The Skinny Confidential Him & Her Podcast - Dr. Peter Attia Pt. 2 On Hormones, Ozempic & Weight Loss, Alcohol Effects, Insulin Resistance, & Testosterone Replacement Therapy

Episode Date: August 31, 2023

#604: Peter Attia, MD, is the founder of Early Medical, a medical practice that applies the principles of Medicine 3.0 to patients with the goal of lengthening their lifespan and simultaneously improving their healthspan. He is the host of The Drive, one of the most popular podcasts covering the topics of health and medicine. He is also the author of the #1 New York Times Bestseller, Outlive: The Science and Art of Longevity. Today we're sitting down with Dr. Peter to finish our conversation from Monday and discuss all things nutrition, how things like alcohol affect your body, and everything you should know about supplementation. To connect with Peter Attia click HERE To connect with Lauryn Bosstick click HERE To connect with Michael Bosstick click HERE Read More on The Skinny Confidential HERE To subscribe to our YouTube Page click HERE For Detailed Show Notes visit TSCPODCAST.COM To Call the Him & Her Hotline call: 1-833-SKINNYS (754-6697) This episode is brought to you by The Skinny Confidential This episode is brought to you by Westin Hotels At Westin hotels, there’s amenities and offerings aimed to help you move well, eat well, and sleep well, so you can keep your well-being close, while away. Find wellness on your next stay at Westin. This episode is brought to you by Betterhelp BetterHelp is online therapy that offers video, phone, and even live chat-only therapy sessions. So you don’t have to see anyone on camera if you don’t want to. It's much more affordable than in-person therapy & you can be matched with a therapist in under 48 hours. Our listeners get 10% off their first month at betterhelp.com/skinny . This episode is brought to you Primally Pure Primally Pure has harnessed the power of natural ingredients in their complete line of non-toxic beauty products. Visit primallypure.com and use code SKINNY at checkout for 15% off your order. This episode is brought to you by Delola Spritz Visit DelolaLife.com to find a store near you that carries Delola and follow @delola on instagram to learn more! Please enjoy responsibly. This episode is brought to you by Beekeepers Naturals Beekeepers Naturals is female-founded and the products are clean and effective, third-party tested for all pesticides, and the brand is dedicated to sustainable beekeeping and helping save the bees. Get 20% off your first order at beekeepersnaturals.com and use code SKINNY at checkout. This episode is brought to you by Armra ARMRA Colostrum strengthens immunity, ignites metabolism, fortifies gut health, activates hair growth and skin radiance, and powers fitness performance and recovery. Visit www.tryamra.com and use code SKINNY at checkout for 15% off your first purchase. Produced by Dear Media.

The following podcast is a Dear Media production. She's a lifestyle blogger extraordinaire. Fantastic. And he's a serial entrepreneur. A very smart cookie. And now Lauren Everts and Michael Bostic are bringing you along for the ride. Get ready for some major realness. Welcome to The Skinny Confidential, him and her.

I mean, we spend so much time in our practice dealing with hormones for both men and women, and we could certainly talk so much about that. You know, the first thing I always want patients to understand is both HRT for women, estrogen and progesterone, and TRT for men are insanely safe if done correctly. So there's a lot of really, really bad, bad science, horrible press, and lazy, lazy, vestigial old thinking that has people believing that these things are harmful. Welcome back to part two of a two-part episode, obviously featuring Peter Attia. If you missed part one, that was released earlier this Monday on podcast and on Tuesday on the YouTube video version. And like I said, in that episode, we covered so much ground with Peter. This is the second part of that conversation all around longevity,

health, supplementation, hormones, muscle building, cardio exercises. Again, anything that touches the health system and the body. This is what we're covering on this episode, the part two of the part one. Again, like I said, if you're just tuning in now, be sure to go listen to part one so that this part two makes sense. For those of you that are just tuning into part two and don't listen to me and go back to part one, I want to give you some background on who Peter Attia is. Peter Attia is the founder of Early Medical, a medical practice that applies the principles of medicine 3.0 to patients with a goal of lengthening their lifespan, simultaneously improving their healthspan. He works with some of the world's greatest performers from athletes to entrepreneurs to podcasters like

myself. And he just knows his shit when it comes to the human body and optimizing our health and our lifespan. He's also a New York Times bestseller. Most recently, his book Outlive, the science and art of longevity covering all of theseseller. Most recently, his book Outlive the Science and Art of Longevity, covering all of these different topics. With that, let's welcome Peter again to part two of his episode that we did recently. Peter, here we go. Skinny Confidential, him and her show, Peter Attia, part two. This is the Skinny Confidential, him and her. Mental health. Talk to us about that aspect of your sort of mission. Well, I mean, this is something that is probably the most important. I would say that the biggest

advantage of this book having taken almost seven years to write is that fact, right? Which is, when I started writing this book in late 2015, early 2016, this wasn't even on my radar. So it wouldn't have been something I particularly cared about. And only because the book had to be rewritten a couple of times in part because of what I wrote about did the importance of emotional health come to the forefront such that even though it's only one chapter of the book, I think it's probably the most important chapter of the book in a weird way. I mean, it's certainly the chapter that I would say I get the most feedback on. I got an unbelievable email yesterday actually on our website from a woman who said, I was listening to your book on audio, and immediately all I could hear was my husband's

voice. You sound like him, and the way you speak is like him. My husband was a very successful person. She explained his profession. I won't state it now just so that I don't offer any ways to identify her, but he was a very successful so-and-so, and he killed himself. And she said, I think listening to that chapter of your book for the first time has helped me to have empathy for him and understand him. And I just thought, and she wrote it in a much more eloquent way than I can express it, but that really kind of shook me up, but also made me realize like, yeah, there's a lot more to this

than just the length of your life even though that's a very extreme example which is suicide which can affect obviously the length of your life but i think it speaks more broadly to quality of life and so that whole chapter and more broadly just my interest in this topic i think stemmed from something that esther perel have you guys had esther on No, I'm dying to. It was, I was trying to say, I knew, I remember reading your book that she said something to you and you're probably going to share it. I couldn't remember if it was her or Louise Hayes, but. Yeah, yeah. So she said to me circa 2017, which was around when I started seeing her,

isn't it ironic that you're so obsessed with trying to help people live longer and yet you're putting no effort into being less miserable. Um, which I thought was, I mean, that's, you have to know Esther to understand just how brilliant she is and how like she just always gets to the issue. Like she just, what, you know, what maybe a really good therapist would take a year to figure out she could figure out in like a day what were you quote-unquote miserable about like what i remember at one point and i've heard you say that you used to have a ton of anger issues or you'd get really upset if something didn't go exactly how you wanted it to go like was that is that the root of it was it anger or was it depression well i think anger was a manifestation of it i mean i think you know i think the roots for everybody are different, but they probably all go back to the types of,

I think many of our negative behaviors as adults are kind of manifestations of adaptations to probably things in our childhood. A lot of those adaptations are actually very positive. I mean, I think that's, by definition, an adaptation is a change. And if an adaptation sticks, it must have had some benefit to it. I do believe in the sort of Darwinian nature of evolution in that sense. So the real question is,

are there negative things that are getting dragged along with those positive adaptations? And I think think for me, the adaptations were towards perfectionism, workaholism, rage. And that little triad had a lot of positives to it, but it just had a lot of negatives too. And I think that was sort of by 2016, the negatives were starting to outweigh the positives. So it's almost like the qualities, the perfectionism gets you so far, but then it stops taking you to the next level and you have to address that. So how did you address that with Esther and what tools did she give you to not be so, you're quote, miserable?

Yeah. So it was pretty complicated and there were many people involved. It wasn't just Esther. So I'm also very fortunate to have a really close friend who's a psychiatrist. So he's one of my best friends from medical school, one of the first people I met at the very beginning of med school during orientation. His name is Paul Conte. And Paul and I were practicing together. We shared an office in New York at the time. So this is long pre-COVID. This is back when you actually had to show up at the office every day. And so Paul and I had an office in New York and he was commuting from Portland. I was commuting from San Diego. 10 days a month, we were still there together. And, and Paul's kind of watching, you know, this guy who's known me for 25 years, I mean, he's watching me kind of spiral. And by the fall of summer, summer, fall of 2017, he's like, look, I think you need to go to this place in Kentucky.

I think you need to go to this place called the bridge to recovery. And I was basically like like there's no goddamn way like i'm not i'm not fucking doing that also sounds like a skeptic kind of a little bit of a weird name but yeah and i looked it up online and i was like this is like a place for addicts and stuff like i'm not doing like i'm not an addict so why would i do that and by the way you got to go there for like six weeks and they take your phone away and you can't be in communication outside of worlds weeks yeah i was like i'm not there's no way i'm doing this so paul is really kind of pushing me like you need to go to this place esther is you know working on stuff with me but you know i'm not fully open. And to make a long story short, I, I, I very reluctantly, almost

without choice, truthfully at this point, you know, agree to go in December of 2017. But after two weeks I, I, I leave, you know, I mean, it's not like I leave AMA, but I'm like, I had some breakthroughs. I thought I was better. And I was like, okay. I, you know, it was like the day before Christmas. And I was like, I don't want to be away from my family for Christmas. So I came back to San Diego and that was, those were really big breakthroughs. And that then got me working with another therapist named Terry real, who I write about and who's written an amazing book called, I don't want to talk about it, which is I think the definitive book on male depression that kind of got into deeper and deeper work about my childhood, my coping strategies. And, you know, unfortunately that led to one more trip into longstanding rehab, another three weeks.

I went into a place called Psychological Counseling Services or PCS in Phoenix, Arizona. And I would say that that was probably the most transformative thing I ever did, was those three weeks there. And when you say that, do you mean in your life, in your marriage, with your kids, with your business, or with everything? Everything, for sure. With myself. So given that I was the problem in everything, what's that line in the Taylor Swift song? Hi, I'm the problem, it's me. Yeah. So given that basically the version of me that was showing up for everything was the problem, yeah, that had to be. So my relationship with myself had to be fixed to then become a much better husband, a much better father, a much better friend,

a much better boss, whatever it was. I predict one of your books, your next books will be on emotional health. Well, I don't know that that will happen because, and that's what the publisher wanted, by the way, here. The publisher was like, don't put that chapter in the book. You know, chapter 17. They're like, don't put that in there. I think it's important for the book. Well, they were like, if you really think that's worth writing about, just write another book on that.

And I was like, I'm not writing another book. Like, this is the way it's going to be. Yeah, you have wrote a book. Seven years. Yeah. I'm like, we're done with books. I want to go back quickly because I think this plays in part a lot of times into emotional health and many people may not look at it, but I do think it's a factor. We talked about earlier alcohol and that substance.

As I've gotten older and as more information's come out, I've partaken less and less in alcohol. I still do. If we're going out and we're being social, you know, like we enjoy a good tequila. But what I realize is, you know, one, I'm getting older and I just can't do it like I used to. It's just like, I just can't hang. My hangovers now are absolutely horrendous. And how old are you? I'm 36. Oh my God. Wait, wait till you're like 50. It's insane. What a difference.

Well, and the kids wake up no matter what, crack of dawn, three-year-old, one-year-old. So it's insane what a difference well and the kids wake up no matter what crack a dawn three-year-old one-year-olds it's just like yeah there's no party good enough for me to want to deal with that chaos but also like talking to people like yourself and just learning more data and you know we've had our brain scan and just looking looking at the effect of alcohol maybe we could talk about that a little bit and go into the calories and also just how you think about it yeah and again here's another example where I love to lay my cards on the table. Like I feel very fortunate of all the addictions I've had. None of them have been to substances, right? Like I have an enormous empathy for people who struggle with substance

addiction and I don't see myself as anything but purely lucky when it comes to the fact that the dopamine producing cells in my body don't get stimulated from ethanol or opioids or all of these other chemicals or gambling or any of those things that are the less societally accepted addictions. And to your point, Lauren, I mean, there's a two-edged sword to your addiction being success. Because on the one hand, the good side of that sword is, well, it's societally acceptable and it's largely productive. The bad side is no one ever wants to fix the underlying problem because there's so many good things coming along the way. It's easy to ignore it. Whereas the alcohol, and we're going to come back to your question, but just to get this point, the guy who's in the ditch with the bottle, there's nobody looking at that guy going, yeah, nothing's wrong there. So sometimes when you have these other addictions, attention comes quicker because the destruction is so obvious.

Okay. With all that said, though, I've never struggled with alcohol. I love it. I mean, I have no idea what it means to be addicted to it. I've never once felt that I have to drink it or that I can't stop. I've never once had a drink alone in my life. Like, but that said, like I freaking love tequila. I mean, I love it. I love mezcal. I love nerding out on the different regions of Mexico. And I'm not a connoisseur. Even you talking about it makes me want to have some. I know.

I literally could have a tequila right now because we're all here together. So as much as I enjoy it, I think the literature is quite clear that there is no health benefit from alcohol. None. None. I really believe. And we're working on a very long piece on this. So as you know, I have a podcast that comes out every week. We have a newsletter that comes out every week. We have a whole bunch of other things, but the two other things that we work on a lot, within the podcast, there's kind of a subscription thing where once a month,

subscribers get a very, very deep piece of content. This is like a 20-page article that is months of research. And we've been working on one on alcohol for quite a while now, for about the last four or five months. So this question is so steep in my mind. And so we've reviewed every single study, including the studies that sort of suggest there might be a benefit to alcohol, something called the J curve, which means at very, very low levels, there's a bit of, you know, having no alcohol is associated with a higher risk of death than having some alcohol before the risk starts to go back up again. There's the so-called French paradox. Why is it the French can eat all of this fat and yet they have the lowest risks of obesity and

disease? Is it the alcohol that's offsetting it? Of course, I think there's a million other reasons. So we could talk about the proof for that, or we could just sort of take it on face value that I don't think there's any real benefit to ethanol in a pure chemical sense. All of that said, I think there are relatively low negative consequence for modest amounts with a few, call it exceptions and ways that you can manipulate it. What is, in your opinion, a modest amount? A drink a day, provided it doesn't have one of the two enormous knockoff negative consequences of alcohol. I think there are two really big ways that alcohol creates damage long before you actually see the molecule damaging your liver.

Meaning, because alcohol leads to fat accumulation in the liver. So alcoholic fatty liver disease is what leads to cirrhosis, which is this obvious consequence of... When people die as a result of their alcohol, it's either acutely because they die in a car typically or chronically because of liver damage. Let's put all that stuff aside. It's not that it's

not important, but that's not what you and I are worried about. Certainly what I need to worry about when I drink are the following. Is this impacting my sleep? And if I drink with less than three hours between bedtime, it will. Yeah, same, same. So that's rule number one. If you're going to drink, get it out of the way early. So I'd much rather have a glass of wine at 6 PM before dinner than have a bottle of wine or a glass of wine after dinner and have it bleed into sleep. The second area where I think the modest drinker can get into trouble, maybe you don't, but I think Lauren will be able to relate to me. It will lower my inhibitions around

other foods. Whatever little willpower I have managed to scrounge together to avoid dessert, it goes way down after I have a drink. It's like why people go after they've gone out and they've go get like pizzas or McDonald's or fast food is because like they would never do that normally. But now they got that buzz on like, oh, I'm going to go get that shitty food. Yeah. And honestly, I even feel it before I get it because I don't even drink to the point of getting a buzz.

Like I probably would need three drinks to have a buzz. And that's a rare night. By the way, well in the business of shamelessly plugging restaurants, I have no affiliation with Commodore. I don't know if you guys have been there. I have not. We've heard amazing things though. Amazing.

And the mezcal selection is out of this world. And the only reason I thought of that is I was there a week ago and that's the only time I will violate my rule of more than a drink and i will do four one ounce like shots of mescal different kinds yeah four different kinds but in progressive flavors and you know again what does it do it just lowers your inhibition you are just that much more likely to have dessert or whatever else is going on. The whole basket of chips. So yeah. For me.

Oh yeah. One, maybe one drink is moderate a night. Like what if you only drank once a week, but you had like four drinks, would you say that's worse than having one a night or is it like. Probably a wash. It's probably a wash. I mean, I look, I think four a week, four in one night could probably, you know, depending on the volume again, that's the other thing too, is we really want to think about it as grams of ethanol.

And I know for myself, like if I'm pouring myself a glass of wine, sometimes it can be a glass is really like a third of a bottle kind of thing. It's just like, did I have a glass? Maybe. So one needs to be a little bit careful. Yeah, yeah, exactly. The other question that's interesting on the alcohol front is, is there anything sort of special about red wine? Because the argument might be, well, red wine has polyphenols in it and it has other chemicals that are antioxidants that may,

independent of the ethanol, have an impact on health, in this case, a positive impact. The evidence for that is, I would say, inconclusive, but not that strong. So I think, again, our net view on this, and again, I'm very open about this with my patients. I'm like, look, I'm not going to sit here and tell you not to drink, even though that's probably the healthiest thing to do, is don't drink crappy healthiest thing to do is don't drink crappy alcohol so my motto is don't drink on airplanes right because like the alcohol is garbage right so like why would you drink garbage alcohol and then the but then the other thing this all has to be counterbalanced against is i think the reason that the epidemiology typically shows an advantage to

alcohol is the pattern in which alcohol is consumed. These studies don't look at people in college doing Red Bull shots. It's typically a more Mediterranean style of the glass of red wine with dinner, which is very pro-social and I think has a lot of other benefits. Because social interactions have been proven to increase longevity in ways just because maybe you're happier life. Absolutely. And I also think, and not that this is like carte blanche to just go and drink every night, but I think for many people, like a glass of wine is a really nice unwind. And I don't think we can fully discount or necessarily capture the benefits of that. When you deal with all these high performers,

is there a lot of people that come to you with the alcohol question? Is that a question you hear often? Yeah. We talk a lot about that. Yeah. I would think that too, just because they live, like they're such high performers, but it's a lot of stress. So you get people who like, want to wind down or have like a vice at the end of the night. For, for people that are maybe, you know, not looking like, what are some things or some effects that you see alcohol have on the health system or on our bodies that maybe people aren't thinking about? You mentioned fat. I mean, I think everyone knows about the liver. No, the effect on the liver is huge.

If you do look at deaths of despair, so what are deaths of despair? So it's overdoses, so accidental overdoses. So these are not, you know, people that are trying to kill themselves. These are people who are taking drugs and they overdose and then suicide and then alcohol related death. Those are the three drivers of, of alcohol, of, of death, what I call deaths of despair. There's like 225 000 of those a year wow so it really becomes a question and this goes back to your point lauren like okay you know the really high stress person who's using alcohol to unwind it's a slippery slope right because you don't really want alcohol to be the crutch that you lean on to unwind and to cope with your stress you don't want alcohol to be the crutch that you lean on to unwind and to cope with your stress.

You don't want alcohol to be the thing that you lean on to blunt pain somewhere else in your life. And I think that one has to take an honest appraisal of where they are in that. It's one thing to say, yeah, like I really enjoy having a glass of wine with my friend and my wife or my whoever after dinner or before dinner or whatever. And that's versus like, I am so high strong or I am so lonely or I am so fill in the blank where you're using alcohol as a crutch. I think it's important to check yourself and be like, okay, you know, like we just were in San Diego and we had a lot of alcohol, but now we're back in Austin and it's like no more alcohol. So I think for me, it's constant checking and balancing and making sure that I don't have too many.

I think that really analyzing it from an outside perspective has been helpful. Last thing on alcohol. Is it fair to say, you know, I've had friends come to me and this was me too a couple of years ago. I looked all of a sudden after having our first kid and that thing about dad bods is true. I was like, well, I need like out of nowhere. I'm like, I have that. I'm like, I have no muscle mass anymore. If you look at him now, he had a dad bod.

No, but I've been working on it for a while now, but I have friends now coming to me and they say, okay, they're going to do this. They're going to do this, but they're still going to maintain drinking alcohol four to five times a week. I'm going to show Peter a picture of your dad bod. What I have been saying to them in my personal opinion is that it's really hard to get the results you want from a fitness perspective. If you're going to keep consuming that much alcohol. And I think people like, you know, they go on the diet and they get in the gym, but like, it's almost like you're running up the hill just to go right back down.

Yeah. Not the leanest there. No, no, no, no, no, no. And small. But hey, it's, you're holding a beautiful baby. That's true. Yeah. Not the leanest there. No, no, no, no, no, no. And small, but Hey, it's, you're holding a beautiful baby. That's true. Yeah. He had the baby. So he has an excuse, but from your, from your perspective, when we, you talked about the calories earlier in alcohol, if you're trying to lose weight or you're trying to put on muscle, like what kind of effect does the alcohol play

in, in holding some of that back? I, again, I think it's hard all around, right? I think it's, it's the calories that come with it are huge. The knockoff effect it has on eating other crap you shouldn't eat. And then truthfully, you feel worse. In the sleep. It's a performance. Yep.

So you don't perform as well. I am someone who travels a lot. And I'm constantly trying to be healthy when I travel, but it is a struggle. But leave it to the Westin Hotels to fix this issue. Okay, you guys, first of all, they have over 200 destinations around the world and they're committed to all things wellness. So what they've done is they've made travel an opportunity to actually enhance your well-being. They have like this whole situation that's dedicated to move, eat, and sleep well. They even have a Westin workout fitness studio. It's equipped with state-of-the-art equipment, and you can customize your workouts while on the go.

They have Bala products that you can borrow during your stay. They really thought of everything. You can do your own thing in your guest room with workout and recovery gear. It's all available on On Demand through Weston's gear lending program. You should know they also have Eat Well. They have Weston chefs and craft design dishes to keep your well-being in mind. So they've really zoned in on portion control. They think about nutritional balance. They're just committed to helping you eat healthy, nourishing meals. And lastly, they have Sleep Well. This is all about recharging your body and mind with a restorative sleep. Weston's even has a renowned heavenly bed. So they really thought of all the things health and wellness-wise at Weston Hotels. There's amenities and offerings aimed to help you move well, eat well, and sleep well.

So you can keep your well-being close while away. Find wellness on your next day at Weston. This show is sponsored by BetterHelp. I know so many people get down on technology, but if there is a good thing about technology is we have access to things now right on our phones, right on our computers that we never had access to before. One of the themes that we talk about on the show all the time is mental health and the importance of speaking to someone if you're feeling like you're in a dark place or even if you just feel a little anxious

or just like you got to get something off your chest. For years, therapy was so inaccessible to so many, but now with BetterHelp, it's accessible to everyone. What we love about this company is they bring therapy with licensed professionals right to your home at the convenience of your couch, your bedroom, wherever you want to do it. Long gone are the days of having to get in your car,

go into an office, sit in a waiting room, and then get into your session. That has always felt a little bit awkward for Lauren and I having to go and actually be there in person. So being able to do this from the convenient and comfort of your own home, it's just a different energy. You're able to get a little looser, feel a little bit safer. And like I said, have conversations with licensed professionals. What I also like is you're able to vet all sorts of different therapists on the platform and figure out who's right for you. So many experts that have come on this show, when they come and talk about what has helped them achieve the things they've achieved in their life point to therapy. So it is definitely something that we firmly believe in. The

results speak for themselves. We've met so many incredible performers that have used this as a tool in their tool belt to just be the best versions of themselves. So let therapy be your map with BetterHelp. Visit betterhelp.com slash skinny today to get 10% off your first month. That's betterhelp.com slash skinny. one thing that I did during both my pregnancies that I still do is I switched to a lot of clean non-toxic beauty products I when I got pregnant with Zaza examined everything I was using and went through all my products and basically donated anything that wasn't non-toxic and one thing that I replaced that I'm still using to this day through both my pregnancies is Primally Pure's body butter. Okay. They have this body butter. It's almond vanilla. It is absolutely magical. It's all non-toxic ingredients and it's like

natural almond and organic oils. And I love using this after I get out of the shower. But here's what I do. I dry brush in the shower and I get really exfoliated. And then I get out and I pat dry. And then I use this incredible body butter. And I went and looked at the ingredients because I got so addicted to it. And you guys are going to die. It's like tallow from grass-fed cows, which Paul Saladino recommends using on your body. It's filled with vitamin A, D, E, and K. Primally Pure has so many different non-toxic products. If you haven't tried tallow in your skincare yet, it is time. Use code SKINNY for 15% off your Primally Pure purchase. That's www.primallypure.com. Use code skinny at checkout for 15% off your order. Visit primallypure.com for 15% off your order. Insulin resistance. Hot topic right now. I think a lot of people are realizing they either have it, they know someone who has it.

Is it mainly in women? I don't know a lot about it, so I would love for you to do a deep dive into it. Insulin resistance is, in many ways, kind of a precursor to a lot of bad things that happen disease-wise. Michael, you talked about the four horsemen a minute ago. So we talked about heart disease, cancer, neurodegenerative disease, which includes the most common of these is Alzheimer's disease, but also other types of dementia. All of these, and those three things, by the way, account for like two-thirds of deaths. Those things are all made worse if you are insulin resistant and insulin resistance

is the precursor to diabetes. So let's start by what is insulin resistance? How is it diagnosed? How do you fix it? All those things. So to understand what insulin resistance is, you kind of have to understand what insulin is. I have tried in vain to explain insulin resistance without explaining insulin. It doesn't go very far. So insulin is a hormone made by a little gland behind your stomach called the pancreas. It's a very important hormone. So important that if you can't make it, you will die unless it is replaced. So there's a disease called type 1 or juvenile diabetes where the pancreas can't make insulin anymore. And until about a hundred years ago, those kids all died. So what does this hormone do? So this hormone is secreted from the pancreas into the bloodstream

in response to glucose. What is glucose? Glucose is a very, very simple sugar. It's what most of the carbohydrates we eat are broken down into. That includes complex carbohydrates like starches and simple carbohydrates like sugars. But they ultimately get broken down into this very simple ring called glucose. Glucose is a very important molecule. It provides a lot of our energy, and our brain in particular is so dependent on it. So everything about the way we regulate it is very important. If the glucose level in your blood gets too high,

which it does the moment you start eating carbohydrates, it can become toxic. So we have to be able to take it out of the bloodstream and put it into mostly the muscles, but also the liver. We'll just talk about the muscles because that's where you put most of it. So let's pretend you drink, I don't know, a sugary drink with a lot of glucose in it. It'll probably have fructose in it too, but let's just talk about the glucose. What's the fate of that glucose? You have the capacity to put hundreds of grams of glucose, 200 grams, even in a man, 300 grams of glucose into all of your muscles. But to get it there,

you need a channel. You need something that the glucose can get from the blood into the muscle like think of a tube like a straw a short straw that goes between the muscle surface the cell of the muscle and the bloodstream for that straw to know that it needs to go from inside the cell to outside the cell needs to be told chemically to do that and And the thing that tells it is insulin. So insulin is floating around in the blood in response to high amounts of glucose. Insulin binds to a receptor. So a receptor is just like a, think of a glove sitting on a surface and insulin is the ball. The ball lands in the glove and that triggers inside the cell a chemical signal that tells the straw to come up to the surface which then lets glucose pour into the cell and the fancy word for that is

glucose disposal so glucose disposal is a very important reason we want muscle so you remember going back to the very beginning of the discussion we talked about why is muscle so important that's a big part of it because of the glucose glucose disposal people would have less you can't do it as well that's right okay so high glucose disposal and then of course there's all the structural reasons you want to have muscle okay so insulin resistance means the baseball glove when the baseball lands it, when the insulin hits the insulin receptor, the message isn't getting through to bring the straw up. So all of a sudden, what would happen? Well, now you have all this glucose,

you make all this insulin, insulin tells the the muscle bring me the glucose receptor sorry the glucose receptor the glucose transporter and it's not happening so it has to make more insulin so the first step of insulin resistance is elevated insulin which is called hyperinsulinemia that's just the fancy way to say too much insulin hyperinsulinemia. That's just the fancy way to say too much insulin, hyperinsulinemia. So the first way that you diagnose insulin resistance in somebody is you give them a glucose drink and you measure their insulin level 30 minutes later. I had to do that pregnant. Yeah, and I bet that they only measured you two hours later. The normal test for a pregnant woman is measure your glucose, give you a glucose drink, then measure it two hours later. I've never seen someone kick and scream more about drinking a drink.

It's so gross. Who wants to drink that? It's really gross. And that's a good poor man's test when you're pregnant. Because pregnancy does induce glucose insulin resistance. So we just have to make sure it's not so far that you get what's called gestational diabetes, which some women get. And if they do, they might need medication to help with that. And in some cases, they might even need insulin during pregnancy. But when we look at this in our patients, we look at not just the glucose level, which can tell you if this might be happening, but a more sensitive test is looking at the actual insulin level, but you have to look earlier. You have to look like 30, 60, and 90 minutes after you have that drink. And when that insulin level starts to go up, even if glucose levels are normal, you know you have insulin resistance. Why this is happening is very interesting. There's a guy I interviewed on my podcast

named Jerry Shulman at Yale who's done the most research on this. And he's demonstrated that it's actually the intramuscular accumulation of fat droplets that is the thing that's impairing that chemical transduction of the signal in the muscle cell. And that's actually why the muscle is getting insulin resistant. So can you build more muscle to push it out? Yeah. So what's build more muscle to push it out? Yeah. So what's the treatment for this? Well, it's really interesting. When Gerald Shulman was doing research on this,

a lot of the research they do, they're doing on college students. And he said the most important thing that they needed when they were recruiting subjects for their studies was they had to be sedentary. Again, it's very hard for someone who's 19 to be insulin resistant. So the key is they can't be active. So rule number one, if you don't want to be insulin resistant, is be active. And basically, I think the three biggest drivers of insulin resistance are inactivity, excess nutrition, going back to the bathtub analogy, so too much energy intake, eventually

that fat spills out of the subcutaneous, good areas, and then into the bad areas. Excess nutrition means just too much food. Too much food. Yep. And then too little sleep. So there's an even more technical way to measure insulin resistance that you don't do in normal people in a clinical setting, but you do it in the lab. I've had this done on me. It's called a euglycemic clamp. It's a very, very fancy test where they put two IVs in you and then they

run glucose and insulin in simultaneously and they try to figure out how much insulin you need to keep the glucose at a fixed level this is a crazy test sounds like my worst nightmare in hell i can never be a part of your practice if i have to oh no no we don't do that absolutely that literally sounds like my version like i am eliminating myself oh my god no no that's what they do in the but but that's what they'll do in in clinical studies but this is the gold standard so using this clinical gold standard a researcher at the university of chicago showed that if you took healthy volunteers who were insulin sensitive and for i believe it was 10 days you only let them sleep four hours a night.

Which by the way, I did that for five years, like in residency. You do that for 10 days, you will reduce their glucose disposal by 50%. So less than two weeks of horrible sleep gets you well down the path to being a diabetic. Wow. So it's not even just a fitness and a nutrition thing. If you're sleeping bad. If your sleep is jacked, it's very hard to fix this problem. People that brag about how they only get five hours sleep.

I don't know what there is to brag about. I understand that there are many people for whom life's circumstances are challenging and maybe getting as much sleep as is ideal is difficult, but there's nothing about insufficient sleep that's good for your health or good for your performance. There's a fourth one, by the way, that's the hardest one to really quantify, but it's high stress. So high stress leads to high cortisol and very high levels of cortisol persistently lead to insulin resistance. She's like pointing at me.

I call it MUS. It's made up stress. I say there's no saber tooth tiger. Stop with the saber tooth. We will walk into any room. He's looking for the saber tooth everywhere we go no one of the challenges in my personal life is the saber not looking for the problems right tell me why i don't i you know i think i as i've analyzed it as i've gotten older i think i grew up with an anxious mother who's half japanese and i don don't blame all that on her. But there was like, her and I share a similar stress pattern. I think I'm just wired to look for things that maybe like others... I think I'm just wired that way. His dad used to wake him up in the morning to go to school,

hit the door open at six, turn the lights on, say, get up. No, when I met her, I found it strange because she's like, hey, we need these dim lights and these music and these wake up. I'm like, wake me up like a cat.

I got to wake up. I need a second. I can't talk about QuickBooks at 9 a.m. I need a minute to collect my thoughts and have some water. Fill me up before you fuck me. I almost perform better

when there actually is stress than when there's not, when I, when there's, when there's things not going on and it's a stable, then I, then I kind of get a little bit like, it is a little bit looking for the like danger around the corner. And I don't know if that's a wiring thing or if it's just, I don't know. I mean, it's a few things. And over the years I've done a lot of work to try to mitigate it, obviously working out and being healthy and sleeping and all that has been helpful. But yeah, I just, it's just, I've always been wired that way. Well, it's interesting. I mean, and it's not entirely clear by the way that that would need,

that would necessarily lead to a negative pattern of hypercortisolemia because, and that's part of what makes stress a more complicated variable to understand is it's not so much about the perception of stress as it is the internalization of stress. You know, that we do have tests that we can use to measure those things. It's not as objective as the other three metrics. There's probably, yeah, like probably if I really get deep and really started thinking about it, I could probably, there's probably just like stuff from childhood that, that probably will come up that I have to figure out like why I'm like wired that way. But it's not as bad as she says. And where there was a few years ago, if you would have met me like, Oh, that guy's a stress

case. Now I'm like, I'm more even keeled as I've gotten older and as I've learned tools to manage it. Right. A lot of the stuff we were talking about today has helped manage it. But yeah, just, just, I've been wired that way forever. What do you think about people on metformin for insulin resistance and how does semiglutide, how do you say it? Semiglutide, yeah. Okay, play into this insulin resistance conversation if it does. Okay. Metformin is an interesting drug that has been used for, in the 40 years outside of the US even longer as an early stage, what we call a first line drug for people with type 2 diabetes.

We have a pretty good sense of what metformin does, but not necessarily how it works or why it exerts its effect. But I think for the purpose of simplicity and not, because I don't think people want all the biochemistry in the world, metformin blocks something in the mitochondria. People may have heard of the mitochondria, these little organelles with inside cells that are the power plant of them. They make ATP. That's what takes the energy out of the food we eat and makes the chemical energy that we need to run our bodies. And metformin blocks a very specific little part of that. But the net effect of it is metformin prevents the liver from making more glucose. Because not only do you eat glucose, but the liver makes glucose. So it makes sense that if someone has type 2 diabetes, you want to reduce

the thing that is making part of the glucose that they're getting. A knockoff effect of metformin is you probably do lose a bit of weight on it. Now, it's not a huge amount of weight loss, and it's not clear what the weight loss is from, though it seems likely due to the appetite suppression from the drug. These days, virtually nobody is taking metformin for weight loss, but instead they're taking it for insulin resistance, which I think is the right reason to take it if you're not able to exercise sufficiently. I'll come back to why if you can exercise sufficiently, I don't think you should take metformin. And there's also a group of people who take it

because they think it will just make you live longer this is a so-called gyrot protective benefit gyrot protective is a word that means it has a benefit that is not specifically through the reduction in the risk of a given disease but instead is just through a broad application of anti-aging pathways and these are people that even would have no insulin resistant issues. That's right. That's right. And I was one of those people. So from 2011 till 2018, I took metformin for that belief system. I stopped taking it in 2018 because I kind of lost my belief system around that. And I was also measuring some other variables around exercise and felt that it, that the net effect of the drug on an, from an exercise perspective standpoint was negative.

And that the negative, the negative effects on the exercise front were more than enough for me to just say, I don't want anything to do with this drug until there's a more compelling reason, which we're looking for. So that's what you're saying is the exercise, if you can exercise efficiently, it's more effective in your opinion than taking the drug. Yeah, for sure. Okay. So let's fast forward to what semaglutide is. So semaglutide is an analog. So it's a copy of a hormone that our body makes called GLP-1, glucagon-like peptide 1. This is a peptide, a hormone, just like insulin, but it's not made in our pancreas. It's made in our intestine. This is a hormone that is also secreted in response to carbohydrates. And this class of drug, and semaglutide was not the first of these, liraglutide, there are others that came out first, but these drugs are used also to treat people

with diabetes because they increase insulin sensitivity. And interestingly, they result in weight loss. So there is a drug out there called Ozempic, which was used to treat people with type 2 diabetes. And the observation was, wow, it's reducing their glucose levels. So their hemoglobin A1c is coming down, but they're losing weight. do a study and see what if we gave the drug at slightly different doses we'll call it a new name we'll call it wagovi instead of ozempic but same drug and can we just give it to people without diabetes and see if they lose weight and the answer was they do they lose a lot of weight so in about 2020 that paper was published and that led to what we've seen now, which is a pretty significant adoption of the use of that people, because I think so many people have seen maybe what they deem as success from a weight loss journey on this stuff. Obviously, there's a real application for people that need the medication for diabetes. What we've said, not being experts, is that you got to maybe be careful with this stuff if you weren't somebody who's necessarily needing it from a metabolic or

from a medical standpoint, because to your point, it suppresses appetite. But tell me if I'm wrong here. I thought I heard you mention one time that some of the things you had seen or some of the data or maybe even some of the patients was that the weight loss of muscle compared to fat was outweighing what a healthy weight loss journey should look like. Meaning, I think you said like normal weight loss is a fourth muscle and three-fourths fat. And then, and tell me if I'm wrong here. No, you're a hundred percent right. And unhealthy weight loss is maybe two-thirds muscle, one-third fat. And that's what you were seeing in some people or some studies. But you also, when you're talking to me, there's a little bit of a, to me and tell me, an undertone of like an indifference.

Like I can almost see that you, it seems like it's per case. Yeah, everything is, everything is. So to follow up on your point, we were very early adopters of the use of semaglutide in our practice. The first time we gave it, and by the way, I'd prescribed liraglutide to patients as early as 2014. The effects were modest, but better than other traditional appetite suppressants out there. And appetite suppressants have a long and sordid past within medicine. So we could spend a whole podcast just talking about the science of appetite suppression and the risks that have been often found with some of these drugs. But there was something different about semaglutide. It was truly the first of these

drugs that didn't, on its face, appear to have catastrophic consequences and had remarkable efficacy. So two things, it really, really worked and it didn't seem dangerous, at least in the short term. That was a big deal. You're right in that we think ideal weight loss is probably about 25% lean, 75% fat or better. If you can do 90, 10, no, that's even better than 75, but 50, 50 is not so great. You just don't want lean outweighing the- Not even that. I want fat to be at least three times the lean. Okay.

Now, again, if a person is morbidly obese and has plenty of lean mass and plenty of fat mass, you'd probably tolerate a higher amount. But the first thing we started noticing in patients on semaglutide was they were losing a lot of weight, but like half of it was muscle. So yeah, a person lost 20 pounds, but they lost 10 pounds of muscle and 10 pounds of fat. I don't have a great answer as to why, other than the appetite suppression seemed so profound that these patients had a hard time eating protein. Protein is a particularly satiating macronutrient. And so if you're not hungry at all, the last thing you want to do is force feed yourself protein. And we saw some other really

negative things that, again, I don't want to generalize, so I can only tell you what I saw in our patients. But we saw a lot of people drinking their way through semaglutide. With alcohol? Yeah. Alcohol, okay. Yeah, so they would just, they would sort of like, because let's be honest, like even if your appetite is suppressed, you're still pretty good having a margarita. You don't want to have a salad and a chicken breast, but you could probably down a couple margaritas if you're not, if you're feeling pretty good having a margarita. You don't want to have a salad and a chicken breast, but you could probably down a couple margaritas if you're feeling a bit nauseous.

And so we would see these patients and they're losing weight, but they're actually doing a transition of calories to alcohol. So again, the scale looks better, but they're not getting healthier. Or maybe even in some cases, they're feeling more confident. They're going out more. They're being more social. Sure. There's lots of potential reasons. So I think this just made us think even more and more critically about risk versus reward.

And to your point, there are absolutely people who benefit so much from this drug. Sure. Now, we don't really use it anymore. Truthfully, we use a newer drug called terzepatide. Manjaro is the trade name of it, but terzepatide is a keyboard on fire. Yeah. Looking this up. It's, it's actually a much better drug because it is both GLP one and another hormone GIP,

and it seems to produce better results and fewer side effects. And fewer side effects mean people can continue to sort of eat reasonably, meaning eat more protein. So I think we probably are weaning any patients that we have on semaglutide and putting them on terzepatide. And again, like if you're a patient who's really metabolically ill or really

overweight, and you've tried all these other things, I think these are, I think these are reasonable options. But I do, I do worry when I see people who are showing up to our practice who say, I got a wedding in six weeks. I got to lose 10 pounds. Like, put me on this drug. The iconic Jennifer Lopez has launched Delola Spritz. Okay.

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I was going to ask you from your perspective, and I guess maybe for people that don't have access to someone like yourself that are just kind of, because we know, I mean, there's a lot of people that are doing this stuff now. It's become very popular. What are the long-term worries that you have? And this could just be a generalization. Like if somebody is maybe not a pure health candidate that's doing it because they want to tighten up that 10 pounds or 20, what do you see as the long-term risk? That's part of the problem, Michael. I don't think we know. And that's the problem I have with really being able to tell my patients, like this is a lifelong strategy. And that's what I say to patients as well.

I'm like, look, I think there's probably a net benefit to you doing this in the short term. So let's give it a shot. Short term meaning? Let's, let's do this for a year. Oh,

basic. I mean, that's not like like you're not saying a month no but i think what i'm limited by is the duration of the studies right like you know we've seen patients on these drugs for a year for two years and then follow them for another couple of years and i say to patients if because the real question is let's just say it's a significant weight loss. So let's say it's a person who's got to lose 50 pounds. They're starting at 275. You're going to get them down to 225. What's the probability that you're going to lose that weight in a year? It's really high.

You're going to succeed. The real question is, what's the probability you're going to stay at that low weight when you stop the drug in a year? Have you seen anything after that people do stay at it or have you seen the opposite? Most people regain, it depends, anywhere from all of it to half of it. But we've seen some other weird things that definitely give us a bit of pause. We've seen patients that have enormous cravings that come back after. So there's a whole science here that's really just being explored. Andrew Huberman and I are going to be doing a podcast on this in a few weeks where we are going to look at the effect of GLP-1 inhibition on cravings because there was a really interesting article that came out by one of the three scientists

who discovered GLP-1. There were three scientists who discovered this hormone many years ago and one of them came out with a piece six months ago that said there's a real risk that people that go on these drugs are going to lose pleasure in food indefinitely like they're going to completely lose the ability to find pleasure in food so some people get more cravings and some people get less pleasure in food after they come off of it no the the people on it will lose cravings in food but that might be a permanent problem and then there's these other people who have a suppression of cravings that completely explodes when they are off the drug. So it could go either way.

Yeah. Basically the point is, at least to me, there's a whole lot we don't understand yet, and when you're dealing with uncertainty, you just have to, I think, decide, is this really worth the risk? Am I better off trying harder on these other ways to lose weight and improve my metabolic health? Or do I really have to take this chance and realize that, hey, in a year I might be sitting here saying, well, am I going to stay on this or am I going to go off it? And if I go off it,

am I going to gain everything back? And oh, by the way, three weeks ago, another paper just came out in the New England Journal of Medicine with a better drug than both of these drugs. This drug, it's almost comical. I'll be doing a podcast on this in two weeks. It's got GLP-1, GIP, and glucagon, yet another pancreatic hormone. In this study, the women lost 38% of their body weight. Jesus Christ. Can you think about that for a second? What's it called? Fuck.

It's got its sort of chemical name, which I forgot. It doesn't have a brand name yet because it's only finished its phase two. So it's going to be a while until that drug is out. Damn. I'm empathetic and understand why one would choose to do these things. Because I imagine if you're on that journey and you've been struggling and you're really wanting to have that aesthetic and lose that weight and you find something like this, it's really easy to take that in the now without weighing it against the future consequences,

especially right now when people are saying, hey, we just don't know. It's like, well, okay, they're going to get an immediate result on something that is so important to so many people, but also where there's a ton of pressure, right? Speaking of kind of in that category, not category, but similar for guys, TRT. What do you think about that? When do you think guys should start that? I mean, I think TRT is a topic we spend so much time in our practice dealing with hormones for both men and women. And we could certainly talk so much about that. The first thing I always want

patients to understand is both HRT for women, estrogen and progesterone and TRT for men are insanely safe if done correctly. But there's a lot of really, really bad, bad science, horrible press, and lazy, lazy, vestigial old thinking that has people believing, including a lot of doctors, that these things are harmful. So TRT absolutely categorically does not cause heart disease, does not cause prostate cancer, and HRT absolutely positively does not cause breast cancer. So just put that out there. Okay, with all that said, there is a ton of TRT abuse going on out there. There are a lot of doctors who have no business prescribing this to patients who have no business

receiving this. Endocrine management is complicated, and when you muck around with this system, you really need to know what you're doing because you can very quickly eliminate a guy's potential to make testosterone. And when you do that, especially what I see this, I don't, we don't have these patients in our practice because we don't have 25 year olds in our practice, but I, I see this outside of the practice. There are, there are guys out there in their twenties that are going to TRT clinics to get testosterone and it's not being explained to them that in a matter of a year or two, they're not going to be able to make their own, which has lifelong implications for their dependency on

the hormone, but also their ability to have kids. At some point, your fertility will be impacted heavily by this. When it comes to treating testosterone, you're really treating symptoms more than you're treating numbers. It's interesting that you say that. I was talking to Michael about this. A lot of people I know, a lot of women are coming to me to say that their husbands aren't having sex with them anymore. And I said to Michael, this surprises me because when I was, you know, in high school, I always heard the opposite. I always heard my wife won't fuck me. I hear the other way around. I don't know if it's because

I talk to a lot of men equally as women. So I don't know if it's just more women are more comfortable telling me this, but I'm hearing a lot of men are not having sex with their wives. Or maybe also because we're getting older and some of our friends are a couple older. Or is it because there's more estrogen in our food? What is going on? Well, I think libido is a very complicated topic and the hormone side of it is just one piece of it. And I actually have, I did two of the most interesting podcasts I've done in the past year are not hardcore science-y podcasts, which are a lot of mine, but it was a podcast with a woman named Sharon Parrish, who's one of the country's, if not the world's foremost experts

on women's sexual health issues. And a guy named Mo Cara, who is the equivalent on the male side. And so we went into so much depth on the female side about arousal, orgasm, all sexual function in women and men. And it turns out that there are a lot of things at play here. And testosterone is clearly one of them, both for men and women. In fact, testosterone replacement in women is a very important part of treating low desire. Also, depending on how you administer it, or for women at least, difficulty achieving orgasm. So as an example, women with low arousal respond very well to intranasal testosterone. So there's an intranasal spray that for women is really potent. And because it's a nasal spray, it hits the brain very quickly and they have a very quick response to libido.

An intravaginal spray of testosterone increases orgasm. So again, very complicated. With men, it seems to be much more based on systemic testosterone levels. But again, I think, you know, I could come up with explanations like stress. It could be in a higher stress. If men are more stressed, they're certainly less interested in having sex. Same is probably two of women. If men are more distracted, they're probably less interested in having sex. If they're stressed, they need to have sex. Sure. Sure. Every time he's looking for the

saber tooth i'm like all right let's go in the bathroom kids are popping out of nowhere so we're gonna get creative these days no but i i i do i agree with you i think that she's hearing these issues from the lens of maybe some people that are frustrated but i i don't think there's a one size like do this one thing and it solves it i think that there's for each individual many different things that could yeah and sometimes testosterone is a big part of the answer but but what we look for is low levels of testosterone coupled with some semblance of what the symptoms are so symptoms are low libido, low motivation, low energy, low mood. Is age a factor? Well, age will typically factor into the level of testosterone, which does decline with age for

sure. Peaks at about 18 to 25, and then it's basically a downhill train from there. And then of course, difficulty putting on muscle mass, insulin resistance, by the way, testosterone administration improves insulin sensitivity. And so if you see the cluster of symptoms with the biochemical findings, then we would like to treat that. on and we're friends with him for a while and he was talking about TRT and how he's implemented, but he was saying the same thing you're saying, which is a lot of young guys start abusing this stuff without the right clinical supervision or doctor supervision too early. And then it becomes this lifelong problem for them where he was saying he started doing it later in life and now manages it with a physician and it's been a game changer for him. He looks amazing. Yeah. But I think there's a lot of people that just don't have the knowledge or they go, oh, my tea's off.

So I'm going to go and jump on this stuff. And they don't have the longstanding understanding of what that effect will be over the years. Yeah. I mean, look, I've been saying to my wife, like, I think now that I'm 50, I'm kind of ready to start thinking about it because I've always had pretty low levels of T. This is super nerdy and maybe more nerdy than people care to hear, but the problem is actually way more complicated than just the testosterone level, right? So testosterone is a really complicated hormone that works only when it gets into a cell and binds to something called the androgen receptor. So think about it again. You have another one of these baseball mitts in the cell. Testosterone is the hormone. It has to get into

the cell, bind to the androgen receptor. That new thing, which is a new complex, the testosterone bound to the androgen receptor, has to then migrate into the nucleus of this cell where it acts as what's called a transcription factor which tells genes to start making proteins that's what testosterone does we have no idea when i check your blood i don't know how many androgen receptors you have so if you have a low level of t but you have a low number of androgen receptors it might be that giving you more t doesn't do anything interesting conversely you could have a modest tea, but lots of androgen receptors,

and you would actually benefit from more testosterone to fully saturate those. So I always tell patients, we don't know what's going to happen until we do it sometimes. You have to be a little bit empirical. But do you think a good, maybe like a rough age range is 50 plus? I mean, I have lots of patients younger than me who were on trt and we also sometimes use another hormone called hcg which is an analog of luteinizing hormone

that at least preserves testicular function so you you give them this hormone and it tells it has their body make the testosterone so that there are some workarounds here if you're doing it in younger people and we have people who are you know 50 and 60 who are on nothing so it's it's always a case by case basis and i i just think that like the moment you start doing paint by numbers in medicine you're host you're just you're just practicing veterinary medicine before we go I have to ask you about NAD. What are your thoughts on it? Again, I think that the evidence for the administration of NAD as a life-boosting molecule is non-existent. So the story of NAD, like why is everybody talking about it? The story is, well, as we age, NAD levels go down. So that's true.

That's a well-established fact. And so the thinking is, well, if you take something that's going down as a person ages, do you undo aging? That doesn't appear to be the case. So, for example, testosterone goes down as you age, giving more testosterone makes you feel better. It's not clear that it reverses aging in any meaningful way. Although maybe it might offset some of the downside of aging, but it doesn't appear to be the case with NAD because NAD can't be taken orally. It's only something you can do in an IV.

There's obviously some impediments to that. So what instead is being done more commonly is using oral precursors to NAD. One's called NR, one is called NMN. Do they ban NMN? Or do they... You know, I think that one of the companies that made it filed some shady lawsuit against another one to ban it such that they could be the only ones that could make it because they had a slight variation on it. I mean, it's just a total bunch of nonsense. And look, the truth of it is any clinical study that's been done on these has either demonstrated no benefit whatsoever or basically the types of benefits that I think require a little bit of winking and statistical chicanery. I think it remains to be seen. My guess is there is an

application for which increasing NAD, either through intravenous NAD administration or using these oral precursors, could be beneficial. Again, that's not an impossibility, but is it going to be the elixir of life? I'd say no chance. So when it comes to, and this is the last thing I know because we're up on time here, supplementation. And again, you're going to look at everybody's levels and it's going to be different for everybody, but are there certain go-to supplements in your routine or your patient's routine that you're like hey there's clear benefit to taking these few things on a weekly basis we don't have a list for everyone but i do think like

most people are not eating enough fish to get sufficient epa and dha meaning what you don't like fish or you don't like taking those big ass capsules eating enough fish to get sufficient EPA and DHA. Meaning what? You don't like fish or you don't like taking those big ass capsules. I'll take the capsules. But I've also heard some of the- Is there a brand that you like? Yeah, I like Carlson's. No affiliation.

Okay. So not enough fish, not enough omega, vitamin D like- Vitamin D is a funny one because I don't think it's been studied correctly, but we do like to see everybody's vitamin D level kind of between about 40 and 80. And so for a lot of people that does require supplementation. I think almost everybody is deficient in magnesium. So we, you know, most of our patients are supplementing at least two different forms of magnesium. For me, you know, when it comes to sleep, I'm obsessed with a couple supplements. So I really like using glycine.

I love glycine. And I like something called ashwagandha and I use something called magnesium L3 and A. So it's even a third form of magnesium I take. So those things are part of my sort of sleep cocktail. And then, yeah, and then everything else is very specific. So sometimes you're correcting a deficit. So, you know, people are low methylators. You'll give them methylated B vitamins. In some of our higher risk dementia patients, we kind of have some other supplements that we kind of go down the rabbit hole on. Peter, you are a wealth of knowledge. You are welcome back on this podcast anytime, like literally open invite. i'd love to have you and your wife get your little desk out there honestly you and your wife should come on we should do him and her

i am just so excited you came on tell everyone where they can follow you find your book everyone should go buy his book it's incredible incredible book pimp yourself out thank you so much well it took him seven years yeah that's right that's Seven years. I'll be back for the next one. Peter Attia MD is the Instagram handle and Peter Attia MD is our website and earlymedical.com is where you'll find the most interesting information. Thank you so much for coming on and go listen to your podcast. That's right. The Drive. How did I forget to plug that?

I will be listening to a bunch of different episodes that I feel like you referenced. This is amazing podcast. Thanks, Peter. Thank you guys.