The Peter Attia Drive - #50 - AMA #5: calcium scores, centenarian olympics, exercise, muscle glycogen, keto, and more

Episode Date: April 22, 2019

In this “Ask Me Anything” (AMA) episode, Peter answers a wide range of questions from readers and podcast listeners. Bob Kaplan, Peter’s head of research, asks the questions. If you’re listening on a podcast player, you’ll be able to hear a preview of the AMA. If you’re a subscriber, you can watch or listen to this full episode on our website at the AMA #5 show note’s page. PLEASE NOTE: We are currently building a private RSS feed that will allow subscribers to listen uninterrupted on the podcast player of their choice. This will be released shortly. Questions are pulled from the AMA section on the website (peterattiamd.com). Any subscriber is welcome to submit questions. We discuss: Coronary calcium score: what it means and how to interpret your results [1:15]; How to train for the “centenarian olympics” [18:00]; Explaining the blood glucose response to various types of exercise [35:30]; The Tabata protocol [43:15]; Exercising on a ketogenic (or low-carb) diet: performance, muscle glycogen, adaptation, and more [49:30]; The work of Dr. Gabor Maté and its impact on Peter [54:15]; What's the best book you've read in the past year? [55:45]; What is “pattycakes?” [59:00]; What is the latest and greatest of egg boxing [59:30]; 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 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.

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Welcome to AMA number five. As always, I'm joined by Bob Kaplan, my head of research. As a reminder, these are for subscribers only, and if you're a subscriber, you can watch or listen to this full episode on our website. If you're listening to this on your podcast player, you'll hear a preview here, and then you'll have to finish listening to it on our website. Please continue to ask questions on our AMA forum as we look forward to continuing to answer them. In this episode, we talk about calcium scores or CACs. We do kind of a deep dive into exercise, talking about my notion of the Centenary in Olympics, and how you would exercise a 25 knowing what you know now.

Talk about the tenets of exercise and I go on a little rant about Tabata. I go into glycogen during anaerobic exercise while on keto and some of the things I learned back in my time of non-stop keto. I also finally divulge the Atia Curry recipe which I think if I were only allowed to eat one thing for the rest of my life, that's probably what it would be. And finally, on this episode, we reveal the egg boxing belts. They kind of make a silent appearance, but they're unmistakable. Welcome to another AMA.

So let's just dive right in. A lot of questions came in on coronary artery calcium or a cac. And so just, this is a general question. What is the deal with cac? Some people say it's a marker. Other people say something else. So take it away. So a coronary calcium score is a CT scan that's done dry,

meaning without any contrast. So you lay on the CT table and it's a very quick scan. And because there's no contrast, anytime you see something that's really, really bright white in there, which is normally what color contrast would be, you know it's calcium. So there's a scoring system where you can actually get some anatomic detail, not to the degree of understanding how much narrowing there is of the arterial lumen, but you can see which arteries, so the left main artery, the circumflex artery, the left anterior descending, the right artery, the posterior descending artery, and the amount of calcification is then scored and ranked against a

percentile. So, you know, this is one of those things that is certainly helpful. And, you know, if there's one branch of statistics that medicine sort of innately teaches you, it's based theorem where you update your probability based on new information. My problem is not with the calcium score. It's with sort of a school of thought that says, well, a calcium score, if it's zero, means nothing matters. You're sort of scot free. And that's, unfortunately, that's just categorically untrue. And the data bear that out.

So a negative calcium score, meaning a calcium score of zero absolutely means actuarially at the population level, a lower risk of a coronary event. And when we say coronary event, the term mace is what we use to describe it. It made your adverse coronary event or cardiac event, so heart attack, stroke, or cardiac death. But it's not zero. Furthermore, and this is where it gets a little complicated, nearly 50% of fatal MIs occur in non-calcified areas of coronary arteries.

Now, those data are also a bit misleading because many of those patients still had calcifications elsewhere. So the way I think of calcification is it tells you how many times you've been broken into and what kind of repair you've done. I mean, that's a gross approximation. So a biomarker tells you how bad a neighborhood you've done. I mean, that's a gross approximation. So a biomarker tells you how bad in neighborhood you live in. So if you do a blood test on somebody and their, you know, LP little a is high or their LDLP is high and they have lots of inflammation and all these other things, that says you live in a bad neighborhood. It's dangerous. There's a chance

there's going to be a break in. When you see a calcium score that's anything other than zero, well, that tells you you've already had an advanced lesion. And that lesion had to be repaired. Because when you, and I won't go through Stari's seven levels of atherosclerosis, because it's really complicated and it's hard to do without pictures. We got a whiteboard last time.

We needed the whiteboard this time, okay? We could throw in the show notes. Yeah, that's right. We can throw in the show notes, which is the sort of different types of lesions of atherosclerosis. But calcification is an incredibly late stage repair. So when you have calcification in a coronary artery,

I mean, you've had real damage and it's been repaired. And that becomes a marker of risk that basically suggests you need to be more aggressive in taking care of this case. But when it is zero, doesn't change the fact that you live in a bad neighborhood, and it doesn't change the fact that you can have lots of arterial damage that just hasn't shown up at the stage of calcification.

So you can have plenty of soft plaque that's still there without calcification. That's still an enormous marker of risk. And that doesn't get picked up with calcification. So what we typically do with patients is, and it depends, every case is different. And so, you know, there are sometimes when I just do a calcium score on a patient, and if it's zero, I don't do anything further.

There are other times when even if it is zero, I still reflex into a coronary angiogram, so a CT angiogram, which does pull much more anatomic detail, including the presence of soft plaque. But even there, you still can't really see plaque that is vulnerable. But if a patient has a coronary calcium score that is zero, and their CT angiogram looks impeccable, that's a much better sign than anything not being in that case. And of course, it begs the question, well, would you still treat a patient in that situation? That's a hard question. But it also depends on your time frame. And so the younger a patient is with that finding

the less confident you are that they are one of the lucky people that seems largely immune from coronary artery disease, where I find these tests most helpful is actually not in young people, but in older people. Hey everyone, hope you enjoyed a sneak peek of this AMA. AMAs, along with extensive show notes and member-only discounts on products that I think are awesome, are available to subscribers only. So if you're interested in hearing the remainder of this AMA, or want to access any other benefits that come with being a subscriber, please head over to

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