The Rich Roll Podcast - Unlocking the Science of Longevity with Peter Attia, MD

Episode Date: March 20, 2023

Today we explore science-backed truths behind healthspan extension and healthy aging with Dr. Peter Attia. Peter is a graduate of Stanford School of Medicine, a former surgeon, and a world-renowned physician who has dedicated his life to understanding the science of human health and the art of living a longer, more fulfilling life. The occasion for Peter’s return is the publication of his new book, Outlive: The Science and Art of Longevity—a groundbreaking primer that challenges the conventional medical thinking on aging and reveals a new approach to preventing chronic disease and extending long-term health. Today’s conversation offers a short overview of all of the subjects covered in the book including the roles that exercise, nutrition, and sleep play in preventing or delaying the onset of the primary conditions that unnecessarily end most people’s lives too soon. But in large part, we focus on the story of Peter’s emotional health during a dark time and the critical role that emotional well-being plays in the quest for a longer, healthier life. Note: As a gift to our listeners, Peter has generously offered 10 signed copies of this fascinating book for us to give away. So if you would like to enter to win a free copy, go to richroll.com/subscribe, join the mailing list (if you’re not already subscribed), and look for an email on or around April 3rd with further instructions. Show notes + MORE Watch on YouTube Newsletter Sign-Up Today’s Sponsors: InsideTracker:  insidetracker.com/RichRoll GoMacro: gomacro.com  BetterHelp: BetterHelp.com/richroll Indeed: Indeed.com/RICHROLL Thesis: takethesis.com/RICHROLL Plant Power Meal Planner: https://meals.richroll.com Peace + Plants, Rich

The Rich Roll Podcast. When it comes to lifespan, there really are four big elephants in the room. The first is atherosclerosis. More people are going to die from cardiovascular disease than anything else. Cancer is number two. Then you get into neurodegenerative diseases. And a lot of this roots back to metabolic health. I forgot that one, right? It's almost the easiest one to forget because directly, it doesn't actually account for the loss of many lives. But once you have type 2 diabetes,

your risk of those other diseases doubles. Today, my guest is Dr. Peter Attia. He's a former cancer surgeon and researcher who got his MD from Stanford. He is one of my go-to doctors. I would say the go-to doctor for me for anything performance or longevity related. I think exercise is the single most important longevity drug we have, bar none. Peter is both a visionary as well as a world-renowned physician who has dedicated his life to understanding the science of human health and the art of living a longer, more fulfilling life. I got a couple more things I would very much like to mention before we dig into this one,

but first. We're brought to you today by recovery.com. I've been in recovery for a long time. It's not hyperbolic to say that I owe everything good in my life to sobriety. And it all began with treatment, an experience that I had that quite literally saved my life. And in the many years since, I've in turn helped many suffering addicts and their loved ones find treatment. I've in turn helped many suffering addicts and their loved ones find treatment. And with that, I know all too well just how confusing and how overwhelming and how challenging it can be to find the right place and the right level of care. Especially because, unfortunately, not all treatment resources adhere to ethical practices. It's a real problem. problem. A problem I'm now happy and proud to share has been solved by the people at recovery.com who created an online support portal designed to guide, to support, and empower you to find the

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starting that journey. When you or a loved one need help, go to recovery.com and take the first step towards recovery. To find the best treatment option for you or a loved one, again, go to recovery.com. The occasion for Peter's return to the show is the publication of his brand new book, Outlive, The Science and Art of Longevity. And Peter's basic thesis is that aging and longevity are just far more malleable than we think. And with the right roadmap, we all have the power to plot a different path for our lives, one that lets us outlive our genes to make each decade better than the one before. And Peter has generously offered up 10 signed copies

of this groundbreaking book for us to give away. So if you would like to enter to win a free copy, go to richroll.com slash subscribe, join our mailing list. If you're not already subscribed, then look for an email on or around April 3rd with further instructions. In today's conversation, we offer a short overview of all of the subjects covered in the book.

But in large part, this discourse centers around the book's final chapter, which tells the story of Peter's emotional health during a dark time and highlights the critical and generally underappreciated role that emotional wellbeing plays in the quest for a longer, healthier life.

So without further ado, this is me and Dr. Peter Attia. Well, Peter, it's great to see you. Thank you for coming back to do the show. I've been looking forward to this for a very long time. I woke up this morning to an interesting text from you about the loss of voice and saw your Instagram video. So first and foremost, like, how are you feeling? Are you even like up for doing this?

Yeah, I actually feel fine. I just sound worse than I feel, but thank you for agreeing to still sit down. Yeah, of course. You sound a lot better than you did in the video earlier. And, you know, before we even get into anything, I think it's curious and interesting that you spent, what did you say, like seven hours

on calls and Zooms yesterday? Yeah. And that is not unrelated to the final chapter of your book. And your podcast is called The Drive. You are somebody with a tremendous amount of drive. And so perhaps deep down, there's still the superhuman complex or the workaholism gnawing away at the back of your brain.

I suspect so. I suspect that it's something probably you can relate to with your own past, but I don't think addicts ever fully recover. I think they get into recovery, but I will probably always struggle with workaholism, perfectionism and those things. You and me both, there's lots to untangle there.

And that's perhaps where I wanna spend a good amount of today's episode. But before we even discuss that, I did put out, I re posted your little video and put up a little poll and said, is Peter gonna be able to do the show today? Answer A, yes, Peter always finds a way. B, there's no possible way. 74% believe in you.

So we'll roll the dice and see how this goes. And I just wanna say that at the risk of a sort of self-indulgent monologue at the top here, forgive me for being a little bit long-winded, but just to kind of set the stage. As I'm reading Outlive over the past couple of weeks to prepare for today, which I adore this book, it's a great service and congratulations on finishing it.

I think it's gonna help a lot of people. But in my kind of semi unconscious, I have a lot of things swimming around in my kind of semi unconscious, I have a lot of things swimming around in the back of my mind. As you know, my swim coach from Stanford, Skip Kenny recently passed away. We had a little discussion about that. Prior to that Dick Jokums, who was my coach.

Exactly, right. Well, Skip was 79. The cause of death had to do with, I guess a hip surgery that he couldn't quite recover from, but he did have Alzheimer's. Just the other day, I had an athlete in here called Timothy O'Donnell. I don't know if you know him.

Of course. But he, at age 40, suffered a widow maker in the middle of competing in a half Ironman, survived, finished the race remarkably. But that was a very interesting discussion about, the nature of heart disease and the kind of strangeness of being such an elite athlete. You would think somebody like that would be immune

from suffering from something like that. So that sense of mortality is kind of percolating in my consciousness. And next week I'm going to New York City. My dad is having a heart procedure, a valve replacement after two failed attempts at this. My mother is suffering from dementia. My grandfather died, who was a champion swimmer,

died at 54, suddenly from a heart attack. I'm 56. As you know, I've got these back issues, which you've been very helpful with, thank you. But my point being that mortality is very much top of mind for me. Healthspan, what's truly important, is kind of really front and center for me

in a way that it hasn't been previously, kind of just very present with that. So I'm really grateful to have you here today to walk us through the nuts and bolts of HealthSpan Extension in a really grounded way. As I said, I think this book is really important for so many reasons and not the least of which, the vulnerability that you bring to your own experience

and journey with the science and your own lived experience. So thank you for that. And again, you go through all of these sort of pillars of health span, the objective, the strategy, the tactics, et cetera. And the concluding chapter is all about emotional intelligence, which probably people are gonna find somewhat surprising,

but I found to be revelatory. I sort of think you buried the lead. I might've put that chapter first. I understand why you didn't. And there were two views on this, Rich. So when I wrote the book, the editor felt that that shouldn't be in the book. Felt that that could be another book if you want,

but that doesn't belong here. And then conversely, I had a close friend, Hugh Jackman, read the book. He was one of the only people who did. And he said the same thing you did. He said, this is the opening chapter, not the end. And so there was a tension between those two views. I didn't really know where I stood.

And in the end, I think the negotiated truce was, it'll be the last chapter, but it'll be in this book because I don't wanna write another book. Yeah, well, for anybody watching or listening, please don't get two thirds of the way through the book and not complete it would be my message to everyone. And as a sort of precursor to getting into that, I do think we should, you know,

create some context here and define some terms. And, you know, perhaps let's start. I do, well, let me say this. We did a fantastic podcast, our first podcast. I don't wanna be duplicative of that. And also I know that you're doing a couple other podcasts and each host has their own kind of thing that they're gonna be diving into.

I feel sort of somewhat uniquely qualified to focus on the emotional health aspect of it, but we should just canvas this a little bit so we understand what we're talking about. So first let's just start with like how you got interested in this field to begin with. You mean the field of longevity period? Yeah.

I mean, it really, I think, started when my daughter was born. I think that just crystallized in me a shift from the focus on performance where, you know, at the time, swimming was my life prior to that, cycling and all other sports. But I don't know,

there was just something about it, which it sounds really cheesy, I think, but just holding that baby, I was like, that I didn't even really want, if I'm gonna be brutally honest. I mean, my wife knows this. She really wanted to have a kid and I was indifferent. I thought it would kind of cramp our style a bit,

but my indifference and her desire led to us having a child. And then even the whole time my wife was pregnant, I half jokingly said, I don't think I could like this kid as much as I love our cat, because we had this cat that I really loved. And my wife just rolled her eyes.

And then of course, the second she's born, like literally there are genes that just start transcribing. And I just look at this little ball of nothingness and I think, oh my God, like I'm obsessed with her. And that, yeah, that was my first inkling to think about mortality, right? That was the first time I thought about, I want this moment to last forever,

even though it won't with this child, but maybe one day I'll have a grandchild and I'll experience this again. But, you know, my training in medicine had nothing to do with this. And frankly, I don't think anybody's does. I mean, that's part of the problem. I think as I talk about in the book

with this notion of medicine 2.0, medicine has come a long way in 150 years and it's done amazing things, but it's a little bit of the, what got you here won't get you there. So in some ways, I think if I have one gift, it's that I can usually identify people who are really smart

and somehow convince them to mentor me. And that's sort of what I've spent the last 12 to 14 years doing is just figuring out who the best people are in exercise science, in lipidology, in oncology, in endocrinology, and just learning from them. I mean, and sometimes that would mean

like literally flying out to be in a clinic with them for a month and just seeing as many patients as possible and seeing what they're reading and trying to understand it and then kind of cobbling together a thesis around what this means. And in some ways, I think the book is kind of the culmination of the thought process and it's much neater today than it was

when I started the book almost seven years ago. Well, the background hum here to add like a layer of nuance is one of you commencing this journey from a perspective, from an engineer's mind, like this is an engineering problem that I'm going to solve. And, you know, your background is in mathematics. On some level, you're a quant guy. Like I could see a parallel universe

where you're like a hedge fund guy and a character in billions or something like that. Like that's kind of the cloth from which you're cut. You have this early career in medicine. You go into consulting, you return to medicine with a kind of of renewed focus or interest in this particular field with this idea of medicine 3.0, an evolution of the way we practice medicine

from a kind of diagnosed and prescribed perspective into one that's more focused on prevention, avoidance, delaying, with a very specific focus on these four horsemen, right? Which are the four main killers. If we could eradicate those, delay those, et cetera, we're all going to be extending our lifespan. So talk a little bit about those four horsemen

and why this is kind of the locus of the discussion. Yeah, when it comes to lifespan, there really are four big elephants in the room. And there's really a fifth that I think warrants discussion, but it factors so much into health span that I usually talk about it more over there. The first is atherosclerosis and you've already talked about it personally.

It doesn't get as much attention as I think it deserves. And I think that's almost just because we're so used to it. I mean, everybody's heard the stats. It's the number one cause of death in men. It's the number one cause of death in women. It's the leading cause of death in the United States. It's the leading cause of death worldwide. Just no matter how you cut the data, more people are going to die from cardiovascular disease than anything else. Cancer is number two, pretty much consistently in the same boat, right? For men, for women in the US, out of the US. Then you get into neurodegenerative diseases. And in some ways, I think these are kind of some of the scariest. We certainly have the

fewest treatments for them. And they run the spectrum from dementia, Alzheimer's disease, specifically, which is the most prevalent, to Lewy body dementia, which is kind of a hybrid between a movement disorder like Parkinson's and a dementing disease like Alzheimer's. And then of course, Parkinson's disease. And then you also have a whole bunch of dementias that are not Alzheimer's specific, such as vascular dementia, frontal temporal dementia, things like that. But all of these things are kind of in some ways shortening our life. And in the case of the latter, also reducing the quality of our life, which then bleeds into this other idea that I think doesn't get enough attention in medicine

2.0, which is quality of life. And it's such a glib term. The medical definition of health span is something to the tune of the time of life in which you are free of disability and disease. But like you and I are just as free of disability and disease as we were 30 years ago, but we're not the same guy as we were 30 years ago. There's much more to it than that. And also that doesn't even capture the emotional health piece of it in my mind,

which I think is, even though it's only 1 17th of this book in terms of, you know, content, that simply reflects my expertise in it, not my belief in the importance of it. So we have these four horsemen and the kind of premise here is these are the things that are disabling and, you know, destroying lives more than anything else, the biggest barriers

to longevity, health span extension. And they take years to sort of grow and mature. And we have this period, this typical period, what you call marginal decades, right? Where we're in slow decline as these diseases progress to the point where they're typically diagnosed in a medicine 2.0 paradigm and then treated with a battery of pharmaceuticals, et cetera.

And your thesis is we need to replace these marginal decades with what you call bonus decades. And this goes to, now I understand the graph that is your podcast. I never knew what that graph was. That's your podcast icon, your graphic. Now I understand that. And what was interesting in the book about you,

maybe you can elaborate on this graph and what it means, but it's all about kind of pushing everything out, you know, a couple of decades later. But behind that is this fact that when you really look at the science, like we really haven't extended health span at all in how long, 50 years? Well, if you even just talk a lifespan and you go back 120 years,

on paper, we've doubled lifespan, right? It's gone from about 40 to about 80. But if you subtract out the top eight causes of infectious diseases, it hasn't budged at all. That's quite dispiriting. Right. So one way to look at that is the glass half full approach is what an amazing job we've done

figuring out a way to die of far fewer infectious diseases. And that's basically been on the back of two things, right? That's antibiotics and vaccines. You know, we've eradicated things like smallpox and polio and things that were devastating. We now have antibiotics, right? There's a good chance you and I would be dead by now if we lived 120 years ago,

just on the basis of some infection. So that's amazing. But, you know, it's sort of, there's also, you know, the expression of like, when the tide goes out, you see who's not wearing their shorts, right? Well, it's kind of like the tide has gone out and we kind of realize, well, wait a minute,

like we're not wearing our shorts when it comes to these other diseases. We haven't really figured out a strategy. What worked for those diseases, what worked for acute care, doesn't work for chronic diseases where prevention is what matters. Now that word is so diluted, it almost has no meaning

because of course everybody on the surface agrees with prevention. Well, of course we should have prevention, but I think what's missing is the timescale of prevention. When you talk about a person who has a heart attack at 50, that thing didn't start brewing when they were 40. Certainly didn't start brewing when they were 45. That thing was brewing when they were 40. Certainly didn't start brewing when they were 45. That thing was brewing when they were 20.

And if we'd acted when they were 20, they wouldn't have had a heart attack at 50. Right, there's a graphic in the book of a young man who was in his twenties, right? Who died from an act of violence. He's 23 years old. There's a, yeah, like a scan of his LAD and you can see the plaque build up already, right?

Which is not uncommon, probably the typical case. And the idea being that, yes, we are, you know, hard at work on these diseases at a very young age. And to the extent that we can catch these things sooner or develop better, you develop better technology and protocols and systems that incentivize these types of testing, tests and scans early on that we could intervene at a point where we could actually circumvent them.

Yeah, and I think a big part of it just has to do with, there's an inconsistency sometimes in medicine. You know, causality is one of the most important things in the universe, right? This is, if you just think like metaphysically, causality is such an important concept. And sometimes in medicine, it's very hard to establish. But there are certainly cases where we know it to be true. So we know that smoking is causally related to cancer. And because

of that, we have a very clear strategy for smoking cessation, which means before you start smoking, we're going to tell you not to smoke. The second you smoke, we're going to try to get you to stop smoking. We don't wait until you've been smoking for 20 years to say, well, you've now accumulated a lifetime risk exposure to smoking. we should do something about it. So in other words, I think when it comes to smoking, we have the idea right. But when it comes to the factors that are driving, say heart disease, we're completely backwards, right?

We don't act until a person's risk, tenure risk typically is above 5%. And think about that. We wait until your five year risk, your 10 year risk rather, for a major adverse cardiac event is 5% or more to say, now it's time to do something about your lipids. But if we know which lipids are causally related

to this disease, why wouldn't we act immediately? Why wouldn't we? Like what is preventing that? I mean, I know that if you do a blood panel and you have elevated numbers in problematic areas, unless those elevated numbers are beyond a certain threshold, the typical response is gonna be,

it's not that big of a deal or there's nothing to see here. Yeah, which was certainly the response in my case when I was in my mid thirties and had a bad family history and even had a speck of calcium on a calcium score. I think the simplest reason is you don't have the trial data, right? So it's very difficult to do clinical trials, obviously.

And prevention trials are the most difficult of them all because you have to wait the longest period of time for an outcome. So there's simply no scenario by which we're ever gonna take a group of 40 year olds who are healthy, take half of them and do, you know, placebo. And for other half of them do aggressive lipid management and see what happens over the next 30 years.

It's an impossible trial. Right, but at the same time, it's not a binary thing. Like in smoking, it's pretty clear, right? But as you kind of eloquently point out, when we get into nutrition, it becomes unbelievably complicated. Obviously, a doctor may tell you, you should start exercising or exercise more,

but beyond that, there's no specificity to that. So you spend a lot of time talking about the different modalities of exercise, et cetera. So it becomes, it's a Rubik's cube of, to the 10th degree, right? Trying to figure out what the interventions and protocols should be on an individuated basis based upon what you know about where a person is

in the very early indicia of any one of these horsemen. Yeah, and I think it just requires a bit more flexibility. I mean, I think that's another subtle part of what medicine 3.0 is, which is the term, again, it's one of these things, the term prevention and preventative medicine has lost a lot of its meaning, as has the term personalized medicine or precision medicine.

But on some level, what these things mean are, you have an individual, you will never have a clinical trial that tells you everything you need to know about that individual. It's simply impossible. Clinical trials take a whole bunch of people. They're all heterogeneous. It squishes down a result into an average. It spits out basically a homogeneous response. And it says this is evidence-based or it's not. But within that trial, there are lots of different responses. And we kind of have to understand what that looks like because no one that I'm gonna look at is the exact average of the input

of the thousands of people that went into that trial. They're gonna be one of those thousands of people. So we have to sort of figure out and triangulate, like, what does that look like? And what's the implication for them? And of course, layer in other things. You know, you asked a question, should we be aggressively managing everybody's lipids

early in life? It's also a question of risk appetite that can come with side effects, right? I mean, to get the levels, to get lipid levels where they need to be to basically take heart disease off the table, you have to do it pharmacologically. There's no change in nutrition one can make, no amount of exercise that's gonna move the needle that much,

but that comes with a risk as well. And so it always becomes a question of that asymmetry of risk. And I just don't think that those are questions that can be answered in a heterogeneous fashion. Right, and in our internet age, that's a very unsatisfying answer, right? Like we wanna know, like, you know,

stake your, you know, plant your flag in some extreme position and, you know, create an audience around, you know, whatever it is that you're, you know, waving that flag around and you can get a lot of attention and there might, you know, I'm sure there's kernels of truth and all of those things, but the truth is much more complicated

and sort of masked than that, which makes this difficult. And I guess that brings up kind of a more meta conversation around the state of health span science in general. I mean, one of the things I appreciate about the book is that it's so grounded, you know, and you're not making any kind of crazy claims and I've become kind of accustomed to and somewhat annoyed by-

Allergic to. Yeah, allergic to, you know, what this healthspan conversation has become, which is about moonshots essentially. And it's fun to kind of cast your gaze into the future and imagine a world like in that movie Elysium where people get into pods and it diagnoses you and cures you immediately.

And maybe at some point, who knows, we'll get there, but it's certainly not where we're at right now. And so conversations around, I'm gonna live to be 180 or 120 and do all these sorts of things are really not helpful, right? And your work is very much a departure from that narrative. I think people might go into this book

expecting something like that, because that's kind of what the conversation looks like right now. So what is your take on, you know, what that conversation, you know, is all about right now? And how does that differentiate from what you're trying to say and do? You know, I don't think you're mutually exclusive

and going back to kind of what you said earlier. I mean, I do sort of think in a parallel universe, I could have imagined myself being kind of a quant at a hedge fund. And well, given the name of the hedge fund, what are you supposed to be doing? You're supposed to be hedging. Everything is a hedge in life.

You always have a contingency plan. And I always say to the people who tell me, I don't need to exercise. I don't need to do this. I don't need to do that because I believe in cellular reprogramming is gonna totally rescue me in 10 years. I say, if you're right, that's wonderful.

If you're wrong, you won't have a chance to come back to today and undo the damage. So what's the downside in doing everything in your power to extract as much value as possible out of the current rudimentary tools like exercise, nutrition, sleep, et cetera. And if you show up in 10 years,

the worst thing that's happened if the moonshot is there is that you've wasted 10 years taking care of yourself. the worst thing that's happened if the moonshot is there is that you've wasted 10 years taking care of yourself. Contrast that with the alternative asymmetry, which is you screw around for the next 10 years and there's no moonshot. Now the worst thing that happens is you're on a very quick path to death.

These are completely asymmetric. And I think that, I don't know, I think that that kind of thinking has just always been sort of a part of how I think about stuff. So in some ways I might be the least interesting, least sexy person in this space, because I'm really just trying to think about it through the lens of what we know.

And look, I mean, it's funny you mentioned, I was on seven hours of Zoom yesterday. Well, two of it was talking to scientists about a particular technology around epigenetic reprogramming, but in a much more nuanced way than gets discussed sort of in the gen pop. So it's something I'm very interested in. But in particular, for example,

like looking at reprogramming lymphocytes and T-cells to extend immune function in the elderly. Because I would argue that if you could fix one cell in the aging body, it might be the immune system. Because you're going after two diseases, right? You're going after all the infectious causes of death, which for you and I are nothing, but actually by the time you get to 80 and up,

pneumonia does start to play a role. But I think it would also have the biggest impact on cancer. Why is cancer growing exponentially as we age? It's probably two things, right? It's probably the accumulation of genetic damage that leads to mutations that results in cancer cells. But I think it's equally that our immune system is weakening and therefore not fighting back the cancer. So am I super excited about the idea that we could genetically reprogram through an epigenetic rewrite immune cells and fix that problem?

Absolutely. If does it happen in our lifetime? I have no idea. But it certainly wouldn't prevent me from doing everything I can to maximize my odds of sticking around long enough. Right, and on the medicine 3.0, you know, idea of early intervention,

some of the technology around early testing must excite you as well, because if we can develop technologies to catch these things at their inception, that's huge, right? And there does seem to be some progress in that realm. Yeah, I think with cancer, the unfortunate thing is that we are still relatively limited in treatments. So I'd say the most exciting thing that's happened in cancer in the last 20 years, certainly the last 10 years, has been immunotherapy. And there's been a kind of what I would call minor success and a major success.

The minor success has been the use of adoptive cell therapy. So that's when a patient has a tumor and let's say you can't treat that tumor with all the traditional means. So you can't cut it out. It's too disseminated, not responding to chemotherapy. Radiation, of course, is no longer of any value,

but you can harvest some of that tumor, and within it, you can find lymphocytes. You can find their own immune cells that know how to at least attack and kill the cancer, but you don't have enough of them. You can expand those cancer cells outside of the body, plus or minus genetically manipulating them and put them back in.

And they can go and if they're insufficient enough numbers, overcome the cancer. That works in a small number of patients. Now the holy grail there is why can't we make it work in everybody? Because in theory, you can always find some lymphocytes in a patient's tumor that figured out how to get there and how to at least kill some of them.

And the main reason is they get exhausted when you expand them. So it actually comes down to the longevity, if you will, of the T cell. So let's bracket that as one problem that's interesting to solve. Second thing in oncology that's been really exciting is these things called checkpoint inhibitors.

I write about them briefly in the book. These are drugs that basically take the brakes off the immune system. And so if you have an immune system that happens to be primed to recognize the cancer, you can take the brakes off it and it'll go nuts. Now, the bad news is that most people's immune system doesn't recognize their cancer well enough to be affected by that. The good news is if you are in that camp, this works almost every time. So those two things are huge, but collectively, we're talking about a 5% to 8% dent in cancer treatment. So all things considered over the past 50 years, that's amazing.

There's been nothing that's probably had a bigger impact, but where's the rest of the Delta gonna come for the next decade for you and me and for my patients? I think it's gonna come from earlier and earlier detection. Because the one thing that is abundantly clear, and I go through several examples in the book, is that stage for stage, the fewer cancer cells you have in your body,

the better your body will have a shot at beating a cancer with even traditional treatments. So even if you're talking about garden variety colon cancer being treated with garden variety chemotherapy, when you have a billion cells in your body, your odds are way better than if you have a hundred billion cells in your body because of the number of mutations

and the number of chances that that cancer has to escape the chemotherapy once you have an enormous expansion. Same is true with breast cancer. I mean, that's where we have the best data on this. So liquid biopsies, which are probably what you're referring to, are tests that now allow us to take a couple tubes of blood and look for something called cell-free DNA. So normally if we take a couple tubes of blood out of your arm and we're not looking that hard, we're going to see all your white blood cells,

your red blood cells, glucose, potassium, all these sorts of things, right? But if you use really, really, really fancy equipment and high throughput screening, you will notice some DNA that is not from the cells because most of what is in your blood is cells and liquid, right? It's just plasmid cells.

But there's tiny, tiny, tiny fractions, like 10th of a 10th of a percent of fraction of DNA that is not from the cells in your blood. And these new techniques can not only identify where they're from, hey, this is DNA from a liver cell. This is literally DNA from your pancreas or your lung. They can also predict if there's cancer in that organ

based on the patterns of methylation on it. And that could then prompt you to go and get a more thorough investigation, which means we're going to sort of hopefully figure these things out a lot sooner. These things are still in their infancy. We are using these types of scans or these types of blood tests in concert with early and pretty kind of high-tech MRI scans that are not sort of traditional scanners. And the good news is, yeah, we're gonna catch things really early.

The bad news is you're gonna catch a lot of things that aren't cancer. So this gets into that natural tension of everything you do has a cost. And usually the financial cost is the least of your worries. The bigger cost is, I can be pretty sure that you don't have cancer, but in the process,

I'm gonna identify a few things that probably aren't cancer, but warrant follow-up. And that creates stress and anxiety. And that's a real cost. Right. And this is something that you're doing with your patients in your practice, but I'm imagining the medicine 2.0 paradigm,

let's for purposes of just an example, a 32 year old male listens to this and says, I'm gonna go get checked out for everything now. I'm inspired by Outlive and Peter's message, goes to his GP and says, I wanna get tested, do all this stuff. What is the response that that person is going to get? Like, are they gonna run up against some kind of barrier

that's gonna prevent them from even being able to avail themselves of this kind of testing? Probably, I mean, I had my first colonoscopy at 40, which at the time was 10 years before any recommendation. That recommendation from 50 has now been lowered to 45, thankfully. I still think it's too high. I really do believe everyone should have their first colonoscopy at 40. But when I had my first one, I had to fight like hell to get it. I was paying out of pocket. No insurance company would ever cover it. And so, yeah, the view is, what are you doing? And again, my view

comes down to just risk and asymmetry. A good 5% of people who die of colon cancer are diagnosed with a colon cancer that occurs at or before the age of 40. That's not a huge number, but it's not zero. And colon cancer is the third leading cause of cancer death. So my view is, the upside is that I get to mitigate that risk. The downside is the cost, because I'm paying out of pocket and the risk of the bowel prep and the risk of the procedure and the risk of the sedation. And I can quantify all those risks.

I can quantify this risk. And on my balance sheet, there's no comparison. And I mean, I think part of it is you can say, well, Peter, gosh, you're equipped to do that because this is your profession. And what I hope is that I'm arming people to do the same sort of calculation. Because I think we do have to do that

and we have to be our own consumers of this stuff. Right, but we have this monolith that is the healthcare system and it's gestalt towards bankruptcy and the costs that are incurred from treating all of these chronic ailments, you would think that there would be a financial incentive to front load patients with these types of tests

and early detection scenarios to avoid those costs later down the line, but it's so entrenched, it feels like an impossible task to, you know, kind of rewire the system and create better incentives. Yeah, it's, as you probably know, I grew up in Canada and Canada has a single payer healthcare system. And there's almost nothing about Canada's healthcare that I think is better than the US's, as broken as the US's is, because the Canadian system has got more problems. But there are two things that Canada or a single payer system does better. The first is it actually provides

healthcare for all. And that's, we don't need to get into that discussion here, but it's a tragedy that the number one driver of personal bankruptcy in the United States is healthcare related cost. That's unacceptable. So nobody should be without healthcare. But the second thing that a single payer system does very well, and this gets to the heart of what you're asking about, Rich, is the payer owns the risk for life. So there is an incentive to prevent. Right now, my health insurance is Aetna. Two years ago, it was Blue Cross. Three years from now, it's going to be United. What incentive does Aetna have today to care about spending a dollar on me when they are pretty much positive they will not own my risk in 20 years when the chickens come to roost, right? Like that's the fundamental problem. It's the portability of risk. And I don't, I mean, I've thought about this problem so much, but until you

fix that problem, until there is true risk ownership between the patient and the payer and the provider, and that is carried out over the course of your life, there is no incentive for them to carry any of that risk. Yeah, I don't know what the solution to this is, but it's not good. But I do have hope when I see people like yourself who have carved out a really successful practice outside of that paradigm. And what we're seeing with functional medicine doctors,

et cetera, like people finding different ways of practicing medicine that has a higher priority on the things that you're talking about. One of the interesting things when it comes to the four horsemen is the overlapping nature of all of these things. And one thing you talk about in the book

is we tend to treat these things in isolation as separate things, right? Like, but in a Venn diagram, they're all overlapping in terms of what's driving them or causing them. And a lot of this roots back to metabolic health, which I feel like is a new frontier that finally is getting the attention it deserves. And it's something that you, you know,

have been steeped in for a long time. So explain a little bit about what metabolic health is and how it relates to, you know, the onset of these chronic ailments. Yeah, I'm glad you brought it up because I kind of got distracted when you first asked me about the four horsemen. I forgot that one, right?

Yeah. It's almost the easiest one to forget because directly it doesn't actually account for the loss of many lives. So if you count up the graveyards with heart disease, cancer and neurogenic diseases, that's a lot of bodies. If you go and ask the question, how many people died from type two diabetes

or fatty liver disease or insulin resistance? It's a relatively small number of bodies, but the direct contribution of those to the other three horsemen is enormous. Because once you have type two diabetes, your risk of those other diseases doubles. So I think of them as a continuum. I don't think of them as discrete diseases. Diabetes has a very clear diagnostic cutoff. When your hemoglobin A1C exceeds 6.5%, which means that your estimated average blood glucose is now above 140 milligrams

per deciliter. We put a label on you. You're called type two diabetic. But what about when your average blood glucose is 130 milligrams per deciliter or 120 milligrams per deciliter? I mean, this is a continuum, right? So I think of it as what happens when you're hyperinsulinemic, first earliest signs of this insulin resistant, then you're kind of get, usually the next thing you're going to start to see is fat accumulation in places where we're not supposed to store fat. So, you know, we were really well designed to store fat in our sub-Q space, you know, cover up the six pack, all that stuff. That's totally fine place to have fat, but we were not designed to have fat around our organs, inside our liver, around our heart, pancreas and kidneys.

Those extra fat cell places, fat does really bad things when it gets in there. It's very inflammatory. And that might be, in fact, I wouldn't say it might be, I would say it is the most underappreciated driver of residual risk in cardiovascular disease. Meaning even once you fix smoking, blood pressure, and lipids, you can still have risk of heart disease just from those

fat stores. And when we think about how many people are walking around with non-alcoholic fatty liver disease, so as its name suggests, this is fat accumulation in the liver that is not driven by alcohol, which was historically the thing that we thought was driving fat in the liver. And it was. This is devastating both in terms of liver pathology. If left unchecked, that will progress to something called NASH,

which ultimately would result in cirrhosis. This is probably the leading cause of liver transplantation today. And if not today, it certainly will be within a couple of years. So directly, there's a huge pathology there. But indirectly, I think what it's doing to these other things is, you know, these other horsemen is a huge problem. I don't think we're aggressive enough in screening these things. I talk a lot about that and talk about how

we could be much more vigilant and catch these things earlier. And the challenge is, you know, in some ways, these are the hardest things to fix because it comes down a lot to exercise, nutrition and sleep. You have to manage nutrient, you have to be exercising. I mean, there is simply no better elixir for metabolic health, fuel partitioning, glucose disposal than being active. And if your sleep is dysregulated,

it's almost impossible to overcome it with enough exercise and nutrition. How would one know if they're accumulating fat around their organs? The easiest way to get a quick glance is doing a DEXA scan and a good DEXA scanner can estimate what's called visceral adipose tissue or VAT. We use nomograms that basically show the percentiles

by age and sex, how much VAT is acceptable. So in our practice, any patient that is above the 20th percentile for visceral adipose tissue on a DEXA scan, it's a huge red flag. Liver fat is also relatively easy to identify. Once it gets bad enough, it'll start to show up in your liver functions. Sometimes the doctor will then say,

well, look, we should go and do an ultrasound to take a look. If a person has liver fat, the treatment is usually to try to get them to lose weight. I think we could be a little bit more specific than that, but that's clearly the best first line. usually to try to get them to lose weight. I think we could be a little bit more specific than that, but that's clearly the best first line. And in terms of metabolic health in general,

you mentioned elevated blood glucose and what would constitute type two diabetes and perhaps a little bit of a lower number indicating being pre-diabetic, but there's a whole range of prevention that we're not looking at right now to disrupt that, you know, train that's already been pulled out of the station.

Yeah, diabetes might be one of the worst examples of where we just wait too long. You know, we really, you know, we wait until you're at 6.5 before we really bring out the big guns. And I also think in part it's because we're optimizing with a different set of tools. The majority of the treatment,

the real treatment for diabetes is drugs. Like if we're gonna be honest, right? I mean, we pay lip service to exercise and nutrition, but I think most people understandably, and I don't wanna be critical of the doctor, right? The doctor's got to see a patient every 12 minutes. If you're running a clinic and you're taking care of patients with type 2 diabetes, you've got 12 to 15 minutes with each patient. In 12 to 15 minutes, assuming you even understand enough about exercise physiology and nutrition,

are you going to have an impact? Or is it easier to change the prescription and adjust the multiple medications we have that are very effective, by the way, at curbing type two diabetes, not really reversing it, but keeping it in check. So there's a structural problem that is just getting in the way of doing that. And if you wanted to fix this, you would have to actually do something that reverses it. And I don't think the medications are doing that. I mean, I think you have to basically change their nutrition status, change the exercise, fix the sleep.

Right, despite the pharmaceutical intervention, for a lot of people, it's just a bandaid on top of the causality, right? And not looking at the causality is not doing anybody any good. That's right. It actually, I mean, I'm glad you brought that up. It just comes back to this other issue

of causality again, right? I mean, I believe that, and I'm not alone in believing this, right? I don't think this is particularly controversial. Diabetes is a disease of energy imbalance, right? It's a carbohydrate disorder. It's a carbohydrate metabolism disorder that results from overnutrition.

But part of that overnutrition is exacerbated by a lack of insulin sensitivity. Again, it's sort of a, our body's a miracle in some ways, right? So if I drew your blood sugar right now, if I checked a blood sugar on you and it was a hundred milligrams per decil now, if I checked a blood sugar on you and it was 100 milligrams per deciliter, that would be a perfectly normal level. That signifies that you have about

five grams of glucose in your entire circulatory system. Five grams is not a lot. That's like a teaspoon of glucose. That's perfectly normal. If I drew your blood sugar and it was 200 milligrams per deciliter, you would be a type two diabetic. The implication is you have two teaspoons of glucose in your circulation. This is not a big difference. When you consider that your muscles can hold 300 grams of glucose, of glucose, your liver, 150 grams of glucose. So think about this. You could easily get a person who is a diabetic with 10 grams of glucose in their bloodstream down to five, if all you could do is get their muscles to hold more and their liver to hold back a little bit, because your liver is the one that's kind of percolating it out there. I mean, this is a game of millimeters

and it's not rocket science to tip the balance in your favor if you take, and I hate the word, but if you take a holistic approach to the organ system. Right, and this is a big part of the interventions that you pursue with your patients. But a lot of this begins with getting your patients to use a continuous glucose monitor. We talked a little bit about this last time, I think.

So I don't wanna go too deep down this rabbit hole. It seems like at least on the internet, this is controversial, which I don't really understand. Like any information should be good information as long as it's paired with a solid foundation of understanding and education around what these metrics mean. But certainly it provides a window

into what's going on metabolically with the people that you're working with. And I've used one myself and it's been fascinating to see how my body responds to various foods. And in particular, and you go into this in the book, the impact of stress and sleep on how your body metabolizes glucose. Yeah, absolutely.

I mean, probably the only subset of patients that I would be very hesitant to use a continuous glucose monitor and would be someone with a history of an eating disorder where you just put any additional stressor around food. To me, that would be probably a contraindication. But you're right. It is, it's attracted a bit of a strange controversy from what I would describe as,

you know, a crowd that probably wants to view the lens, view the world through a very narrow lens of evidence-based medicine, which is, you know, if there is no evidence that a person without diabetes can improve their health with this thing. It should never be used. There's something to be said for that, right? If we don't at least consider those things, then we'll be beholden to nonsense all day long. But we have to remind ourselves that the absence of evidence isn't the evidence of absence.

Again, close without say. So instead, in my mind, I justify these things by saying the following. Look, there is no shortage of data that demonstrate for non-diabetics, that is to say for people whose hemoglobin A1c is below 6.5, it's unequivocal that lower blood glucose is better than higher blood glucose, even within the quote unquote normal range in terms of all cause mortality. That means if you have someone whose average blood glucose is 100 milligrams per deciliter, healthy, that would be a hemoglobin A1C

of about 5.1. And someone whose average blood glucose is 120 milligrams per deciliter, also clearly not a diabetic, that person would be about a 5.6 to 5.7 hemoglobin A1C. The all-cause mortality difference is real. So those data, of course, are based on hemoglobin A1C. The all-cause mortality difference is real. So those data, of course, are based on hemoglobin A1C and not CGM, but the CGM is allowing you to measure the average blood

glucose, which is being imputed by the A1C. And therefore, I don't think it's an enormous leap of logical faith to say, if the CGM can help you manage to a better blood glucose, there's potentially a better outcome there. Another criticism that I've heard is that, well, you could eat bacon all day and your blood glucose would be- Yeah, gaming it. Or when you gamification the whole thing, then it's all about like lowering that curve,

which might drive some unhealthy dietary choices. And I think that's a totally valid point. My sort of response to that would be, well, by that metric, we should never use anything that could be gamed. By that definition, anything can be gamed, right? Like that would mean that body weight is a totally irrelevant metric, which is not true.

Because you could gain, if I said, the only thing that is going to determine the outcome of your life is your body weight, you could pick up smoking tomorrow and you'd lose weight, but nobody thinks you're improving your health. So you also have to be a rational actor to do this, right? You have to realize that,

yeah, even if I just ate bacon every meal, every day, and my blood glucose went down, I'm probably not improving my health. So we have to be careful we don't throw the baby out with the bathwater when we start to come up with silly examples of how people can engineer and goof off with the game. Right.

I opened this by saying we were gonna go right into emotional health, but I'm glad that we've talked about the things that we have talked about. And before we launch into that, let's just say within this strategy of avoiding, preventing, delaying, minimizing the four horsemen, you have these four tactics basically,

which involve exercise, which your thesis being that this is the most important driver of healthspan extension of anything that you could do. And lifespan. And lifespan. You have nutrition, you have sleep, and then you have emotional intelligence. But- And the one I omit, by the way,

just because it would have been another book, is all of the medical management. You know, it's sort of like- Right, that was my butt. Like there's nothing in this book about pharmacology, supplements, and that seems to be the thing that people wanna talk about the most, right?

Like what is the supplement, the NAD, the NMN and like all that kind of stuff, right? Like this is not part of anything that you're talking about. I mean, I do talk about a couple of drugs, talk about rapamycin, there's a whole chapter on that. That was fascinating actually, I didn't know that whole story about Easter Island. Yeah, it's pretty cool.

I talk about lipid lowering drugs. I talk and that's about it, you're right. I don't really go deep into the other stuff. The initial plan was there was gonna be an appendix in this book that was gonna deal with just the, what I thought were the 20 most relevant drugs and supplements. As I started to write said appendix,

I realized it was gonna add 200 pages to the book because I couldn't do justice to each one of those in under about 10 pages. And so that idea quickly got sort of shut out. So the good news is I write extensively about those topics elsewhere. I podcast about those topics elsewhere. And I just felt that, you know,

this was the most interesting stuff to be writing about. Cause it was the stuff that was not getting enough attention elsewhere. This book almost never happened also, like in the epilogue or in the acknowledgements, you basically were like, I worked on this for a long time. I missed my deadline for a year, the publisher back, you know, like this almost never happened.

Why was this so difficult for you to complete? I think there were two forces. I think the first is, I don't know, did you experience this when you were writing your book? I mean, as a perfectionist, did you just feel like, I can't put this thing out there cause it's not a hundred percent? A million times. Yeah, so. Yeah, like that's, yeah, this thing out there because it's not 100%. A million times.

Yeah, so. Yeah, like that's, yeah, this goes in, okay, good. Elaborate, like this is, we're getting into this stuff I really wanna talk about with you. Yeah, yeah, so there was the, it's not quite good enough yet, it's not quite good enough yet, it's not quite good enough yet.

I think there was a much deeper problem going on, which is I was early on by 2008. So I started the book in 2016. 17 is kind of a blur. My life is falling apart as the book describes. 18, I'm trying to pick up the pieces of it. And by 19, I'm back to kind of writing. The publisher is furious at me at this point. This is a different publisher, by the way. So Penguin is my current publisher. The other publisher I won't name, but it's one of the other big five. They've kind of had it with me at this point. This is a different publisher, by the way. So Penguin is my current publisher. The other publisher I won't name, but it's one of the other big five. They've kind of had it with me at this point.

But at this time I know I gotta, I can't just ignore this emotional health piece. Like I gotta be able to write about this cause it's such an important part of health span and health span matters as much as lifespan. So on the one hand I feel conflicted cause I wanna write about it. And on the other hand, I feel like I can't write about it

because I don't have my act together. You weren't well enough. I wasn't well enough to write about it. Yeah, comment on it. So I was sort of spiraling out of control in early 2020, when basically the publisher just kind of shot me an ultimatum. I remember I was filming Limitless actually.

I was in Norway and some, I was actually trying to fly back from Norway. I remember this was filming Limitless actually. I was in Norway and some, I was actually trying to fly back from Norway. And like, I remember this very well. I was in this dark, awful hotel in a place I'd never seen before because the flight got canceled and I got stranded in some small place. And I get this really nasty email from the publisher,

very threatening. If you don't deliver this thing by such and such a date, like we're gonna take action, blah, blah, blah, blah, blah. Wow. And I just called my COO and said, wire them the money tomorrow and tell them to fuck off. And so that was the end of that. It wasn't that long ago.

Yeah, three years ago. Yeah. And then the book basically, I just said, I don't wanna write this anymore. I'm done with this. And then the events of 2020 unfolded and fast forward, uh, to late 2020. I, I was talking to Michael Ovitz, who's a close friend and I don't know why it came up. I don't know why the manuscript came up. This part, I don't

remember. I think we were talking about his book, which I had maybe just read. And I was like, Michael, I can't believe it took me this long to read your book. I loved it. Blah, blah, blah, blah, blah, blah. And he was like, send me your, send me the manuscript. And I was like, Michael, I can't believe it took me this long to read your book. I loved it, blah, blah, blah, blah, blah, blah. And he was like, send me the manuscript. And I was like, oh, it's not that good. And he's like, just send it to me anyway. So I did. And he read it.

And then he's the one that said, no, no, you gotta finish this thing. And he said, if you can get me something within, he said, try to get me something within like six weeks that I can send to my friend at Penguin. And that's what kind of resurrected the whole thing. Resurface the whole thing, yeah. When you were here the first time after we wrapped the podcast,

you shared with me a little bit about your personal journey. I knew nothing about that, I had no idea. And then in reading this final chapter of the book, it's really powerful. You really laid it out with quite a bit of vulnerability. And I think it's really important. And you recognize the importance of this, basically the emotional health piece being like

the most important thing, because if you don't have your act together with this, what is the point in extending your health span? Like what, like Esther Perel says to you, like, why do you wanna live longer? Like when you're so miserable, which sets in motion, you know, this journey towards recovery.

So talk a little bit about what was going on with you leading up to this realization. I think there were really two big things that were obviously related, but temporally distinct. So I think by 2016, 2017, I was probably working. I mean, I was working really hard. I was traveling constantly. My wife was pregnant with our third child. I was nowhere to be found. I mean, my two kids that were at the time, my daughter and my son,

didn't actually think I lived at home. They actually thought I lived in New York or San Francisco or wherever the hell I was traveling. You know, I had offices in two different places and all this kind of stuff. But I think it's worse than that, right? Like, I wish I could just say, oh, it's just that I was like a super hardworking father

who was like just, you know, working really hard to make a lot of money for his family. No, oh, it's just that I was like a super hardworking father who was like just, you know, working really hard to make a lot of money for his family. No, I think it was also that I was getting more and more detached, you know, and more and more just sort of selfish. You know, I think naturally I'm a very selfish person. And I think that selfishness was just growing and growing and growing.

And, you know, the event that comes to a head that I write about is after our youngest son is born in June of 2017, I barely make it home for his birth. I don't think I write about that, but I was in New York when my wife went into labor. She was annoyed that I even went to New York the week she was due, but I was like, yeah, don't worry, I'll make it back.

And of course I barely make it back. So I get to the hospital maybe an hour before he's born. And then two days later, I'm back on the road. And about five weeks later, I'm in New York. A friend of mine from Boston is in town. We're getting ready to go out. And I get a call from her and she says, you know, our youngest son just had a cardiac arrest. I'm in the ambulance with him. We're heading to, you know, UCSD, Radies. He's an infant. He's five weeks old, yeah. And he, you know, we still to this day

don't really know what happened. He probably just had some awful vasovagal insult, but you know, by some miracle, it happened to happen during the day, the nanny saw him roll his eyes back and turn blue. And luckily my wife is a nurse practitioner. You know, she's done critical care her whole life. So just did CPR and I'm like, put them on the floor, you know, sternum compressions, the whole thing. While the nanny calls the paramedics four or five minutes

later, they're there just as he's coming back. And for reasons that, you know, I can finally say this without breaking down, but for reasons I, you know, I can finally say this without breaking down, but for reasons I'll never understand, I just didn't get on a plane to go home. I was just so detached. I literally just treated it like it was a patient. I was like, okay, call me when you get to the ICU. And then for the next like five days,

I just did a check-in with the doctors every day. And I didn't drag myself home until 10 days later. 10 days later you came home. Yeah. And it's just, it was just so blind to what an asshole I had become. It's so hard to, I mean, I don't know you that well, but it's hard to fathom that you would make that choice.

You know, understanding a little bit about, you know, what, you know, kind of your makeup, I can see how this would come to be, but it's shocking to hear that, but I think it's really courageous for you to admit that, not just in a podcast, but in the book as a way of illuminating like the depths of like how far gone you were in terms of your emotional health

at the time. It was very hard to write that. It was, and honestly, it's something I, to this day, my wife's only read one chapter of that book. That's she hasn't read the book yet, cause it's not out yet. But I did ask her to read that chapter. I wouldn't have written that chapter without her blessing.

Cause I know that that's something my kids are gonna read one day. And like my son will read that one day, he's five today, but he's gonna read that one day and know that his dad didn't come home. And it's so funny, he says, I don't know how he knows this, but he must have heard us saying this, but he always says, mommy saved me.

And lately he's been saying, daddy, did you save me too? And I say, no, I didn't, Harry. I didn't save you. Mommy saved you. Daddy wasn't there. Why weren't you there? Like he's starting to ask these questions. And so-

You're the healer. This is your identity. Yeah. So there will be a reckoning for this. I mean, there will be, there's no question. So as the summer of 2017 bled into the fall of 2017, I was spiraling out of control. Like, I mean, there's just,

I don't know what was driving all of this, but I mean, I almost got into a fight in a parking lot with someone. And this is like, I mean, this was more than just a shouting match. Like I was going to kill someone in a parking lot over nothing. Literally some guy left a note on my car,

you know, a chirping note in my car. And I was like, oh really? I mean, so around this time, Paul Conti, who you know, is one of my closest friends. We were, we met the first day of med school and immediately connected over our love for Ayrton Senna, who my youngest is actually named after. And Paul and I shared an office in New York.

So we saw each other all the time. And he just said, I think you need to go somewhere. I think you need to go somewhere. I think you need to go somewhere for, for, for, you know, for like residential care. And I was just completely reluctant to do this. I mean,

he talked about, you need to go into a trial. You know, he was talking about this place called the bridge to recovery, which was for trauma. And I was like, I mean, it just doesn't make any sense,

dude. Like, what are you talking about? And he's like, he goes, you gotta, you gotta trust me. Like you live like a trauma victim.

Everything about you is a response to trauma. And I don't know what it is, but you know, he just basically said in a non-condescending way, you kind of just gotta trust me. And so ultimately I did go there. I went there at the end of 2017 for two weeks. Had anybody else told you that, you would not have listened. That's correct. Right.

Yeah. The stuff in the book about the bridge, from my perspective, as somebody who's been in treatment. Yeah, yeah, I wanna hear your thoughts. Pure comedy. Like just- You mean you can see it, right? Textbook, yeah, like hilarious. Like your resistance, just refusing to participate,

you know, unable to share even the remotest, you know, kind of emotional response, completely detached from, you know, any ability to connect with, let alone articulate, like what was going on inside of you. It's pretty funny. It's good stuff. And to the point where this goes on,

I can't remember whether it was the first treatment center or the second one where the other inpatients are like, is this guy a serial killer? Like he's just sitting there silently. He won't talk like what's going on with this guy. Yeah, I mean, at some point they gave me a piece of paper that had all the different types of emotions. And they were like, just see which

one of these you are. Like, I know you say it's anger, but there must be something besides anger. Like, is it anger because of hurt? Is it anger because of embarrassment? Is it anger? Like, they were really trying to help me expand my vocabulary because I sort of showed up as a monosyllabic idiot, right? So, you know, the two weeks I spent at the bridge was absolutely the beginning of the change, but I think incorrectly left after two weeks and everybody sort of felt I really needed to be there for at least six weeks because it's really designed as a bigger program. The first two weeks is really just to uncover what the heck is going on, The first two weeks is really just to uncover what the heck is going on,

but you don't get handed any of the skills to go about fixing it. So even when I came back, I wasn't really in a position to kind of fix anything. Sure, yeah, it's interesting. Like you leave AMA, right? Like the patient, the smart doctor guy is a terrible patient.

You're somebody who resides in your mind. You pride yourself on your intellect. You're a very smart guy. These are people that are very resistant to this type of help, right? Like, okay, I understand this intellectually. I get it. Like, I'm gonna now solve this problem with my brain,

not understanding that it is that brain that created the problem to begin with. And the journey towards recovery involves disentangling all of that, letting go and allowing people in to help you. But you're somebody who is basically fueled by self-will and your own sort of independent way of doing things outside of any external inputs. And the interesting thing is I think when I left the bridge, I was definitely cracked

open. And I think I did great things when I got out in terms of like, it's not like I didn't, you know, do therapy and Esther introduced me to a guy named Terry Real, who was amazing. But there was also certain things I missed that I think you only get in residential care. And one of the things was every night at the bridge, you went to a 12 step meeting in town. So every single night, imagine that for 14 straight nights, you are at a 12 step meeting and they don't care which 12 step meeting it is.

So I was doing AA, SA, like NA, it didn't matter. I went to all of them. But are you just like leaning back? Well, I mean, no, initially, of course I was. Initially I was like, why am I here? I don't even have my phone. Like, what am I doing here? Like, ugh.

But I'll tell you, by the time I started to crack open, I was really moved by this. And I remember when I got back to San Diego thinking, I wish I could go to a 12 step meeting, even though I'm not an alcoholic. Like, I wanna listen to what they're saying. Like I want to hear that there's someone else who's struggling with something.

And I think that was a missed opportunity. Yeah, so a seed is planted. You've got Paul, you've got some introduction to the notion that trauma plays a role. You are resistant to the idea of being an addict in any way. Like I'm not an addict. Like I, yeah, I almost got in a fight. And like, yeah, I realized like I work too hard

and I'm not present with my family. But does that really put me in the category of these other people? Like you're struggling with your ability to connect and relate to what is being presented to you. And I think I started to fix, I did, I guess it was probably by about the summer of 2018. I really did start to make some really big improvements

with my wife. And I really started to heal from all of that hurt. Now I was still working way too hard. I was still traveling like a dog. And I don't write about this in the book, but this goes on for another year until November of 2019. I have probably the closest I've ever had to a nervous breakdown at the time.

It was actually in Austin. So this is where I still live in San Diego. Every year I go out to watch Formula One. And so sure enough, I go out to Austin to see Coda and I had an amazing lead up to it, hosted a bunch of podcasts. There was some people I wanted to interview there. The night, the morning of the race, I wake up and I just have a total anxiety attack, which I've never had in my life. And I decide I can't go to the race. So I just call an Uber, go to the airport and go home. I miss the race. And I get home and my wife thinks it's really weird. And she assumes it's, well, maybe he's just feeling like really burnt out and just needs to be with us more.

But something was definitely broken. And the next day we had, our team was in town. We were supposed to be making a bunch of content videos and I just completely flipped out. I was at the whiteboard, literally trying to make the first one. And I made a mistake and I flipped out. Like, I was like, I'm done, I'm done, we're done.

Like this whole thing's over. This was 2020. 2019. Oh, this is before the stuff you talk about in the book. Okay, wow. And then I spiraled into a very deep hole of like, I mean, very significant thoughts of self-harm, very desperate, so bad that Paul actually flew down

to San Diego and we hold up in a hotel for a day. And Paul's diagnosis at that time was crystal clear, which is you are so angry at yourself for how much you punish yourself that you're kind of turning your anger inward now at the guy who's been whipping you. Like there's a guy inside who whips you and you are now so angry at him that you wanna hurt him. And he's like, you have got to stop this. And I was like, okay, okay, I'll start taking,

you know, and I, again, I just did this stupid thing of like, I'll do a little bit less, I'll do a little bit less, I'll do a little bit less. And I limped along until I didn't. The elevator's going down. You had a couple opportunities to step off, but you needed a little bit more pain. Yeah.

So 2020, it really all comes to a head. Yeah, and I think I would have been able to limp along for another couple of years had it not been sort of the acute crisis of COVID and who knows, maybe it would have happened regardless, but it all kind of came to a head one day in a really scary way. And it's really weird that we're talking about all this

because I just think people are going to, I still, to this day, when I talk about this stuff, well, I've never really talked about this publicly. So there's a part of me that worries that, you know, side of me, I'm just not sure I want people to know about, but it's when this particular Wednesday in April of 2020 started like any other day, right? So wake up and it wasn't like any other day, because this was, you know, slightly, you know,'t like any other day because this was, you know, slightly, you know, this is during COVID. So it was, you know, different hours.

I sort of scheduled a day where I would do my work early, early in the morning because we had an East Coast team. So we'd start calls at six in the morning, et cetera. A lot of my rituals are kind of gone. A lot of the sort of things I do for self-help are being thrown out the window. But I do always, you know,

do something for pleasure before I work out. So I'm either going to go and shoot my bow and arrow or go and get in my simulator and drive and then exercise. And then by 10 o'clock, I get back to work. So I go out to shoot my bow and arrow and I'm really shooting poorly. Now, archery is a pretty objective thing. Like there's Xs and you're trying to hit them. And I'm, for me, I'm, I'm, I'm off. And I am so pissed off that I take these carbon arrows and I start snapping them on my thigh. Now, these things leave welts on your legs that last for a week when you break them. That's how much it hurts. And I couldn't stop breaking them on my leg,

every one of them. And then I decided in my infinite wisdom that the best thing I could do then is go and get in the simulator and drive. Right. Because- Let's just ramp this up another notch. Well, because it's like, look, I didn't get the self-validation doing this thing.

I'm gonna go find another way to get self validation. So I go and get in the simulator, get into the hardest car on the hardest circuit. And sure enough, I'm spinning. Just can't keep the car in control. Amazingly, I don't break the simulator. And then I decided, okay, I'm gonna go and work out. And for the first time in my life, I'm going to go and work out. And for the first time in my life,

I'm actually too upset to work out. Like I can't, I don't have the motor control to lift weights, which is very, it just strikes me as an impossible scenario. The rest of that morning spirals out of control, but culminates with me absolutely losing my mind and taking a table in our living room and throwing it across the living room. Um, wow. At which point my wife comes running in thinking that the house has been broken into and the rest of it is a bit of a blur. Her at first trying to console me, but then quickly realizing it's way too dangerous to be near me. And then just telling me to get out. I ended up in a motel

and didn't eat or drink anything for, I guess, three days, was on the phone with Paul, Esther, Terry, convincing them that I was ready to go home and all of them saying, absolutely not. Like, if you go home, we're gonna call the police. Wow. Like, there's only one thing that left for you to do. You have to go to this place called PCS,

Psychological Counseling Service, which is this place in Phoenix. And of course, I just fought with them for hours. this place called PCS, Psychological Counseling Service, which is this place in Phoenix. And of course I just fought with them for hours. I was like, I can't do it, I can't do it. And they're like, you're missing the point. You're acting like we're giving you a choice. You can't do it because don't you know who I think I am and I'm so busy and I have all these responsibilities

or I can't do it because I'm too scared to do it. I mean, obviously there's fears underneath that. But it's all being, it's all being, I'll tell you what the fear was, Rich, truthfully. The fear was I'm not fixable, so why are we fucking around with this? And that's really the core of the whole thing, right? Like that's what starts to get revealed.

Like what is behind this rage? What is the this rage? What is the relationship between that rage and trauma and your relationship, not only with your past, but with yourself, right? Yeah, so I think the surface fear is, it's impossible for me to go away for a week. And they said, it could be one, it could be two,

it could be three, that's gonna be decided by them. But I said, even a week is impossible because I can't go off the grid. Like when you're at these places, as I'm sure you know, you don't have a phone. Sure. You're not doing anything. Like you're in therapy 13 hours a day, seven days a week,

group therapy, individual therapy. I mean, it's the most exhausting thing you can do, but you're absolutely right. Underneath it was the much deeper fear, which is I'm that guy? I'm that guy who has to go into rehab every three years and never gets fixed? Just euthanize me.

Like, why are we doing this nonsense? Right, and it seems like, and correct me if I'm wrong, there's this tension or dichotomy of kind of holding two contradictory perspectives on yourself. On the one hand, you know, look at me, I'm so successful. I have all these responsibilities from the outside looking in,

it appears that everything is together. And I know how to solve this better than anyone because I'm me, right? And on the other hand, I'm the worst piece of shit in the world. I should just die. I am broken. It's irreparable.

Like who cares? Why even try? And you're absolutely correct. And then on top of that, there's the shame of, God forbid, anybody actually think I'm special if they could only see how horrible I am. Right, right. And the fear that at least publicly,

anyone would know that you have some fallibility. Especially so deep, right? It's one thing to be like, oh, I eat too much chocolate or something like that. But this to me was like a rot to the core of like who I was, right? This was not just a quirk of personality or, you know, oh, I struggle with smoking or something.

No, no, this struck me as like a fundamental, like this was the, to me, the lowest possible, you know, set of character traits one could have. Which also creates the best place to begin this kind of work, right? Like that, you know, you hit bottom. Yeah.

So hopefully that creates a space of willingness to entertain a new way. Yes, it's sad to say I had to hit rock bottom. And of course, you know, here we are three years later, my life is completely different in all ways, infinitely better. People, you know, sometimes people say to me, it's a question I think you can ask anybody, right?

Like if you could go back and talk to the 20 year old version of you, what would you tell them? What would you do different? On the one hand, I think you can ask anybody, right? Like if you could go back and talk to the 20 year old version of you, what would you tell them? What would you do different? On the one hand, I wish I could say, figure this stuff out 30 years sooner, buddy. Like you're going to save everybody, including yourself, but more importantly, people you love, you're going to save them so much pain. On the other hand, I think, I don't know if I could have figured this out unless I was in the basement, right? Like I just, I think at least for me,

I needed to be in so much pain to actually do this thing, to go through this stuff. I mean, do you think about that the same way? You and me both, buddy. You know, I mean, when you present emotional health as this core pillar in health span on the kind of subject of early intervention, like all of this is about like, how do we catch these things,

diagnose them, start treating them way earlier on than we historically have been doing. The tricky thing with emotional health is it does require willingness. So you could, if somebody came up to you when you were 28 or 24 or 30 or whatever, and tried to intervene and get you to understand that this is important, there's no way

that you would have been game to, you know, dive into this, right? So it's a lot more difficult, but perhaps had that intervention occurred when you were eight years old, or there were modalities in place to, you know, help you make sense of confusing things, you know, in your childhood during that period of time,

it could have created a different trajectory. Yeah. You know, for me, the sign that this was really, I was ready to go through it was, the most important thing I had to let go of was whatever changes I'm about to make will result in me being less effective in my professional life.

That's the big one. Yeah. That's the big one. And that gets to the root of your sense of self and the incident workaholism that's a manifestation of that unhealthy sense of self. Like the facts of your experience, as they say in the parlance of recovery, like the facts of your experience, as they say in the parlance of recovery,

like the facts of your experience are very different from mine, but the emotional landscape is so relatable to me. Like there's a lot of overlap. Like we've manifested our disorders in different ways, but it's so similar to me in so many ways. And there is that thing of nurturing that dysfunction under the illusion or the belief that that is the engine

from which you've been able to create a pretty great life. And if you're to go and if you're to dismantle that, then what becomes of you? Like you aren't gonna be able to do the thing that you do that has distinguished you and crafted this identity and sense of self. All the success, everything. Yeah, and then the funny thing is,

maybe by some metric I'm less successful and less driven today than I would be had I stayed on that path. But the opportunity cost of that was too great. And I'm actually really comfortable with that. One of the things that I never thought could go away, I talk about this in the book, is the whole Bobby Knight thing. This was one of the most important realizations I ever had when I was at PCS, which is what my inner monologue sounded like. And it sounds, well, it's a little hard to believe I wasn't aware of it, given that it wasn't just an inner monologue sounded like. And it sounds, well, it's a little hard to believe I wasn't aware of it,

given that it wasn't just an inner monologue. It was actually also an outer monologue. I would constantly say things to myself out loud. Whenever I made mistakes, the self-talk was not just in my head. It was verbal. It would come out. And it was awful. The reason I called that Bobby Knight is that's who it was modeled after. It was, the reason I called that Bobby Knight is that's who it was modeled after. It was coach Knight is gonna strangle you if you make a mistake. And it was anything, it didn't matter. If I screwed up making dinner, if I screwed up a shot, if I screwed up anything,

if I was late to a call, I remember one morning I woke up and there was a call on my calendar at six that I had forgot about. And when I woke up, I did a whole bunch of other things before and I missed the call. I mean, instead of just emailing the person and saying, I'm really sorry.

I mean, I must've beat myself up about that for a day. And this exercise that they had me do there was one of the most powerful things I've ever done. And when they suggested it, I thought, that seems kind of dumb. Like there's no way that's gonna work. And they were like it, I thought, that seems kind of dumb. Like there's no way that's gonna work. And they were like, every single day, two or three times, something is gonna happen

that's gonna prompt you to wanna scream at yourself. Take out your phone and record a message, but look into the eyes of your best friend and pretend that they made that mistake. What would you say to them? I mean, the first few times I did this, I was in tears because it was such a shift of how kind I would speak to that person.

Hey, Peter, I know it's frustrating. You just didn't have a good drive today, but I think there's a lot on your mind today. And you did okay, but you gotta watch the apex going into this corner. And like, I literally, I was like talking like I was a kind coach. And there was an accountability

where every one of those I would send to my therapist. So Katie Powell would get every one of those as a text message. She'd get like two or three of these voice messages a day for four months. And it only took about four months for that to go away. That is really amazing to me. Yeah, that's powerful.

Think of how old I am and think of how many years I had this ingrained pattern of screaming at myself. And I mean, I don't even wanna repeat the stuff I say cause it's so vile, but like, it's not like you idiot. No, no, it's much harsher than that. And in just four months of being mindful of this every single day, I don't even remember. It's so hard for me to remember Bobby's voice.

That's a powerful testament to neuroplasticity that you could rewire that because that is so deeply ingrained. That's something that I share, this inability to extend compassion to myself that is second nature to extend to another human being. I don't know if, I don't think you know this, but before Christmas, I went up and spent a week at Paul Conti's clinic.

No, I didn't know. Doing some trauma work and family of origin work. And it was revelatory for many, many reasons. Like I'm just so grateful that I was able to have that experience and I learned a ton, but perhaps the biggest revelation that came out of that was this very thing of my inability to exercise self-compassion,

like the negative self-talk and the standard to which I hold myself is far beyond anything that I would expect of anybody else to the point of just utter cruelty and the extent to which this not only runs deep, but infects like everything that I do to my detriment. So first just, I mean, obviously I've kind of always known this, but like really trying to understand that

and then creating that lattice work to understand that. And then, you know, creating that lattice work to understand how that relates to childhood trauma and then beginning the process of undoing it, like has been, you know, has been extraordinary. Despite like all the years that I've been in recovery, like all the years, everything that I've done, I still have had some of this sort of repressed rage that would come out periodically,

not to the extent that it did with you, but enough where my wife would be like, you really need to figure out like why you're behaving this way or why this stuff kind of comes up. And I sort of delayed it and I would rationalize like, well, I'm doing all these other things, like what else do I need to do? But there was this thing sitting there,

like just waiting like a ticking time bomb that needed to be looked at. And the fact that I took a week to just begin that process has been extraordinary. So I'm curious in your case, what did you discover in terms of that rage? Which I think probably a lot of people can relate to. Like, why do I get angry at this thing or that thing?

Like, how does that connect to your past? And how did you begin to like make sense of that so that you could untangle it? I think as you obviously learned with Paul, I mean, I think there are lots of different types of traumas. There are big T and little T traumas, right? There are, sometimes it's easy to focus on the big T ones and I've had a big T trauma, couple, I think.

But what I think I learned at PCS was I've probably been more undone by the little T traumas. It's probably more some of the neglect and the sense of, I mean, truthfully, I think the single most important insight is that I had never until I got there. And this, remember how they said, you might be there for a week, two, three.

I was there for three weeks. I was like one of the 5% of people that was there for 21 days. I didn't have my breakthrough there till the 19th day. I mean, two weeks in, I thought I was better. I was ready to go home the next day. And Paul called me and said, look, we've all pow-wowed,

you know, me, Esther, Terry, Katie, like the whole team has pow-wowed with their team. And we think you are not quite there. There's one thing you're not willing to let go of. And I was like, are you freaking kidding me? What? And they're like, you haven't really accepted the fact that the child in you was really hurt by these things and these adaptations. They, they're not in the child's best interest anymore. Like your response, these things that you did as a kid are not normal childhood behaviors.

If you saw your kid doing these things, you would be devastated by how sad it is and by the loss of their innocence and by the loss of their childhood. And for example- In other words, sorry to interrupt, but in other words, the story that you had been telling yourself was these things happened,

but ultimately they made me who I am and they gave me this engine and propelled me to do all of these other things. And yeah, it wasn't great, but like I've made peace with it. That's right. It was, these things were really bad and I get it. And I would never want my kids to endure these things,

but you have to understand, like they've been way more net positive than negative, especially now that we figured out what these negative things are and I have coping skills for them. And they were saying, no, no, no, no. You gotta go back. Such a quant perspective on that. You gotta go back and realize like this little boy

that never wanted to celebrate a birthday, like this little boy that wanted his daddy to be there and he wasn't there, like those things aren't okay. And that kind of took me down into an emotional free fall that was, I think, the final layer of excuses because I think you can probably relate to this, but one of the ways I had rationalized my bad behavior for so long was my kids aren't going to suffer

what I suffered. And I think that addicts can sometimes do that. They can sort of say like, well, I'm making this up. This wasn't the case in my case. My dad used to beat me with a belt every single day. And look, I'm not beating my kid with a belt every single day. So it's I'm not beating my kid with a belt every single day.

So it's fine. Meanwhile. Give me a medal. Yeah. And I think that that was also a very important part of my motivation was when I finally realized how much I was hurting my kids.

It was, they weren't actually experiencing the traumas I experienced, but they were experiencing a whole bunch of new ones. And the kids of alcoholics don't always go on to become alcoholics, right? But that doesn't mean that trauma isn't intergenerational. It really is. It weasels its way down.

And that realization coupled with being at rock bottom was sort of like, you know what, I'm gonna stop it. I don't want this going to my kids. Yeah, there's a couple quotes from the book that kind of really hammer on that point. One of which is this idea that children take on the shame of those around them, like understanding that even if on paper you feel like you're the dutiful dad

and you're protecting them, et cetera, that all of this emotional dis-ease, you know, percolates into their conscious awareness and impacts them and their behavior later in life. And the other one being, this idea of covert male depression and this statistic that 90% of male rage is helplessness masquerading as frustration.

Like that's a zinger. It speaks to me. And look, that was something Terry told me one day in a therapy session. And I was talking about it with Esther recently or not recently, like recently after that, or shortly after that. And she said, I want you to write that down on a Post-it

and stick it on your monitor. I mean, it's, and it's so true. How often do I find myself even today getting angry about something? And if I just stop and think about it, I'm helpless. I feel helpless. I feel powerless. Yeah. And we're just, I mean, again,

I think for men in particular, it's very difficult to articulate that and accept that. And it's so much easier to just channel that helplessness into some form of anger. Or workaholism or exercise addiction or any number of modalities that basically society isn't gonna frown on too hard and you can get away with

and may very well even make you successful, which makes it so pernicious. Yeah, that's the irony, right? Is a lot of the people that I met in both the bridge and PCS had all of these socially unacceptable addictions. And I think by the end of it, I came to realize we're pretty much all the same.

There's no difference between us. Yeah, you go on that journey from sitting there, just identifying all the differences, why you're not like any of these people, until finally you realize it's kind of all the same. Totally all the same. One of the thoughts I had when I left was, would we be better off?

I wonder what you think about this, Rich. Right now, when you look at sort of recovery programs, they're often organized around the end state. What's the addiction? So if your weakness is alcohol, drugs, sex, gambling, et cetera, workaholism, perfection, like we're gonna organize those people together. I almost wonder if we could organize it more by root cause. Like if your shame is the result of this type of wound

and that drives you to do this, this, this, or this, like you should spend time with these people too. It's almost like a matrix approach where we think about what the end state is, but what the root causes were as well. And there might be some benefit in both of that because that's what I found really, I found really beautiful actually was getting to know so many other people through these experiences at both the bridge.

And these are people I'm still in touch with. Like we still have a text thread. This is like five and a half years ago. And everyone's story is different, but boy, what was the expression like, history never repeats itself, but it sure rhymes. Like there are some really common patterns here. And I think everybody sort of feels alone sometimes.

I think that it really is, you know, to your question of, you know, root cause versus manifestation. of root cause versus manifestation. The addiction is the adaptation. That is the humans attempt to try to cope with the root cause and it works for a long period of time, or you wouldn't do it and then it stops working, right? And then it creates chaos and havoc and all the rest.

But the kind of drum that I've been beating is really that it is all the same thing. And you can quibble around, you know, differences in root causes, this trauma, that trauma, but you know, Paul or Gabor Mate or Esther would probably agree that so much of it is so deeply rooted in something that happened in your childhood, whether it's a big T

or a series of little Ts, et cetera. But you're correct. Like, is it alcoholism, heroin addiction, gambling, whatever? To me, it doesn't matter. Like it's all the same thing. And addiction lives on this huge spectrum. And I think almost anybody is going to be able

to identify themselves. If they're really being honest with themselves, if they do a rigorous inventory, they're going to see that, they're somewhere on that spectrum. Maybe they just scroll a little bit too much on their phone, or they keep getting involved with the same kind of bad relationship or what have you.

It shows up in innumerable ways, but ultimately it is the same sort of compulsive behavior that drives negative outcomes that you perpetuate and feel unable to control that ultimately escalates. So whether it's a substance, a behavior, what have you, you know, unable to control that ultimately escalates. Right? So whether it's a substance, a behavior, what have you, you know, our outward manifestations are different, although there's some overlap in the kind of workaholism

and the perfectionist realm, but it really is the same thing. And I think that we need to broaden the conversation around the nature of this condition and create a bigger welcome mat for people to engage with it. Because I think the sort of traditional secrecy around or the shame that surrounds it prevents healing

for a broader population of people. Like I may have gone into 12 Step earlier had I known a little bit more about it or hadn't been, you know, it was so mysterious that I had a whole set of ideas about what it was and what it wasn't that maybe kept me from getting sober sooner. I don't know.

But that's a big reason why I feel so strongly about talking about this kind of stuff and why I wanted to, you know, make your experience a larger focus of this conversation. Yeah, it's sort of interesting to think about, just talking about this stuff and still publicly at least feels strange,

but I really- I think it's really important. I have no regret that I've written that chapter. I think people are gonna really respond to it, Peter. And I think it's a great service to let people know that this was your experience and you were able to get to the other side of it. It's empowering.

And I think, cause I think a lot of people, the people look up to you, they respect you, they revere you and for you to say, hey, I'm a human being and I had this experience and this is what happened as a cautionary tale, but also as an exercise in male vulnerability to model that, I think is courageous and important. And also finally, sorry to interrupt,

but like you mentioned your kids and how important that was in your realization and in your recovery program and this idea of how we pass our, you know, behaviors and our traumas down the line is so important because I think the addict sort of thinks, well, I'm doing this, but I'm not hurting anyone, or this is my problem or leave me alone. But the pathology is much broader than that.

And, you know, Terry's quote in the book was the one that was of everything like, I think the most powerful. So I wrote it down, I'm gonna recite it. He says to you, "'Family pathology rolls from generation to generation "'like a fire in the woods, "'taking down everything in its path "'until one person in one generation

"'has the courage to turn and face the flames. That person brings peace to his ancestors and spares the children that follow. And this idea that you wanted to be that guy, like I want to be that guy too, you know? I think for as difficult as this journey has been, and it will be, by the way, this is the most difficult journey I will face the rest of my life. I don't think, you know, for as small a fraction of the book as this represents, from an effort perspective, I probably put more effort into this than even my exercise. But that's the motivation. And even, it's also a bit of, you know, just, I got a lot to make up for. You know, I think I'm really lucky that my wife is still with me, frankly. I don't think any other woman would have put up with me.

And so I owe them the best version. Yeah. Well, thank you for that. It feels weird to like, kind of, you know, switch gears at this point. But, you know, switch gears at this point, but you know, having explored that with you and this being a chapter in your book and the importance of this in terms of,

not just how long we live, but how well we live, like, you know, what are the medicine 3.0 changes that we should be thinking about? And what can individuals who read your book or who are listening or watching this, what can they start to do to, you know, tend to this aspect, this important aspect of our wellbeing? Yeah, that's a great question.

I think the first thing is just, I talk about this briefly, but it's pretty unusual for someone who's out of shape to not know they're out of shape. If you're having a hard time walking up a hill, if you're having a hard time climbing stairs, if it hurts when you get out of bed in the morning, it's hard to not know that. It's really easy to be emotionally broken and not fully appreciate it, or more to the point to be like me and be in total denial. I think the single most important thing a person has to do here is if for no other reason

and to no one other than themselves, start asking questions like, are you living in a way where your relationships with other people are healthy? What was modeled to you? What did you see? And if you go back and reflect on that, do you think that that represents the best version of how people can interact? There are lots of tests people can take. For example, you're probably familiar with the adverse childhood event score, the ACE score.

This is something that's readily available online. I do recommend people take it, right? If you're sort of sitting there thinking like, I don't know what trauma is, well, this is a checklist of 10 things, some of which are really obvious, like you're raped, that's trauma. But your parents going through a divorce when you're a kid is trauma, right? So, you know, when you kind of go through an inventory like that, it at least gives you some sense of vulnerability. I think that we talk about this a little bit,

that it's a little harder for men to do this, but whether you're male or female, I think you've got to ask yourself the question, do you have someone you can really confide in? Do you have a friend that you could tell anything to? There's a test for it they call it. Do you have someone you could call in the middle of the night if something was wrong?

If you can't answer yes to that question, I wonder why. Is it because you don't feel comfortable that you can share that? Or is it because you really don't have that person in your life? I think everybody benefits from psychotherapy and I don't think it's very sexy. What's very sexy today, what's very in vogue today

is like psychedelics, right? Like, you know, all you need is a trip to Peru with a shaman and everything's gonna be fixed. And I talk very briefly about this in the book, but I've had most of these experiences and some of them have actually been very positive, but they aren't the healing process. They are just disruptive, right?

They just disrupt your psyche enough that they make you open to the change. But the change has to come from finding a therapist, in my view, who you are comfortable enough to be able to speak with. And I think it's rather agnostic to the specialty or discipline. I do think-

The important thing is that you are engaging with some modality from a place of openness and honesty. Yeah, and it's just as we would say, look, you gotta go get a blood test. You gotta go get this test done. You gotta go do these certain things. Like you should know your VO2 max. You should know your bone mineral density,

you should have a DEXA scan. I think we should take the same approach here, which is you should be able to have someone that you emotionally check in with and someone who can ask you questions and get you thinking and provoke you a little bit and figure out what your state of emotional health is. This must really fuck with your engineer's mind though,

right? Because it's not a math problem. It's so messy and non-linear. Yeah, so in our practice, Rich, we have this thing called the longevity risk assessment, the LRA. It's how we anchor our thinking about every patient. So we believe that there are a discrete number of things that are a threat to your lifespan and

healthspan. So in no particular order, cardiovascular disease, cancer, neurodegenerative disease, falls later in life, automotive death, orthopedic injury, and disruption of emotional health. Those are basically the big seven. So you can see that each of those can interfere with lifespan or healthspan. For each of those things, we have inputs. So how do we make a diagnosis to establish risk? Because our first goal is to rank order those seven to understand how to prioritize effort. So there's 25 things that go into the model, right? So what's your family history? What are your labs?

What's your VO2 max? Like da, da, da, da, da. As you can imagine, the hardest thing to get inputs for is the emotional health piece. And then there's outputs that come out of this. So based on how you rank them, that determines what your behavioral changes

are going to be. When I do this exercise for myself, what do you think is my rank order? Remember my family history is rife with cardiovascular disease. What do you think is number one for me, the greatest threat to my longevity? Your emotional health.

Yeah, it's number one on my list. I think I have emotional health number one, I think I have cancer number two, I think I have at this stage, probably automotive death being number three, you know, and it kind of, by the way, atherosclerosis is like number seven for me right now,

because even though my family history risk is so high, we've basically engineered that problem almost to nothing. And yet you're right, boy, do we struggle with coming up for the inputs because only if a patient is willing to be this vulnerable, can we truly understand what their sense of purpose is, what the state of their relationships are, where they find joy, fulfillment, happiness,

all of these things. And I'll be honest with you, like half my patients never wanna talk about that stuff. It's just maybe three quarters of my patients have no desire to get into that. And that's okay. Maybe they will one day or maybe they do with somebody else.

It's gotta be, well, let me ask you this as a question. Do you find that that is more the case with your male patients than with your female patients? I don't think I have a large enough sample size to answer that, but I will say this, it's true for both. I don't know, I'd have to really think about the proportionality of it,

but there is an epidemic of misery. I mean, it is an epidemic. You know, the loneliness statistics seem to be creeping up pretty rapidly and the long-term implications of that. And, you know, coming out of COVID and how that fractured a lot of relationships or just sort of made us more accustomed to being cloistered in our homes and not with people.

Like, what does that look like played out over a number of years? I'm amazed at, cause I see it in myself. So maybe I'm more attuned to see it in others, but the number of people who are so willing to work so hard at the expense of personal relationships. And again, I say that not in an accusatory tone, like I say it as someone who does it.

And I always worry, like I just have to remind myself that one day none of this stuff is gonna matter. I talk a little bit about a book that David Brooks wrote called The Road to Character. It was a very important book for me to read during this journey. I read it really when I was in the middle of hell. And, you know, it was one of those things.

Like there's no one thing that changed for me, right? It was an accumulation of things. But his framing of thinking of your life via its resume virtues versus your eulogy virtues is something I still remind myself of every single day. Yeah, and related to that is our guy, Arthur Brooks. Yes, of course. He talks about real friends and deal friends, right?

And you know, the crisis that's visited upon many a successful person when they realize all of that success and the drive that led to that has perhaps created more damage than value and trying to put the pieces together and find a sense of wholeness with oneself and one's relationships untethered to external validation or everything that went into,

you know, accomplishing all of these things that, you know, we deluded ourselves into thinking we're gonna make us happy. Yeah. That's a tough. I have a real soft spot in my heart for people who have achieved superstardom. And I've been privileged enough as you have

to meet a number of these folks. And I think it's hard. And again, I'm sure nobody's sitting here feeling sorry for someone who's famous and rich, but with it comes a real sense of isolation and who's real and who really cares about me and who doesn't and who's using me and who has another agenda.

And I think one needs to be thoughtful before they decide they wanna be a public figure. Yeah, I think that's probably very true, right? On the subject of, you mentioned hallucinogens, there was another quote in the book that I wrote down where you say, "'Too often I see people tethering their hopes of transformation solely to a ketamine trip or a journey to the jungles of Peru with a shaman

to guide them through the mind blowing experience of an ayahuasca journey or some other singular experience. Or even as in my case, thinking that two weeks in a facility such as the bridge is enough after which we can continue as though nothing fundamental has changed. And I think that this goes to, it's not unrelated to the narrative

around health span extension. It's this allure of the quick fix, or if I just do this one thing, all will be well, and I can maintain my operating system. Yeah, it's sort of like, imagine you've never exercised in your life. Okay, so you're a 50 year old who's never exercised. By the way, a lot of people like you, right?

The trip to the bridge or the ayahuasca journey might be the thing you need to realize, holy shit, you need to exercise. But guess what? Now you need to exercise. But guess what? Now you have to exercise. So I don't wanna say like these things are good or these things are bad. But my point is in my experience,

this emotional health thing is a journey that is rooted in daily practice. And some days are good and some days suck. Meaning some days I fail so badly and I feel so ashamed and I feel horrible that I was a dick to my assistant. But one thing I learned that's so important is, I can't remember if it was, I think it was Esther who told me this and she,

of course she's so eloquent. She said it so much better than this. She said, Peter, it's not about how many times you screw up at this point. It's making sure you make it right. And she was talking about it through the lens of my kids. Like if you're gonna get mad one day and you're gonna yell at your kids again. And they might think it's daddy of old, right?

But it's like, no, no, no. The difference is you make it right, right away. It's the healing that fixes it. And I'll give you a really silly example. Like on the weekend, my boys were running around playing around and our youngest is, he's kind of going through that phase.

He's five and he's just not listening to anything, right? So, and one of the things he keeps doing is he keeps running around smacking everybody in the butt. Like this is his favorite thing to do is he'll walk up and smack you in the butt as hard as he can a hundred times. And you're like, Ari, enough, enough, enough, enough, enough. And finally, after like the 10th time, I just screamed at him.

I'm like, Ari, get in your room. And he just like, you know, ran into his room. And I was immediately, I felt full of shame. Like, you just scared this kid. You're like, and I went into my office and like started to work. And then I was like, I have to go and fix this right now. I have to let him know that I'm angry at you

because that's not what you're supposed to do. But I shouldn't have yelled at you that much. And I go in his room and it was just such a sad, awful reminder of what a childhood feel, what a child feels like in shame. He wouldn't look at me. He was on his bed, head down. And I kept saying, Aerie, listen, I wanna talk with you, buddy.

I wanna talk with you about what just happened. It was like 10 minutes later. He wouldn't look at me. And I said, Aerie, listen, daddy's really upset that you're walking around smacking everybody in the butt, but I shouldn't have yelled at you like that. I'm really sorry.

Can we hug? And he wouldn't, this was like an hour. He was really, he wouldn't come out of his room for an hour. So I think in the olden days, I would have just beat myself up over that for so long. And I would have continued, I would have actually taken it out on him more paradoxically. But instead within an hour, everything was fine.

And we kept talking about it. And I was like, look, Ari, you know why we don't want you doing this? You can't do it at school. You can't like, you know, it's not like we're not gonna discipline you, but I'm gonna make sure that I'm not blowing up at you because I'm frustrated.

That's a silly little example, but that's the interstitial fluid of what this stuff is about. It's making mistakes, fixing mistakes, as opposed to beating yourself up and making bigger mistakes. Yeah, a couple of insights on that. I mean, it's about the half-life, right?

So the period in between the negative action and the amends or kind of reaching, returning to some level of equilibrium shrinks, just like in meditation, you get that little extra gap of time to choose how to respond rather than to just impulsively react, super important. And the more you practice that you get better at it.

Early in recovery, a guy that I know, shout out to my boy, Scotty, said, "'If you're gonna eat crow, eat it hot.'" Right, so it's like, you're gonna fuck up. Like just deal with it right away, the faster you deal with it. My instinct is to like pretend it never happened and deny it and of course it just metastasizes

and gets worse and worse and worse. I think with kids, the other layer to that is making sure that you're not projecting your bullshit onto them. Like you think like, oh, I need to make this right. I'm gonna go to my kid and I'm gonna make the amends and apologize, but you're kind of vomiting your own bullshit onto them. And it's not for them to take on your dysfunction.

Like, oh, I'm so sorry and this is my thing. It's like, that's just actually making it worse. And so for me, a lot of the work is around like maintaining my container. So I'm not pouring out all of that kind of nonsense and putting it on the kid. And I'll do it without even being aware that I'm doing it. Like give me an example.

I think that we often try to parent in opposition to the dysfunction of our own parents, right? So I grew up in a household in which my mother was very afraid of everything, like extremely fearful and worrisome and would kind of vomit that onto me, which then made me a very risk averse person or thinking the world is threatening and dangerous.

Of course, I don't wanna do that to my child, but then I'll catch myself like, well, we're just worried about you. Or like, I just, you know, I care so much about you and I don't want this. And it's like, I'm doing it. I'm perpetuating this pattern. I'm doing the very thing that I promised I would never do.

And I've convinced myself that I'm doing it out of concern for this person, but that's not really what it is. It's some kind of weird programming. Interesting. That's built in that unless I'm mindful, I will just default to. I mean, it speaks to this point. This is a lifelong journey. Yeah.

And I wish that it were easier, right? Like I wish that there were biomarkers that I could follow for this the way I can follow biomarkers. You're crazy. Well, I mean, of course. You can't get in a simulator. Yeah, so the simulator is life.

We're in the simulator. Right. We've gone almost two hours. We haven't said anything about exercise or nutrition. I'm sitting here in the back of my mind as I'm listening to you talk, like debating, like, do we even do that now? I think people will kill me if we don't spend at least a couple minutes on that.

We talked a lot about, didn't we talk about exercise a lot in the first podcast? We did, we talked about, we did a lot on zone two and on VO2 max, the importance of, you have a whole chapter in here on the various modalities of exercise. We're told to exercise, but what does that actually mean?

Here are the pillars that you need to be building in parallel strength, endurance, of course. And you explain all of these things, stability. Yeah, exercise is probably the biggest section of the book. It's three chapters. So there's more airtime is devoted to exercise than anything else in this book. What's interesting about that.

And like, yes, I don't wanna like go over stuff we've already gone over, but there's two things that I'm curious about. The first is there is this adage that you can't exercise your way out of a bad diet. So that leads me to believe that actually nutrition is more important than exercise. Your thesis is that exercise is by far the most important.

I think that adage by far the most important. I think that adage stems from the, if you're purely thinking about it from a weight perspective, right? So if you're thinking about it as, is exercise the best tool we have for weight management? The answer is no. Nutrition is the inputs matter more than the outputs

on weight management due to the adaptations that come from energy expenditure. In other words, if you take a person who's, you know, gonna ramp up their energy expenditure by a thousand kilocalories a day, they're gonna accommodate by eating more as well. So if it's a weight management problem, yeah, you can't really exercise your way out of it.

But I would say, sorry, I know you're in the middle of sharing an additional thought, but just to interject here quickly, what comes up for me in thinking about heart disease and neurodegenerative disease, both of which are diseases of the circulatory system and me having this in my lineage, that means that I need to be more careful about what I'm eating. And yet, despite that adage, when I'm training a whole lot, it's like, yeah, but I'm like burning so many calories. It's like, I can like, this is not gonna be that big of a deal

to now thinking like, actually this is like, I do need to be really careful about this kind of stuff. You alluded to this just briefly a while ago, which was the science around nutrition is like the murkiest of all the science. If I think about, okay, we just talked about how squishy emotional health is. So let's put that aside for a moment.

But if you wanna talk about pharmacology, sleep, exercise, nothing is more murky than nutrition. I don't need to explain why. I write about it at length. So let's just pause it that that's a correct statement. Yes. That there is no field of human health for which the data are more ambiguous.

I was half tempted, the editor would not let me do this. I was half tempted to make the nutrition chapter instead of being two chapters that probably total 80 pages to make it one page, which is is this is all we know about nutrition. If you want it to be black and white, this is all we know. Which is? Don't eat too much, don't eat too little. There are certain micronutrients you need to have.

Avoid things like E.coli. Like there's like 10 things that I can tell you with absolute certainty. And obviously nobody would care to read that. So of course I expanded on all of that. As it pertains to nutrition, I've really changed my tune over the last 12 to 14 years. And where I stand today is not where I stood

a decade ago, not at all. Today I believe that energy balance is the single most important driver of ill health as it pertains to nutrition. I think that there are lots of different ways to regulate energy balance. And there are lots of third and fourth and fifth order terms.

And I write about those in detail. What types of fats are more healthy? How much protein, animal versus plant protein, all of those things. But at the end of the day, it's really my conviction. And I, you know, this, if there's one chapter that I shared with more people as experts to get input before I finished putting pen to paper,

it was this chapter. Because I wanted people who kind of had different points of view from me and what do you think about this? What do you think about that? And what I've distilled down is energy balance matters and matters the most. So that's an input equation, not an output equation. So we exercise not to burn calories,

we exercise for the structural and metabolic benefits, but not the energy expenditure benefits per se. On the input side, to regulate input, you basically have three levers that you pull. You can either, and again, this is not something our ancestors had to think of because food was relatively sparse, but in our environment today,

most of us need to think about regulating. Certainly I do. There's no chance I can walk around eating as much as I want whenever I want in whatever quantity. Undernourishment is not the low hanging fruit problem here. That's right. I do have some undernourished patients, but 80 to 90% of people are dealing with, you know, being a little bit overnourished. So our strategies are, we can calorie restrict. So we can literally just say independent of when I eat or what I eat, I will eat less. We can do dietary restriction,

which means I will restrict elements within the diet, or we can time restrict. I will restrict when I eat. Each of those has its pros and cons, but ultimately they're in service of the same thing, which is consuming less. Now, once you make the decision of which of those paths you go down, and they can be mixed and matched, right? Like you can say, well, I'm going to be on a plant-based diet or a keto diet, and I'm also going to only eat between 8 a.m. and 2 p.m. Again, these things are totally mixable. Then the question becomes,

okay, there's four macronutrients, carbohydrates, fats, proteins, and alcohol. How much do you emphasize each one? I start with alcohol because it's the easiest. It technically serves no purpose in our diet. So it's a nice hedonic pleasure, but I deconstruct the data and make the case that there is no dose at which it is healthy, despite what some of the really bad epidemiology tells you, which is that there's a reverse J curve and technically like one to two drinks a day is really healthy and abstainers have the,

you know, have a slightly higher risk of mortality. That's not true at all. So zero alcohol is the best, probably up to one drink a day has minimal effect, but after that, it starts to actually climb up. There's lots of other reasons to avoid alcohol, by the way, especially if you're in the business of trying to lose weight because alcohol is itself a very oxidizable fuel.

So the body's gonna preferentially oxidize ethanol before it oxidizes everything else. So you don't really wanna turn off fat oxidation if you're trying to lose weight or postpone it or delay it or move it down the queue. You wanna keep it front and center. So it's just an unnecessary calorie burn. And sleep dysregulation.

Absolutely, sleep dysregulation. Also, if you're anything like me, anytime I drink, I wanna eat more. So it becomes this counterproductive thing. So just look, I'm not gonna sit here and say, don't drink. I do, but again, it comes down to risk. Understand the risk. Is it worth it?

I refuse to drink anything that isn't exceptional. So if someone serves me a glass of wine and it doesn't taste amazing, I'm not gonna drink it. I'm a snob in that regard. It has to be good if I'm going to take the risk. When it comes to the next three macronutrients, protein is where I place most of my emphasis. This is the one where I really wanna make sure

my patients are getting one gram per pound of body weight. And the reason for that is that the maintenance and preservation of lean muscle mass is such an important part of living long and living well. Sarcopenia is such an underappreciated cause of quality of life reduction. Sarcopenia meaning loss of lean mass and strength. But how much of that is the result

of lack of proper exercise versus protein intake? Like I know you have this perspective on protein, but are people walking around not eating enough protein? Like it's hard for me to imagine that that's truly the case. And I understand, especially as you age in these later decades, that it's important to make sure that you're getting enough protein

and you're doing the kind of exercise you need to maintain and build lean muscle mass. It's very hard to maintain lean muscle mass once you're our age. We become anabolically resistant as we get older. So what a 20 year old can get away with paradoxically is less than I can. And that's going to be less than what I can get away with when I'm, you know, 70 and 80 years old. And that's really the game I'm playing. I'm playing a long game.

So I'll give you an example. If you look at some of the epidemiology, which we can discount pretty quickly, but even if you just take the epidemiology on face value, it would suggest that for people under 50, eating less protein is associated with lower mortality. And for people over 50, eating more protein is associated with lower mortality. And on the surface, you sort of think, well, I can see why when you're older, you might need more protein

because of the anabolic resistance and all these things. Even if the difference in those mortalities was identical in relative rates, you would still favor a high protein strategy because of the absolute difference in mortality. In other words, your mortality is much higher when you get older. So even an equivalent relative reduction in that risk

would be a far greater impact on actual mortality. But an added complexity to all of this is what that protein is packaged with, right? Protein, you're not intaking protein in isolation unless you're just doing protein powders, right? So is that protein coming in the form in something that also has a lot of saturated fat, et cetera? What are the considerations that come into play with that

versus plant-based proteins, absorption issues, et cetera? Like it starts to, you know, the complexity of it starts to expand pretty quickly. So those are two different things which we should talk about. So we'll start with the bioavailability. So animal protein is simply more bioavailable than plant protein that generally has to do with the fiber that's associated with plant protein.

That's an easy problem to overcome. There's two ways to overcome it. The first is you cook the plant, right? So when you liberate that fiber, you make the plant protein more bioavailable. You can also just consume more of it. So you can do this in a really technical way using, you know, die-cast scores and things like that, which I don't recommend. For my patients who are plant-based, we typically tell them how many grams of the most important amino acids they need to eat

in a day. So we're basically saying, you need this much leucine, you need this much lysine, and you need this much methionine. You're going to have to eat more protein to get them because you don't get, you know, if you're not eating an egg, it's going to be harder to get. Like you can get a gram of methionine in a single egg, but if you're not eating an egg, you're going to have to go around the block to get it. So instead of saying, look, just fixate on a total amount of protein that seems a bit abstract, it's getting them to understand how this food has this much leucine, lysine, and methionine and focusing on that. And again, so now you're focusing on the important amino acids. As far as the fats that they're packaged with, I think of everything I write about in this book,

there is no area in where I was more frustrated to not have a more definitive point of view than on the relationship between saturated fat, monounsaturated fat, and polyunsaturated fat when it comes to human health. Virtually all of the data on this subject matter pertains to cardiovascular disease. And I spared no expense at turning over every stone and looking at this. And it became literally one of the most unsatisfactory things I've ever done in my life in terms of how uninteresting the results were. Basically, the summary is this, and this is where I kind of end out myself, is the safest thing appears to be monounsaturated fats, right? So if you're going to do it on the basis of the Leonhardt study and the PREDIMED study,

which are really the two best studies we have. I mean, the PREDIMED study is hands down the best nutrition study we have in the history of our species. It makes a pretty compelling case that a diet high in monounsaturated fat is at least superior to the other diets that were tested. it makes a pretty compelling case that a diet high in monounsaturated fat is at least superior to the other diets that were tested.

The epidemiology seems to validate that. The next question then becomes, and I would have assumed the data would have been very strong in favor of polyunsaturated fat ahead of saturated fat. But as you know, you have all these different camps and tribes. You have this one group of people who say

polyunsaturated fats are horrible because seed oils are the devil. And the reality is it's really hard to find compelling data to make that case. If you look at the most relevant, most extensive Cochrane collaborations, which are, these are meta-analyses that are hundreds of pages long,

and I've gone through these. You could argue that there is a slight benefit to displacement of saturated fat with polyunsaturated fat when it comes to reducing the risk of heart disease. But my view on this problem is it's a bit of a major in the minor and minor in the major, because most of that downside of saturated fat seems to be transmitted through its effect on lipids. So there's no denying that a diet high in saturated fat for many people will raise atherogenic lipids. I have stopped trying to fight this problem because for most people, we can control it so easy with pharmacology that what I say is, I want you to come up with the diet

that is gonna be the best for your other things that I have a much harder time controlling pharmacologically. Your energy balance, your insulin sensitivity, and your inflammation. I can measure all of those things, by the way, they're just very hard to control with a drug. So I wanna control those with your nutrition.

And if that means you can only fix that with a diet that has a little too much saturated fat in it, and it's driving up your ApoB, that's okay. Cause that's the one thing I actually can control really well. And for other patients, that's a diet that's really low in fat, or that's a diet that has very little saturated fat. For the past six months, for the first time in my life, actually, I've never done this before. I've been tracking everything I eat. Just out of curiosity, just to see like, cause I'm not really trying to restrict anything.

So the only effort I'm making is getting my 180 grams of protein a day. Everything else is just, I'm like kind of curious, like how much fat am I eating? How much carbs am I eating? I have a weird diet. Like I'm equal fat and carb and high protein. So I think I'm working out to be about,

I'm like probably 35% carb, 35% protein, 30, sorry, 35 carb, 35 fat, 30 protein. Totally weird. Yeah, that is weird. Totally weird. I think you say in the book that for whatever reason, you seem to have a high tolerance in your ability to eat saturated fat

without any kind of downstream. Yeah, when I was on a ketogenic diet, which I was for three years, I was on a ketogenic diet from 2011 to 2014. There were a couple of confounding factors. I was also training like crazy. I mean, this was sort of peak adult training performance for me.

I was averaging at least three hours a day of really serious training. But I mean, I was getting 80 to 85% of my calories from fat and probably half of that was saturated. And my lipids were not out of whack at all. I mean, I was, I mean, you look at any biomarker of me in that era. I mean, my triglycerides were in the 30s.

My HDL cholesterol was high. LDL cholesterol was modest. I mean, it was below the 20th percentile. That has to be unusual though. Like I could not do that. I couldn't come anywhere near that and be healthy. Yeah, I don't know why it happened in me. I've seen a few other people for whom it works as well,

but I think it's the exception and not the rule. And I've also had some patients who they've gone on ketogenic diets. Everything has gone well, except their cholesterol goes through the roof. They look like they have familial hypercholesterolemia. And I say, well, we got two choices because I don't like this.

Either we drug it or we try an experiment, which is if you really feel hell bent on being on this ketogenic diet, would you be willing to totally change your fat composition? And in the cases where patients have said, I really wanna stay on the diet and I don't wanna be on a drug yet, let's go all monounsaturated and higher polyunsaturated

and really cut down the saturated to like 25 grams a day. And in some cases, not all cases, in some cases about half the time it fixes it. So saturated fat, I think drives atherogenic particles by driving up the synthesis of cholesterol itself, but also by impairing the liver. And more importantly, I think by impairing the liver's clearance of cholesterol.

So it's a tricky molecule. It gets complicated. My brain wants to make it simple. LDL-C high, no good, ApoB, not in range, bad. These are things that need to be addressed immediately. Then I'm on my phone and I'm scrolling through Instagram and people are literally peeling a stick of butter and taking a bite out of it.

And then eating their steak for breakfast and talking about how everything you've been taught about LDL, dietary cholesterol, all of that is nonsense. This is the way that we should be eating. And there's a lot of people who are very influenced by a number of people who are advocating for this way of eating. So, care to comment.

Yeah, it's very disappointing for me to see that kind of stuff. I try to stay as far away from the diet wars as possible. Yeah, and this book is the furthest thing from anything tribal. Like, you know, you really have, in a culture in which there's a sense that if you want to make an impact,

you have to be, you know, somewhat extreme or have some kind of contrarian perspective. Everything that you do lives outside of that. It's all very grounded, but sorry, I interrupted you again. No, I just, look, I've seen, I've had patients show up to my practice that are on incredibly extreme diets. And I just, I take it as my, first of all,

I feel like I've got the time to work with somebody, so I don't have to solve this problem on day one, right? So if somebody shows up and they're on like the carnivore diet and they're eating steak three meals a day and putting butter in their coffee or whatever, I don't know if that would be a carnivore diet but whatever, and their labs look horrible, I say, well, all right, let's talk about this diet.

Like, what is it doing well for you? Why do you like it? Oh, well, I feel great. I've lost all this weight. I said, great, okay. Let's talk about why those things might be happening. And what are you not getting from this diet? So then they'll say, well, plants are toxic.

And I say, okay, let's think about that for a minute. Like, let's go down the, like, is there any data to support that? And look, if you get somebody who's intellectually honest, you might say, well, look, I don't dispute that you might feel better having gone from eating a standard American diet, which had a lot of stuff in it

to being on this highly restrictive diet. The question is you took 57 things out of your diet and you feel better. How do you know which of the 57 things it was? Don't you think we ought to go back and try to do this in a slightly more thoughtful way? Because I would say we don't really have any evidence that the diet you're on now is sustainable.

It might be. Again, this gets to kind of risk and uncertainty. Like it's possible that humans can live on that diet and be perfectly healthy. It's just improbable. And when people have their blood work done and they see these elevated markers and are told not to be concerned about that, that feels-

I probably devote more airtime to trying to dispel those myths. And I actually did a recent AMA just on that topic, which was on, again, the causality of ApoB. This is such an important concept. I mean, it's come up now three times because it matters. If something is causal, then anything that increases it

has to be viewed as problematic. Here's what's not causal. HDL cholesterol is not causal. A lot of people justify their elevated LDL cholesterol or ApoB by the fact that their HDL cholesterol also goes up and their triglycerides go down. And so they say, well, look, we know that high HDL cholesterol and low triglycerides

are associated with lower risk of heart disease. So who cares if my LDL cholesterol is high? Well, here's the problem. When you look at both the clinical trial data and the Mendelian randomization data, they're all in the same direction. The Mendelian randomization data, I can explain in

a moment what that means if people want to understand, make it abundantly clear that high HDL cholesterol is not causally associated with a lower risk of heart disease and low HDL cholesterol is not causally related to a higher risk of cardiovascular disease. Therefore, causally related to a higher risk of cardiovascular disease. Therefore, it doesn't matter if they're higher or lower. They're not causal. Conversely, when you look at LDL cholesterol and you look at all of the Mendelian randomizations and all of the clinical trial data, it all moves in the same direction. Higher LDL cholesterol is causally related to more ASCVD. So when someone says to me, these two biomarkers got better and this one got worse,

I'm gonna ignore this one and pay attention to these two. I say, you're ignoring the causal one in favor of the two non-causal ones. That's a bad strategy. And explain the difference between LDL-C and ApoB in terms of a blood marker that one should be paying attention to? How about I'll give a real quick primer on cholesterol

because I think it's important to understand, right? So our body, every cell in our body makes cholesterol. It's an essential molecule for life. So despite the fact that it's sort of been demonized, if you couldn't make cholesterol in every cell in your body, you wouldn't have been born. That's how, it would have been lethal in utero. So our body has to kind of solve a problem,

which is it needs to move cholesterol around the body, but cholesterol is a fat. And we can't move fats around in water. And we use our circulatory system, which is water to move fat around. So we have to come up with a way to package them in water-soluble things. These things are called lipoproteins. Some of them have high density. Some of them are low density. Some of them are intermediate or very low density. So the low-density lipoprotein, called LDL, happens

to contain a lot of cholesterol, a lot of this cholesterol and triglyceride. The LDLs are wrapped with a protein called apolipoprotein B. There's one and only one apolipoprotein B on every LDL. And there's also one on every other atherogenic particle in its lineage, which is the IDL, the VLDL and the Lp little a. In this sense, ApoB is the most important biomarker we have with respect to lipid burden. Because by knowing the concentration of ApoB, you know the exact concentration of the total number of atherogenic particles. So it is a better predictor of cardiovascular risk than LDL cholesterol, which is the more common test that is developed, which just looks at the amount of cholesterol

within the LDLs. So one is saying, how much cholesterol cargo do you have in the LDL particle? The other one is saying, how many total particles do you have of not just LDL, but the other bad actors? I got you. And ApoB is, it's only relatively recently that it's kind of come on the scene as the thing that people should be looking at, right?

Like, cause- Finally. Maybe not for you, but for like sort of in medicine 2.0. Sure, sure. I mean, Alan Snyderman has been, you know, screaming about this for three decades. Believe it or not, the US is the last country to come around on this. It's been largely entrenched in the LDLC dogma.

But you're right now, it's becoming more mainstream and we encourage anybody to go out and say to your doctor, not only do I want my lipid panel, I wanna see my LP little a and I wanna see my ApoB. What are some of the other tests that should be requested in terms of scans? I mean, we can start with heart health, the calcium scan, but there's like soft plaque scans now

and other types of things, right? Yeah, we prefer CT angiograms over calcium scans. So a calcium scan is just a quick CT scan of the heart with no contrast, and it will only show calcium. But 15% of the time, it'll miss it. It'll either miss calcium or miss soft plaque. So it's a CT angiogram, which is more expensive and has more radiation, but if done right, still has less than four or 5% of your total annual allotment of radiation is a much better test. And I think these serve a purpose, but they don't have to be done on

everybody, right? So they're helpful for people who are on the fence about treatment, depending on their age. So if you have a young person who maybe has a higher family history risk, but they're kind of ambivalent about being treated, maybe seeing that they already have a finding on their CTA is the thing that they need to move ahead. Conversely, if you have a person who's really old and their numbers look really horrible, but they also don't wanna be treated, seeing a completely normal scan at a really advanced age could also maybe steer you off treating

if they're resistant. And how, it would seem to me that these tests for heart health would not be unrelated to understanding risk for neurodegenerative disease as well, right? Given that they are diseases of the circulatory system. But otherwise, testing other than genetic testing, there doesn't seem to be a lot that you can do

to predict these or to see where you're at in terms of the development of those diseases. Well, when it comes to Parkinson's disease and Lewy body dementia, it's a little harder than with Alzheimer's disease. I think with Alzheimer's disease, the ApoE genotype is the dominant gene, not the only one. There's at least 20 genes that are playing a role

in those diseases, in AD specifically. But ApoE is the dominant one, and that's an easy test to get. But it is important that people understand what it says and what it doesn't say. So ApoE is not a causative gene. It's not a deterministic gene. It's a risk gene.

So fortunately, only about 1% of people who develop Alzheimer's disease do so through a causative pathway where there's a deterministic gene that guarantees they're going to get the disease. There's three genes that I won't bother naming that account for 1% of Alzheimer's disease. And if you have one of those three genes,

unfortunately you will get Alzheimer's disease. And if you have one of those three genes, unfortunately, you will get Alzheimer's disease. This is an awful set of genes and they typically afflict people very early in life. So when you hear about someone who got Alzheimer's disease in their 40s or 50s, it's almost assuredly the case. I write about this in some length in the book. I write about it not so much

because it's such a big problem, but because it's such a big problem but because it's where the diagnosis and nomenclature around Alzheimer's disease came from. And I believe it's part of the root cause of why we have such a hard time understanding the disease today. With Chris Hemsworth in Limitless,

there's that amazing sequence where you have to tell him that he has this double marker, which creates this enhanced risk for Alzheimer's. But that's, I mean, what percentage of people have that? About 2% of people, 1 to 2% of people. It's very rare and it was pretty shocking when we got his blood test back. I certainly wasn't expecting that.

Yeah, I mean, how did that go? And like, how has he changed some of his lifestyle habits as a result of that news? Well, when I, so the whole plan for that was, we did a blood test when Chris was in LA. It was like the end of 2019. And we were gonna start shooting in January, 2020 in Australia. And the plan was I'd get the results back,

but I would never talk about it with him until we were on camera. I mean, that's fine. I get it. But then I got the results back and I saw that he had the E4, E4 combo. And I sort of thought about it for a day and I was like, yeah, there's just no way.

Like this is a hard discussion to have with a person under any circumstance because the moment you start talking, a way like this is a hard discussion to have with a person under any circumstance, because the moment you start talking they're only picking up a fraction of what you're saying. Once they hear Alzheimer's disease risk higher, do you really think that they're gonna pick up on the nuance of it's not deterministic and we have things that we can do to mitigate risk.

And there's other genes that can offset this. Like no chance. And I know this from experience. I've had this discussion so many times. It never- It's like that scene in the movie Contagion where Matt Damon's being told that his wife is, and he doesn't hear any of it.

Yeah. So I called Darren Aronofsky, who's the director. And I said, hey, I know that you guys wanted to do it a certain way, but I gotta talk to Chris about something. And I can't tell you what it is, cause it's not your, you know, this is his between him and I.

So you gotta just take a leap of faith on this and decide that it's okay for me to kind of break this one part of the filming and do it. So Darren just had Chris call me directly and we sort of FaceTimed. He was sitting there in Australia with his wife, you know, hanging out. And I just had that call me directly. And then we sort of FaceTimed. He was sitting there in Australia with his wife, you know, hanging out. And I just had that discussion with him.

And I think he was kind of like, okay, so what does this mean? Explain it. Okay, okay. All right, so what does it mean? Which is again, the totally normal response. And then we didn't talk about it again until filming, which was probably like three weeks later.

And then of course, after that we got, and I don't remember what that's like, but I haven't even seen that episode. So I don't remember anything of how it happened. That's been over three years. But then since that time, it's become a much bigger, now he really understands it, right? Like now he's dug in deep and he understands, okay, my risk is going up this amount. You know, we've done a bunch of other

things to look and, you know, done some scans and made sure that, yeah, everything looks perfect right now. But now, you know, your highest priority from the standpoint of your longevity is probably going to be taking a bunch of steps to delay this thing as long as possible or frankly eliminate it. And by the way, there are lots of people with ApoE4 genes who do not get Alzheimer's disease. Yeah, it's heavy.

You talk in the book about another, one of your patients, a woman who in a similar situation, you know, is on the receiving end of that news, but you know, having 25 years to work on this, you know, in advance of perhaps any symptoms showing up whatsoever. And that's really the crux of where your, you know, your focus as a practitioner is like, how do we use these intervening years

with this understanding or this indicia that something might be happening to divert it, delay it. I think that's where there's a really big divide also between medicine 2.0 and medicine 3.0. And there's probably no greater example of that than Alzheimer's disease. I think it's very difficult for medicine 2.0 to acknowledge that this is a disease

for which prevention is an option. And there was a lot of, you know, Darren Aronofsky after Limitless came out, forwarded me some texts that he got from some angry people. Like how irresponsible of you to do this. How dare you like tell, you know, have Chris find out that he has this gene. Like, you know, people were really pissed off. Not all of them, of course, but some of them. And I, you know, Darren said,

what do you think about this? And I said, look, I'll tell you what I think about it. I said, I think that just demonstrates a person's bias. This is a person who obviously, you know, believes that the best thing, you know, let's just assume that this is a good person. First of all, this is a person who is in their best interest and their, and their best judgment believes that nothing good comes of telling Chris that news. Well, let's dig into that assumption. If nothing good comes from telling somebody that news, by definition, you believe you can't do anything about it. By definition, you believe this is a fait accompli. And I just said, look, I'll show you tons of data that say that that just said, look, I'll show you tons of data

that say that that's not the case. I'll show you tons of data that say how you eat, how you exercise, how you sleep, how you manage hearing loss, how you manage depression. Those things are very related to the development of dementia. Which is empowering because it gives people agency and to do these things,

irrespective of whether that person ends up with Alzheimer's or not, or any number of other chronic ailments is in your best interest to do anyway, right? Like all of these things are gonna make you healthier and happier, delay these chronic illnesses. But even in the event that you ultimately succumb or whatever, you're doing what's right for yourself

and your long-term health. Well, just as in the exercise sections of the book, I talk about reserve, right? You want the highest VO2 max possible so that you are starting at the highest place when that decline kicks in. You want the most muscle mass, you want the strongest body possible

because there's nobody that, if anybody's coming here to tell you, you're not gonna decline, like they're crazy, like we're all declining. So the goal is maximize your reserve, have as much water behind the dam as possible so that when the drought comes, you can survive longer. Well, this applies to cognition as well. And that's why I pretty much

am doing every single thing in the E4, E4 playbook myself. And I would encourage everybody to be doing that. In other words, we should all act like we're Chris, Because whether you're E3, E2 or E4, you're not immune to this disease. And even if you don't get the disease, or even if you looked in the future and you had a crystal ball and it says, okay, you will not get Alzheimer's disease. It doesn't mean you won't cognitively decline.

We're all gonna cognitively decline. So what, you know, why does sleep matter? Why does exercise matter? Why does insulin sensitivity matter? All of these things matter because they're going to continue to preserve as much cognitive horsepower as possible for as long as possible, independent of a disease state.

We talked a lot last time about the centenarian decathlon. So I don't wanna repeat that, but I did wanna drill down on one thing, which seems to be like this thing that you've been hammering a lot on social media, which is grip strength. Like this is your jam, right? It's talking about grip strength.

What the fuck is up with grip strength? You know, hanging from a bar, being able to open a jar and all that, why is that a proxy for the kind of strength that's important to be working on and thinking about as we age? So we really only have two ways that we interact with the outside world, right? Most of us are not walking around headbutting things, these guys and our feet. So anything about those things that are not working perfectly leads to big problems. We'll save feet for another day because that's a whole enormous problem

that works its way from feet to ankles, knees, hips, and back and the rest of it. When your grip strength suffers, it limits your ability to do pretty much anything with your hands from opening a door, opening a jar, pulling something, all of those things. So, I mean, just start with the data, from opening a door, opening a jar, pulling something, all of those things. So, I mean, just start with the data, right? So if you look at the data and I include a figure in the book about this, right? If you look at the strength of the association between grip strength

and any disease, all cause mortality, I include onset of dementia, death from dementia, it doesn't matter. The stronger you grip, the longer you live. And we can never do an experiment to see and prove that that is causal. But what we can do is we can look through the Austin Bradford Hill criteria of epidemiology and check off all the boxes that say, boy, most of those things suggest that this association has causality built into it. Is it the grip strength itself? Or is it the fact that somebody with good grip strength is probably doing lots of things

for their overall strength and wellbeing? I think it's more the latter than the former. I think grip strength just happens to become a very good proxy for, because if you have a strong grip by definition, you're strong here, here, you probably have stable scapula, things like that. It's also an easier thing to measure. That's why VO2 max is such a strong association with lifespan. It's not that it's the strongest

thing. There might be something out there that's stronger that we haven't measured. Maybe if we took the time to measure lactate threshold, we'd see that it's even slightly better. It's just that it's very reproducible. It can be done across any lab, any study. And it's been studied in millions and millions of people. And the same is true with grip strength. It's objective, it's easy to measure.

But I think it, as you said, I think it's a proxy for something bigger, which is it's an overall proxy for muscle mass, strength, things like that. And is the best way to develop grip strength hanging from a bar? No, no, definitely not. Like you're doing on Instagram or how do we work on that?

That's a test set. So I'll do those sets to test. It's really carrying things. It's by far the best way. So farmer carries. Again, I get grip strength by deadlifting and doing other things as well, but I don't, these are things that are all kind of secondary. What everybody should be doing is carrying. This is the human

superpower, right? Michael Easter writes about this in The Comfort Crisis, I think, which is there's no animal. We're pretty pathetic animals if you think about it, right? Everything can run faster than us over a short period of time, swim faster, they're pound for pound stronger, all this other stuff. A couple of things we do really well, over 24 hours we can cover pretty much more territory than any other land animal. And we can carry far more weight upright.

No one can come close to that. True, I never thought about that. Yeah, obviously a horse, if you domesticate it, will carry more weight on its back. But yeah, like it's not like a gorilla can carry more weight upright than we can. Like we were really, we were born- That's surprising, I would think a gorilla could.

Not for a long distance, no. They're not, they don't have that stability, right? Like we can stand up and just carry things. So like, it's not a big ask for a guy our age to carry his body weight in his hands. Yeah. You know, half your body weight in each hand and be able to carry that for minutes.

Yeah. So farmer carries, that's the main thing. Yeah, I mean, that's literally, if you did nothing else, but that, that would be the most important thing. And then of course, there's so many variations on these things. There's a billion threads I could pull on exercise and nutrition with you.

We gotta wrap this up at some point, but I don't want you to go without talking a little bit about this notion of healthy addictions. You just put up a blog post the other day about this. And this is something I've been thinking a lot about as it pertains to my own behavior and habits, of course, but also more generally, the way that we can all sort of hide behind healthy addictions that society, you know,

smiles upon or which, as I said earlier, you know, make us successful, whether it's workaholism, exercise addiction, which I'd like to hear your thoughts on. And also, some of these nutrition protocols with fasting, intermittent fasting, delayed eating, all these sorts of things are ways to mask eating disorders or extreme diets, et cetera. We can just say, well, I'm doing the carnivore diet

or I'm doing one meal a day or all. It's like, actually you have an eating disorder. That's what's really going on here. You're just doing what's trendy right now. Or whether it's training for an Ironman, endurance sports, of course, like all of these things. If you're prone to addictive behavior like I am, I can easily burrow into any number of these things

and hide contentedly for quite some time. And I've done that. You know, one of the things I think that's really interesting to ask, and I ask myself all the time, have you, I'm sure you've listened to it, but I don't know if you listened to it recently. You know, the commencement speech by David Foster Wallace,

This is Water? Sure, of course. It's one of my favorites. So that was another thing I'll tell you when I was really in the throes of early recovery, I'd probably listen to that once a week. I could almost recite it off by heart. And it really speaks to me. And one of the things that constantly sends chills

my spine is when he talks about how we're all addicts. And he words it through religion, like we all have a God. And he talks about how some people, their God is the actual God. And he kind of alludes to the fact that they might be the lucky ones. But if your God is power, you're never gonna be powerful enough. If your God is intelligence,

you're always gonna feel like a failure or a fraud. If your God is your body, you will die a thousand deaths before they actually bury you. And I think that that goes back to kind of a question you asked earlier, which is how do you take stock of where your emotional health is?

I'll tell people, go and listen to David Foster Wallace's talk five times and go through it. Like be honest and look inwards when you hear that. Like, where is your God? And don't say you don't have one, right? Like just because you're an atheist doesn't mean you don't have one, right? Like, just because you're an atheist doesn't mean you don't have a God.

And I think about this all the time. Like, I think about how much did I worship my body? And of course I still do to some extent. And I think about how can I slowly start to let that go? Where can I release this tension between I place such a premium on my body that I'm doing all of these things to take care of it. But at the same time, I can't worship it so much

that I'm unwilling to let it go as it goes. And I think that's like the biggest challenge that I think I'm going to face in the next 50, whatever, how many years I have left, 30, 40 years. I don't know. But it's the graceful aging part that says, like, you gotta let go sometimes, like, do the best you can,

but don't do so much more that you ruin this experience of living. And like, it's hard to imagine how restrictive I used to be in my nutrition. It's insane. And in some ways, like my nutrition today is so unrestrictive. In some ways as a response to that.

It probably looks pretty regimented to the ordinary person, but for you. Sure, I eat a pretty healthy diet compared to the average American, I'm sure. But it's like, I wouldn't, if my kids make brownies, like I wouldn't hesitate to eat three of them. Like I did, like it's that, I'm not restrictive in that way. What you're talking about involves threading a needle

and doing a bit of a dance. Because on the one hand, like you have this whole thing about the centenary and decathlon. I wanna win the centenary. Like there's a drive there, there's a commitment. There's maybe even a little bit of an obsession and the personal growth comes in holding that loosely.

You can have something that you care about, that you're working towards, but which you also maintain some level of healthy distance from. Like that ability to be okay with where you're at and who you are while also working towards some type of self-improvement is a, you know, it's a weird kind of thing that you're trying to hold,

right, like it is water that you're trying to, you know, that's slipping through your fingers. But I think the key to the whole thing, and I think you'll agree, is this piece about self-love. If you hold yourself in healthy regard, then you can be okay with the natural progression of your own decline,

a decline that you're trying to slowly arrest. And yet at some level are also at peace with. Yeah, I agree that that's the ultimate challenge and if you if you don't have that healthy self-regard then you are going to be driven in an unhealthy way to achieve this other thing which you've convinced yourself will solve that problem for you yeah I think that I guess that's one of the things that I even hesitate to use the word longevity sometimes because the way I think of it you have that's one of the things that I even hesitate to use the word longevity sometimes because the way I think of it,

you have to spend a while explaining what it means and how it includes all these other things like you're talking about. Whereas for the most part, I think when you hear the word longevity, you think immortality, you think perfection. And truthfully, the first version of this book, that's what it was about.

So why the book didn't come out. These things happen when they're supposed to happen. And there's a spirituality in that Peter, right? Like you talk in the book a little bit about what was the quote that you were exposed to when you first arrived? Oh yeah, like religion is for whoever spirituality is for. Religion is for people who are afraid of hell.

Spirituality is for people who have been there. Right, so my immediate question to that, and maybe we can end on this is, what does your spirituality look like? Like how has that impacted you? Or this recovery journey that you've been on, has that led you into a place of greater openness and receptivity to things perhaps a bit more mystical?

I wish I could say yes, but the truth of it is no. I think the biggest impact it has had on me, which is probably some variation of spirituality is that it's made me feel much less significant in the universe. spirituality is that it's made me feel much less significant in the universe. I don't think, I think it's so much easier for me now to appreciate my irrelevance on this planet. And that makes it easier for me to focus on the things that matter.

I, you know, when my wife met me, she used to, she made a t-shirt for me. It's a bit of a weird story, but in residency, you know, we worked really hard. We worked like 120 hours a week. And I still in residency, despite doing this, was adamant that I like write this book about surgery. And I would work on this thing with all my free time. And it took like years.

And I, it was basically, it all my free time. And it took like years. And I, it was basically, it ended up being a very small little book, but I had to read, I forget like 19 pages a day of surgical textbooks for three years and then summarize it. And I'm working on this nonsense. And my wife was like, why are you doing this? And she's like, well, what's your legacy going to be? Like, you you gotta have a legacy in this world. And so one day she made me a t-shirt that was like, what's your legacy or something. It was kind of mocking me. And I just think like, I think that's nonsense.

Like, I'm not gonna have a legacy. Like if I died tomorrow, outside of my wife and my kids, everyone will forget about me in three months. And I used to like that thought, like to fight against that used to be so much a part of my existence. And I am so at peace with that now that I think that's the closest thing I can say

to spirituality, which is, I was at Rick Rubin has a beautiful place in Italy. And we were there with him last summer. And it's an old place, but Rick is like the third person to own it in 500 years. And I was so moved by this place because I felt like it was the most irrelevant I've ever felt in a good way.

And I remember thinking, I would love to die here and be buried there so that the carbon, nitrogen, oxygen in me became a part of that vineyard. And I don't know, I just think that that's, to me, that's spirituality. It's just, it's not mystic. It's just appreciating the carbon cycle

and knowing that we're all just kind of doing the best we can and not much more. I think there's something- It's pretty uninspiring. No, I think there is something quite beautiful and mystical built into that. There's of course this appreciation for impermanence and the humility that that provides, right?

And I think embodying that sense of impermanence and humility allows you to more clearly see and understand and appreciate the things that actually matter in the present, which are your relationships, et cetera. And it divorces you from like the legacy, like that burning desire that's driving you when that gets snuffed out or at least muted somewhat,

you can then actually start living your life and stop running away from it, right? Like you say in the epilogue of the book, that basically this drive to understand healthspan and longevity was driven by this extreme fear of death and a determination to have a lasting legacy is born out of an unhealthy relationship with death, right? And coming to terms with that and making peace with that

allows you to actually live your best life and ironically extend your health span and life span in so doing it, right? I believe so, yeah. Yeah. Beautiful, man. Well, this was great. Probably a little different

than some of the other podcasts you're gonna do. If you want the tactics, probably tune into Tim Ferriss. Who knows what you're gonna do with Andrew Huberman. Rogan could go in any one of a million directions, I suppose, but this was really special for me. And I appreciate you being so open and honest today. And like I said, at the outset,

the work that you do is really important. It's meaningful to me. It's meaningful to millions of people. And I commend you on your commitment to it. And actually finally following through on this book, which is now gonna be out in the world in which you ended up voicing yourself, yes, after some consternation about your ability

to read your own book. I'm really glad I did it. Yeah. Yeah, good. I'm glad I didn't have to do it under these circumstances, but I'm really glad I did it. Yeah, good, man. Well, we certainly didn't cover all of it. We covered maybe 0.0001% of it.

So perhaps I can control you to come back and talk with me more. I'd love to, and you gotta come out and spend some time in Austin with me as well. I would love to do that. Thank you, Peter. Let's get some tea and some ice or whatever you need on your voice.

But we did it, three hours. You made it through, powered through. That's 74% that believed in you were correct. Cheers, thanks. Thanks. Peace. That's it for today. Thank you for listening.

I truly hope you enjoyed the conversation. To learn more about today's guest, including links and resources related to everything discussed today, visit the episode page at richroll.com, where you can find the entire podcast archive, as well as podcast merch, my books, Finding Ultra, Voicing Change in the Plant Power Way, as well as the Plant Power Meal Planner at meals.richroll.com. If you'd like to support the podcast, the easiest and most impactful thing you can do is to subscribe to the show on Apple Podcasts,

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Plants. Namaste. Thank you.