The Peter Attia Drive - #04 - AMA #1: alcohol, best lab tests, wearables, finding the right doc, racing, and more

Episode Date: July 9, 2018

In his first “Ask Me Anything” episode, Peter answered your questions submitted to him via Twitter. We discuss: What are Peter’s thoughts on alcohol consumption and health? [4:00] What are the best lab tests to request from your PCP, and what are the best markers for longevity? [14:00] What are the best wearables and why, and why does Peter use a continuous glucose monitor? [35:00] How does one select the right physician as a patient? [47:00] Why does Peter race cars and what’s the hardest thing to learn as a new driver? [54:30] What is Peter’s current exercise regimen and what are his thoughts on exercise for improving lifespan and healthspan? [1:20:15] What is Peter’s strategy for learning something deeply? [1:33:00] What is Peter’s process for forming his beliefs? [1:53:30] What does Peter’s diet look like these days? [1:57:45] And more. Learn more at www.PeterAttiaMD.com Connect with Peter on Facebook | Twitter | Instagram.

Hey everyone, welcome to the Peter Atia Drive. I'm your host, Peter Atia. The drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions I've gathered along the way. I've spent the last several years working with some of the most successful top performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other

topics at peteratia-md.com. Welcome to the inaugural AMA. Ask me anything not to be confused with against medical advice. After getting a lot of really good questions on Twitter and realizing that I didn't have the bandwidth or wherewithal to respond to all of them, and especially in such a short period of time, or short period of space rather, Bob Kaplan, who's my head analyst, and I put up a little ask me anything on Twitter. Post and over the next week we gathered a bunch of questions.

They were amazing questions. We organized them. We got probably over 200. Obviously couldn't address them all in this episode, but we kind of bundled them and I think in many ways we got through probably half of the intended content that people had asked about. So in this episode, Bob interviews me.

I didn't really look at the questions before or spend much time preparing, but I also thought it would be more enjoyable that way. And I will say it went by pretty quick, so I guess we were having fun. Depending on how people like this, I think this is a format that we should probably repeat and maybe we'll do this quarterly, depending on what the demand is for it. And hopefully we can use this as an opportunity to sort of answer specific questions without necessarily dedicating an entire podcast

to some of the topics. So without further delay, welcome to AMA number one, and hopefully it's one of many. What time did you have to get up today? I got up at 3 a.m. Was that because you had to catch the train that early? Or was there any other reason you got up a little early? The train was at 5 a.m.

So I got a little, a little mini workout in before I got in the train. I wasn't sure if I was going to be able to squeeze one in today. So we're going to do a double because we'll work out after this. Very nice. Are you still doing the squat every day routine? Yes. Literally squatting every day. So this morning you just wanted to make sure you had some time for squats.

Just a little bit of time for squats. Yeah, just work up to a daily max and get in, get out, get the uber, jump on the train. Well, I think this is officially the first time you're being introduced by voice at least to people, though anyone who's been reading Nerd so far, we'll understand that you are my right-hand guy on all things pertaining to blogging and being a nerd. You are the head analyst in our practice and also a very close friend and probably one of the people who's had his foot furthest in my butt to be doing a podcast.

So if I'm gonna do it, I was gonna drag you into it. And I guess this is our first experiment with an AMA. I think we probably stuck out a tweet like two weeks ago and how many people ask questions? I feel like there was like three or four hundred questions came in. Yes, definitely over a hundred questions. So... Well, I haven't been paying attention to them, which is why I see you on the tweet,

but I'm guessing you've aggregated them and I have a feeling I'm going to be hearing them. Yes, so I don't think we'll get to all several hundred questions today, but I did put a bunch of them into buckets so that I'm hoping to cover a lot of ground. I'm all yours. So let's start with alcohol. It's a little early for that, isn't it? Yeah, well, it's five o'clock somewhere. Mm-hmm.

So this question, I'm just going to read the whole question, but we'll cover the alcohol. I think if there were more characters, I don't know what is it, 280 characters now? The 140 it used to be, so I think this person got all the characters in. Thoughts on consumption of alcohol, marijuana, are we sleeping enough? Ever tried cold water therapy and a shout out to Iceman Hoff, Wim Hof? How can we best enhance brain function? Are we working too hard? Are we too removed from nature? Oh Jesus Christ, I can't even remember the first question. Alcohol, thoughts on consumption of alcohol, which is a little generic. Okay, so I put this into a couple of categories. The first is just a purely physiologic, what

is the effect of the molecule ethanol on the body? And just as I sort of talk about sugar or other things, it's really important to understand that ethanol is a toxin, but of course the dose makes the poison. Now, the thing that I think many people forget who are not in the world of toxicology is that there is a probability distribution that drives the impact of a toxin on a population.

And there are gonna be some people at one end of the spectrum who are largely unimpacted by certain toxins and there are gonna be others who are not. And so ethanol is no exception to that just as Tylenol or pick your favorite poison could be. So again, Tylenol meaning like even though it's at low doses very efficacious as an analgesic, at high enough doses, it's hepatotoxic. So, start with position one. I'm not convinced that there is

a single benefit to ethanol, the molecule, in the human body. So, ethanol in its metabolic pathway, and it's uniquely metabolized by the liver, one of the byproducts is something called aldehyde, which is a toxin. It really has two, and this is a bit of an oversimplification, but it has two effects. So there's an effect on the liver, and then there's effect on the brain. The effect on the brain is what people drink alcohol for. It's the buzz.

It's the CNS depression that also comes with some euphoria. So it's a bit of a paradox there, because ethanol, it's effect in the CNS is that of a GABA agonist and GABA, of course, being is a non-excitatory or depressing neurotransmitter. But I think as most people will understand, certainly ethanol can have an excitatory effect. So you've got this brain-effective alcohol, you've got this liver effect. The liver effect is very similar to that of sugar or fric-posts.

They have very similar metabolic pathways, not identical, but also not surprising that they overlap, given that fructose is fermented to make ethanol. So from that standpoint, no benefit to ethanol. But again, different people tolerated through different amounts. As a general rule, each beverage, and I'm not talking the kind you pour yourself where they're a little longer, a little taller, but an ounce of distilled spirits is about 15 grams of ethanol. An appropriate, maybe four ounce glass of wine is also about 15 grams of ethanol, as is a beer, 10 ounces, 12 ounces, again, depending on the alcohol content. So as a general rule of thumb, each drink is about 15 grams of ethanol.

One of the things if a patient asks me this question that I'm thinking is, well, what's your liver function right now? And the best proxy we have for that is the ALT, one of the transaminases. And, you know, so when I see a patient that's walking around with an ALT that's already at the upper limit of what we consider normal by range today, which I do not consider normal, which is probably 42 on our lab. I consider below 20 normal. I'm always asking the question, do they have fatty liver right now?

And if they do, is it more in response to ethanol or is it more in response to fructose? That said, I have at least two patients that I've taken care of either in the pastor currently who consume seemingly unbelievable quantities of ethanol, some of them averaging between eight and twelve drinks a day. And by ultrasound, their livers are normal. By LFTs, their livers are normal. Looking at coagg studies, every other marker you can look at, their liver function is perfect. And these guys are sort of the genetic outliers who have a remarkable tolerance to alcohol. So the point I'm trying to make here is I want to get a sense of how much harm is coming

purely in a hepatic sense from alcohol and then make sure we're drawing a line well below that. But the second point is perhaps the bigger point, which is the why. The why are we drinking alcohol? And I say this as a guy who likes alcohol just as much as the next person, but certainly in my life, I've started to ask, am I drinking just for the sake of drinking? Am I drinking because I'm trying to soothe some other issue? And does my drinking lead to a behavior that I'm otherwise not happy about.

In my case, personally, that generally tends to loosening the reins on what I eat. I don't think I'm unique in that. I've got many patients that, when confronted, will say the same thing, which is, yeah, ultimately, that's the problem with ethanol. You go out, you get a couple of drinks in you, and things that you otherwise wouldn't eat, you just start eating. So, not that this is at all scientific, but my rule of thumb is the following.

As a general rule, I don't wanna drink. If I'm going to drink, it's going to be good alcohol. I'm going to make it purpose-driven drinking. So, I don't drink on airplanes, because the alcohol sucks. Like, I'm not gonna, just because they're pouring me some half-ass glass of wine, I'm not gonna drink it. But if I wanna drink wine, I'm gonna drink wine that is exceptional. If I'm not going to just because they're pouring me some half-ass glass of wine, I'm not going to drink it. But if I want to drink wine, I'm going to drink wine that is exceptional. If I'm going to drink tequila, I'm going to drink tequila that is exceptional. And if I'm

going to drink beer, it's going to be exceptional. And because somebody's going to ask, what are my favorites? My favorite wine is Cleo, which is a Spanish blend. And I've been drinking it since 2007. And I've had every bottle from 07 to 14, and I'm fully expecting that people listening to this are not gonna go and start buying Cleo like crazy, because sometimes it's hard to find that I'm gonna be really pissed off if I can't get it. Tequila, I know everybody raves about 1942, and I think it's good, but the Class A azul repassato

is absolutely my favorite. It must be consumed neat, no ice, no lime, no nothing. And my favorite beer, I'm not willing to say what it is because it is so hard to find. And honestly, not to be a selfish prick, but I'm simply not willing to share it with anybody. One of the guys who works for me's part time job is sourcing it across the United States and Belgium.

So I'm sorry guys. I'm not gonna Let on with that is so that's my thoughts on alcohol Okay, and he can I make a follow-up please? Okay, so more or less you said there's nothing beneficial I'm sure you're gonna get but what about what about the French paradox? What about red wine? Isn't a glass of red wine maybe two for for men, maybe three, maybe six, depending on who you ask, isn't that associated with better health or less cardiovascular disease or more longevity? Yeah, I mean, I think the red wine thing came about through two things that you mentioned. One is the French paradox, which is, boy, the French seem to live a lot longer and they drink

more or go, it's got to be that. Of course, I think that to get into that topic in detail would sort of take the rest of our AMA and it really has to do with just a poor understanding of epidemiology. So there are a lot of things that explain the French paradox. They also smoke more. I don't think that necessarily means smoking is better. So it probably has a little bit more to do with what they eat than what they drink or don't drink. The other thing that I think has a lot of people with this lingering idea that, you know, a glass of red wine a day must be healthy. And I wanna be clear, I'm not saying a graph of a glass of red wine a day is harmful,

but I'm saying it's not benefiting your health. Is the risk-veratrol story? So, risk-veratrol is a compound that is identified in very small quantities in red wine. And there was one lab in particular at Harvard that many years ago, and I say many years ago, like probably 15 years ago, maybe 10 years ago, David Sinclair's lab had studied this in high concentrations

and they showed that it enhanced longevity. And that created like this huge wave of everybody wanting to take risk veritable supplements. There are two issues with this. The first is, even if you believe those data, which I categorically do not, and no lab has ever been able to reproduce them, and I'm not even convinced that Sinclair today would believe that those were valid, you would not get that amount of risk-baratrol in a glass

of red wine. It's sort of like the, should I be eating more dark chocolate to live longer? Maybe, but you're probably better off just taking cocoa flavonoids if you buy that that's the active ingredient that's going gonna enhance nitric oxide production. The one thing I guess I'm glad you asked this follow-up question, because I have some patients who will argue this, and honestly, maybe they're right,

which is there are some patients who say, look, just a single glass of wine a day helps me unwind a little bit and isn't there any benefit in that? And I guess the answer is possibly. And so the question is, does the net benefit of that, which could be a lower amount of cortisol, a lower amount of emotional distress, could those things be beneficial relative

to any of the potential drawbacks of ethanol, such as increased appetite dysregulation, or I'm not even getting into sort of pathologic behaviors. Maybe. One thing I have observed in the aura ring has made it very easy for me to track this is one drink in the evening does not impact my sleep two or more Absolutely does and does so in a profound way The two things that happens are my resting heart rate will be 10 beats higher It will take very long for me to reach my resting heart rate. So what you want is your resting heart rate to be achieved within the first third of your sleep cycle.

And more importantly, and perhaps more surprising to me is my heart rate variability gets squashed. So I have a very low average heart rate variability when I have more than two drinks. And even the volatility of my variability is very low. And that is reflected in my sleep. It also definitely compresses rem cycles.

So even though when you have a few drinks, you're groggy and you think you're sleeping better, you're just less conscious, but you're actually sleeping worse. Okay, let's move to the next one. Best lab tests. It's the bucket that I put this one under. So there are a couple of questions at least. One question was, what four to five tests can we go to our PCP or primary care physician and request they run? Second question, what are the best lab tests as markers for longevity? Well, so the first one is, and I guess you could divide these into things that you really only need to have checked once, and then things that maybe you ought to be checking more than once.

So a couple of things that everybody needs to have checked once is LP-little-A and APOE. So LP-little-A is a phenotype, but it effectively reflects a genotype, the LPA gene. And we're going to have an entire probably two and a half hour discussion on LPA. So I'm not going to say anything more about that. But suffice it to say, if you're listening to this and you don't know why I'm suggesting that you will, but everybody needs to know their LPA. LA, preferably their LPA. little a particle number, but Lp little a mass is to a first order a reasonable approximation. Apoe, of course, is a gene and it exists mostly in three forms, the two, the three, and the four. There are others, but they're almost, I've never seen one. And because it's a gene, you get one from each parent, so therefore you can combine the two, the three, the four into six combinations,

two, two, three, two, four, three, three, three, four, and four, four, and it is important to know those. In my opinion though, I will certainly find myself arguing this point with physicians who say, why the hell would you ever want a patient to know that? There's nothing you can do about it, because of course this gene is probably the second strongest gene to predict Alzheimer's disease by magnitude

but the strongest by far by frequency. In other words, it's the one that matters more at the population level. I would agree with the logic of said physicians if I felt that there was nothing one could do to impact their chances of Alzheimer's disease. Obviously, I think that that's sort of nonsense. You and I, and Dan co-authored a paper with Richard Isaacson at Cornell and a few of his colleagues on Alzheimer's prevention.

So we're obviously in the camp that thinks Alzheimer's disease is at least somewhat, if not significantly preventable. And therefore, genotyping gives us great insight. Furthermore, Apoe genotype gives enormous insight into cardiovascular risk, something that we probably ought to do a dedicated discussion around ApoB, ApoC, and ApoE, just straight up ApoToc. I'd like to talk more about that now, but it's probably irrelevant. So you got to know your LP, little A, you got to know your APOE. The other thing that, again, I sort of think a lot about is if LP, little A is the single most important,

like a protein, then LDLP or APOB would be the next most important. So that's also something that I really think got to be tracked. Boy, we're only allowed five, huh? Because I really, I guess I take for granted that we can just order lots of lab tests. Can you explain, just start to back up, when you say LDL P or APOB,

I think some people might think like you can get either or test, but they're more or less testing for the same thing. Can you explain how APOB relates to the LDL? So there's actually two APOBs, there's APOB 48, which is an APO-lipoprotein that sits on something called a chylamicron, and then there actually two APOBs, there's APOB 48, which is an APO lipoprotein that sits on something called a chylamychron, and then there's an APOB 100, and there is one and only one APOB on each of the following molecules, VLDL, IDL, LDL, and also LP, little A. So by counting the

number of APOBs, you are counting the number of LDL particles, but because you measure apob in mass, it's measured as milligrams per desolate of apob, versus LDLP is measured in number or in animal per liter. So the number will look very different. If I said, tell me your apob and your LDLP, they will have different units and therefore not look anything alike, but their proxies for the same thing. And that of course changes. It's influenced by four things.

It's influenced by the amount of cholesterol you synthesize, the amount of cholesterol or sterile that you reabsorb, the amount of triglycerides you have to carry around, and your clearance of the particles, which is primarily driven by something called the LDL receptor or LDLR that sits on the liver. And because those four factors can all change in response to diet and drugs, to different extents, obviously triglyceride is by far the most sensitive to nutritional change. LDL receptor, probably the most genetically preset, that there are ways to tweak these things and certainly drugs tweak them.

So we've got lots of ways to do that. But this is an important thing to know. I mean, the four-lipa proteins that, approximately, this order are important is Lp, little A, L DLP, small LDLP, the subset of LDL that are below some cutoff, typically about 20 nanometers. And then we don't have a way to measure something called the VLDL remnant. So we use the Poor Man's Proxy as I look at VLDL cholesterol, which you take the non-HDL cholesterol and subtract the LDL cholesterol, which you get off a standard lipid panel.

That's especially helpful if at least the LDL is measured directly. But then of course, you're often compromising and getting an indirect measure of the non-HDL. So, but that probably is a better proxy than taking triglyceride and dividing by five, which is the other poor man's way to get a VLDLC. And I like to see that number less than 15 milligrams per deciliter. Did you just find a utility for total cholesterol test? I have zero utility for total cholesterol. I think the only time a clinician should ever even pay attention to that number is if you

have a patient that you are concerned has FH, familial hypercholestralemia, and you're trying to get them approved for a PCSK9 inhibitor, then you will actually need to know their total cholesterol and their LDL cholesterol because you will use cutoff, typically, total cholesterol, more than 350 LDL cholesterol, more than 250 milligrams per desolate, or as you're cutoff. But I don't pay attention to LDL cholesterol. I don't pay attention to total cholesterol. And I pay minimal attention to HDL cholesterol. I'm more interested in the ratio of triglyceride HDL cholesterol. But as we know now, increasing HDL cholesterol pharmacologically does not seem to have any benefit.

I'm not even convinced increasing it dieterally does, I think it just goes along for the ride. In other words, I think that the things in a person's nutrition that increase their HDL are benefiting, but not because of the HDL, the HDL, C is going up as a result of it. So I guess after all that rambling, I've basically said three things, which is LP Little A, APOE, LDLP. I think everybody should encounter an oral glucose tolerance test, and in particular one that uses insulin as well as glucose.

So not uses insulin, but measures insulin. So you would take a fasting glucose insulin level. You would consume a standardized amount of glucose. Typically it's recommended to use 75 or 100 grams of liquid glucose called glucola. We do that for most of our patients. However, I am now on occasion using normal glucose to challenge them. So 100 grams of glucose in the form of rice or potatoes, because I do think there's a subset of people who you're getting misleading responses from when you're using liquid glucose, which is actually quite unnatural.

You don't consume glucola regularly. I mean, I didn't look in your fridge, but. You know, I've got six bottles back there, but I save that only for the special occasions, like along with the other alcohols that I like. Now, the shit is horrible, taking enough of those glucose tolerance tests. In fact, I'll probably never do one again.

I'll probably from now on only do them with, you know, rice or potatoes or something like that. Is that complicated to do the OGTT with insulin? Or is that something that most... Well, you know, it's interesting because I do see some stuff on Twitter about, hey, why do I need to go to my doctor to do that? I can just do it at home.

And you can do it at home with the glucose response because, you know, we have portable glucose monitors. But insulin can't be measured easily. It's not a test you can do at home, so it needs a laboratory. If you're not seeing the insulin, you're not knowing the answer. If you fail a glucose tolerance test on glucose levels, then you've really failed. What do I define as a failure? I want to see fasting glucose, typically below

90. I want to see one hour post-prandial below 120 to 130, depending on the amount of muscle mass the person has. And I want to see two hour glucose below 100. In other words, I have much more rigorous standards than the laboratory form would show. And you can be there and still have hyperinsulinemia, especially post-prandial. Usually a person there will not have hyperinsulinemia when fasting, but it's not uncommon, in fact, I'm seeing a patient tomorrow. I was just looking over his labs today. And he's great fasting glucose. Fasting insulin is below six, which is my target.

At one hour, his glucose is like 114, great, but his insulin's 56. And at two hours, he's fine, below 100, and his insulin is below 20. So what is the implication there of this guy who's got basically only one X on his record, which is his one hour insulin is 56? Well, that's, you know, as Joseph Kraft describes that, that's diabetes in situ. So that is post-prandial hyperinsulinemia, which is a harbinger to insulin resistance. And look, he might be five years away from being insulin resistant, but that's exactly the time I'd like to be able to intervene. And so this is one of those tests where yeah, it would be a lot easier if we could just do it at home with our glucose cometers, but I think it is worth

the hassle of doing it and getting the the actual insulin data. Boy, what else do I like to see? I've already got pretty heavy focus on the cardiovascular, so I'll try to avoid any other cardiovascular stuff, although obviously a C-reactive protein, a homocysteine, or an oxidized LDL, or an oxidized phospholipid are really, really helpful. But I think since we're only going for five,

probably ALT, which I alluded to earlier. I think today we're just seeing so much fatty liver disease. And again, the labs, which are basically showing you plus or minus two standard deviations, have just seen an upward drift of this over decades. And I was actually just talking about this with Rob Lustig a while ago on another podcast which I don't know what order we're going to release these things but that'll either have already come out or be coming up but we were talking about how we both sort of share this point of view which is we just kind of ignore the laboratory references on many of these things and for ALT on our lab up to 42 is normal. If I see a patient walking around at 38 I'm highly alarmed.

You made a great point about that too. I snuck in and listened to that podcast. Sneaking and listening on the podcast already. Membership has its benefits. The ALT, so 42, I think you said, is that's considered normal today, but 30, 40, 50 years ago, that was not considered normal. That's right. Why? I mean, I think Rob would argue and I would agree that as we've seen an increase in fructose consumption, it's driving a greater and greater prevalence of Nafoldi. This was a condition that wasn't even recognized 20 years ago. If the last data I looked at are any indication by 2025, the combination of the success we've had treating HEPC and the ramp in rise in Nafoldi means by 2025, the combination of the success we've had treating hip-sea and the ramp and rise in Natholde means by 2025, this will be the Nash, which is the sort of Nash, Natholde to Nash to cirrhosis, that pathway will be the leading indication for liver transplant

in the United States, which is sort of hard to contemplate when you realize that in the year 2000, less than 1% of liver transplants were for non-alcoholic fatty liver disease. And I think one of the things about the lab, the reference ranges, is that they're based on the population mean. So 30 to 40 years ago, a normal ALT would be actually considered lower than 42. But because the national average is higher, when you look at a lab test, you're within range, you may be at 42, and you're looking at it and saying, I want it below 20.

Yeah. The other thing I've seen enormous drift gone, even just in my very, very brief career on a relative basis, is estradiol levels in men. I mean, I've seen two upward shifts in the range at the same lab over eight years. So men are becoming more and more and more estrogenized. And there's lots of reasons for that, which we'll probably talk about on another podcast. So those are my, I can't even remember, I lost track how many labs I recommended, but I think the spirit of the question was if you're going to be a minimalist, what are you going to do? You got five in there definitely. Does that cover just in general

or does that also cover the markers for longevity? Do you wanna get into like, if you could actually measure some things for longevity but you really can't in a lab test that you would wanna look at? So if we're talking longevity purely in terms of lifespan, how long, you know, looking at someone's blood,

can you get a sense of how long until they're gonna die? The way to think about that, so what you're not gonna get on a standard blood test is any of the longevity genes. I mean, you can get some of them, but you certainly ApoE would be one of the longevity genes. LP, Little A would be a longevity gene in inverse, so the lower your LP, Little A,

the greater your chance of cardiovascular mortality. So the way I really think about longevity in blood is the three things that you're looking for in blood disease-wise are what is this person's risk of atracellarotic disease? So heart disease or stroke? What is this person's risk of cancer? What is this person's risk of neurodegenerative disease? So as you march down those things, you would say, well, cardiovascular disease largely driven by three things, lipoproteins, inflammation, and ethereal dysfunction.

How much of that can we see in blood actually a lot? On the lipoprotein side, we can see most of what we want, which is the Lp little A, the LDL, the small LDL, I'm talking particle number, not cholesterol, and the VLDL as alluded to. On the inflammation side, we can see specific and non-specific markers of inflammation. So on the non-specific side, we can see things like fibrinogen, C-reactive protein.

On the specific side, you can see things like ox LDL, LPPLA, two ox phospholipid, those things. Very helpful. And the theal health is the hardest thing to see, but I include insulin here because I think that insulin is in and of itself actually toxic at high levels to the endothelium. James O'Keefe just recently was on a paper that looked at cardiovascular health in patients with type 1 diabetes so that they were able to actually use the insulin doses that people

were using as a way to actually assess the impact on the... I can't remember if it was myocardium or endothelium. You can look at things like homeocystine. We also look at something called asymmetric dimethylarginine or ADMA and SDMA, which are inhibitors of nitric oxide synthase. So the way I tell patients is, the younger you are, the more your blood tells me about your risk of cardiovascular disease. So a 40-year-old person who otherwise doesn't have like some dramatic,

you know, L.P. Little A through the roof or something crazy, the blood tells me probably 80, 85% of what I need to know. The older a patient gets, the more I would probably rely on things like CT&Gograms or even usually by the time they're older, a calcium score becomes less relevant. Calcium score can be somewhat helpful in a younger patient, though. But, you know, the latest study I saw, which actually just was an editorial that came out two days ago based on a study in one of the atherosclerosis journals, was, you know, looking at 50% of patients that had events had them at the site of non-calcified lesions. Not a huge vote of confidence for how why a low calcium score is that helpful.

On the cancer side, I think that's really, frankly, where blood gives us the least insight. Until companies like Grail have fully functioning liquid biopsies where you're looking at, I think Grail's probably looking mostly at RNA and DNA. Other companies have looked at circulating proteins. But until these liquid biopsies are there, we don't really have much insight into it.

Also, virtually every cancer is a result of a somatic mutation, not a germline mutation. So knowing your genotype doesn't really help outside of a few outlier things like braca or linch. So in cancer, it really comes down to understanding inflammation, which we've already addressed, and metabolic health, which again was also part of the cardiovascular stuff, though I didn't go into it. But so for me, minimizing hyperinsulinemia becomes very important. And I suspect we'll probably have an entire

discussion on the role of IGF in cancer, and IGF BP3, because I think it's actually quite controversial, but that can also provide some insight. And then Alzheimer's disease actually, I think, is more closely related to cardiovascular disease in terms of risk stratification. So first of all, knowing the patient's ApoE immediately gives me a bucket to put them in, which is low, medium high risk. I mean, that's, I don't call it that, but that's sort of how you can think about it. medium high risk. I mean, that's, I don't call it that, but that's sort of how you can think about it. And then you look at the other dimensions of it, which is there's a vascular component to that disease, and that basically proxies what you're seeing in cardiovascular risk. So the more you can improve the cardio metabolic profile, the more you can improve that. Then there's the metabolic

component period, which is kind of like the glucose utilization part. And that sort of reverts back into all the metabolic stuff you see in cancer. There's an entire thing around toxins, which unfortunately is probably the one that we have the least insight into measuring. And you know, for very high risk patients, we do refer them to Richard Isaacson's clinic at Cornell, which is a dedicated high risk clinic. And certainly there, if the cognitive test warrants it, they'll do lumbar punctures and start to look at CSF for other markers, but obviously we don't do that.

And unfortunately, we don't have too many patients that are cross-moginating over there. I don't want to harp on this one, but I thought it was a good point that you brought up. You touched upon with the insulin, and that some people will get their, they'll get their glucose tested. You know, every year and they say, my glucose is fine. It's 82 or whatever it is.

And you know, if they assume that their insulin is fine too because they're clearing their blood sugar and it's 82, can you explain just why you're not, I mean, you're literally not looking at insulin, but insulin could be elevated and you wouldn't know it. Yeah. And usually the person walking around with a fasting glucose of 82 probably doesn't have a very high fasting insulin. It's the post-prandial stuff you worry about. And then this gets more complicated because you then have to worry about, are you being misled by the test? So I'm sure many people are listening to this who are already aware of this, but I'm sure enough people aren't that it's worth the time. But if you take somebody who's on a key to genic diet or a very carbohydrate restricted diet, it's more common than not when you do an oral glucose tolerance test on them that they will have this paroxysmal, very elevated glucose,

very elevated insulin after being challenged. So they'll have a low fasting glucose, low fasting insulin, and then you give them the glucola and their glucose and insulin are sky high. I think I may have told the story once on a podcast about a guy I knew who had gone on a little carb diet and everything had gone great and bubble by, lost a bunch of weight and got healthier and everything was amazing. And then his brother who had type one diabetes needed a kidney transplant and he was a match. So they said, well, all right, we just got a test,

you make sure you're not diabetic or anything before we take one of your kidneys. They did an OGTT and he quote unquote failed and he called me at distress and he was like, oh my God, I can't even give my brother a kidney and I said, well, here's the thing, you gotta have him repeat the test. And you gotta refeed with 150 grams of carbohydrates,

just to eat 150 grams of rice, potatoes, whatever, for about three days, leaving up to the test. They repeated the test. Obviously, everything was fine. The next time you call me, he was leaving the hospital after the transplant, everything had gone well. The other thing with fasting glucose, by the way, that's kind of useless,

is it's helpful if you're fasting glucose is 150. There's clearly a problem, but I get patients that get very upset or phosphorylated if they're fasting glucose is 105. And I got to tell you now that I wear a continuous glucose monitor and I know my glucose 24, 7. The difference between a fasting glucose of 90 and 105

in the morning is much more function of my cortisol level than it is anything to do with my insulin sensitivity or anything like that. So it's important to understand the role that even stress can play on glucose. And that's why I think fasting glucose is directionally interesting, but it's the insulin that gives you the more fine-tune insight. Okay, this might be jumping around a little bit, but you talked about your continuous glucose monitor. And I think a couple people asked about that because they realized that you have a CGM and

you're not diabetic. Because usually when you have a CGM, people say, aren't you diabetic? Because it's what it's typically used for. So we could get into A, why do you wear this CGM and then probably a pretty nerdy game of would you rather, which is obviously not the glucose, but let's say like an OGTT with insulin. Would you rather see that in a patient or if a patient could have the, you know, the Dexcom 5 or whatever the latest and greatest is and and you knew exactly what they ate for like a month, and you could follow those numbers. Are you gonna learn more about that patient

through one of those tests or the other? Well, that's a good question. I think that to have CGM data on a patient, and a lot of our patients don't wanna wear CGM, although I think that's gonna change with the Dexcom G6, so I started my career using the G5. No, the G5 I love, but I could understand why if you didn't actually have diabetes, that was a bit of a stretch because you're inserting this needle and it was just a bit more involved,

plus it required calibration twice a day. Then a company called Libre got bought by Abbott and they had a no calibration one that got quite popular, but we've used it a lot and I find it to be categorically useless. It's so inaccurate and you can't force a calibration. Also it doesn't interact with your phone, so it's just useless in that regard. So, do those both use a needle in the same place? The Libre is typically inserted on the back of the arm, and it was at the time a much easier way to insert.

The new Dexcom G6, which I don't think is out yet, but I've been lucky enough to have a prototype for a while. The G6 inserts the same way as the Libre. It's plug and play, it's trivial, it requires, you don't even feel it going in, it's a much smaller needle, it goes in much faster, so you're not the one responsible for the velocity which it goes into. And it also doesn't require calibration. Though you can, I still spot check mine once a day. I've been blown away by the accuracy. And its interface with the phone is second to none.

So it's just, it's amazing. I think in reality, if I had a month of CGM data with accurate food information, that's probably more valuable to me than the OGTT, even though I'm giving up insulin. Meaning, I'm not going to get to see the insulin, but I also get to see, you know, a month of someone in their real environment eating the likelihood that I'll miss in that entire month because they're going to probably eat something really bad. If I can see how they're reacting to that, that's probably pretty good, but look, it's still not a complete substitute for that hyperinsulinemia. So it's not perfect, but I also find that the CGM for me

is one of the, it's along with my sleep ring, it's the stickiest device I've ever used. Whereas any other wearable I've ever used, it's like after two weeks, I don't want to wear it anymore because I've already learned what I need to learn. I know how many steps I take, why do I care? So I've got this whole theory around what wearables matter. You know, it's like, are you measuring something that matters? I don't want a wearable that's telling me

something that's irrelevant clinically. Is the device actually measuring what it claims to be measuring? Is it, am I able to get feedback in real time? Because that was the problem with the Libre, as you couldn't get real-time feedback. You know, unless you were going to carry around this other device it came with, whereas with the Dexcom, you're getting real-time feedback. And so, as real-time exists, meaning when you eat something, you don't see your glucose move at that moment, but I certainly know after a meal how that meal or the amount of exercise of the amount of stress I was under impact at things. And then do I have an ability to sort of fix it? Do I have any control over the outcome?

So, you know, CGM for me continues to this day, even though we're probably three years into doing this stuff. I mean, it's hard for me to imagine a day when I'm not going to want to know my glucose every minute of every day. How much of those two things, particularly the CGM, maybe the ring too, because you're talking about a lot of things, probably sleep, exercise, diet, etc. Are these things almost like accountability coaches? The idea that you get this real-time feedback of the stuff that you're eating, if you're

going to eat some crap, whatever it is, you know that it's gonna show up. Do you think that there's any of that aspect to those things? For me, there definitely is, especially on the glucose ring. I had a buddy stay here last night, and like after we went out and grabbed dinner,

and then on the way home, he's like, oh, do you mind if we stop at the store? I want to get some stuff for the morning, and he got a little box of granola. And so, you's like, oh, do you mind if we stop at the store? I want to get some stuff for the morning. And he, you know, got a little box of granola. And so, you know, this morning, you know, get up to our thing and he eats some of the granola, but left the box. And as he left them, like, God damn it. Like I love granola, but like, it's candy.

It's not, it's not. It's like, you know, so I just threw it out immediately, like, open the thing through the granola out and make sure I wouldn't eat it. And in part, I think it's that I know that if I eat it, I have to look at my CGM, just go up and it just pisses me off. So it's like, I'm not going to do it. And maybe if I didn't have that CGM, I would have mainlined that whole box of granola. There's a question in here that I have to get to because it might relate to this.

It says, how do you think having children has changed you most? I often think of like what's at the dinner table and what's left over in terms of your, you know, if you want to call it willpower or food that's left over, that might come into play. I mean, I hate to blame my kids for anything, but I'm easily 10 pounds heavier and 10 pounds fatter thanks to them. I think the biggest issue is the food environment. You know, here in New York, I eat really well because you mean, you see my kitchen, the worst thing I'm going to do. Yeah, yeah, the worst thing I'm going to do is have a little extra almonds tonight. Like, there's just nothing bad to eat in here.

And this is where I'm at my weakest is when I'm, you know, in my place. And it's not to say I don't go out and eat a burger and fries sometimes because certainly New York offers more of amazing, decadent food than any place else. But I think we're most vulnerable in the environment that we eat most. And for some people that's work, for some people at home, whatever. And so I think the challenge of having kids, at least for me is that you just have more kid food around and try as you might to say we're not going to have that kind of stuff in our house.

I mean, look, I'm guessing my kids eat better than most kids. I mean, I don't have juice in the house. So to like a couple times a year, there's like, you know, some diet coke after a birthday party or something. But, you know, for the most part, it's pretty good, but there's still a bunch of crap. Like, you know, those crackers, wheat thins, my son, who you know very well, he calls them weathens. And he freaking loves those things.

Like, it's all he wants to eat. And he comes home from daycare and he's like, daddy, I want some weathens. And I'm like, what? Weathens. I don't know. What are you daddy, I want some weathens. And I'm like, what? Weathens. What are you talking about, Reese? Weathens. Oh, wheat thins got it. So, and I-

We not thin, we not. And those things, I mean, I don't know if you've had one of those in a while. They're freaking awesome. Yeah. They must be just, they're so, I don't remember them being that sweet when I was a kid.

The texture too. Yeah. I remember, yes, there's a period. I would stack them up, I think too. Maybe stack up a couple of them. Yeah, yeah. Yeah. You don't eat those things one at a time.

I feel like Will Ferrell and what was that hilarious? Old school? Old school. It just feels so good when they just hit your lips. And then the other thing is, there's just like a lot of the times, like if I'm, you know, the kids will want homemade mac and cheese, which is like nowhere near as bad as the crap you get out of a box, but look, it's still mac and cheese. And if they don't finish it, I still have this immigrant mentality I grew up with, which

is like you don't throw food out, which is horrible, but I was really raised like that was so instilled in me that you don't throw food out, which is horrible, but I was really raised like that was so instilled in me that you don't throw food out. So if my kids don't eat their mac and cheese, I'm like, yeah, I got to eat it. And part of that's just, I want to eat it. But part of it's like, I really don't want to throw it out. So I'm just as likely to finish off their salmon or steak as I am their their mac and cheese. So I don't know. I mean, I think the benefits of having kids have probably outweighed that, but that's definitely a drawback of having kids. So, before we leave the lab tests,

this is technically not a lab test, but I've heard you talk about it a lot. And it's something that people probably could do, and it might be a good exercise for them. And that is family history. You can tell you a lot about your risk. Maybe more so than some markers. Can you talk about the importance of that a little bit?

Yeah, I think it's certainly more important than doing a whole genome sequence. So I've had a number of patients, I mean at least half my patients over the last few years have either done a whole sequence or at the very least done something like 23 and me. We run that through Prometheus. I'm trying to think of a single time when anything in there altered our treatment plan beyond what we already knew. Maybe the odd patient that shows up with a Tom 40 mutation who was otherwise in APO 333 that you think, okay, you're probably a little higher risk than we thought for Alzheimer's. So maybe that's one exception.

You know, we get some insights into caffeine metabolism, but we almost always know the answer before we, you know, we look for it just based on what they tell us clinically. But the family history is incredible. And a lot of the times you can see things in family history like you can often spot an elevated LP littleP. little A

before you get the bloods back. Cause usually I've done a history and a physical on a patient before I get their first blood test back. And it's not uncommon for me to see just a violent streak of heart disease in a family and be like, okay, you're gonna have an elevated L.P. little A. There's no two ways about it.

And sure enough, they come back and it's high. And you could see that their dad had it, their dad's mom had it, their dad's mom's ways about it and sure enough they come back and it's high and you could see that their dad had it their dad's mom Had it their dad's mom's mom had it and you just sort of because it's a codominant inherited gene So you can see how it rattled through the family Certainly also gives you a great insight into cancer and dementia as well less. I mean, I think dementia's harder because obviously the further you go back the Less long people were living and you don't necessarily answer.

But as a general rule, we really look for the mosaic and pattern of a person's predicted mortality based on their genes. And things will skew it. Your parents smoked and you don't smoke and they're getting disease all over the place. It's hard to infer there. You know, I have a patient whose mom just died very recently from lung cancer, but it was non-small cell lung cancer. So, you know, what do you do with that?

She was a heavy smoker. He's not. Does that really increase his risk? I mean, as you know, we do a staggering amount of work on cancer screening in our patients, and you basically are the guy who runs our model on that. And it's actually a cancer by cancer issue. There are some cancers in which, you know, a first degree relative that has it, it's a big, you know, and sometimes it's not obvious,

like the first degree relative that has bladder cancer and what's the relationship to you having prostate cancer advice versus. So when we do the cancer screening in particular, we have the patients go back and do an even more detailed double click on their family history of cancer. So yeah, I think family history is probably one of the more important things we get out of the history on the patient. MD selection.

I think you've received this question more than once. How do I find a good doctor? So what is the best way to find a really good primary care physician? Are there specific tell-tale questions labs I should bring up with a perspective PCP? I think we covered that. But also to see if they've picked up a medical journal in the last 20 years.

You know, I sort of actually had this discussion with a patient on Monday who's looking for a concierge, you know, primary care physician since I'm not a PCP and many patients come to me already with a PCP, but sometimes they don't and they want to have this question. So, you know, I kind of walked him through my mental model, which is there's no one-size-fits-all. Here, you just have to decide what it is you need and want. So I think about availability, affability, ability, and advocacy

as sort of the four broad pillars that you're looking for in a physician. And it's pretty much impossible that you'd find all of those in the same person. So what do I mean by those things? So advocacy is the physician who's connected and knows how to help you navigate through a storm. When you need to go get a colonoscopy,

they know the absolute best endoscopist, and if God forbid, like something comes back with a positive finding, they know exactly the right surgeon and boom, boom, boom, and not only do they have the roletex, but they know how to help you get through that. They will be your, you know, your advocate in the system. I personally think that's very important. I think many people aren't actually thinking of that, but it's important to,

to sort of ask a doctor explicitly and directly about that. Ability to me is, obviously obviously I just think that that's the single most important thing. I mean in the end, yeah bedside manners, great affability is important, but I'll never take affability over ability you'd want both. They're not mutually exclusive, but don't be confused, don't be confused by affability at the expense of ability. So we'll come back to how maybe how you can assess ability, but that's important. Affability business, like do you get along with this person?

And I think you should be able to get along with your doctor. I mean, I think the days of going to the doctor who talks down to you and is basically preaching a bunch of commandments, you know, it just doesn't make any sense. Like you just don't want those kind of people around because yeah, in the end, they might be the expert, but if they can't bring you along, then the relationship probably doesn't fit.

And if I have a patient in which I feel like I can't bring them along or I don't connect with them, I certainly say to them, maybe this isn't working, you know. And in the end, you maybe need somebody different from me who can communicate in a way that you like to be communicated with. Availability is basically or access is, like, are you looking for someone that you can call 24-7 and that's when people are looking for Concierge docs that's generally what they're looking for

There are lots of non-concierge docs though that still have and within the world of concierge look You've got like the $30,000 your concierge guys and you've got the $3,000 concierge guys And so you also have to be able to think about okay Well within that like what's the difference between those two? What's worth $27,000 more per year? If that's the, and that those are literally like, that's probably the range that I see in New York for concierge PCP. But I guess the person asking this question is probably thinking mostly about ability. I think, you know, the question included something about, have they read a medical journal in the last 20 years.

I mean, that's a good question because so much of what we learn in medical school is pretty much irrelevant by the time we're practicing and the lag between when something becomes a finding and when it becomes mainstream or obvious enough that everybody's doing it, you know, I've seen that number estimated at anywhere from 12 to 20 years. So, yeah, it seems like a pretty inefficient system. So I think there you just want to talk to your doctor and say, look, how busy are you clinically? How much time do you spend reading literature? And again, I wouldn't use buzzwords like evidence, do you practice evidence-based medicine? Because what doctor is going to say no to that question? Like it's sort of a silly question. So it's mostly just trying to inquire about the curiosity of the person, their passion around learning. Because I think in many ways, if you're not learning quite a bit as a doctor,

you're probably not practicing great medicine. If you're not sort quite a bit as a doctor, you're probably not practicing great medicine. If you're not sort of trying to get smarter on diagnostics or, you know, advancements in the field, then I, you're probably stagnant. And it's not to say that a doctor who's stagnant can't do great work on certain things, but for most people, they don't want to have like six doctors in their life. You know, they sort of, you want to go to one person. So I think that's how I sort of think about that. Unfortunately, I'm not really a fan of a lot of the labels that people put on. Like, well, I, you know, I practice functional medicine or I'm part of, you know, this organization

or that organization. I just, I don't know. I think in the end, you got to just evaluate the person individually regardless of those features. And I don't know if that think in the end you got to just evaluate the person individually, regardless of those features. I don't know if that answers the question, but... I think so. I think one of the things that I was thinking about is people will ask, people will be relatively specific and they'll say, I live in Boise, Idaho. Do you know a good doctor there?

You may or may not know a good doctor there. However, it probably brings up the point that if you can get a referral from somebody that you really respect and think is a great doctor and knows their stuff, that a referral probably would be pretty valuable there too as well. But it's very hard probably to refer somebody if you're in your own practice as a doctor to really vouch for somebody else across the country. Yeah, I mean, my ability to do that is,

if it's going to happen, it's going to be my luck. It's going to be, I already have a patient there and they've got a doc who I've entered. Like, I've patient in Seattle who's got an amazing PCP up there who I won't name now or else he'll get inundated with a million people, but frankly, I think his practice is probably full, but every time I've had a patient move up

to Seattle, it's like, that's going to be your doctor because the guy's, like, he is the epitome of what a great PCP is. And I love reading his notes. I just, I love interacting with him and I love that, you know, we compliment each other. In other words, there's a whole bunch of things that I do that, you know, look, he sort of knows a little bit about, but he wants to know much more about lipidology and cancer screening and you know, some of the exercise stuff we're doing. But then there's a bunch of stuff he does that I like his knowledge of you know, when the patients traveled to this part of the country, you got to be aware of this

particular parasite that can show up and here's how we're gonna vaccinate you against this and here's how we're gonna You know, you were in that cave in Texas. Well, you're very susceptible to this kind of thing. And just, you know, someone's got like a an HSV flare and like he knows all of the tricks. And so that's probably the easiest way for me to refer people as that I've worked with the doc directly. Going back to the point though, I don't think people should be afraid of this process taking a while. In other words, if you go down the path and you find somebody and you think this is going

to be my doc, and you know, six months in, you don't like him or her, do it again. Keep doing it, keep doing it. And a lot of the questions you ask, the doctor's reaction to those questions, is probably a litmus test. So, if you sense that a doctor is put off by a curious patient who's showing up wanting to be actively involved in their health, well then you don't want that doctor. You don't want someone who's intimidated or put off by your interest and obsession in this stuff as a patient.

Segway into racing. You got a number of questions on racing. This one stood out to me. I'll just ask it first. What was the hardest thing for you to learn when you were becoming a driver? I suspect this is racing not when you got your driver's license. But you could answer that one too. Parallel Park. I think the hardest thing is something that I still struggle with is So when you think about driving like what are the sort of elements of it? The first I guess is sort of understanding conceptually what's happening You don't have that many inputs when you stop to think about it. You have throttle you have break you have steering and you have shifting So you know, you have a clutch and a gearbox. Those are your inputs.

Those are your tactics. You go up and down on those things. Furthermore, you only have four contact points. You have four tires that touch the surface and everything else is in service of those things. So, and then also in the spirit of fours, there are basically four things that determine how faster you're going to go, which is the tires, because they're the contact point, the engine, which provides the power, the chassis, which includes everything from the stiffness of the vehicle to its aerodynamics and its downforce, and then the driver. So you as the driver make up one component of those four things that determines the outcome. You have these four contact points as the tires and you basically have four inputs.

So I think the first thing that one has to learn is vision. Like you have to understand, well I guess the line slash vision I put together. So there's obviously a line that a driver takes. If you're watching a race on TV, you're noticing that all of the drivers are driving in the exact same place unless they're overtaking another driver. But there's a optimized, fastest way

to go around any race course. And for every circuit that I would drive, either real or in the simulator, I know the line like inside, like I know exactly where the car needs to be at every moment in time. And I think for some people that takes longer, for me that was one of the few things that didn't take long

because maybe because I'd already ridden a bike so much, a bicycle, and in time trialing where you're on these every second counts, like you learn exactly where the apex of a corner is, how to take a corner all those things. So I think that came to me pretty easily. In driving, you have two types of steering issues when you're going around a corner.

Obviously, cornering is what makes driving hard. It's easy to drive in a straight line really fast. It's hard to drive around a corner really fast. And the two things that tend to go wrong are understeer and oversteer. easy to drive in a straight line really fast. It's hard to drive around a corner really fast. And the two things that tend to go wrong are understeer and oversteer. So, understeer is when the steering wheel is turning more than the wheels are turning. So, that means that if you're trying to turn to a corner around the right, your wheels are pointing in a direction that is turning you to the right, but you're drifting to the left. right, your wheels are pointing in a direction that is turning

you to the right, but you're drifting to the left. So that's called understeer. You are steering less than you would like to. That is a relatively easy problem to correct, and it's also a relatively easy problem to see because where you're going is not where you want to be going, and that is almost always the result of too much speed. And again, for every situation you have to decide, are you backing off the throttle? If you're on throttle, you're actually applying brake, et cetera. Oversteer is the opposite of that.

Oversteer is the back end of the car is starting to come out from behind you faster than you want it to. So that means the car is now going to turn faster than the rate at which you've asked the front wheels to turn. Now, I think learning to correct an oversteer is for me the greatest learning curve because it's not something for which the initial queue is visual. It's actually something you feel.

You feel oversteer in your butt, because it's basically your butt and the seat are starting to go in a direction that you don't wanna go. And there's a well understood way to correct an oversteer, but it's well understood conceptually. It's not necessarily intuitive. The first step of correcting an oversteer is intuitive, which is changing the angle of the wheel,

the front of the car. It's the pause and the correction that comes after that is, it's like, and I got them positive that there are many drivers out there for whom this was a trivial exercise to learn, but for me it was not. And in fact, one of the things that my coach had me do was he was like, look, you just got to get comfortable going sideways. And so he sent me off to Sprint Car School.

You know, Sprint Car is those huge wheels in the back, little wheels in the front, very small cars in terms of weight and staggeringly overpowered. But you're basically driving that car sideways. You're drifting the whole way. I was like, hey, should I go to drift school? And he's like, no, no, no, go sprint car. I mean, that's, that's where you'll really learn this stuff. I think the other thing that was hard to learn, although I'm so much better at it now that it's, I mean, not the same good at it, but I'm so much better than where I started, is understanding how to modulate, you know, a one out of 10 response on the throttle and the brake. When, when you're driving in the street, you're not really thinking of that stuff. You're on the gas.

You're not on the gas. You're on the brake. You're not on the brake. But in a race car, even how you come off the brake pedal, you know, if you're at a five out of 10 brake, do you go five, four, three, two, one, or five, three, one off? And those will produce, especially at high speeds and with turns, that will produce a very different sensation. In one of those, you're flipping the car around

and the other one you're driving quickly through the line. And so learning how to modulate throttle and break pressure and making those as smooth and elegant as possible. That took some time. Sounds like playing an instrument, not that I play an instrument, but if I were to play an instrument well, you'd probably have to know those things. Yeah, I don't play an instrument either, so I can't speak to it.

So on the oversteer, just because I'm curious, I always think of left turns as a NASCAR, maybe just in my head when I'm thinking of turning. So if you're doing the oversteer and your butt sticking out so the backside is moving out to the right, so you're oversteering, you're oversteering and you're moving too far to the left. How do you correct that? So the first thing you do to correct an oversteer, if you're in that situation is you actually jerk the steering wheel to the right to flip the front of the car.

And then you're basically going to pause for a moment and let it correct and then come back on to throttle and pick it around. And so when you watch, look at, you know, there's a guy named Chris Harris. There's lots of guys online that, you know, are great to watch, but Chris Harris is one of my favorite drivers. And he's like a drifting machine. I mean, this guy, he's really got it down. But if you want to be able to drift a car, you basically have to put the car into an oversteer and then hold it there for a long period of time.

So one of my favorite videos is Chris Harris drifting one of the 911 GT3991. So of course, maybe we'll find the video and link it to people, but it's, he's test driving like the first generation of the GT3 RS. This is probably like 2015, and he's, I think he's at the Porsche circuit, and there's this one turn where it's like one of the most beautiful examples of a controlled oversteer drifting around. And it's one of the most beautiful examples of a controlled oversteer drifting around. And it's one of those things when if you watch it and you're not a driver, they make it look really easy.

When I watch it, I'm just going, God damn it, how does he do that? Because I'm actually watching the micro adjustments of his hand and I'm like, he is so talented. I will spend the rest of my life trying to become half that good. Speaking of talent, one of the questions is just comment on the reasons you are a great fan of Senna. You know, I mean, I think I have done Senna is probably considered by many people to be the greatest race car driver ever.

He died, of course, quite tragically and quite visibly on May 1 1, 1994 at Imola in Italy in an accident that is to this day still debated as to the cause of it, though I have very strong point of view on what the cause of the accident was. You know, I think on many levels, one, he was just so naturally gifted. I was talking to actually one of my patients the other day, and he was telling me a funny story about how he, I don't remember the connection, it was like his girlfriend's brother or something like that. Grip in the UK was, like a guy like me, not a

professional driver, but a guy who really took his driving seriously and had spent years and years trying to hone this craft. And one day he's at a track and he finally lets off his absolute fastest lap of his life in this car on this track. And this was back in 1980 and there was this kid there and they were like, hey, can this kid go take your car around for a spin? You know, he's never been on this track before.

He's never been in your car before. And he said, yeah, okay, whatever. So the kid goes out and went six seconds faster than he had just gone and smashed, like, which was then faster than anyone had ever driven any, you know, that type of a car on that circuit. And of course, the kid was Senna. So there's just this raw natural talent. The other thing I think is just this incredible passion. There are some drivers like Schumacher, who you could equally make a case would be as great a driver, and certainly by number of championships

will be the greatest driver, but you know, had a much less emotional way of going about things. I also think just what Senna stood for both on and off the track. I mean, I think many people were not even aware of how much he cared about Brazil and the people of Brazil until after his death when people realized how much of his enormous wealth he had contributed to, fighting poverty in Brazil. And to this day, the Center Foundation is kind of a remarkable organization there.

I'm constantly moved by the response that anyone from Brazil has to send. Our nanny is Brazilian. And I don't even think she was alive when Sena died. But I mean, she knows everything about Sena. We talk about Sena all day long. My son's name is Ayartan, so she just loves taking care of Little Erie.

I was in an Uber two weeks ago up in San Francisco, and the guy had a Brazilian flag all over the car and blah, blah. And of course, we got talking, and he started asking me about this, and then five minutes into the discussion, he goes, wow, you're really a Senniffan. And I was like, well, yeah. I mean, that's all we talked about, the whole way to the airport. So, you know, that you could still find,

you know, something to talk about with so many people, it's sort of amazing. And I think many people look back at the era that Senniff raced as the golden era of Formula One. Because it wasn't just that you had Senniff, it was that you had Prost, you wasn't just that you had a Senna. It was that you had Prost, you had Mansoul, you had PK, I mean, you had amazing drivers. In an era where the drivers mattered more than they matter today, and that's not to take anything away from Hamilton or Vettel

or any of the great drivers today, and those two are amazing drivers. I think Lewis Hamilton's probably the best driver today, but the cars are so much better today than back then, so much safer. They have a so much more downforce. Back in the late 80s and early 90s, I mean, you were basically riding on mechanical grip alone. And when you look at videos of these guys driving,

there's just amazing things. And then of course, there's like, when you look at videos of these guys driving, there's just amazing things. And then of course there's like, God, I think it was 93. There's this very famous lap that I think was at Donington where Santa started in the four position, meaning so he was fourth on the grid, so didn't have a very good qualifying.

And by the end of the first lap, he was in first. That we should also link to that. Remember, you sent me that link. Yeah, that's like, you'll never see that again. That was sort of considered the greatest lap in the history of motorsport. Of course, the other thing that I think is amazing is his qualifying time in Monaco in 80,

God, I'm so 89, maybe 88, where he qualified about a second and a half faster than Prost. And Monaco's a short, fast circuit. On the longest circuit, you could never see a second and a half difference. When you see, so, you know, in racing, we measure things on the qualifying lap, they're measured to 1,000th of a second for a reason. There's a reason it's not to the 10th of a second, you know, because the difference between

49.47 and 49.49 is pretty big and those would otherwise both be 49.5 But when you're Qualifying ahead of a four-time world champion, which pro-st was a second and a half faster You're just playing a different game than everybody else. You know, Senna won three world titles, although I will always maintain that he won four, because in 89, he was disqualified in the final race in Japan for reasons that I think are completely political and completely bullshit. So as far as I'm concerned, his disqualification was nonsense, and Senna was, Senna died as a four-time champion. I'm convinced that he not died in

94. He would have won the World Championship that year, no question, even though it was the Williams 15 car that they were in was having trouble, but the fact that Graham Hill almost won Damon Hill. The fact that Damon Hill almost won that year is the number two driver. It tells me that Santa would have absolutely won and probably would have been incredibly competitive next year. So, you know, had Santa not died, I mean, you know, he could have easily had those seven world championships that Schumacher had. But yeah, he'll just forever sort of be my favorite. And I love like, I mean, if anyone has, if anyone's watching this and is even remotely interested in this stuff and they haven't seen the documentary center, it's such a beautiful.

That's going to ask if that would be the one that you would recommend. Yeah, yeah, yeah. It covers a lot of this. Yeah, yeah, yeah, for sure. Another racing question. This is a simulator question. How does I racing improve your real world racing skills? And could you do more official races or races with fans also favorite car?

So I racing is a software program which you run in a simulator. You don't need a simulator to run it. You can probably just run it off your PC and play with like, you know, toys. But in a simulator, it's really designed for a simulator because of how high-end it is. I think that I racing is good for every element of driving, but it does have a couple of drawbacks. The first is, we were talking about oversteer earlier, and you'll remember that I said that oversteer is not as visual as understeer, and that oversteer is something you first feel.

The simulator can't really capture that. So when I'm in a car and eye oversteer, it's much harder to correct in eye racing because I lose the warning. I only know what's happening when I actually see that I'm spinning. So it's not that it can't be corrected, it's just it's harder. So it throws your timing off a little bit and what your correction looks like. The other thing that you know obviously a simulator doesn't do compared to being in the real car is you don't have the same physiologic stress.

So I probably have more seat time at a course called Button Willow because it's relatively close, meaning it's only like four hours away, but it's in Bakersfield. And I like to go in the summer because nobody else likes to go in the summer. I can't understand why. And it's hard. I mean, it's, you know, you're in a fire suit inside of a closed cockpit car. When the temperature in the shade is 108 degrees Fahrenheit,

it's probably 130 in the car. You know, it's like the little stuff. Like what do you do when you can't keep the sweat out of your eyes? What do you do when your core body temperature is two degrees higher? And what do you do when your core body temperature is two degrees higher? And what do you do when the dust is blowing in and bubble, bubble, like, you know, so you can't, that's just, and to be able to concentrate through that takes practice and you don't get

that practice in the simulator. Though I do, like, I'll wear my helmet in the simulator and do it in a room that's hot and try to, like, mimic some of that stuff. Where the simulator is incredible is just the economics of it. Every day you're in a race car on a track, it's thousands of dollars. It's just, unless you're incredibly wealthy, it's cost prohibitive to really learn how to drive a car well

in a car. So just like pilots spend most of their time in simulators long before they're up in the air, it's the same thing. And so when I want to learn a new car or learn a new circuit, I want to get a few hundred hours of that on the simulator before I go there when it makes the experience much richer. And if I don't have that luxury, for example, button willow is not in eye racing. So the first time I drove button willow, I ended up having to watch tens of hours of onboard film in of drivers driving Button Willow.

And even that just couldn't prepare me for it the way driving in the simulator could. As far as my favorite car in the simulator, it really depends on what I'm what itch I'm trying to scratch. If I'm trying to go as fast as possible, it's the promosda, which is not the fastest car in there, but obviously formula cars are much faster than closed wheelcars. And, you know, they do have a formula one car in there.

I think they have the MP430. It's just still too fast for me. So even though it's a faster car, the things outrageous. So the, but the promosda, like, I'm getting to the point where I can drive that car relatively close to its limit, probably within one to two% of its limit as far as closed Wheel cars It depends like relatively aggressive and not that difficult to drive closed wheel car in there But it's it's amazing how fast it is is the Ferrari 488 GTE It's a beast and I like the roof 911 which is actually really hard to drive

But it's so freaking powerful. And it's like, that's a car that will punish you. Just punish you if you make a mistake. And there's something, you know, if you're going to get punished, I'd rather get punished in the simulator. So it's nice to learn that. But honestly, like, you know, even driving a Miata in the simulator is still a blast. Cars are just fun to drive. So there's one more question related. It's as curious what your choice of daily driver is. It depends on what one's optimizing for, I guess. Grossaries?

Yeah, exactly. If you're optimizing for groceries, for being able to pick up your kids, I used to drive in E92 M3 and that was amazing because it had such a bit, it had a big enough trunk that if I took both wheels off my bike, I could put my bike in my trunk. And that was essential when I was like riding my bike a lot because, you know, three times a week I'd be training at a remote location where I had to take my bike. So, you know, to have a car where I could easily move my bike was a given.

You know, fortunately if there's one thing that driving an race car has done is it's made me less of a knucklehead driving on the street, so I don't feel quite the need or the desire to drive or stop. Yeah, exactly. I thought you were setting me up. They were going to high five. Top gun. You know, they're filming a second top gun, I'm told.

Miss on the top hit on the bottom. That's the only way to do it. I, the word on the street is they're filming top gun too. I heard that. Yeah, yeah, I can't wait to see ice. Man. I love 9-11s.

I think they are great. I think no car really combines the practicality of you can drive this car every single day and it's really fun to drive. So it's like I call it sort of a civilized beast. So you mentioned putting the bike in the trunk of the car which kind of gets to exercise. You got a bunch of questions about your exercise and exercise in general. So let's go with your exercise in terms of this is a question about open water swimming

The question is knowing what you do now How would your preparation for those long open water swims Have changed still as many hours in the water prior to a big event would your feeding strategy be any different? Yeah, I probably would have still spent the same amount of time in the water but that's because I was not a natural swimmer and You know, I was still at a point where even just basic stroke mechanics were not automatic. So, you know, if you remember I talked once about this idea of being unconsciously incompetent, consciously incompetent, unconsciously

competent and unconsciously competent, I never got to that fourth stage, so I would vacillate between stage two and three. So I think, you know, I probably just needed the time in the water. That said, I would absolutely be feeding a lot different than I fed. At the time, I was feeding exclusively on, oh, what the hell was it called? Well, one of the, I used hammer strength, hammer perpetuum, I think it was called not hammer strength. That makes the gym equipment. I thinkuum, I think it was called, not hammer strength. That makes the gem equipment. I think it's called hammer perpetuum, which was probably the least bad of the high-carbie fuels.

It was multi-dextrin-based. Then I used something that began with a C, like, cyto-mix. Cytomix is a thyroid hormone. I didn't use that. Yeah, I think it was called Cytomix. And I would supplement, I put some stuff in it. I don't remember. Oh, I would put in, no, I would, there was a drink in the UK called Maxim that was a flavorless multidextrin. I would add that to,

I would vacillate between the hammer, perpetuum, and the Maxim spiked cytomax. That's what I used to use. And I think what I would do different today is I just wouldn't be a high carb diet. I would be a highly, highly fat adapted, totally different strategy, and rely as little as possible on glycogen

for what I was doing. So when I was swimming, my RQ was probably 0.85 to 0.9 most of the time. So meaning I was relying more than half of my energy requirements were coming from glycogen or glucose. And by fat adapting, I'd like to, you know, have done those swims at an RQ of 0.75, which would dramatically decrease my requirement. I would probably then instead be using generation you can, I'd probably use a bunch of bio-steel as well. I think that was something we weren't paying enough attention at the time to the importance of branch chain amino acids. So that's probably how I would change. Now I'd have to

sit down and do the math and experiment at what amounts I would need, but I would probably do, yeah, I could think of two different ways I'd experiment with it. One would be doing more concentrated, less fluid requiring, especially on the cold water swims where you're not getting as dehydrated and then minimizing the feeding. Because I used to feed I think every 20 minutes, and I'd do about 250 CC every 20 minutes. And I might change that. I might have gone that. I might have knocked that down to like 250 every 30 minutes at a lower concentration of, you know, alternating you can with the bio-steel or something. This is a naive question, but how do you refeed and drink while swimming?

So it depends on how fast you're trying to go. If you're trying to really go fast, so you have a kayak on the side of you and you're swimming. So if the kayak's on your left, when your right arm is in front, you arch over and you with your left hand, grab a bottle that's on a carabiner on a rope, and you flip on your back. The bottle's already opened, you chug it, and drop it,

and rotate and keep swimming. And it should take about seven seconds to do that. So that's if you're hauling ass. If you are exhausted and you need a break or you need to also pee, you just stop and tread water and grab it and do it. But you can't touch or be touched by the person in the kayak Or the boat or anything like that. So that's why the We would use these bottles with loops and carabiners and ropes and we had a big elaborate system And in other swims where I didn't have a kayaker We built this pole long-ass pole that had a little cup at the end

He's like a fishing pole? Yeah, exactly. And they shimmy that thing out from the side of the boat. For the pole, you couldn't do the rapid feed. It's just too many moving pieces. But the rapid feed, you'd be taking the kayak or would be standing in the kayak with their arm out to their side perpendicular to create the most distance so you could come up and grab it. I really loved practicing that.

That was like my favorite little ninja move. Interesting. It sounds a lot different than the, at least when I watched the Tour de France, they called the Musettes and the slings. The danger there was that the people would stand in the middle of the road, the peloton going by, and it was like a magic trick. You would just see it would be gone and whoever carried the sling would carry the food and carry the food to all the different people, but that's a different ballgame.

Yeah, that's real skill. So what do you do for exercise these days if you're not open water swimming? I still lift weights three days a week. That's kind of like the one staple thing that is not negotiable in my life. So no matter how busy travel gets or wherever I am, it's I'm always gonna be in the gym sort of Monday, Wednesday, Friday, lifting plus or minus some metabolic conditioning thrown

in there depending on, you know, what else is going on. These days I am on the other four days, the Tuesday, Thursday, Saturday, Sunday, I'm riding either the Peloton or the Wahoo Kicker, which is like a trainer that you put your bike on and hook it up to something called training. No, I ride trainer road, actually, as the program that then generates the workout. I have not swam, except for a month, where I started swimming again in February of this year. I have not really been in the water in a year and a half,

which feels really odd, given how much swimming was sort of everything in my life for so long. That's probably one thing I'd like to figure out a way to reprioritize is to get back in the water even twice a week. I miss it so much. And I think there was something,

yeah, there's just something in my body, misses about that. I also there was something, yeah, there's just something in my body misses about that. I also had picked up running again probably three years ago and really started to enjoy it again. It took a year to start enjoying it again. It was that painful for the first year. And then once I started to enjoy it again, I really, I got the itch to, hey, could I maybe get back to running, you know, a 5K under 18 minutes or something like that. But then, I just got distracted and that's when I got back on the bike.

The bottom line is I don't actually train, I just exercise. I don't actually do anything that's impressive. I just do my little putts workouts. I also spend a lot more time on movement, perhaps. So, I take the sort of flexibility movement correction stuff a lot more seriously than I ever did because I've sort of seen the impact of that on injury prevention and the absence of that

on injury generation. And you've never done a triathlon, is that right? So you mentioned run bikes, why? That's right. I've done all three of those things at one period. I mean, I was a pretty decent runner in high school, a pretty decent cyclist, probably during two periods of my life, at least as a time trialist, and that's really cool to what a triathlon is. And pretty good open water swimmer. So, yeah, in theory, if you could have taken me from three different chapters of my life,

I could have at least done a triathlon. I don't know that I could have ever done it at the level of the guys who are really good. I mean, I have friends who are in the eight to nine hour Iron Man category. I don't think that's even theoretically a number I could have hit. I'm not even,

I remember one day sitting down and really like going through like what I thought physiologically could be done. I wasn't even sure if I convinced myself I could break 10 hours for an Iron Man. And again, I think when you're doing an Iron Man, I think for many people the goal is just to finish the thing, not to break 10 hours. But when I see these guys out there that are breaking 9 hours on Iron Man, especially people who aren't professional athletes, and I have friends that are at least two friends who have broken, maybe three friends out, I think about it, who as non-professional athletes have broken 9 hours on Ironman. I mean, total awe of that. That to me is a remarkable achievement. The distances are, you're running a 26.2 mile path.

Yeah, you're swimming two point four miles, which is that's a rounding error. You can't win the race in the water, you can only lose it. The bike is 112 miles and then the run is 26.2. Looking at exercise in general, a lot of people ask, what's the best exercise for longevity?

What is the best exercise to improve muscle mass? And can you expand on lifting weights? Your entire life is something you should never stop doing. So exercise for longevity, exercise to improve muscle mass, and expand on lifting weights. I think the exercise for longevity is a hard question, because I don't think we really know the answer. So instead, it's probably easier to

bifurcate it into two questions, which is exercise to improve lifespan and exercise to improve health span. So how does exercise improve lifespan? Well, I would have to somehow positively contribute to the delay or to delaying the onset of atherosclerotic disease, cancer, neurodegenerative disease. I think there's plenty of evidence

that suggests that exercise is beneficial in all of those arenas. And then I think the question is through what mechanisms, so that you could then go from saying exercise to understanding specifically what it could be. So, you know, cognitively, we probably see some benefit from a certain subset of hormones, right, that basically, you know, does BDNF, for example, increase with exercise,

and what is the impact that that's going to have on brain health? On the cardiovascular front, and also on the cancer front, my guess, and I think this is true on the dementia front, I think that anything that exercise those that helps you dispose of glucose more efficiently and helps your muscles become better sinks for glucose is probably going to improve things. I think taking that off the table, because I think that's sort of the one given, the question is, are there benefits on the cardiovascular system specifically for an exercise that go beyond that? I think the answer is probably yes.

Like everything, there's a dose. You can also probably exercise too much. And there's probably like all complicated questions. There are people who are more susceptible and less susceptible to the effects of too much exercise. There are people who can get a certain dose of exercise provides all they need. But that said, I think even more of the benefit of exercise is on health

span, meaning enhancing the quality of life, and that's cognitive, but also physical. I think too many people confuse health span and lifespan, and you hear too many people say, I don't want to be old because, you know, I don't want to, you know, be decrepit and et cetera, et cetera. But to me, that's sort of like an odd statement to make. It's like, why wouldn't you want to be old and be fit? And don't just accept that getting older means not being able to do things. So at about the age of 40, it starts to become much harder to maintain muscle mass if you're not deliberately doing something about it. And so that's why I would say lifting weights is probably the single most important thing

you can do because I think that muscle mass, as you get older, becomes an enormous difference between people who are frail and people who are not. And other things matter, of course, certainly bone density and things like that matter and getting into how you can optimize those things is beyond the scope of this question. But even within lifting weights, then I would say that rule number one is don't get hurt. So you see a lot of people, especially younger people doing things that they don't need to be doing, even I've adjusted what I do relative to what I used to do, just based on the trade-off. I use a hex bar to deadlift instead of a straight bar because frankly it's a bit easier.

It's easier to use my glutes and I feel like I'm much less likely to hurt my back. Are there benefits of a straight bar over a hex bar? Sure, but the benefits to me aren't worth the risk. When I back squat, pretty rare that I'm going to go over 275, even though as a high schooler I would put four plates on that bar. But again, I don't power lift, I'm not competing, nobody cares how much I lift except me, and I'm not even sure I should care that much. I've taken a very different approach. I don't overhead press at all. I only press with dumbbells now, not barbells, even when I'm doing any bench or inclined

bench or anything like that. All of my overhead shoulder work is now stability work. Everything that's going to work shoulders below is done below the shoulder. That's how a huge impact on my shoulders. They're just, and they're totally fine. You know, so you have to learn to make compromises as you age, but you shouldn't, at the same time, you shouldn't compromise the expectation

that you will be strong. You should be able to walk through an airport and carry 250 pound bags if you need to. Because if you can do that, if you're already struggling to do that in your 40s, you're gonna have a really hard time whipping your grandkids around when you're in your 70s. So it's sort of like, how do you minimize how quickly you're going to decline? We went over wearables, but just for the record, what wearables do you use?

That's the other question. You've mentioned wearing a glucose meter. What devices are out or on the horizon that you'd recommend for more instantaneous feedback than just a scale? I think we got the answer on the CGM. And how well does the Aura ring hold up doing pull-ups working with barbells dumbbells? Do you use something else for tracking while training? So going back to the CGM thing, there are really are three out there. There's DEX comms, there's the Libre by Abbott, and then Medtronic has one.

I don't think anybody's really using the Medtronic socially, so it's mostly the dexcom or the Libre. The Libre is cheaper, I believe, and it doesn't require calibration, but other than that, I find it not helpful because, as I said, in our hands, both individually and with patients, I think we're seeing accuracies

that are plus or minus 20%, which I just think is, that's not good enough. individually and with patients, I think we're seeing accuracies that are plus or minus 20%, which I just think is, that's not good enough. The Dexcom G5 was about plus or minus 7%, the G6, I think, is probably plus or minus 3 or 4%, it's so accurate. And of course, the challenge is, it'll be a long time truthfully before these things are cheap, because right now they're not really being targeted towards a consumer market. They're medical devices. And so, the economics of these things are very different.

They're going through a huge regulatory burden. I mean, the FDA really scrutinizes the way these things work for understandable reason. Because if you're going to have a patient dose their insulin based on this thing, it's got to be exceptional. My hope is that in time, as the demand for this and the public increases, they're become second-tier versions of these things that it's complicated because, of course, the thing the FDA would always be concerned with is if we allow a less robust version of this to go on the consumer market, will it invariably end up in the hands of people who actually

need the more robust version and then make the incorrect diagnostic choice? That's the thing that would keep you up at night if you were doing this. So again, that's just beyond my pay grade to figure out how to solve those problems. But I certainly hope that there's a day and it's probably four years, five years from now, when the CGMs are really tiny, you guys basically the size of a contact lens, it's a tiny patch, it's a 400 to 1000 micron needle that you just smack on your belly every day and you just dispose of it in a way it goes. As far as the auroring, I think I've tried every sort of sleep device out there, and I just don't think any of them compared to the auroring in terms of its accuracy. And I just don't think any of them compared to the aura ring in terms of its accuracy. And in part that's because it's measuring off an arterial waveform and I think they're

hardware is better and stuff like that. The only activity I have found that I have to take the ring off for is deadlifts. Because most other things aren't, you're not putting that much weight on it. Like even if you're to pull up is only your body weight. Even if you're doing a pull down, like if your pull up is only your body weight, even if you're doing a pull down, like on a machine with more than your body weight, it's not at least unless your bob, that's not that much more than my body weight.

You might not be able to wear one with your pull ups or with your pull downs, but I cracked one doing deadlifts. So, and I think that's just cause it's just sitting right there. But most other things, like even with heavy dumbbell presses, it's not really where the weight sits. For me, your finger is actually above the weight and the weight is being rested on your palm. So I can't think of another exercise I do.

Oh, if I hit the heavy bag, I'll take it off. So I've got another bucket here. Going to keep going? I got a little bit more juice left in me. Does that mean we're not having fun? I was worried that we would spend way too much time on this and a lot of the stuff here too. We can get into all the, some of the other topics too that would require another two hours

per topic. This one could be one of those, although we might be able to do this. Thinking about thinking, learning about learning. So there's a few questions here. What is your strategy for learning something deeply? Yeah, this is like a better question for Tim Ferris. I mean, Tim's codified this stuff. Do you have a particular strategy or how does it go?

Is there something you want to know about? I only know one way to really learn things, which is not necessarily efficient, but it's just basically total immersion. It's probably not an accident that when I wanted to learn how to swim, I went to Terry Lothon and learned to swim via total immersion. When did you learn how to swim? When was that?

It was 31, 2004. So when you got into open water swimming, when you realized you wanted to get into open water swimming, you didn't know how to swim. Right, I had to learn how to swim. Okay. It was a necessary condition. So I remember in 2011, when I became, maybe 2010, 2011, when I became really interested in lipids, just basically realizing, looking at my family history,

I'm probably gonna die of heart disease. That's sort of how almost every male that I'm related to has died of heart disease. So, I knew enough to know one, I probably don't know the answer. And two, I should learn about this. And that's when I met Tom Daye Spring, who became my first teacher on this topic.

And since that time remains unquestionably the greatest mentor I've ever had in this space. And I've also got to know guys like Ron Kraus and Alan Snyderman and Jamie Underberg. I mean, I could just rattle off the names of all of these guys, Tara Dahl. They've all been incredibly gracious with their insights in their time,

but yeah, the approach I took was just like, give it to me all. Don't try to give me the cliff notes. Just, I'm gonna frickin' learn it. And at one point, even contemplated going back and doing a fellowship in lipidology. But of course, the problem is I couldn't as a surgeon because I had to go back and do internal medicine.

You know, I would have to go back and spend two years doing internal medicine. I'd only get one year credit for surgery and all that stuff. So I realized, no, I don't need to become a lipidologist. I can just learn what the lipidologist knows. So it's reading papers, it's watching lectures. But in many ways, your learning comes from doing. So I think some of the most interesting things I've learned have been a privilege of just

taking care of somebody. So you see a complicated case. Some of my most interesting lessons have been reviewing cases with Tom or Ron or Alan. You know, I went out to visit Tom. I remember once about two years ago for two days and all we did was review cases for two days, and all we did was review cases for two days, and every time we saw something that was particularly interesting, he would like, because he's Tom, just bust open a lecture on that entire topic, and then we dig super deep into that

stuff. So, I think that's just kind of the way I learn, you know, same sort of approach with trying to learn the hormone systems, and learning to drive a car or for that matter or whatever it is. It's sort of like you just got to get at least for me. I don't think I'm a particularly efficient learner. I'm a brute force learner. You revealed something.

Tim's probably talked about this. That if you want to expedite your learning, find somebody who's basically already done exactly what you're saying. What is your strategy for learning something deeply You basically grab the person who's probably learned this stuff at the deepest level and you don't let go You try to extract as much information as possible from that person who's already done gone through the process of trying to learn whatever the topic is Very deeply. I think that's a especially of their way of teaching resonates with you. Math is complicated once you start to get outside of the basics of calculus

and algebra. And I just remember there were some professors that they just had a natural way of at least the way they explained something was the way I was wired to hear it. And then there were others who were brilliant but I didn't have a goddamn clue what they were talking about. Like I could never really learn from them. So part of it was just knowing how to pick and choose your shots and like, who are the people that are going to be, who are going to resonate with you? And it's not necessarily the person who knows it the best. It's a person who can teach it the best, at least during that phase. And then maybe as you get further down, like I don't think anybody could have done for me

what Tom did at the outset, because I just don't think anybody has put that much thought into teaching lipidology in the world. I mean, I really mean that. Now that I've been at this for quite some time, I don't think anyone on the planet has put more time into teaching and educating and codifying the insights of lipidology

and the science of lipoprotens than Tom Tasebring. Now, there's surely somebody out there who knows more than Tom about this stuff, but I can't imagine there's anybody who's thought more about how to teach it. So, it's just luck. I mean, just purely luck that I could fall into, you know, sorts with a guy like Tom and others like that. Well, I think it's could maybe call it the

reverse Feynman, but Feynman talks about how to learn something and it basically comes down to being able to teach it to somebody who doesn't understand it. And you've kind of taken the inverse in some ways too, where you look at teachers and it doesn't necessarily matter what their level of understanding is of that topic. If you're not clicking with that person and it doesn't seem like you're extracting much information, whether you're not a good student or that person's not a good teacher, I think you're relatively quick to say there's more stuff out there that I could probably latch onto.

And like today with the internet, it sounded like about a hundred years old And like today with the internet, sound like about a hundred years old, but like with the internet, but you go on YouTube, you can download lectures of all these different people. With the Google and the YouTube. With the interwebs, the twitters,

with all the GBS and the Wi-Fi. The problem is, you know, it's too much information. So part of it is like trying to figure out the person teaching this to me, do they know what they're talking about? Hopefully they do. But then ultimately, you have so many different avenues and so many different venues in terms of media.

If you can you listen to it or do you read it or does somebody face to face, does somebody teach it to you? Where I think the answer can be kind of customized to whoever asked that question about your strategy for learning something deeply. I don't think there's necessarily more than that. Well, there's another thing I've done, which I'd be remiss to not mention is you at some point, I've just hired people to help me learn. I mean, that's what you lead is a group of people whose job is to basically help me learn. It's to, it's to basically help me learn. It's to basically shortcut the system and cheat by saying,

Bob, we have got to know everything about IGF, IGF, BP3 and growth hormone. I don't have the time. If I'm going to learn this in detail, it will take three years. If you're going to learn it in detail, it will take three months. I may never actually get to know it as well as you, because you will have done all of the heavy lifting and you will have turned tens of thousands of pages into 50 or 100 pages for me. And I know having been the guy that once made those 50 to 100 page synthesis that the devil was in the details

and I had so much nuance around it, that I will now give up. But in an effort to to geometrically increase knowledge, that's probably a price I'm willing to pay. So that's let me turn the question to you since you have more experience doing this now than me. When it's here calls you and he's like, Bob, dude, we got to know everything about X. What do you do? Some form of total immersion. What I typically try to do, I'm trying to think of some of this stuff, like Tom Fordy is a good example. Yeah, so that was about six, a year ago we had to know everything about Tom Fordy and its

relationship to ApoE4. And I knew nothing about it, and I still, there's probably plenty to learn about it. But a lot of times what I'll do is I'll try to find either a paper or a usually a paper because lectures are actually usually simpler to understand. But something that's kind of complex and I read it and just go. And do you specify like a review article that you want to start with or do you want to start with primary research? I typically I'll go to a review article that's covered all the stuff that's relatively technical and I'll read it and I won't understand, I don't know, 90% of it or something like that. But part of it might be just the mindset or the mentality that I think like, wow, this

is going to be great when I know all this stuff. And then I try to immerse myself in it. Probably it's like a combination of stuff. YouTube, the lectures, if you can find, this is one of my hacks, I think, though that's kind of a pejorative, I would say that I've learned that some of the best researchers, when they give talks, they're not necessarily speaking to their colleagues and just geeking out on this stuff. They have to explain it at a lower level. And so I'll watch something, I'll try to watch like the simplest or the easiest

stuff for it's way oversimplified. And I'll watch that lecture and I'll pick something up and it's probably like learning a lot of things, whether it's a sport or an instrument or things like that, that you maybe it's like a little dopamine hit or something that you pick up something and you feel like you're actually learning something and you you can now read a sentence in that deep review paper or one of the experiments and you actually understand what it actually learning something, and you can now read a sentence in that deep review paper, or one of the experiments, and you actually understand what it means now at some level. And then I'll try to find a great book on the topic, which for Tom Fordy, I don't know if there is one.

All those of you out there listening, looking for a book to write, it's the Tom Fordy story. Yeah, so. Two M's. So usually, most other topics, you usually be able to find a good book and something that's like a relatively fast read. Sometimes you get very lucky and Sid Mokrji writes

the biography of cancer and you want to learn about cancer and you feel like you're reading like a novel but you're actually learning. Like the best kind of learning is like you don't even realize that you're learning. It's just like, it seems like it's entertaining. That's probably why sometimes I gravitate to some of the YouTube talks and the people who are good at teaching those things.

That's sometimes why when I ask you for a short overview of something, you send me a hundred and fifty four page document on it. Yeah. And it's probably a sign that I don't understand it all that well. That's the mark-twain quote that you sometimes talk about. If I had more time, it would be a shorter letter, so to be able to synthesize it and condense it is a challenge. So, I guess being very specific now that you hear you say that, it reminds me of other

tricks that I would use. I definitely like to start with the most recent review article on a topic. I never want to start in the primary literature because it's too narrow and I want a larger overview. So, for example, if tomorrow I decided, if I didn't know anything about LP. And I wanted to start from scratch, I would go into PubMed and search LP. If I was lucky, I'd know who the players in the field were. But generally, by looking at the citations, you'd pretty quickly figure out Sam Temecas is God, and then I would look for the last three review papers Sam Temecas has written on the topic.

I would start by looking at the figures. Once you understand the figures, you actually know what's going on, and then from there, I would go. And of course, the other thing I do is I'm just kind of a pushy little prick sometimes. Like, I just don't hesitate to reach out to people. You're the same way. Like, every week you're emailing the author of some paper. And honestly, I think that they never view it as pushy even though we feel like, oh, are we being too obnoxious by bugging them? But the reality of it is, they love it. This is their life's work. There's like one other geek out there who wants to know everything about their life's work. Have you, I don't recall

you ever getting a response to one of your emails where someone says, piss off? No, I mean, sometimes I may not get a response at all. And I just, I figured some of these people are massively busy, but otherwise, it's the opposite. Overly, helpful, you think, wow. So that's another shortcut, right? It's like, okay, you figured out who the expert is,

you've read the review papers, you've got the 80-20 view, now you look at the experts to help you get the last 20%. Now you want to go 20-80. Yeah, and for me, it's different than, say, my wife who's a journalist, she doesn't mind not knowing a lot about a topic and just finding an expert, grabbing them and asking a lot of questions. I think this is like, it's my ego, maybe gets in the way or something like that. I don't want to talk to Sam, I don't know if he's gonna say

his name right, to Mekis, until I feel like I have a pretty good grasp of what's going on and this guy's not gonna think, what an idiot. But the reality is he's probably not gonna think, wow, what an idiot. He's probably thinking like this guy's taking an interest in this topic. It's really interesting, but that defense mechanism,

I think, maybe has helped me in research in some ways where I think I really want to know my stuff before I contact the researchers, but then when you do, they'll usually give you more insight, better insight, and a different way of looking at things. And even with the papers themselves oftentimes, when you talk to the author, you get a different perspective, even from you read the paper. Absolutely. You read the paper, but they tell you about all the sort of like how the sausage is made

and the things that they had to take out of the paper because maybe they didn't have enough evidence to support it or the editors were like the papers too long. You got to take this out. Yeah, you're going to get a much more interesting story. Yeah, I don't know if that was helpful, but I think part of it is you really, whatever it is, you really want to have to, you have to buy in, I think, as well. Because I think a lot of people are looking for a shortcut, maybe, but a lot of what you're talking about, too, with exercise and research and things like that, where you get immersed

in stuff, like it's sort of carry water, chop wood, and don't stop. Just do it relentlessly. I mean, you know, it doesn't have to be burning the candle of both ends necessarily, but it just has to be continuous and relentless and you have to keep moving in one direction, I think, and you can take a bunch of different approaches, but you really have to wanna learn the stuff.

There's just so much information about virtually everything that you would wanna know. You can get like a free education that's probably better than any education that was out there, other than the people that you can want to know. You can get like a free education, that's probably better than any education that that was out there, other than the people that you can meet and talk to and I think that that's huge. So this is sort of the flip side,

and your life to date, what did you waste the most time doing and what do you wish you'd done with that time instead? This is gonna sound like a shitty answer and a cop out, but I really mean it. It's not any activity or thing that I've done. I don't regret all the time I spend boxing and doing martial arts, even though you could argue that I'm worse off for the concussions.

I mean, I had some bad ones. I had one really bad one where I was hospitalized and I'm convinced I'm 20 IQ points lighter than I should have been as a result of that. And it's so easy to say, well, I, and I have a time's thought, oh, God, I wish I, why didn't I just play basketball instead or something where I didn't like get brain damage. But I don't because I know that boxing without boxing, I could have never done what I did after. You know, I could have never gone to college without it in terms of the discipline it taught me. after. I could have never gone to college without it. In terms of the discipline it taught me. What I really regret is the time I've wasted thinking about things I couldn't change.

It's the amount of time and energy I have wasted on things that don't matter. And I don't mean that in activity. I mean that in dysfunctional emotion. you know, it's the amount of time I thought about that ex-girlfriend and you know, for a year pined over her and wondered, you know, why she dumped me or something like that instead of just moving on, you know, or the amount of time that I spent pissed off at that person who did something bad to me. I actually think that that's the shit we have to be guarded against. Did I watch too much TV as a kid? I don't know, probably not by today's standards,

but yes, I've thought many times, I wish my parents forced me to learn six languages when I was a kid instead of letting me do any dumb shit like playing with firecrackers and running around the neighborhood or whatever. But you gotta be careful with those things. Maybe I'd be a different person today if I'd been raised in an environment

where my parents were constantly forcing me to be hyper-efficient or whatever. So yeah, look, I wish there were many things I had spent time learning that I didn't learn, but at the same time, I'm not sure I'm willing to give up the six hours a day, six days a week I put into training when I was growing up. But I think I've wasted way too much time worrying about things that don't matter, worrying about things I can't change, and not spending enough time

in the present with the people who are sitting right in front of me, who matter. That's probably my biggest regret on that front. What impact did you're upbringing having your insane career path? Slash constant drive. Oh, this is a tough one. I don't know if I can talk about this shit publicly. I think I would just say this. I think I am fortunate that I found largely productive outlets for my obsessions

and my numbing of pain, which I think everybody has. And so all of these, all of the things that have impacted us in those way are largely two-edged swords. I think things happen to kids that make them want to be special, make them want to be better, and sometimes that gets channeled into doing things that are ostensibly bad, quote unquote, or ostensibly good, quote unquote. I don't want to discount the positive effect my parents have had on my life because I

think it has been positive, but unfortunately, I'm also aware that much of my drive is probably unhealthy and probably stems from unhealthy events that, yeah, I don't really want to talk about. So this one's related to thinking, I'd like to know what your process is for forming your beliefs. There seem to be a lot of narratives slash absolutes that people get stuck on in the nutrition world and really miss the quote, it depends end quote part that you seem to have. I don't know if I can attribute this to Feynman, but certainly some one I admire has made the point that most facts have a half life. So I think that's kind of the first thing you have

to wed yourself to is there's a chance that what I think I know today won't be true tomorrow. And you just have to keep that softly in your mind. You don't have to like wake up and berate yourself with that fact every day, but you just got to softly remind yourself that, look, I think this is true. I may have mentioned this on a podcast once before, but in mathematics, there are proofs. But in biology, there are no proofs. You don't prove anything. An experiment proves nothing.

And this something Feynman has stated very eloquently, actually tweeted it a couple of months ago. Something to the effect of all we do in science is basically increase the probability that we believe something is actually true. But there's no definitive proof of anything. I mean, even frankly, you know, Newtonian physics, which seemed all but said and proved until relativity came along. I mean, it's all probabilistic. and it's all probabilistic. So I think if you just show up with the mindset

that says, look, we're looking to increase our knowledge by gaining confidence in the probability that certain things are true or not true, you just get a little bit of the humility that says, yeah, I gotta be ready for this to not be true one day. And look, there are things I believed five, six, seven years ago that I still believe are true. And there are things that I believe then that I don't think are true. In all cases, I think I've just appreciated more nuance, more exceptions

to the rules. And I think the other thing is, this is something I think we have the luxury of doing by the nature of the way that practice is set up is It's primarily like a knowledge acquisition grab so We're kind of not wedding ourselves to the notion that we are we have to be right we're wedding ourselves to we want to know the most And I talked about this. I think I'm the podcast with Patrick Ashana C. But if you think more about how can I know the most, rather than how can I be right the most, I think that also takes a little bit of the edge off.

My brother actually has a relatively recent movie, but remember Charlie Wilson's war, there's a scene near the very end when the Americans are happy and obviously the Russians have retreated and now the question is what should the US be doing to support Afghanistan? And Gus is making this point and I'm going to bastardize this. Hopefully we can find the clip and link to it. You know what I'm talking about? Where it is telling the story about the boy gets a horse and everyone says, oh, so good for the boy and Gus goes, it depends.

And then the boy is on the horse and he falls off the horse and he breaks his leg and everyone's like, oh my God, it's so sad. He's like, we'll see, right? And then there's a war that comes and all the boys have to go off to war except the boy who broke his leg and all the boys that go off to war died. Everyone's like, oh, it's so great.

Oh, wow, wow, wow. We'll see. And the story keeps going. I don't want to say anymore because I've already probably screwed it up 10 ways to Sunday. But I just love the approach of like, we'll see. I mean, we don't really know shit. And we certainly don't have a crystal ball.

I mean, which is not to say I don't have conviction about certain things. I have conviction about a lot of things. And the challenge of medicine is you do have to make decisions. So you don't always have the luxury of saying, we'll see, we're going to do nothing because there's a risk of doing nothing. And so when I have patients that say, Peter, I don't want to do this because you can't give me a 100% chance that it's the right decision.

I say, that's fine, but I have a much higher belief that if we do nothing, the outcome is this, and that's worse on a risk-adjusted basis than the outcome of doing something, even though I can't guarantee you it's a perfect outcome. And that's maybe a bit cumbersome in concept, but I think that's an important thing to keep in mind as the other end of this is you don't want to be paralyzed in your inability to make a decision because of uncertainty. If you need absolute certainty to do everything, you have to play checkers. Or chess for that matter. And as important as a game as chess is, in the end, it doesn't mirror life because you have complete knowledge at all the time.

At every point in the game, both players have complete knowledge. In many ways, poker is a better example of life because you never have complete knowledge. Yes, the probabilities can help you. And there is difference between good players and bad players. Those who understand the probabilities, those who don't, those who, but more importantly, it's like what can people read and not read? And I think the analog in life is not about necessarily reading people, but it's about being able to think about data when there's an incomplete set. I think a couple of fine-man quotes, first principle, because you must not fool yourself, and you're the easiest person to fool.

And then he once said that his definition of science is the belief and the ignorance of experts. And I think sometimes people use that as like a tool to wield against, you know, any, anyameek is out there who knows everything about you know doesn't know everything but knows a lot you can just be like well you know fine and says. You're ignorant. I always turn that one of myself and think like i'm trying to learn about this stuff but like never forget your ignorant there's a lot that you don't know and one of the things that. And one of the things that is apparent to me, at least when you think about it, is that as you get older, and if you've been in a game

or you're trying to learn a lot, or you're trying to grow or better yourself, think back to five years ago on some topic that you've learned a lot about. So I imagine if you think about lipidology and you think back to five years ago and think, I knew nothing about that subject or something like that. But a part of you, five years ago, thought, well, I know way more about, you know, if

you're ego gets in the way, you think like, I know way more about this stuff that I'm going to start saying things with, you know, platitudes or certitudes about my confidence in what I know. But I do think like nutrition just lends itself to, you can be so sure of something because you can never really be proven right or wrong if you're gonna be using epidemiology. It's sort of like you're kind of right, you're kind of wrong but you can never really be proven wrong necessarily

so it's pretty easy, I think, to go out on a limb, so to speak and say something's really good or really bad and you can gather all the information. You can collect all the confirmation bias you want. And it's going to be really hard to disprove your theory. If it disagrees with the experiment, it's wrong. The fine-mances. That's like who?

You don't do experiments. Yeah. And you need to, we'll probably link, I mean, to Feynman and his New York Brooklyn accent is unparalleled. We've got a couple of questions about your diet. Why did you decide to discontinue your ketogenic diet? What differences in your health and performance have you noticed since? And what does your diet look like these days?

Well, I, um, I discontinued a ketogenic diet after three years. In the moment when I discontinued it, it was basically like I was just missing my all singing, all dancing, famous Curry Star Fry, which was like probably my staple meal in college and med school and throughout most of life. That was like probably my favorite meal. And so on a bed of rice,

I would put this huge curry stir fry that had like all of these awesome vegetables and very spicy and blah blah blah. But you know, you couldn't eat that in ketosis even without the rice because just that volume of vegetables would usually boot you out. And certainly with the rice you were going to be gone. And I was just kind of like, you know, I just missed this. I just need to start eating this again. Also, I was kind of missing certain fruits. I felt like I was just like not, again, I didn't feel like I needed them from a health wise

perspective. I just felt like I just missed them. I enjoy eating these things. I haven't had a banana in three for 10 years, except for the hot one, you know, or something like that. So it just, for me, it was just, that was what it really came down to. And, you know, I think the impact of leaving, you know, different people have different responses

to a ketogenic diet. I think some people, at my end of the spectrum, respond as well as anyone can respond. I mean, for me, it was, I mean, it's hard to articulate, right? I mean, on every dimension, things just got better. I mean, my mental clarity, my resilience, my biomarkers, my performance eventually, it did take a while. I certainly took a step backwards for the first three months, then regain mostly aerobic

function. It was probably 18 months before I surpassed an aerobic function. And I was actually with Steve Finney last week, and we were talking about this that I really regret not taking muscle biopsies throughout that three-year journey. I think that could have been quite insightful. But I also know having now put people on ketogenic diets

and been around a lot of, you know, people on ketogenic diets, that I was about as good a responder as you're gonna see. And there are others that have responded as well as me, but there are lots of people who don't respond as well. And so, going back to the previous question, I think that's where you have to have a little bit of humility, which is no offense to the keto community out there who I'm probably

pissing off at the moment. But I'm highly put off by this view that ketosis is for everybody. And if you try a ketogenic diet and it doesn't work for you, well, you screwed it up or something. And it's just like, that just strikes me as patently false. So anyway, that, I don't know if I answered the question, was the question, what it, okay, oh, then the other question is, what do I do now? Now, I mostly vacillate between time restricted feeding and non time restricted feeding with a much simpler set of principles on how I eat, which is just try not to eat junk. So I don't really restrict my carbohydrates deliberately at all anymore, which I know is going to sound

crazy to people listening to this, but I just restrict bad carbohydrates. And as a general rule, if it comes in a package, it shouldn't be eaten. So like the weathens. There's no rule for weathens in the diet. Right? Graham? Sure. There's a weathens tree somewhere. It's our paleo ancestors. Were you there? Were you there? Are you sure there wasn't a tree? You know, it's a very good point. I wasn't there. It's quite possible that weathens grew on trees with Graham crackers. My favorite, my go to starches, you know, I definitely

like potatoes and I definitely like rice. And I probably will, you know, if there's seven days in a week, I four of them, I'll be eating those with at least one of my meals. So yesterday, I usually, I'm not eating breakfast still. So yesterday, I woke up, you know, I did my morning routine, rode the peloton for 45 minutes, had, you know, made made my coffee, my special fancy coffee after that, and puts it around and worked, and whatever did all my sawpations did this thing. The other thing came back to my apartment at 2, still had an eaten, and then made a shake. So I make this shake called the Peter Kaufman, which I wrote about on the blog like six years ago, which is a little bit of heavy cream, almond milk, frozen strawberries,

spoon of almond butter, and then a you can protein, chocolate protein, with a ton of ice. So it makes, we're going to have one right after this by the way, and about five minutes. So, I hope you're salivating for the Peter Kaufman. And so that's a pretty high fat shake where the only carb you're getting is the superstar, to which basically doesn't act like a carb. You obviously get some in the almond butter and there's virtually none in the frozen strawberries. And then that evening, yes or evening,

so I didn't eat anything else the rest of the day. Obviously, you know, I had like water or something like that. And then in the evening I went out for dinner with a friend and we went to a Greek place and, you know, I had a smoked salmon appetizer. It did come with like little pita chip breads, which I didn't eat, although in truth, I will often eat those because I freaking love them,

but just yesterday I didn't feel like eating them. And then I got a lamb entree that came with some potatoes, these lemon potatoes that these guys make that are ridiculous. You know, no dessert came home, had some guys make that are ridiculous. You know, no dessert. Came home, had some tea. That was it. So when I look at my CGM from yesterday, my highest glucose was about two hours after dinner, maybe an hour after dinner, but it was about 117 milligrams per desolate, it was my peak glucose yesterday.

And the other thing I really pay close attention to is what was my peak nighttime glucose? So by the time I went to bed, it was down to 90. And I think my peak nighttime yesterday was 95, which makes me really happy, because I almost always see my highest glucose is at night. They're almost always, I think, in response to cortisol. So today we'll have one of those shakes for lunch. Maybe we'll go workout, then we'll shake.

And then for dinner, I don't know what we'll do, but it'll be basically the same sort of thing. It'll probably be, oh, I also had a big salad yesterday. I forgot to mention that. The smoke salmon, the big-ass Greek salad, in a bowl, the size of my head, and then the lamb with the potatoes. So I'm kind of a boring eater actually, which is I like to have lots of vegetables,

including salad. I usually rotate, you know, lamb, beef, fish, and then at least half the time, if not more, maybe a bit of potato or rice. I think you might have tipped your hand when you did a regimented three year pretty much all on ketogenic diet and what kicked you out of a ketogenic diet was your longing for vegetables and fruit, more or less. And then on the exercise side, not doing the muscle biopsies or something like that. So I think most people might be going for the chocolate cake. Oh, you did, you did have one. I had that orange day.

Yeah, or I had six desserts in one sitting. I'm sure I'll go. Anytime I'm with my keto friends, like last week, when I was up with Steve Finney and a whole bunch of the people from Virta Health, I swear I was like, that's it, man, I'm going back on a ketotid. You know, I'm going to go back on a ketogenic diet. And then I got home and I was like, nah, I feel like it.

That's just, honestly, part of it, this is a total cop out, but part of it is just like, it's a pain in the ass with kids. I don't want to get into weird stuff with my kids again, because I remember when I was on a ketogenic, my daughter was always asking me why I didn't eat this, why I didn't eat that. And I feel like, and again, I'm not knocking you key to gender diet. And I think I could, I could do it and do it in a responsible, sustainable way as far as my kids.

But I like now talking to my, only my daughter, my son's obviously we don't talk about this stuff yet. They're not old enough. But, but with Olivia, there's definitely a lot of talk of like the other day, like, you know, it's her birthday and there's a ton of ice cream left in the fridge and she came home from school and she's like, Daddy, can I have a bowl of ice cream?

And I was like, how know you can't have a bowl of ice cream? What the hell are you talking about? She's like, well, mommy lets me. And I was like, I pretty sure mommy doesn't let you have ice cream before dinner. And don't you get how bad that stuff is? Like, you get to have that once in a while as a treat, but that didn't grow on a tree.

That didn't come out of, that's fake food, right? And so there's still the opportunity to talk about that. And I like that they're seeing me eat a broader array of food now than I would be if I were on a ketogenic diet. Because when I was on a ketogenic diet, the other thing is I was on such a high calorie ketogenic diet that I had to eat so much weird stuff. Like I had to basically eat a tub of sour cream every day just to get my 4,500 calories that I needed.

What was your ratio of ketogenic diet for epileptic? Yeah. I was talking about carbs to, yeah, so I did it in total, I did it as a percent of total calories. For fat to protein in carbs. Yeah, I was about 90% fat, about 7% protein, 3% carbohydrate.

And the reason that my percents were so high in fat is that my total caloric intake was probably 44 to 4500 calories a day. That was exercising like crazy. Yeah, I'm marvel at what a ketogenic diet sort of technically is. I mean, if you're looking like the Hopkins ketogenic diet where it's it's four to one fat to protein and carbs in terms of I think by weight.

So if you're eating 100 grams of protein and carbs, you're eating 400 grams of fat, which is 3600 calories. So you're really going to 4,000 calorie diets, probably close to what you're maybe what you're doing, right? 75 grams of protein, maybe 25 carbs, maybe lower, and you're doing that. And you don't realize, like, that does take effort. It's not just like I'm just going to eat some meat and I'm going to eat some vegetables and some nuts and seeds. It's gonna eat some meat and I'm gonna eat some vegetables. It's huge. It's huge. Yeah, for it, unless you have the luxury of, you know, a chef or prepared meals, like, I don't know if Quest is doing it anymore, but they were at one point doing, like, pre-made two to one, three to one, four to one,

keto meals, and I think they were doing it with the Charlie Foundation, actually, for the kids with epilepsy. And I ate a bunch of those, like, just as trying them out, and I mean, they were great. I could mainline those things. If someone were like feeding me those all day, yeah, I could go back on ketosis with it,

but maybe I'm just too lazy. I don't know. I know you said that there were questions on stuff that we've already either done a podcast on or we'll be doing a podcast on. So we'll punt on those. Do you want to, What are those topics? So we have a lot of topics around statins.

What are those? So when would you use them? I'm glad to hear you. I'm at what are statins? Never heard of them. Never heard of them. You were talking about Tylenol before, I was drawing a blank too. Smart Drugs and Supplements. So Drugs and Supplements for cognition, also Smart Drugs. I was drawing a blank too. Smart drugs and supplements.

So drugs and supplements for cognition, also smart drugs, drugs for, also drugs and supplements for performance. Heat and cold therapy, which is a really interesting topic. I'm sure we'll dig into that too. HRT, I believe HRT, at least an estrogen and hormone replacement therapy in women, was on your pole, was either HRT or LPLittleA

for the first topic, so I'm sure that might get thrown back into this. That's right, yeah, and I think LP Little A one hands down like 80, 20, but we'll definitely be taught, we'll definitely do a dedicated thing on estrogen and HRT. Okay, atophagy, ABOE, which we got into a little bit, and depression, sort of what genetic effects,

environmental effects, and how do you handle it? So I'm gonna be, I reached out to one of my best friends who's a brilliant psychiatrist, Paul Conty, and actually just a couple days ago, and said, hey, let's do a podcast, and I wanna talk all about depression, everything about it. Environmental triggers, the genetics of it,

treatment strategies, all that stuff. So Paul is totally game to do that. So we're going to do that podcast this summer. We're going to be talking to Ron to Patrick soon. I'm sure Ron does just, we're going to have so many great things to talk about. So I'm sure a lot of the heat and cold, smart drug stuff will probably come up there. We're going to do one with Dom DeGastino soon and that's going to get into a lot of ketosis stuff.

We've already done a great one with Ron Kraus and that's going to touch on all of of ketosis stuff. We've already done a great one with Ron Kraus, and that's going to touch on all of the statin stuff. A topology. Yeah, we'll probably have to, well, we actually, did we, does the Sabotini one know, but we've got the other MIT ones that get in the topology. Oh, yeah, Greg and Monther.

Yeah, MIT. So I think we've got some. Yeah, so we've got some great stuff there. We do need to probably do a dedicated APOE one, and I think we'll definitely get into exercise. In fact, I'm going to be speaking with Mark and Chris Bell this summer. It's odd because we don't know when this is actually going to be released. So I guess we're going to have to release this one early so that what I'm saying makes sense. But

so with Mark and Chris Bell, I'm sure we'll have plenty of chance to talk about exercise, especially around strength training, hypertrophy and things like that. So I think we got it. Is there any other question that we need to get at before we either go make a shake or go to gym? No, I think that's good. I think hopefully we'll do more of these so we can reload and do some more. All right, man.

Well, thank you for compiling all of these. My pleasure. I loved being able to not have to pay attention to any of those questions on Twitter and knowing that you were caught. Oh, that's the one quick thing. It's funny, because I think everybody goes through this where they think, I'm getting off a social media.

I'm getting off a Twitter. I'm getting off a Facebook. It's just, it's doing me no good. I need to just, like the first question. I need to get back out into nature. I think this is doing more harm than good in distraction. And then Peter says, you're gonna need to get on this Twitter and start handling these questions

and, you know, the Twitter wars and things like that. But it really was a pleasure. It's like all the questions that you got were, I don't wanna say all of them, but most of them, at least, were excellent. And I'm just, I just looking at the master list. And there is stuff. There's NAD and nicotinamide, riboside and terrestil being.

Oh, God. We've got all that stuff. So NAD, NAD plus. So you've shielded me for most of these questions. Mostly, yes. All right. Well, maybe we'll figure out, take a look at what you've got here versus there. And we can decide if this is something

we should be doing quarterly or what's the frequency with which we could do AMAs. I mean, I think we got a lot of sort of nothing burger questions out of the way that probably don't come up again, like race car driving questions and childhood questions, but, you know, we'll go from there. All right, man, well listen, thank you very much. And thank you everybody for submitting your questions.

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