by that. Melanoma is such a deadly cancer. And it's like one of those things where, well, the key is not to get it. Well, and my understanding of melanoma is unlike like a basal cell or some of these other skin cancers, you can't really prevent melanoma necessarily by not going out in the sun. It's like a blood cancer that may come for you or it may not. They look at your family history. I don't know, but I remember doing a segment at NBC about these new therapies for it, like these blood therapies, these immune-based therapies that could potentially one day cure it. So what can you tell the average citizen about that?

Well, you're absolutely right, Megan. So unlike basal cell and squamous cell, which are skin cancers that are non-lethal, that are very directly related to your time in the sun. Melanoma is a little bit less clear than that. Now, it seems that there's some association with early in life sunburns or the frequency of severe sunburns, but it's not as clear a link. And it's clearly a much more difficult cancer to just say, here's the solution to not getting it. Um, and so catching it early is essential. Um, but you know, the, the, the skin lesions that ultimately go on to become melanomas can be very tricky. Um, and this is also a cancer that, you know, afflicts young people as well. So, um, what's interesting about it, although it wasn't known at the time, and by

the time I mean, you know, sort of 40, 50 years ago, it wasn't known at the time, and by the time I mean, you know, sort of 40, 50 years ago, what wasn't understood then that is clearly understood now is melanoma, along with a couple of other cancers, happens to have a lot of mutations in it. So I think everybody understands that cancer is a foreign sort of thing. It's a genetic thing where our cells basically become foreign to us and they grow without any regulation. That's effectively one of the two hallmarks of cancer, right? Is a cell that grows without regulation. And then that cell has the ability to leave its place of origin and go to a different place. That's what's called metastases. So those two principles effectively determine what cancer is. Now, mutations, of course, must arise in the DNA of a cell to make that happen.

And on average, a cancer cell might have 100, 120 mutations. Melanomas have many, many more mutations. And that turns out to create a little bit of a weakness for them because every time a cancer cell has a mutation that makes it different from its non-cancer counterpart, it gives the immune system one more chance to identify it and identify it as something foreign. And if the immune system can recognize cancer as something foreign, you have a chance to smack cancer. And in that sense, melanoma is fortunately one of the cancers for which we can now harness the immune system to recognize it as what we would call non-self and therefore attack melanoma regardless of how advanced it is.

Hmm. So, I mean, is it a skin cancer or a blood cancer? Well, it arises from the epithelium of the skin. So it is indeed a skin cancer, but it spreads and it kills you by spreading. So there are very few cancers that can kill you without spreading. Brain cancer is one of them. So glioblastoma multiforme, which is a very aggressive type of a brain cancer, it can kill you simply from the mass effect in the brain, the way it moves out throughout the brain with its tentacles. You can't ever fully move it. And just due to the nature of the brain being in a really finite space, any amount of excess pressure can be deadly. But if you think about it, almost everybody you've ever heard of who

tragically died of cancer died because the cancer spread, right? No one dies because colon cancer is in their colon. They die because colon cancer escapes the colon and typically goes to the liver or sometimes the lungs. So similarly with breast cancer, a woman doesn't die from breast cancer because it ravages her breast. It died. She dies because it spreads to her brain, to her bones, to her lungs. And similarly with melanoma, nobody dies because of what happens in the skin. They die because of how it spreads. And melanoma generally, you will see something that looks just a little off if you pay attention. You know, I watch this carefully because I'm so fair. And I've told my audience the story before I went to the one service that they take the pictures of all your moles all over your body. You got to strip down naked and they take all these pictures, some strangers taking up close

pictures of your freckles and your moles or whatever. And then what I didn't foresee, Peter, is that then they send you those pictures. And if you have the person at your mailbox collecting your mail as your assistant, she gets an eyeful. Yeah. But you raise an interesting point again, which is I think when you talk about the epithelial cancers, which are the ones that basically kill most people, that's sort of 90% of cancer deaths arise from these epithelial cancers. You can divide them into two types, those that are outside the body and those that are inside the body. So melanoma is obviously, it starts outside the body of the skin. And as you said, you can look directly at

it. And by being able to look directly at it, you have a window in which you can intervene before it gets advanced. But what a lot of people forget is everything between the mouth and the anus is also outside the body. So esophageal cancer, stomach cancer, colon cancer, these are also cancers outside the body. And that's why in my view, I think it's unacceptable for people to die from those cancers. We have the technology to be able to screen for those cancers. And furthermore, when it comes to colon cancer, which is one of the deadliest cancers in this country, it always progresses through a very predictable stage of polyp to cancer. In other words, every colon cancer starts as a polyp. And there's a period of time where a polyp is benign. And that's,

you know, most people who have had a colonoscopy probably recall, yeah, I went and had my colonoscopy and the endoscopist said, you know, Mr. So-and-so, I took three polyps, we snipped them, we took them out, we did a, you know, sent them to the pathology lab and they came back normal. And that's a good thing because there's a chance that those polyps will become ultimately malignant cancers. So it does break my heart anytime I hear of somebody dying of colon cancer. And in a way, it strikes me as somewhat more tragic than, say, pancreatic cancer, where I think we have far less of a handle on what the transition from normal to non-normal looks like.

And because it's inside the body, it's much harder to screen for. I will say this, now that I, you know, since I turned 50, that they wanted me to go get a colonoscopy. Can I tell you, I enjoyed it. All right. This, this is why I enjoyed it. The prep, it wasn't as bad as everybody says. It was fine. It was like not the most pleasant thing, but it wasn't anything to complain about. Then you go in the next day and they give you the wonderful propofol, which is so great. Michael Jackson had the weird Dr. Conrad Murray giving it to him every night so he could fall asleep and that's what killed him. But we're not talking about that. We're talking about just one fun dose of it where you count back from 10, you don't even ever make it to eight and you wake up, you don't remember a damn thing.

You feel fine. There's no pain. You get a result that you can either do something about or that you're happy to hear about if you stay on it and you get them regularly. And then you could just spend the rest of the day in bed. It's wonderful. Yeah. I'm going to be 49 in a couple of weeks and I'm having my third colonoscopy shortly. So I'm a big proponent of doing this early and actually doing it frequently, especially if even one polyp is taken. So, you know, our practice is very much outside of what the standard of care is recommended. Standard of care is moving towards 45 for your first colonoscopy, but typically has been 50 if you don't have a family history. And the reality of it is I think we're just missing

too many people when we do that and when we screen infrequently. And it's not to say that there's no risk of colonoscopy. There is. You have to make sure you have a really good endoscopist. There's a risk of everything, including from the sedation. Obviously, a perforation would be the most dramatic risk. But I think these risks are very small and in the hands of the right doctors, I think they're very manageable, but there's an asymmetry to missing a colon cancer. And again, when you hear about these things, and especially in people who are 40, 50 years old, it's very difficult to stomach. Well, and I think with that procedure, there's some, I don't know, cachet and sort of saying how awful the prep was and, oh God, I got to have this thing

done. And it's of course in an area of the body that we don't really like to discuss with one another. But I just want people to know it's really not that big a thing. No, the prep these days is trivial. You're absolutely right. It is. It's not bad. And then the day is an excuse to get off your feet and watch a bunch of Real Housewives or whatever your poison is. Just make sure people, if you're doing it, ask for either a pill prep or a very low volume prep. So back in the olden days,

you used to make people drink something called Go Lightly. So they had to drink, I don't know, something to the tune of like four to six gallons of something that tasted horrible. I mean, it was really bad. And nowadays, you know, like the prep I'm gonna do in a couple of weeks is 12

to 20 pills taken over the course of six hours and then a bunch of water. That's it. That's not bad. Okay. And by the way, before I move off of melanoma and all that is, you know, the good news that you said about the cells and the changing, and that takes the most, it gives the immune system another chance to recognize it as foreign. Are they making serious advances? Thanks to all these immunotherapies that we have now, are they making serious advances in fighting melanoma and those kinds of cancers? Yeah, absolutely. So there's sort of different levels at which the immune system can recognize a cancer. So if you start at one extreme end of the spectrum, you have spontaneous remissions of cancer. Now, these are incredibly rare, so rare that they're

reported in the literature anytime this happens. So this would be an individual who shows up with a cancer and it's riddled their body, and then somehow they get miraculously cured. It's not clear exactly why their immune system finally recognizes that cancer, but it does. And it goes to war against that cancer and it prevails. That's a pretty rare individual. Now, if you move a little bit over, you have another small subset of people who, if you give them something called a cytokine, something that revs up the immune system and the most commonly used cytokine and the most efficacious is something called interleukin-2, you give them a very high dose of this thing called interleukin-2,

you will capture another small set of the population who with that priming of their immune system undergoes the same thing. So they can have completely spread cancer throughout their body. And now all of a sudden it goes away on behalf of the immune system. That was basically the state of the art until about 15 years ago. Then a third layer and a third advanced came along, which was something called checkpoint inhibitors. Now these gained quite a bit of fame when former president Jimmy Carter had metastatic melanoma, which again, historically is a death sentence. That is a six month survival. And he was given one of these drugs, Keytruda, which is an anti-PD-1 agent and miraculously was cured. So what do these drugs do? So what these drugs do is they remove the breaks that are inherently built into the immune system.

So our immune system has to have brakes on it. Otherwise it would just attack ourselves and we'd have lots of auto immunity. And in a subset of people, their immune responses are almost good enough, but not quite. And by removing the brakes to their immune system, you unleash hell. And so that's kind of the next layer. And we have two drugs, one that targets PD-1, one that targets another thing called CTLA-4, not important. And so where are we moving now? I think we're moving into the next phase. And the next phase is the phase that's going to, I think, change the world of cancer. And that is going to be something called a combination of what's called adoptive cell therapy and till therapy,

tumor infiltrating lymphocytes. So the really good news is about 80% of people who have metastatic cancer, the kind of cancer that's going to kill you, actually have antigens, which are things, proteins that are produced by the cancer that are recognized as foreign by their immune system. The problem is most of them don't have enough of those immune cells to do anything about it. And so the real future here in oncology is being able to produce more of those cells so that people can in fact use their own immune system to eradicate their tumors. And I really do think that that's what we're going to see in the next 10 to 15 years. Is this why when I asked my primary care physician about the COVID vaccine and whether I was better

off, this is in the early days, with the Johnson & Johnson vaccine or with the mRNA vaccines, he said the mRNA vaccines are safe, he said. And he said, you bet you should get used to them because someday they're going to cure pancreatic cancer. So my view is that vaccines alone will never, I shouldn't say never, will not be sufficient to cure cancer. I think that, and I could be wrong, but my intuition, and this is based on 20 years of data, is that vaccines by themselves won't be enough. It will be imperative to also take, because all a vaccine does is prime a cell that already recognizes that vaccine into action. But I think what we're seeing today, and some of this literature is not even yet published, so this is really new stuff, is that the issue is not that we don't recognize cancer. I think the work of Steve

Rosenberg, my former mentor, which is, this is work that partially is published, partially is not yet published, demonstrates that 80, as I said, 80% of patients have novel neoantigens to their cancers. So that's not a problem that a vaccine is going to solve. That's a problem for which, given that they're not curing themselves, is a numbers problem. You have to be able to get more of those cells into the hands of their body. And I think that's going to require some bioengineering, right? It's going to require the ability to identify those cells in the body, take them out and replicate them into the tens of billions of cells and then infuse them. So that basically every person will get a different drug

to treat their cancer and the drug will be their immune system. Will be them, right? How far out are we from that? The good news is it can kind of be done right now for some cancers. In terms of being able to do this for any cancer, it could be 15 years because the challenge still is not identifying the cells called lymphocytes that are capable of doing this. It's being able to have them preserve their essence of killing while replicating them over and over again. It's almost a longevity problem of lymphocytes. We can find those subset of cells in you that are the ones that are going to eradicate your cancer, but I have to keep them young enough while I replicate them over and over and over again, such that when I put them back in you, they still have the fight left in them. That's fascinating. Wow. No wonder you were drawn into medicine and then

this related field of longevity. To take a step back on the subject of you, I want the audience to know, and I'm sure we'll run back to this, you obviously became an obsessive studier and academic, and you became an obsessive swimmer and accomplished all sorts of amazing, amazing feats. Swimming, I wrote down a couple of the things. I'm not a swimmer, so it wasn't like I understood exactly what they meant, but I could see that you went far and you went in places that nobody had ever expected you to go, given that you hadn't been a competitive swimmer until you were 20. You did your first pool lap at 27, began your marathon open swimming at age 31. 2008, first male double crossing of the Maui Channel. Took you almost 11

hours and 45 minutes, age 34. You swam the widest point of Lake Tahoe from California to Nevada in seven hours and 24 minutes at age 34. 2009, you crossed the Catalina Channel, this is a big one, from Southern.2 miles, been doing your residency while you were training for this, working 100 hours a week, then swimming three to four hours a day in the pool, then a swim each weekend of up to eight hours in Northern Virginia, which is not far from Hopkins, and so on. Pointing out that many of these endurance swimmers begin in childhood, not you. So your wife, who's quoted in the article article is right. Jill says he is an extremist in everything he does. How, how did you get like that? Cause with the boxing, then the academic focus, then the swimming, that pattern emerges pretty early in your life.

Yeah. I mean, look, I think lots of therapy has helped me shed light on that because I think there's some positives to that and there's some negatives to that. I think the positives are a lot of the things you're highlighting. Sure. It's what allowed me at the age of 18 to basically go from being on the fast track to work at a gas station to being able to get a scholarship to go to college and things like that. So, so there's, I don't, I don't want to diminish the benefit of that internal, uh, milieu, but I also think there's a drawback to it. Um, and I think, you know, a lot of it just has to do with, you know, things in my childhood that, um, I think lots of, lots of kids go through and I

think everybody kind of processes things a little bit differently, but I think there were just lots of insecurities and just a very significant need to gain self-worth through achievement is probably what drove so much of that. This is my problem. I'm not doing enough damage to my kids. I'm going to have to think harder about how to crush their little spirits so they can go on to become successful. Anyway, tabling that. Abby, could you just make a note? Crush the spirit research. Okay. So you decide like a lot of doctors and lawyers, which I also am, not too long into it. This kind of sucks. This is kind of, this is really not actually how I wanted to spend my life. And you, you take a U-turn, maybe a left turn, I don't know, a turn to longevity. So what, what does that even mean? That's not like, that's not like I got out and I decided to teach.

Was that even like a recognized field that you could create a career in when you left medicine? No. And when I left medicine, there's a long gap between that and that. So I left medicine actually two years shy of completing my residency in 2006. And that's a very unusual thing to do. Usually when people leave their residency, they do so in a year or two. You realize pretty quickly, hey, this isn't really what I wanted to do. Or you don't do residency at all. I mean, I think 10% of my classmates at Stanford realized this is cool, but I'm going to apply my medical training to

something else. But that was not me. I mean, I was the most gung-ho, the most hell-bent. But I had become also very frustrated with everything that I was seeing and doing. And I felt like a lot of what we did was very heroic, but didn't seem to move the needle much. We weren't... You talk about pancreatic cancer. I mean, pancreatic cancer is a deadly cancer. It's the fifth leading cause of cancer death, but it's also the most lethal cancer, meaning it's the one for which if you get it, your odds of survival are incredibly low on the order of about 5%. And we would do these very heroic operations that would remove the pancreas and part of the bowel. And if you were fortunate enough to be able to do that operation, which is maybe 20% of people that had pancreatic cancer were even early enough that they could do that operation, it might only be that 20% of those people would be alive in five years.

So I think I just became a little disillusioned with that. And I became a little disillusioned with a number of things in terms of the process by which residents were trained. And I think my wife just got very tired of hearing me gripe about it and writing manifestos and things like that. And she was like, look, I think you either need to just change the system or you should probably get out. And I decided to leave.

My initial thought was to go back to graduate school and do something very quantitative. So I was thinking about either going into finance or just doing a PhD in something more mathematical. I wasn't psyched about taking on more debt. I already had so much of it from medical school. So I ended up moving into a field of consulting. So when I left medicine, I initially actually went and worked at a company called McKinsey & Company and did consulting in credit risk and finance. That's sad that you spent any time doing that. That must have been really eye-opening to you that this was also not what you wanted to do. So eventually you decide to study something that's going to be good for you, good for your fellow humans, good for the world. And let's get into the study of longevity.

So let's start talking about it because I didn't fully understand this definition. Is this your definition or is this the definition of longevity? Hold as the hold on, I wrote it down. It's basically your your lifespan and your health span together. So it's not just, oh, she lived to be 126. It's how well you're living along the way, not in terms of money, cars, all that. How do you still have your mental facilities? Can you still move around? Are you still enjoying your life?

Yeah, look, I don't think I could take any credit for that definition. I think any solid definition of longevity includes both of those pieces, lifespan and healthspan. The lifespan part is a lot easier to understand because it's sort of binary, right? You're either alive or you're dead. That's a one or a zero. The healthspan part is not only a little more nuanced and difficult to understand, it's also the one I think people care more about outside of extreme. So nobody thinks

that someone dying at 60 is reasonable, right? We would all agree that when you hear so-and-so died at 59 or 61, that's a very premature death. But I think people are far less concerned with, am I going to live to be 84 versus 94? That's a second or third order consideration for most people. What matters far more than that is, what is the quality of my life? And I think there are basically three things that make up quality, and two of them are very age dependent. The three things are your mind. So cognitive prowess. So that means, you know, sort of processing speed, memory, executive function, all the things that kind of define your cognition. The second is the physical body. So strength, stamina, freedom from pain, flexibility,

balance, movement, all of those things. And then those two are obviously very age dependent. The third one is not age dependent per se, but I think is equally important. And that is your emotional health. So that's, you know, frankly, the state of your relationships is the largest determinant of that bucket. All right. So on that first one, processing speed, memory, your cognitive abilities, I recently had a great guy on from, he used to head up AEI, now he's at Harvard, Arthur Brooks. Arthur Brooks. Yeah. And he was talking about the second half of life, talking about how- I'm having dinner with Arthur on Friday. I love him. Oh my God. I would love to be a fly on that wall. Because when I was reading up on you,

I thought of him and he was saying, when you get to the second half, you're going to lose some of those things. Not lose, but they're going to go down. And that a smart move to be rather than get depressed about it or in denial about it or to fight what's naturally going to happen to you is to sort of switch your intelligence to a line that does get greater as you get older, which is sort of the more wisdom line. You know, you may not be able to process as fast as the young, I don't know, data guys or idea guys at, you know, Facebook or Meta, but you have a wisdom that a 24 year old-old doesn't have, and you can learn to utilize that. And I loved Arthur, and I loved our discussion, and I got so much great feedback.

But I felt kind of bummed out about the discussion, thinking, is it true that we can't do anything? Because I will say I'm 51, and I don't feel any of that so far. I feel no cognitive decline whatsoever. And there's still a piece of that so far. I feel no cognitive decline whatsoever. And there's still a piece of me saying, maybe I'll be the one. Or is Arthur just depressed? Is there a way of avoiding this? And then I read your stuff and I was like, okay, maybe there is. More exercise. What is it? So let's talk about it. Well, I mean, so again, I think when Arthur writes about kind of the difference between fluid intelligence and crystalline intelligence, which are those two phases you're referring to, look, I think everything is based on the application as well, right? about the speed with which you can compute things and probably much more about the logic with which you can think through things and the ability to sort of be able to read a situation and pivot

and think. And I think that's probably more dependent on your experience than it is kind of the raw horsepower of your CPU. So even if your CPU is not flying at the same speed as it was when you were 30, I don't know that you would notice it based on the nature of what you're doing. Whereas if you were an engineer, you might notice it in a different way. Using surgery as an example, there's no question that someone physically is sort of over the hill by the time they're 40. But in surgery, you have two things that are working, right? You have the physical body, the skill, the time they're 40. But in surgery, you have two things that are working, right? You have the physical body, the skill, the actual ability to use your hands, but you also have

experience. And when you layer these two things together, you'd probably find that a surgeon is at his or her best long after they have physically peaked because they're still physically good enough, but they're more than making up for that with their judgment and their wisdom. So I actually think it becomes pretty complicated when you look at a given individual as to what the peak really means. Now to your question, I don't think one needs... Am I as smart as I was when I was 24, not a chance. When I look back at my notes and the types of things I was able to do, it's pretty remarkable. I'm probably a fraction of that today, but that's okay. I don't need to be able to solve nonlinear differential equations in my sleep to have a fulfilling life

cognitively. No, I can verify that. But I still want to be sharp. I still want to remember things. I still want... For me, the most important of these is executive function. That's probably the one that for most of us matters greatly. And that probably the one that for most of us matters greatly. And that's the one that when you start to lose it, that's your ability to solve complex problems. That's your ability to think even abstractly and things like that and reason. I love writing. So the ability to sort of write a coherent argument out, that's something I don't think I'm going to lose. I might not be as fast about it, but I suspect that we can maintain that for a really long time. And of course,

everybody listening to this knows somebody who's 95, who is sharp as a tack. So it's, you know, is that 95 year old as sharp as they were as sharp as they were at 25? Probably not, but they're still plenty sharp. Why is it so often that when you know that person, they're still working? Is it, you know, chicken and egg, which is it? is it so often that when you know that person, they're still working? Is it chicken and egg? Which is it? Is it the working that keeps them sharp or are they so sharp that they continue to work? I would bet it's a bit of both, truthfully. When I think about retiring, it doesn't even make sense to me. To me, retirement should be thought of as mostly just a financial thing. When are you done working because you have to? That's really, to me, the decision of retiring.

But the idea of I'm not going to do anything anymore than play golf, that's a very unappealing thought. So I suspect that- I can relate. My husband and I were just in Paris over the weekend and I took a quick trip. A friend of ours had a birthday and we went and celebrated and um it's such a great city it's so beautiful it's so clean my god it's so much cleaner than new york right now you walk through new york it's like the garbages are overflowing everywhere we've had it's too long of this terrible mayor hopefully they know guy would do better but paris is like there's not a there's not a even a full garbage can any place you go everything's been been picked up. The streets are so clean, you could eat off of them. It's in good shape. And we were like, oh, maybe, you know, when the kids graduate, they're all off in college, we'll come live over

here for six months. You know, I would never want to leave the United States permanently. Maybe we'll go live there for six months. And I was thinking, yeah, I could do my podcast from there. You know, it'd be easy. In no way am I like, okay, my kids are done with school and now i'm gonna retire i i love my job i would i would be crushed to be not connected some in some way with the news and commentary and just you know cultural observations and so on so i can relate fully to what you're saying and i do think staying intellectually active has the same effects i mean not identical but sort of as staying physically active right on the body the body. So you talk about all of that. I think they're both essential, yeah.

You're so big on exercise, and I'm going to confess this is where I fall down on the job. I haven't been doing a good job of exercise for most of my life I have, but not in the recent past. And I'm inspired because this is what you tweeted out recently. The good news, we have a drug that is very effective at delaying the onset of death and preserving health span. Yes. And then it goes on. This drug is called exercise and nothing else rivals it. And you go on from there, but this seems like rule number one, exercise. Yeah. I'm not convinced there's any intervention that can delay death as long as exercise. So when you're talking about the lifespan side of that ledger of longevity, I could think of some exceptions, right? If you took somebody that has familial hypercholesterolemia, which is a genetic

condition that gives you cholesterol through the roof, That's probably someone for whom getting them on lipid lowering therapy in their 20s will have a bigger effect on the length of their life over the next 80 years. But I'd have to start thinking of those types of examples to come up with a scenario under which there's an intervention that is more powerful than exercise to lengthen your life. Now consider something more important, which is even if exercise didn't lengthen your life one day, I would still argue it is the single most important thing to do because of its effects on health span. And remember what we said earlier, at the end of the day, more people care about how

well they live and how long they live. The difference between 80 and 85 and 90 isn't nearly as important as what you were able to do during that last decade. And the impact that exercise has on both your cognition and your physical body, obviously, is enormous. In fact, I don't think there's an intervention that has a greater impact on your brain than exercise. Again, there are extreme examples that can violate that. You're going to talk to Matt Walker, and he'll explain to you that if someone has really, really horrible sleep, it's going to compromise their cognition. And absolutely, that's true. And it's going to increase the risk of dementia. But when you go outside of sort of the pathological, I think exercise is really hands down the most important drug we have to preserve our body and to preserve our mind. Wow. Okay. So the next question on everyone's mind is what kind? Do I do the pounding HIIT class where I have to do tons of intensive cardio, or do I go to the gym and

lift weights, or do I do Pilates? What kind? Again, if you're arguing this from the standpoint that I would argue it, which is through total longevity, which means how do you extend life and how do you enjoy life better, it's going to be a bit of all of the above in the sense of it's really about strength, stability, aerobic efficiency, and anaerobic power. Those are really the four components that we break exercise down into. And each of those must be trained for with a very deliberate sense of what you're doing. I think that the biggest challenge with exercise is that most people are kind of rudderless. You sort of know it's important. You kind of know I should be doing this thing, but there's very little specificity around what they're doing. And I believe that if you're going to really train to be kind of a kick-ass person in the last decade

of their life, you need to train with the specificity of an athlete. Now, it doesn't mean you're going to be training like you're a football player, but if you think that Tom Brady isn't very specific in what he does to prepare for what he did for the last 22 years, that's crazy, right, you pick any athlete at the top of their game, nothing they're doing is not deliberate. And we have to be the same way if we're trying to be incredible 90 year olds. And our training has to be predicated on those four fundamental pieces. So how would that look?

You know, for the, I know you've got a amazing, uh regimen that you do, but for the rest of us average humans, how could that work realistically for the busy people listening to the show or watching it? What's realistic? What would you say to kick it off? I mean, I always start, I start with, I put the question to a patient the other way. I would say, what do you want to be able to do in the marginal decade of your life? I call the marginal decade of your life, the last decade of your life. So we're all going to die. Therefore, we will all have a last decade of life. You don't know when you enter the marginal decade, but you know when you're there,

right? Most people kind of know when they're in that last decade of your life, but it's not entirely clear the minute you enter it. But nevertheless, we can get a sense of who we're going to be in that last decade. And I ask people to tell me what they want to be able to do. I have to do it in great specificity, right? So I don't want to hear, oh, I just want to be able to move around pain-free and to play with my grandkids. It's like, no, no, no. It's got to be much more granular than that. Like, I want to know exactly how you want to play with your grandkids. I want to know exactly where you want to be hiking. I want to know exactly how many steps you want to be able to walk up, exactly how many pounds you want to be able to carry, you know, that kind of stuff. Once you have that roadmap and we use this model,

we call this the centenarian decathlon. So what do you want to be able to do? What are the 10 things that you want to be able to do physically at the end of your life in that last decade? You then work backwards from there and you say, well, first of all, doing those things implies that you can do this. So for example, to be able to climb so many stairs with X pounds of groceries implies you have a VO2 max of this. So for example, to be able to climb so many stairs with X pounds of groceries implies you have a VO2 max of this. And if you have VO2 max of that when you're 85, how high does it need

to be when you're 75 and when you're 65 and when you're 55 and when you're 45? Because all of the things that you want to be able to do, you're going to get worse at as you get there, obviously. So you have to be able to start from a high enough position where you are currently so that by the time the glider gets down to that last decade, you're able to still meet your objectives. So there's no question you're going to be deteriorating. You just want to make sure that you get your base up high enough that the deterioration still lands you in a good place. Exactly. And I want people to go through that process, which is called backcasting. So in other words, don't sit here where you are today and try to forecast where you want to be. Go to the end of the line and backcast to where you are now. Because most people are going to be in for a rude awakening. Well, I was just going to ask, how late is too late to begin this?

It's never too late, Megan, but look, it's like saving for retirement. If a 60-year-old decides that they want to save for financial freedom, they're going to have a harder time doing it than a 40-year-old. And it's the same here, right? If a person is 60 and they've never exercised a day in their life, it's not too late to start. But I'd be lying to them if I said that they're not going to have a much harder time achieving ambitious goals than someone who starts at 40. Yeah. You're not going to land in the same place as that other person unless you just go to an extreme level. I got it. So we should cover a couple of those. Aerobic, I think we get, you know, aerobic, aerobic activity,

get yourself moving, get yourself breathing heavily, get yourself, you know, whatever it is. I mean, I actually like the real aerobics. That's sort of how I paid the bills when I was younger. Um, but it could be biking, could be walking, could be, you know, classes. It could be also anaerobic. I don't think everyone knows what that is. Can you explain that? Well, there are just two ends of basically, um, you know, a spectrum, which is everyone kind of has a sense of what cardiorespiratory fitness is. This is the, the, the fitness that involves basically your heart, your lungs, and the oxygen extraction and metabolic systems within the muscles. Now at the low end of that spectrum,

we call that zone two. And that's, you know, the, the area at which you are maximally able to utilize both glucose and fat to extract energy called ATP using oxygen. At the other end of that spectrum, so that's the low end aerobic, and that's where you want to be spending the majority of your quote unquote cardio time. That's like when you get on the bike and they say, would you like to be in the fat burning program? You're like, yes, that won't take you to the anaerobic. You've got to get the heart rate higher. You got to get it out of that. Correct. And that whole sort of, you know, unfortunately there's a really rigorous way to know when you're in that zone. And it's unfortunately not what machines and gyms tell you, but we'll put that aside for the moment that it's clearly lower end intensity, but at the other end of that spectrum,

you have a much higher end and anaerobic is much higher. That's correct. The anaerobic end all of a sudden is not something that you can sustain for very long. And it's a spectrum, right? So, you know, there's anaerobic that you can withstand for 40 minutes. Um, and then there's, you know, peak anaerobic that you could probably only withstand for 90 seconds. Um, and then there's, you know, peak anaerobic that you could probably only withstand for 90 seconds. So we're talking about that energy system and it depends how fit you are, right? So the, you know, the fittest athletes in the world could, could be at a low anaerobic threshold for, you know, nearly an hour basically. Um, but everybody's got some limit and you do need some training at that level, at that sort of peak level of maximum oxygen utilization and slightly beyond. And we measure

that using something called a VO2 max. Well, it turns out that that metric, VO2 max, is one of the few areas in all of medicine where a more is better approach seems to be the case. You know how very few things in medicine kind of just get better, like the more you do them, right? You know, it's sort of like everything exists in an optimal range, blood pressure, glucose, hemoglobin, all these things exist in sort of an optimal range. Too much and too little is a problem. So it's all about the Goldilocks range. But VO2 max, meaning maximal oxygen utilization, pretty much just exists on a continuum of more is better. The higher your VO2 max, the longer you're going to live as a general rule. Wow. And it's not subtle, by the way, Megan. If you break people down into categories, and so one of the papers I often cite on this, and I think it was in that tweet that you mentioned,

you sort of look at the bottom 25% of the population, we call that low. You look at 25th to 50th percent of the population, we call that below average, 50th to 75th percent of the population, above average, 75th percent of the population to 97.5 is high, and then elite is the top 2.5 percent of the population. If you compare the risk of being in that top group, the top 2.5% of the population to the bottom group, bottom 25% of the population, there's a five-fold hazard difference in all-cause mortality, 5X. I mean, that's a staggering difference. Same age, if you're assuming same age of these people. Yeah. I mean, an easier way to think about this is when you consider the adjusted hazard ratios for things that we know

are deadly. So I think everybody understands that type 2 diabetes, high blood pressure, and end-stage kidney disease are deadly conditions. The first thing you said was smoking? Sorry, you faded out. Okay, got it. So smoking, I think, has a hazard ratio of about 1.41. So meaning it's going to increase all-cause mortality by 41%. High blood pressure, type 2 diabetes, end-stage renal disease has a hazard ratio of about 2.75, 2.8, meaning it's about 175 to 180% increase in all-cause mortality. Now, when you compare somebody who has low cardiorespiratory fitness, meaning it's as significant as comparing someone who's got normal kidneys to someone who's got end-stage renal disease, which by the way, is more deadly than smoking and type 2 diabetes.

How do you figure out where you are in that scale? So you have to take this test called the VO2 max test. And I'm not going to lie, it ain't pleasant. How do we get it? How do we do it? It's an exercise physiology test. You could do this anywhere. Any place you live, you look up VO2 max test. And the way the test is done, it's usually done on a stationary bike or on a treadmill. They hook you up to a mask that plugs your nose, and it's got a little gas sensor. So it's measuring how much oxygen you utilize, and it's measuring how much carbon dioxide you produce. And you're put in a situation where you're exposed to more and more work. So you're going to have to ride against more and more resistance or run faster and faster or up a steeper incline. And it basically makes you do

this until you can no longer utilize oxygen. So until your utilization of oxygen by your muscles hits a maximum level, and that's known as your VO2 max. And then that number is normalized by your weight. And you can check where you rank because this is all published data. So you could say, well, I'm a female and I'm 51. So according to that, here are the five buckets and you'll see where you fit in. Would you call your doctor and ask for this test? Your cardiologist? How do you get the little- No, I mean- The face thing?

Yeah, you can just do it anywhere. I mean, obviously, if you're old enough, you'd want to make sure your doctor was aware that you were doing this. But of course, any good place that you would go to do this would do an EKG on you to make sure you were okay. But no, these are things that are usually done in exercise physiology labs. Oh, that's so fascinating. My gosh. Okay. So you get your news and if you have bad news, you got to work on getting your VO2 to up. You got to get it higher and it requires aerobic activity and it requires anaerobic activity. The, the really pressing yourself, you know, tough spot of the workout, but strength training, also a piece of it. You mentioned that i mean i

think we understand that just from watching our parents get older you know they seem and then stability was that was the other thing you know like they do seem unstable on my mom does for sure um and you know you worry about them falling all the time and it's it's like you know the life cycle tends to be you know when you're a sandwich generation you and you've got the little ones like the two-year-olds and then you got the the parents who are also 80 you see so many similarities with all due respect ma uh but you know like they're wobbly and the fundamental difference though is when you when your two-year-old falls they they roll with it when an 80 year old falls it is so often that that fall begins a spiral towards basically the end of their life. They break a hip and they're never the same again. So that's stability and strength training, no? To try to avoid that?

Yeah. And stability is more than just balance. Stability really comes down to connecting the body in a way that rids us of a lot of the movement patterns that we develop as adults. So I sort of buy the argument that, and this is not an argument unique to me, right? This is, I think many kinesiologists would argue this, right? Kids are born largely correct. Um, the ability that they have, the way they use their hands, their feet, the way they move is the way we were sort of designed to move. And then we do a lot of things to them that sort of change that. I think we put kids in shoes a little too early. We generally sit them up before they're ready to be sat up. We put them in little Bobby chairs to try to make them walk before they're ready to walk. And we sort of go through these processes and then we become kids in school and we're stuck in chairs all day. Now, this thing that we're doing right now called sitting is quite unnatural to us. It's really not something we ever position until maybe the last couple of hundred years. So it does a lot of damage to us. And it feels so good. Yeah. It damages our necks. It

damages our backs. Our shoulders come forward. Our ribs flare up. We develop all of these horrible movement patterns. And those all impact the way in which we transmit force to the outside world and the way that the world transmits force to us. That's kind of at the root of so many of the injuries we have. You mentioned Pilates. Well, Pilates is a great example of a system that helps you reconnect that way. I don't do Pilates. I do something called dynamic neuromuscular stabilization, DNS, which is another system

that came out of a Czech school in Prague. But all of these systems, whichever one you kind of adopt, and I technically use multiple systems and sort of loop them into one with the people that I work with, they're all geared at trying to get me back to moving like a two-year-old is moving. Oh, that's so interesting. Yeah, Pilates, people swear by it. And I've actually never done it, but's so interesting. Yeah. Pilates, people swear by it and I've actually never done it, but they do say as you get older too, to consider it more and it's hard. It's hard. All right. So that's, that can be a good stability exercise and then strength training. So you've got to do it all. Would you say it's important to work out every day with one of these

programs? You know, the programming is, is, is, is largely a function of how much a person is willing to do. Let's go back to the investment analogy. If you're 40 and your aspiration is to have millions of dollars when you are 60, you're going to have to save a lot of money and you're going to have to have really good investments that generate a high rate of return. So similarly, if you're thinking about that through the standpoint of how much do I need to exercise, how hard do I need to exercise, how diverse and comprehensive does my program need to be? It really comes down to what your goals are. So I can tell you that for me, I have very lofty goals. I'm 49 now and I hope I've got another 40 years or so on this planet. And I want when I'm in my 80s to be functioning the way most people would look at a very healthy

60-year-old today. And as such, I have to train accordingly. And that means I'm exercising every single day. And I'm spending probably, I don't know, 12 to 14 hours a week exercising in all of these disciplines, right? That there's a significant amount of time that's spent on stability, strength, and aerobic exercise in particular. And aerobic is probably the one that is the least time consuming. I probably only spend about, you know, 45 minutes to an hour a week doing kind of higher intensity exercise.

Sure. By, by its nature. But so would you posit then that those who are trying to stave off the loss of mental sharpness by doing a crossword puzzle every day, by doing brain teasers, would be better served by getting involved in a program like this? Or considering doing both. I mean, the evidence is pretty clear. There's nothing that is more neuroprotective than exercise. So lots of people have suggested that mental gymnastics and things like that are beneficial. The data would not suggest that anything rivals exercise for mental clarity. What about food? I think food plays an important role in this and it's probably second on the list. Um, but I don't

think it is as at least according to the data. And again, I have to tell you, when I first looked at these data, I didn't believe this. I, the answer seemed too glib to me. It was sort of like, come on exercise, seriously. Like that's the best we've got. I mean, I thought there was really going to be some hidden thing I hadn't learned of before. But no, it turns out that exercise, both through its benefits metabolically, vascularly, and hormonally, it just can't be beat. Now, I know on food, you are a proponent of something I love, and that's intermittent fasting. And you've got the app and all that. And we did a whole podcast on this over the summer because I do think it's genius. And I think half the battle in doing well at

intermittent fasting, and I've said this the other day, is to just redefine, reset how you think about hunger, about the feeling of being hungry. We've been raised to believe it's a bad feeling. It's a problem that needs to be solved as opposed to just, it's a feeling. And it's mildly uncomfortable, but it's not the worst thing ever. You can have a glass of water in most cases and get past the moment, but it's been reinforced in us for decades and decades that it's a bad thing. It's a problem that you have to solve. So you, my audience, I've told them I do the 16-8, you know, where you only have an eight-hour eating window. And lately I've been doing a little bit more of the six-hour eating window. This show helps me. I do it live from 12 to 2. And so if I can just get through the show,

then I'll eat from 2 to 8. And it's actually not as hard as you think it would be. You are hardcore. You only eat, I think, during a two-hour window a day, and you're on the one meal a day plan, as far as I read. Is that true? Not these days, but I've done it all, right? I probably spent the better part of, gosh, a year or two only eating one meal per day. I've probably spent the better part of, gosh, a year or two only eating one meal per day. I've spent many years doing really long fasts, you know, on the short end, three days, on the long end, 10 days of just water. Come on. But look, I think that time-restricted eating is a great way to practice caloric restriction so you know i think there is a benefit that comes from a period of caloric restriction and again it all has to be kind of tailored to what your goals are um so it's i want you know i want to be thoughtful about it

right i don't think this is the answer for everything and i I'll tell you, when I have patients who are lacking in muscle mass, this is not the first thing I'm turning to, right? Again, I'm far more adamant about putting muscle onto somebody who's deficient in muscle mass, because it's not uncommon to see people who don't have much muscle mass, who don't even have much body fat, whose bone density is kind of suspect. And those are people I don't want ever restricting calories in any shape or form, right? We're trying to build these people up. But for many people, that's not the problem. They actually have a decent amount of muscle mass. They certainly have too much fat. And yeah, calorie restriction outright can be really difficult. If I said,

hey, Megan, eat your three meals per day, but every one of them is going to be... Breakfast is going to be three grapes and lunch is going to be some Malba toast and whatever. I mean, you die. Sometimes it's just easier to say, hey, how about don't eat anything except for six hours and then during the six hours eat reasonably. Well, for many people, that's a far easier thing to do. Yeah, definitely. So is it true, though, that intermittent fasting not only can improve the way your body looks and the way it feels, but your lifespan, your longevity, that low calorie intake, if you can keep it low, could extend your lifespan? You know, I think when it comes to humans, it's very difficult to talk about nutritional interventions that absolutely increase lifespan. Caloric restriction is hands down the most notable dietary intervention across all animal models when it comes to increasing lifespan. So

when we think about the science of longevity, we talk about how we study this in mice, fruit flies, worms, yeast, all sorts of organisms. And these are organisms that span a billion years of evolution, by the way. So when you study something across a billion years and you always get the same answer or mostly get the same answer, it generally tells you something good is going on. And while caloric restriction doesn't always work, it works more often than any other dietary intervention. And it does extend lifespan. Now, there are exceptions to this rule.

For example, it doesn't seem to extend lifespan in mice when started late in life. It doesn't seem to. And mice, we think, are more relevant because they're far closer to us than all those other animals I discussed. It doesn't seem to extend life on all types of mice, and it certainly doesn't seem to extend life in the wild. It might reduce the risk of certain things like cancer, but it also might seem to increase risk of other things. For example, immune-based things such as infection. So anything where

your immune system can get weaker. So I think for the sake of humans, what we can probably say is caloric restriction that doesn't get anywhere near malnutrition is probably valuable provided it does not impede lean mass, which is muscle mass. Yeah, you need that. And you say that basically 80% of the deaths, the non-smoking deaths that happen to humans are, well, can you phrase it that the three categories that you put most of the deaths in? Yeah, I kind of call these the four horsemen, which are basically three huge categories of death. And then a fourth one that sort of serves as the foundation of them all. So the first one of these is the atherosclerotic diseases. So cardiovascular disease, cerebrovascular disease. This is not just the leading cause of death in the United States. It's also the leading cause of death in the entire world,

which is kind of remarkable when you consider that that includes the developing world. Right. That's heart attack and stroke. That's right. Okay. The second is cancer. So that's the second big horseman. Talked about that already. The third horseman is neurodegenerative diseases, of which dementia is the most common and of

which Alzheimer's is the most common form of dementia. And this is one where you see a huge outsized shift in the last two decades of life. So when you look at people over 75, that one really starts to explode. And interestingly, cancer starts to actually come down a little bit. So cancer on a per age basis really kind of peaks in middle age. So kind of 50s and 60s is where we see cancer as the most common cause of death. But then it sort of becomes eclipsed by heart disease and neurodegenerative disease. So those are the three really big

horsemen. And then the fourth one is what I call metabolic disease. And when I say what I call, I mean, I think what anybody would call metabolic disease, which is the spectrum ranging from insulin resistance to non-alcoholic fatty liver disease, all the way up to type 2 diabetes. And while those diseases by themselves don't really kill that many people, they, I believe, are underrepresented in our mortality table for the impact that they have on the other three horsemen. So how do you prevent yourself from, mean i think generally we know cardiovascular disease you have to eat a certain kind of diet and you are supposed to exercise like we know that cancer depends right like don't smoke it doesn't necessarily mean you're not going to get lung

cancer 20 of the people who get it never smoked. There's other things you can do, but none of this is a guarantee. But how do you prevent diabetes? All I know is don't eat too many sugary foods, right? Like, is that basically it? I think the two mainstays of avoiding diabetes are absolutely nutrition and exercise. Again, everything keeps coming back to exercise. But what is diabetes first of all? Well, it's a carbohydrate tolerance disorder. It's a condition in which people can't appropriately dispose of glucose. And so glucose tends to build up in their bloodstream. And why can't they dispose of glucose? Because you have to say, well, where do we normally dispose of glucose? Well, we have two places we put glucose. Every time you eat a carbohydrate, you basically have two places to dispose of that immediately. One is in your liver and the other is in your

muscles, but your muscles are by far the biggest reservoir. So around 75% of your glucose storing capacity is indeed in your muscles. So anything that impairs your ability to put glucose into your muscles is ultimately going to lead to type two diabetes. And the hallmark of that process is something called insulin resistance. Insulin is one of the most important hormones in the body secreted by the pancreas in response to glucose levels. And it is the hormone that tells the muscles and the liver to some extent to bring glucose out of the circulation inside. And so when you think about type one diabetes, which is a disease that shows up much more commonly in young people, that's an autoimmune condition. The body is attacking the pancreas and eroding the part of the pancreas that makes insulin. So those people

end up getting very high glucose levels because theycreas that makes insulin. So those people end up getting very high glucose levels because they don't have enough insulin. And so the treatment for those patients is actually to give them insulin. But type 2 diabetes is a totally different disease. This is a disease that actually starts out with too much insulin because the muscles become resistant to the effect of insulin. And as the muscles become resistant to the effect of insulin, the pancreas must make more and more and more insulin. And eventually that works, right? So that sort of keeps the glucose coming in, but at some point that stops working. And then the glucose levels just become too high in the bloodstream. And that's the definition of type two diabetes.

So it's really a supply demand problem. You're eating too much glucose and you're not creating metabolically active enough muscles to dispose of that glucose. So when we talk about eating, like your dietary habits, is there a way of, you know, exercise? Yes, we know. But is there a way of preventing getting type two diabetes? Like the Mediterranean diet? I know you're not big on these, like do keto, do paleo. You're not that guy at all. But is there something we need to know in terms of preventing this? Well, I have a very, and I appreciate you noting that I just can't stand dietary labels and stuff like that. I mean, I think if one were going to give a nod to one diet, I think you would have to give it to a Mediterranean diet based on the clinical trials,

right? So if you're going to look at all the data, and I say this as someone, by the way, who's personally done all of this. I mean, in residency, I was vegan for six months. Later on, I was keto for three years. So that's like being a Catholic and a Protestant at the same time. So I will say that a Mediterranean diet has the best outcome data supporting all-cause mortality and cardiovascular disease in particular. But I think that that's not nuanced enough, right? If I just said, oh, Megan, all you got to do is go eat a Mediterranean diet, I mean, what does that

even mean? I'll just Google it. You can have so many different ways to interpret that. So instead, I try to think of this very agnostically and without label, which is, you know, and I use something called a continuous glucose monitor on myself and with my patients, which is kind of a crazy idea to some, because this is a device that's normally only worn by people who have diabetes. So it's a little, you can't see it because it's under my shirt, but it's a little device that I wear on my arm. Come on, show us. Just kidding. Just kidding. Take my shirt off. Yeah. I'm just teasing you.

I guess I could have worn a short sleeve shirt if I'd thought further ahead. So, um, but basically this device tells me in real time what my glucose is. So I get a real sense of how, what I'm eating is impacting my blood sugar. And so I'm not, I'm not waiting for sort of a hidden surprise one day where I show up and my doctor says, Oh my God, you've got diabetes. Of course not. Like I, I see, oh, you know what? When I had that fourth bowl of cereal, that was probably a little too much. My blood sugar went to 170. That's probably higher than it should be. So I kind of

like taking this personalized approach to carbohydrate based on that. Because back when I was a cyclist and I was riding my bike four hours a day- Of course you were. Yeah. I couldn't eat enough carbohydrates. So you can't compare what I was eating then to what I'm eating now. I was eating 600 to 800 grams of carbohydrates a day. Wow. Today, I probably only eat 250 grams of carbohydrates a day. And if I eat too much more than that at the current level of exercise, my glucose is going to be higher than I want it to be.

So that's kind of how I think about carbs. Let me add, while we're on the subject of diet and the Mediterranean diet, having just come back from Paris, you know, they're big on their cheeses and their chicken and their protein. They like their protein, but they're also big on the wine. And it was remarkable. I mean, everybody everywhere was drinking lunch and dinner. I mean, every single table at the restaurant was like, okay. And then it was like capped off with on the airplane ride home. We got to the airport super early. We had to be there because my husband's incredibly in love with getting there too early, just like Abby. We got there. It was like 5.45 and a 6.45 in the morning. Sure enough, all these people are drinking then. Like it's 6.45 in the

morning. What are you people doing? So talk about alcohol and its effects. Well, contrary to the French paradox, I would argue that the French, if they do indeed live longer, it's despite that, not because of that at these data in every possible way written about this, that I don't believe that zero is worse than one. So there's some view that there's actually a J curve and that the perfect number is about one drink a day. I think that's untrue. I think it's that basically somewhere between zero and one drink per day, there's really no discernible difference. So if there is a difference, we don't have the resolution to measure it. But once you exceed one drink a day, there is a clear and consistent increase in risk and it becomes greater and greater the more it goes up. So it becomes nonlinear in terms of risk.

It's important to understand ethanol is toxic. I mean, full stop. It is, it is the fourth macronutrient. So you have carbohydrates, fats, proteins, and alcohol. Those are the four macronutrients. It's highly caloric, right? It's, it's almost as dense calorically as fat, right? Almost twice as caloric as protein and carbohydrate. Um, and it is full on toxic. So it's basically, we can tolerate a little bit of this toxin, right? To the tune of 15 grams a day, which is about the amount of alcohol you'd have in a glass of wine or a beer or a shot of tequila. And anything beyond that, you're starting to get into some chronic toxicity. So when I say toxic, I don't mean acute toxicity, right? The

way that you're going to die if you drink three bottles of tequila, that's an acute toxicity. That's very rare. But I'm talking about the chronic toxicity that comes from consuming something. So my view on alcohol is, that's funny you mentioned the airplane, don't drink on airplanes. That's sort of my heuristic for how I think about alcohol. Because at least the airplanes I fly on, the alcohol is not that good. They're just giving it to you to sort of numb you from the experience of flying. So if I'm going to drink, it's going to be good. So I am a little bit of an alcohol snob, actually. So there's certain tequilas, there's certain wines, there's certain beers that I really fancy, and that's the only stuff I'm drinking. So I'm never drinking for the sake of drinking. And yeah, I probably have three to four drinks a

week, but I make them count. And you're never doing like three drinks? No. I mean, sometimes I'll have two, but that's pretty rare. Again, just sort of keeping in, because the other thing is now getting into sort of sleep, alcohol is such a devastating hammer when it comes to sleep. I mean, if you want to come up with a way, if you're looking for a strategy to destroy your sleep, just drink. But what does it do? You say the damage, the toxicity, but what does that mean? How does that manifest? Well, with the effect of sleep, it's probably the creation of

aldehydes and things like that that really impair REM sleep. That seems to be the disruption that we see on the brain from alcohol in proximity to bedtime. So if you look at the different stages of sleep, you have kind of these two light stages of sleep, stage one and stage two. No, and we do cover this with Matt. These deeper stages. But I just mean in general. Yeah, you get stage three, four. If you're not going to become an alcoholic with cirrhosis, what are the risks to you?

Well, at the extreme ends, you have all of those things. Of course, you have fatty liver disease. So that's probably the biggest metabolic downside of alcohol is the infiltration of fat in the liver, even if it does not progress to cirrhosis. Cirrhosis is a very extreme state, but long before cirrhosis, you get to inflammation. Long before you get to inflammation, you get to fat accumulation. This exacerbates insulin resistance. The other thing to keep in mind is that the body always wants to burn alcohol before it's going to burn anything else. So there's a general hierarchy

with which the body wants to metabolize things. But when alcohol is present, it basically prioritizes that metabolism. So I always find it ironic when someone says, I'm really trying to lose a few pounds and they're drinking alcohol. Because when someone says they're trying to lose a few pounds, what they really are saying is I'm trying to lose a few pounds of fat. If you're trying to lose a few pounds of fat, really the last thing you want to be doing is drinking alcohol. So if you're trying to choose between that bowl of ice cream and a glass of wine, because you need to have your one treat and you want to lose weight, but you have no willpower because you're having a bowl of ice cream or a glass of wine, choose the ice cream.

Well, I don't know. I mean, all things being equal, typically the ice cream would be far more caloric than the glass of wine. But if you're anything like me, and I think most people are like this, typically the more alcohol you drink, the more it reduces your inhibitions around food as well. So sometimes it ends up being the worst of both worlds. If I'm going to have two drinks, which I don't have often, if I do, I'm more likely to eat something I otherwise wouldn't eat. Well, and then you get a crappy night's sleep and then you really overeat the next day. We talk about that with Matt too. Like a bad night's sleep is a great recipe for a terrible day of eating.

Okay, let's talk about Alzheimer's and these cognitive declines, these diseases that were the third horseman because those are scary, right? Because as you point out, you dropped, you drop dead of a heart attack. It's not great, but it's not the worst way to go. Some cancer deaths can be quick. Alzheimer's is like you're sentenced to this life of loss day after day and losing the people around you while they're still there. And then they are sentenced as well to watching you deteriorate.

It's just so painful and so awful. I think most of us would do anything to avoid it. So how do we? You know, I think the good news is despite how frightening Alzheimer's disease is, and I think you're right that if you ask most people, what are you afraid of more than anything in aging? Certainly when I ask people that question, the most common answer I get is just that. On the one hand, it's the disease we know the least about relative to cancer and cardiovascular disease. But I think we also have a pretty good handle on prevention there. The adage, what's good for the heart is good for the brain is almost always true. There is probably

one exception, but when you think about all the steps that one takes to reduce their risk of atherosclerosis, so reducing lipids, reducing blood pressure, reducing glucose, reducing all the inflammatory markers that go into it, exercising, sleep, nutrition, all those things that you're going to do to have the most heart healthy existence, they're absolutely doing the same thing for your brain. Another kind of sort of tongue in cheek heuristic I say is what's good for the liver is good for the brain. So if you start to think about all the things that are involved in metabolic health, insulin sensitivity, not having fatty liver disease, not having visceral fat, all of those things, they also tend to do wonders for the brain. And then I think exercise is this important thing. There's, you know, exercise is a drug. It produces a set of hormones. It produces

a set of chemicals that are basically like candy for the brain. So we, you know, we just never want to lose sight of that. I think there are some other things and perhaps the most interesting of them them is the use of sauna, which is, again, something that I was kind of suspect of for many years. I kind of had seen the literature most of it out of Finland. Sauna? Yeah, sauna use. S-A-U-N-A, like the sauna, the thing that's next to the hot tub? You got it, yeah. What?

Yeah. Keep going. Fascinating. Yeah. If you look at the literature out of Finland and you look at the dry sauna use, the reduction in neurologic mortality and cardiovascular mortality is, frankly, on the tune of 50% to 60%, provided it's done at the levels and doses that they've observed. So that's being in a dry sauna. That's an easy, enjoyable thing. It's the first thing you said that sounds great.

You got to get rid of ice cream, got to get rid of alcohol, got to exercise two hours a day. When the hell do I get to sit in the sauna? Well, so the dose appears to be at least 20 minutes, at least four times a week, at least 180 degrees Fahrenheit. Oh, I'll do it. That's great news. Why? What, just like the heat, the heat of it? Well, it seems to be a bunch of things, right? So it forces the body, you know, in some ways, it's kind of like a low end. It's sort of like a low intensity exercise, right? If you've been in a sauna, especially one that's that hot, because 180 degrees is, you know, anyone who's spent time in a sauna will recognize immediately. That's not comfortable. And after 20 minutes in there,

you're pretty psyched to get out. But your heart gets pumping. So I think you've got this vascular benefit. You generate these things called heat shock proteins that basically, at the risk of oversimplifying, clean out a lot of the junk in the body. I think it's a combination of things about sauna that probably render it quite beneficial. Think of it as another stress. It's not the same as steam or getting in a super hot shower or bath? It's a good question. We don't have data on those things. I get asked that all the time. I also get asked, hey, is an infrared sauna the same? I don't know because all of these data that I can point to on this subject matter are all based on dry sauna. So

it's hard for me to extrapolate without doing just that. What else is there on the good list? Is there another little secret on that side of the ledger that we can do? I mean, I think the other thing is probably managing cortisol, right? So I think that stress is a killer. I mean, again, it's sort of a cliche, but it's a cliche for a reason because everybody knows deep down it's true. And stress

is less about the stress that's on you. It's more how you internalize that and how you process that. I think you can take three people that are under the exact same situation, but if they have a very different manner in which they internalize and process that, they could end up in totally different situations. So I think that hypercortisolemia, which is kind of a technical way to explain what's happening when you're under so much stress, is clearly harmful, right? It's... Metabolism is horrible. It's effect on... Wait, what's horrible? The excess cortisol. So if you...

No, it's effect on metabolism. Is that what you said? Okay. Yeah, it's effect on metabolism. It's horrible. It's effect on the cardiovascular system is horrible. It's effect on the brain is horrible. I mean, it basically shrinks the brain. So, you know, too much cortisol is a bad thing. And I think the more we can look to things that minimize that, the better. In fact, that might be some of the benefit that sauna and exercise have.

Because for many people, these things are activities that help us blow off a bit of stress. Therapy, that's one thing you can do. Mindfulness, like meditation. Are you a fan of that? I am. Yeah, very much so. Okay. And other than that, I don't know, isn't that partially luck of the draw? Like I know people who just seem their default is anxious and then there are others who are like, yeah, I'm good. And so if your default is anxious and you're using those tools, what about medications? Yeah, I think medications play an enormous role. I think they're, you know, probably, I think people, you know, the way I explain this to people is these medications rarely work in isolation. They tend to work really well when they're accompanied by really good talk therapy as well. So antidepressants by themselves have

reasonable efficacy, but not great efficacy. But when you combine an antidepressant with effective psychotherapy, it actually has a huge impact. And effective psychotherapy comes down first and foremost to the connection that the patient has with the therapist. That turns out to matter more than the qualifications of the therapist, for example. So I have a few therapists and they are all a really important part of my mental health. And it's taken me a while to find the group of therapists that I have. And I had to go through a number of them until I got there.

And I encourage people to do the same thing, which is if I introduce you to somebody and you don't connect with that person, then let's find somebody else. Because until you really have a great connection with somebody, it's very difficult to kind of go deep on the stuff you need to. So when you say, you know, you're still seeing patients, like what do you, cause I know about your podcast and I know about your app, which I should mention to people, it's called the zero Z E R O app. And that's the, the intermittent, the fasting app. But what, I mean, are you, do you have like a center or a practice

where people can come to you and get all this stuff done? And what is it like executive healthcare? Describe it to us so that we can replicate it in our own lives. Yeah, I do have a practice. It's a really big team. So I've got a group of other doctors that I work with, exercise specialists, nutrition specialists, a research team that supports both the practice and the podcast. And so it's all kind of under one umbrella. Early medical is what it's called. And where are you? Well, it's so it's a virtual practice now. So historically, the practice was bi-coastal between New York and California. But about a year and a half ago, when I moved to Texas, kind of at the beginning

of COVID, you know, it didn't make the beginning of COVID, no one was traveling. So it shut the offices down and we moved everything to virtual and figured out we could do everything that we do virtually. And once COVID went away, we just thought, hey, we don't need to go back to an office. And it never really made a lot of sense because people always had to come to see us. Our patients are really all over the country and in different parts of the world. So an office doesn't really make sense. So our practice is a virtual practice, but I'm based in Austin and one of our physicians is in California. One of our physicians is in New York. Another one is in Virginia. So people are spread out all over the place. But this is so much better than what you were doing because, as you point out, right, you were studying cancers and trying to sort of play run and catch up when somebody had something bad diagnosed.

And now it's all about prevention and staying ahead of the game. And none of this is a guarantee, but you're in it. You're swinging. You're fighting, right? It's like there's comfort in that. And even if you don't win, right? In other words, you do get a disease, you're living well. I mean, we haven't really even talked about just the way you feel day to day in eating well, exercising, reducing alcohol consumption, being mindful and so on.

Yeah, that's exactly right. I mean, prevention is kind of a cheap word because it's sort of a buzzword in medicine. Oh, prevention matters. But the reality of it is it doesn't really matter that much in medicine. And not to be too mercenary about it, but medicine only does what medicine gets paid to do. So we live in a system where a physician has to be able to bill for a service. If you go to your doctor, they have to be able to bill for something to get paid. That's the way the world works. And those billing codes are based on what an insurance company deems reimbursable. So prevention just doesn't really create that much of a billing attractiveness. And therefore, when you look at what most physicians have to deal with when they're in primary care, which are really the frontline physicians that would

be the natural owners of prevention, they can't do it economically, right? They have to see, I don't know, 20 patients in eight hours, if not more. I've talked to physicians who have to see 40 patients in eight hours or 10 hours. You're basically just putting out fires. And so even though we talk the talk, well, prevention is everything, we don't really give physicians the tools to do much about it is everything, we don't really give physicians the tools to do much about it. And we certainly don't create the financial incentive structure for them to be able to do it either.

So this is what worries me because at this point in my life, I have the dough to pay out of pocket and to get a great, great doctor who will spend two hours with me and ask me all the questions and send me for all the preventative tests. And I can get reimbursed after the know, after the fact by some, you know, some of it will get, but the, I remember what it was like to have no money. And that version of me was on like the college healthcare plan. And then for a while, no healthcare plan and would never have been able to do preventative tests or a colonoscopy or any of that stuff. So for the people out there who either have like, eh, insurance or no insurance, what can they do? Well, I mean, look, it's really hard. I mean, I would say on the one hand, the good news

is that I think about 80% of what it takes to really achieve your longevity potential is something you can do without a physician. I mean, think about all the things we've spoken about today. I don't think we've really spoken about much that requires a physician. We haven't really talked about this drug versus that drug and all the cool molecular pharmacology stuff that goes into this because the reality of it is, I think that's 20 to 25% of the game. I think most of the game comes down to how you exercise, how you sleep, how you eat, how you manage stress. And so the good news is you don't need a doctor to do that.

The bad news is you still need the information. And I guess I hope that me and others, people like Matt, are able to provide some of that information so that at least there's enough for people to kind of do it yourself. Now, he has written a book into which he has put most of this information. Have you done that? Are you going to do that? Where can we find all of your thoughts written down? Well, I am in the process of finishing a book that's been in the works since 2016, if you can believe it.

It's such a difficult experience that's been, the works since 2016, if you can believe it. Such a difficult experience that's been, but I'm getting there. So I have a book that should be coming out in the first quarter of 2023. I write a weekly newsletter. Yeah. So a year from now. So I write a weekly newsletter with my research team and that comes out every Sunday. How can people get that? They just sign up for it on our website. So peteratiamd.com. And you sign up and every Sunday morning, you'll get a newsletter. So we're writing about this stuff every single Sunday. And as you mentioned, we've got a podcast every Monday that's coming up to our fourth year, where it's all this type of content that makes it easier and easier for people to hopefully

kind of see a little bit of a signal in the morass of noise. All right. Last question. Where can they get the little glucose monitor underneath their armpit? Just Google those words. Yeah, yeah. So they're called continuous glucose monitors. There's probably two companies that make the majority of them in the US. And unfortunately, this is still something that you need to get a prescription from a physician for, which is unfortunate. And I think that's an awful mistake on the part of the FDA to require prescriptions for these things. I won't get into why they're doing that and why it doesn't make any sense. But nevertheless, I think that's going to be changing. And I think that in the future, people will be able to buy these over the counter just as they

could buy a finger stick device to measure their glucose. Yeah, right. That's just less pleasant. This has been fascinating, Peter. I learned so much. And I'm really grateful to you for sharing your journey, your expertise, all you've learned. And I feel like this is just step one. I feel inspired by you to start living better so that I can live long and well and better. Well, great to hear that, Megan. Thanks for having me on. All the best. To be continued. Don't forget to download The Megan Kelly Show on Apple, Pandora, Spotify, and Stitcher. Leave me a review over Apple.

I read them all. Also, check us out at youtube.com slash Megyn Kelly and hit subscribe there too if you would be so kind. Really enjoy spending this time with you guys and I appreciate you listening and downloading and being there for us. Thanks for listening to The Megyn Kelly Show. No BS, no agenda, and no fear.