The Peter Attia Drive - #338 ‒ Peter’s takeaways on aerobic exercise and VO2 max, insulin resistance, rising healthcare costs, treating children with autism and ADHD, and strength training | Quarterly Podcast Summary #4

Episode Date: March 3, 2025

View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter In this quarterly podcast summary (QPS) episode, Peter summarizes his biggest takeaways from the last three months of guest interviews on the podcast. Peter shares key insights from his discussions on diverse topics such as aerobic efficiency and VO2 max with Olav Aleksander Bu; insulin resistance with Ralph DeFronzo; economics of the US healthcare system and cost-saving strategies with Saum Sutaria; diagnosis and treatment of autism, ADHD, and anxiety in children with Trenna Sutcliffe; and strength training with Mike Israetel. Additionally, Peter shares any personal behavioral adjustments or modifications to his patient care practices that have arisen from these fascinating discussions. If you’re not a subscriber and are listening on a podcast player, you’ll only be able to hear a preview of the AMA. If you’re a subscriber, you can now listen to this full episode on your private RSS feed or our website at the episode #338 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here. We discuss: Overview of topics to be discussed [2:00]; Olav Aleksander Bu Pt.2 episode: metrics to track aerobic efficiency and insights about VO2 max, and the ability of increased carbohydrate consumption to boost performance [4:30]; The best practices for performing a VO2 max test, the differences between VO2 max training and all-out efforts, and the role of energy intake in endurance performance [14:45]; Ralph DeFronzo episode: the pathophysiology of insulin resistance and type 2 diabetes—how they impact different organs, flaws in conventional diabetes treatment, and more [24:30]; Understanding type 2 diabetes beyond the traditional triumvirate of features: the “ominous octet” describes changes in other organs [31:45]; Pharmacological treatments for insulin resistance and type 2 diabetes [41:30]; The importance of early detection and intervention in insulin resistance [50:30]; Saum Sutaria episode: the economic and systemic drivers of high healthcare costs in the U.S. [54:00]; Reducing health care costs: redefining health insurance, lowering drug prices while maintaining innovation, leveraging AI for efficiency, and more [1:07:15]; Trenna Sutcliffe episode: insights on autism, ADHD, and anxiety in children—definitions and diagnosis [1:11:45]; Exploring the rising prevalence of autism spectrum disorder [1:17:15]; Trenna’s views on caring for children with autism [1:21:15]; Misconceptions around vaccines and autism [1:26:00]; Mike Israetel episode: insights about strength training, minimum effective dose, troubleshooting plateaus, tips for beginners, and more [1:28:15]; Topics Peter is interested in exploring in future podcasts [1:40:15]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the Drive Podcast. I'm your host, Peter Atiya. At the end of this short episode, I'll explain how you can access the AMA episodes in full along with a ton of other membership benefits we've created. Or you can learn more now by going to peteratiamd.com forward slash subscribe. So without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to another special AMA episode of The Drive. Today's episode will be the fourth installment of the quarterly podcast summary. In this conversation, I discuss what I learned from the last quarter of interviews and what

I think were some of the most important insights as well as things that have resulted in a change in my work and behavior. Please note that I do not think listening to the quarterly podcast summary even remotely constitutes a substitute for listening to the quarterly podcast summary even remotely constitutes a substitute for listening to the actual episodes. My hope is that it basically helps you think about refining what you might've learned there. And if something you hear in one of these summaries is of interest and you missed the original episode, I hope you'll go back and listen to it. In today's episode, we cover the interviews that I did with Olaf Alexander Bu, Ralph DeFranco, Sam Sutaria, Trena Sutcliffe, and Mike Istretel.

And throughout these, we talk on various topics. VO2 max, power at VO2 max, insulin resistance, metformin, SGLT2 inhibitors, GLP-1 agonists, US healthcare costs, diagnosis and treatment approaches to autism, ADHD and anxiety, zone two resistance training and learning all of the effects of anabolic steroids. And yeah, that sounds like a hodgepodge of topics, but that's because it's pulled from all of these discussions. If you're a subscriber and you want to watch the full video of this podcast, you can find it on our show notes page.

If you're not a subscriber, you can watch the sneak peek of this podcast, you can find it on our show notes page. If you're not a subscriber, you can watch the sneak peek of the video on our YouTube page. So without further delay, I hope you enjoy this special quarterly podcast summary, AMA of the Drive. Hey! Hey!

Hey! Hey! Peter, thanks for joining us on another AMA on your own podcast. We appreciate you coming by. I always appreciate being here. Thank you for having me. Anytime. Anytime. So today is going to be another quarterly podcast summary episode.

A lot of words. Basically what it means is we look at past episodes, cover what the main takeaways are, what your favorite insights were, any changes you made based on behavior to yourself, how you work with patients, how you think about things, anything of that nature from those episodes. The other thing to say is reminder, it's meant as more to augment the episodes,

not necessarily as a replacement. And we get a lot of feedback where people will listen to this and then re-listen to some of the original episodes and find a lot of value in it. Today we'll look at Olaf talking about training performance, VO two max, Ralph looking at insulin resistance, type two diabetes, metformin, SGLT two inhibitors, other drugs, some looking at healthcare, trying to understand why

healthcare in the U S is nearly two times per capita of any other developed nation. in the U S is nearly two times per capita of any other developed nation. Trenna looking at autism, ADHD, anxiety. We have Mike looking at resistance training and kind of diving into everything revolving that. So huge variety of topics, a lot of different things that I think people should find interest in. And I think we'll get it started with Olaf. So do you kind of want to start going through

your episode with Olaf? This was obviously the second time he was back on. Little behind the scenes, we talked beforehand about, hey, let's try and make it a little less technical because the first one was pretty technical. And I think looking back, you probably made it more technical in the first. So I think that's just by nature

how you and Olaf are always going to be. So maybe break down for people what you learn and what your biggest insights were from that. Yeah, and before we dive into this, at least in as long as we've been doing quarterly podcast summaries, I will say this might end up being the longest because just by the nature of coincidence

and which podcasts fall into the past quarter, this is probably the most voluminous set of notes I've ever taken across a set of podcasts. In fact, I would say that two of the episodes that we've covered here, the one with Ralph and the one with Psalm, were easily three to four X the volume of notes I normally take. Impute from that way you will. I've done my best to try to synthesize that but nevertheless there's a lot going on in this past quarter okay you're right I wanted to make the olaf one at the outset just straight into less technical

things and I could not resist the tractor pull of trying to at least explain some technical things so we started the discussion by explaining the difference between things like functional threshold power and critical power. I hesitate to bring these up now because I just don't think they're relevant unless you are a cyclist. But if you are interested I'll just state it, the functional threshold power or FTP is the power that you can hold for one hour. That is one way to test it. You literally get on a bike, usually on an erg, so it's a stationary bike, and you ride as hard as you can without blowing up for one hour. And whatever the average power is that you held as your FTP, much more typically,

for example, when I was a cyclist, we would do this in a 20 minute test and we would discount it by typically 10%, although Olaf suggested only 5. In my experience, 10 percent was necessary. There's something called critical power, which is very similar, but rather than it being the power you can hold for an hour, it's the power you can hold for 30 to 40 minutes. I think the more important distinction here is that you can calculate critical power much easier. You can do it from a set of curves that are derived from three to four individual tests that are much shorter. Why is this relevant? This is relevant because if you want to have other metrics beyond VO2 max for higher end aerobic efficiency, you might want to know your FTP or critical power and critical power is much easier to measure.

So these days, and this ties into another insight, by the way, these days, I don't spend a lot of time worrying about my FTP. In fact, I don't know what it is because I haven't done a 20 minute power test since NOM. Don't necessarily think I'm going to do one anytime soon, probably because I don't want to see how low it is, but it made me realize, maybe I ought to do a critical power test just so that I have another benchmark to be tracking. So we talked about a few other things which I'm not going to go into, anaerobic threshold

and stuff. We covered a little bit of that in the first podcast. Another very interesting insight that came up for me in this podcast, which was really just a personal insight and I hesitate to spend too much time on it, was talking about the relationship between VO2 max and PV02 max or VVO2 max. So if you're a cyclist, what does that mean? PV02 max means what is your power when you are at VO2 max? Again, VO2 max, just to make sure everybody knows what I'm talking about. This is maximum ventilation, meaning maximum oxygen consumption. It's usually sustained for at least a minute when you're

doing the test. So what's the highest amount of oxygen in liters per minute that can be consumed for a minute? And this is achieved during a ramp exercise, almost exclusively done on a bike or on a treadmill, stationary bike. And when you hit that VO2 max, if you're on a treadmill, you will note that, hey, there's a velocity,

assuming you're running flat. Or you might see, oh, actually, I'm on a bike and my PV02 max is the power that I've achieved. Now, some have argued that VV02 max or PV02 max are actually more predictive of sport specific performance than just the number V02 max. And I think there might be something to that because I shared my numbers with all of and the truth of it is I have always had a very low PVO2 max to VO2 max. Stated another way I have always had a VO2 max that is higher than many people who are much better cyclists than me. It wasn't uncommon when I was training that my VO2 max was

15 points higher than people who had a higher FTP than me, for example. And what Olaf suggested there is it speaks to really inefficient, probably over-training aerobically, under-training anaerobically. So there's an inefficiency there. And that inefficiency means that I am actually requiring more energy across the board to put out more power. Now, something very interesting that comes from that is there might be an association between people like that and a lesser propensity to gain weight. And it is true that every time I've done a resting metabolic expenditure test or any time I've done the more elaborate stuff, I've actually done the doubly labeled water test in the metabolic chambers, I always seem to have

a through the roof energy expenditure for my body weight. So I guess for the first time that all kind of came together, which was, wow, on the one hand I have an advantage perhaps in that I have a very high energy expenditure. So relative to somebody else who eats as much as I do, I'm going to be leaner. But the flip side of that is I'm actually quite inefficient at utilizing energy. So again, I found that very, very interesting. One of the things we talked about was,

hey, is there anything that a person can do besides the obvious, which is training, to boost their VO2 max? He mentioned something about beetroot. Wasn't familiar with this, but beetroot concentrate, he said, is rich in nitrates. Body converts it into nitric oxide, and that of course helps with vasodilation, opens up capillary beds. It should be stated then of course that anything that impairs nitric oxide synthase, and there

are many things that do from homocysteine to insulin resistance, is going to impede it. Again, he said at the elite level, this doesn't have much of a difference, but in amateur athletes like the rest of us can be about a 5% boost. The other thing he talked about that I thought was really interesting was, and again, this was to me just more gamesmanship than anything else. And I can't wait to try it the next time I do a VO2 max test, which by the way, is probably going to be this weekend or next. He said, as you approach failure, do a few breath holds. And he said that that produces a significant boost in VO2 max. Again, it's just a reactive over consumption of oxygen. I don't know if

that means anything. One of the other things that I asked him about was the use of acetaminophen. Again, there are some data that suggests that acetaminophen use can boost peak endurance performance by one to 2%. I asked Olaf if Christian or Gustav use acetaminophen themselves during Ironman and he said they did not. He raised a point that I thought was interesting, which is while acetaminophen or Tylenol can obviously reduce the perception of pain, which has been one of the arguments for why it boosts performance, it may impair the athlete from giving off heat

from heat dissipation. And so he just questioned whether or not that might be a worthwhile trade off. Of course, for me, that begs the desire to do an experiment and find out. Another area that we talked about, which again, isn't relevant to me and the way I train, but if any of you are listening and you are really high performance athletes, I think this is arguably probably the single most important takeaway from this podcast is what the upper limits of carbohydrate consumption are while doing cardio activity and racing. So again, if you're a triathlete, if you're a cyclist, if you're a runner, less applicable

in running because the races are typically so short. But of course, if you're an ultra marathon runner, that would not be the case. So everybody's kind of done this math, which is if you're doing an Ironman or something like that, you're probably depending on your level of fitness expending somewhere between 700 and a thousand calories, kilocalories per hour. Let's even be conservative and say you're really really just going easy. You'd be at 600 to 700 kcal per hour.

Now we don't have that much stored glycogen. You've got maybe 50, 100, maybe 200 grams of glycogen if you have really big muscles stored, which you're going to run out of pretty quickly. That's going to supply you for maybe an hour and a half. So thereafter, you have to meet your needs from body fat and intake of carbohydrates. The conventional thinking has always been that you can only consume about 60 grams of glucose per hour. And 60 grams of glucose, of course, is only about 240 kilocalories. This has always been one of my main arguments for why being fat adapted is very important.

Because if you're consuming that 60 of glucose, and that's giving you whatever it's giving you, you have to get the balance from fat, and you're only gonna do that if you're heavily fat adapted. So you get into this cycle. Well, what we've seen unquestionably is, I think the biggest, honestly, the biggest innovation in endurance sports

like the Tour de France and Ironman over the past decade is the amount of glucose that these guys are able to consume. He talked about numbers I had never heard before. As some of you may recall, I interviewed Tadej Pogacar recently, the greatest cyclist on the planet. His numbers blew my mind of the type of carbohydrate intake that he was tolerating, 150, 180 grams per hour. Olaf said that they're now pushing triathletes at the world-class level to 240 grams per hour. Again, this is unbelievable

to me and what that basically tells you is you can meet all of your glycolytic needs indefinitely through that. Now, again, just as Tade said, you have to train this system. These are athletes that are required to now consume gels and eat carbohydrates at a 12% mixture. What does that mean? 12% mixture means 120 grams per liter. 10% mixture is 100 grams per liter, et cetera. Conventional wisdom is that we can't tolerate, meaning our gastrointestinal system cannot tolerate

more than a 5% mixture. And I know from me personally, when I used to be doing ultra distance stuff, I had a hard time going above 5 to 6% myself. But what Olaf said, and what Tadej has also said separately is you can actually train your GI system to double that. And so how these guys are drinking two liters per hour of a 12% mixture, which would be 240 grams. I simply can't fathom, but clearly that's what they're doing. Or they're doing it in some combination, so they're consuming gels plus water that amounts to that mixture.

But I think when you look at the hyperbolic performance of endurance athletes today, it's very quick and tempting to just say, ah, they must be just using drugs we haven't figured out yet. Yeah, it's also the fact that I think another explanation and the one that I find more appealing is that they literally figured out how to double the octane of the fuel. I mean, that's effectively what's happening. It's like a car that went from racing at 70 octane to 140 octane. And I'm not going to bother explaining what octane is.

I'm not even sure if there's a 140, but you know and I'm not going to bother explaining what octane is. I'm not even sure if there's a 1,40, but you know what I'm getting at. So I would say those are probably the most important things. I guess the last thing that I would take away from this is he offered a great protocol for how to make sure you're giving it your best when you do a VO2 max test. This has already been something that I've started implementing a little bit more with our patients and making sure that, for example, if they do have VO2 max test, I've always asked people

describe the protocol and many times I'm not pleased with the protocol, but this was the kind of, I think, really super-duper protocol. You want to do this at the time of day that is a normal time that you would be training. So you want to be well rested, et cetera, minimize traveling the day before. So we try to tell our patients the same thing. If you're coming into Austin for a via 2 max test, boy, it would be really great if it was just a short flight the day before, and if it's international, please come in more than a day before if you want to maximize the test. The warm-up should be basically six minutes, very, very easy.

Six minutes zone two, three minutes at threshold or FTP, two to three times at a 10 to 15 second burst at about what you expect your PV02 max is. Then a relatively short rest of 10 to 15 minutes, get a drink and then get on with it. Yeah, so I would say that those are probably the most important things, Nick, that I took away from this podcast.

So Peter, just a few follow-up questions there. Let's just start with the VO2 max training. So in that protocol, it actually is like a decent warmup that you're having people do. I remember when I've done VO2 max testing, I don't know if they even really had me do any type of warmup. You just kind of went hit hit the treadmill, and then started going. So you're having people go through a little bit of a workout before they get going.

Yeah. And I'll tell you this, I do most of my VO2 max testing outdoors now. I use that VO2 master device, which I love. I'm going to leave from my house. I'm going to ride 10 to 15 minutes to the place where I do my hill repeat. So that's a warmup in and of itself. And by the way, getting there, there are a couple of short little climbs where I'll do 30 seconds of relatively high power just to get up over a little pitch. I will do two to three full runs of the hill at escalating power before I'm truly going to hit my max. So I'll do like a four to

five minute up, maybe 85% of what my maximum power would be for that climb, come down for the same amount of rest period, go up again at maybe 90% of what my maximum power would be, come back down, and then maybe I would go and give it. The third one would be out there. So by the time I've done it, I've really warmed up. And so the other day I done it, I've really warmed up. And so the other day I was talking to a patient who did his VO2 max test at a facility. It was at a university that he went to do it. It was just like a place where you can go and pay to do it.

And I was kind of surprised at what his number was. It was lower than I expected given his training. I said, tell me about the protocol. And he's like, yeah, I just got on the treadmill and they just started cranking it. And I was like, and how long after you started on the treadmill did you hit VO2 max? And he's like, I don't know, five minutes. And I was like, yeah, I just got on the treadmill and they just started cranking it. And I was like, and how long after you started on the treadmill, did you hit VO2 max? And he's like, I don't know, five minutes. And I was like, yeah, that's a garbage protocol. You were not warmed up and ready to do that.

You mentioned you have a VO2 max coming up. When was the last time you tested prior to this? In the spring. And the reason is because I like doing it outdoors. I have noticed because I live in Texas, how much of a performance hit I take in the summer. Like it's a noticeable difference in the summer. So I'm like, yeah, I just would rather do it in the spring.

Fall winter spring is when I prefer to test. Let's say the month leading up to it. So the past month, have you changed your training at all? Are you doing anything in particular for it? Not at all. This is just a data check. It's just like, I had my blood drawn this week, had my DEXA scan a couple of weeks ago. I'm doing a VO2 max. In general.

So if you haven't changed anything, just as a reminder for people, what is your VO2 max training look like in a typical week? Is that one day a week? Just one day a week. Yeah. It's three days a week of zone two and one day a week of interval training, but interval training at that specific four five

upper limit eight minute intervals And I always like when we talk vo2 max training, I think back to One of the actually first video podcasts we ever did with alex hutchinson. Do you kind of want to walk people through? I think a lot of times When you think of vo2 max training or tabata training or like going all out, a lot of times people kind of lose sight at how hard that actually is. Do you kind of want to walk through if you're doing actual intervals, real VO2 max training, what that feels like? VO2 max training hurts less than a true Tabata. I mean a true Tabata, that's where I think people have a hard time understanding what all out means.

I mean technically I don't think the human body is capable of going all out for more than 10 seconds. So even at the level of a Tabata, which is a 20 second effort followed by a 10 second rest repeated eight times or done eight times, even a 20 second, there's just a governor that is self regulating how hard you go. The reverse Tabata where you go 10 seconds all out, 20 seconds rest for eight rounds. That's about the closest thing that I think we're capable of doing as a truly all out. You will increase your VO2 max doing that type of an exercise,

but not nearly, not nearly as much as if you're doing intervals in the three to eight minute range. And by definition, if you're doing something for three to eight minutes, you're not going all out. What you're trying to do is go as hard as you can for that distance and for that time. So it's a different animal. Obviously, I think it hurts more because it's a lower level of peak pain, but it's spread out over a longer period of time. So the area under the pain curve is greater, but it's far from all out and at any moment in time,

the pain is not the same. Can you remind people, let's say you're doing a four minute interval, you're not starting at four minutes, going as hard as you can, and then trying to sustain it. Can you walk through how you think about the energy you put out spread across four minutes? Yeah, technically the power is constant throughout the four minutes. So I know in my mind how many watts I wanna produce

and what I want my average wattage to be over the five minutes. So let's just say I wanna do five minutes at 300 watts. Of course, you're outdoors, so you don't have complete control. It's always jumping around. But I'm really watching the three-second power tracing and the average power to keep it there.

Well, after the first minute, I barely know I'm on the bike. It should be really easy after a minute. If you're dying after the first minute, you've set your target too high. Two minutes in, or two and a half minutes in when I'm halfway done, I still feel pretty good. My heart rate is now going to be within about five beats of what its maximum is, but I still feel pretty good.

It's really at about minute three, three and a half that the pain train starts to leave the station. And that's when it really starts to feel miserable. And that last minute is really, really difficult. If you've done this right, when you finish this, you're really going to need that four or five minutes of very, very easy peddling to let your heart rate come back down to then repeat it. But again, the goal is not to have killed yourself in that five

minutes such that you can't do it again. Because what I'm trying to do is actually preserve that power across all the intervals. Got it. Last follow up on this is you talked about the consumption and like the increase in performance as a result of what they're able to consume when they're performing. How much of a difference do you think that makes or how can you explain it? A lot of lay people probably aren't thinking about that consumption or their mixture. I know a lot of endurance athletes are, but how much of a game changer do you

think it is to have that increase in what they're able to put in their body during events? Well, again, for people like me and probably most people listening to this podcast, this is not something that should be on our radar. I don't think there's ever going to be a day when I'm doing a 10-hour endurance event again and therefore I don't really need to worry about it. If I'm exercising for two hours, that's kind of a long time. So at two hours, I'm fine with just water. I'm living off my own glycogen and whatever.

But it's very difficult now to think about people competing at a world-class level in cycling an Ironman because what Olav and many others have now argued is the problem of peak endurance is effectively an energetic problem. It's basically a question of how much chemical energy in the form of food can you convert into electrical energy via the metabolism of food back into chemical energy in the form of ATP back into mechanical energy? It's just an energy transfer problem. More energy input means more energy output.

The more logs you can put into the fire, the hotter the fire burns, the more steam it makes, the faster the wheel turns. That's basically what it comes down to. And what we've seen over the past decade is quite literally a more than doubling of the feedstock that goes into the furnace. Got it. All right. Anything else on Olaf before we move on? No. Perfect. So next is Ralph on insulin resistance, which I think you said was one of the more interesting

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