WHOOP Podcast - Panos Papadiamantis, Co-Founder of PNOE, the world’s first portable cardio-metabolic analyzer, on what it does, why it can benefit everyone, and how it'll calibrate with WHOOP.

Episode Date: November 5, 2019

PNOE Co-Founder Panos Papadiamantis explains what cardio-metabolic analysis is (3:56), how PNOE works (7:21), mechanical efficiency when it comes to burning calories (11:03), why people often gain back weight they lose (14:16), when and how to combat caloric efficiency (22:24), why all calories are equal when it comes to weight loss (24:51), how PNOE knows how many calories you should consume each day (31:43), what PNOE and WHOOP can do together (32:43), detecting cardiovascular disease (36:24), assessing your posture (43:45), a "one-stop shop" for everything (45:28), training yourself to breath better (46:42), and why VO2 max is "just the tip of the iceberg" (55:46).Support the showFollow WHOOP: www.whoop.com Trial WHOOP for Free Instagram TikTok YouTube X Facebook LinkedIn Follow Will Ahmed: Instagram X LinkedIn Follow Kristen Holmes: Instagram LinkedIn Follow Emily Capodilupo: LinkedIn

We discovered that there were secrets that your body was trying to tell you that could really help you optimize performance, but no one could monitor those things. And that's when we set out to build the technology that we thought could really change the world. Welcome to the Whoop podcast. I'm your host, Will Ahmed, founder and CEO of Whoop, where we are on a mission to unlock human performance. Our clients range from the best professional athletes in the world, to Navy SEALs, to fitness enthusiasts, to Fortune 500 CEOs and executives. The common thread among WOOP members is a passion to improve.

What does it take to optimize performance for athletes, for humans, really anyone? And now that we've just launched all-new Woopstrap 3.0 featuring WOOP Live, which takes real-time training and recovery analysis to the next level, you're going to hear how many of these users are optimizing their body with whoop and with other things in their life. On this podcast, we dig deeper. We interview experts. We interview industry leaders across sports, data, technology, physiology, athletic achievement, you name it. How can you use data to improve your body? What should you change about your life? My hope is that you'll leave these conversations with some new ideas and a greater passion for performance. With that in mind, I welcome you to the

Woop Podcast. So the beauty of this assessment is that you just need 10 minutes on a treadmill to get all of the information you need to build a diet plan, all of the information you need to get a workout plan, but also screen for all the conditions that account for roughly 90% of healthcare expenses today. And you can do that using just a treadmill. Hello, folks. My guest today is Panos Papa Diomantes, co-founder of Panoi, maker of the world's first portable cardiometabolic analyzer. Basically, it's a mask that you wear for a 10-minute

test on a treadmill, and for analyzing your breath, you gain incredible insights into your health and fitness. We've got a couple of these in the whoop office. They are very cool. Panos and I discuss exactly what cardiometabolic analysis is and how Panoi is making it available to everyone, the concept of caloric efficiency, what it means for endurance athletes, as well as people who are trying to lose weight, and other things cardiometabolic analysis can do for you beyond determining how many calories you should be consuming each day, including your heart rate training zones, testing the efficiency of your breathing, checking for risks of heart disease and even examining the quality of your posture.

We've gotten a lot of feedback on calories at Whoop and we've been investigating everything about the science of tracking calories at Whoop. We're excited to be partnering with Panoi to have the opportunity to provide our members the most accurate data available in the future. Without further ado, here's Panos. All right, Panos.

Thanks for coming on the Whoop podcast. It's great to be here. Thanks so much. So we are recording this in Boston in the Woop headquarters. We're very excited to have Pnoe and Woop as partners. And I think the technology you've built is really fascinating. This is a space that people talk about all the time around calorie expenditure, cardiometabolic analysis.

And I have a feeling that most people actually don't know what the hell they're talking about. And I have a feeling that you also really do know what you're talking about. So I'm excited to dive into it. Let's start by, just to summarize quickly, what is Panoi doing? Cool, yeah. So Panoi is a cardiometabolic analyzer. So let me just start by explaining what cardiometabolic analysis is. Cardiomatabolic analyzer is a device that analyzes your breath.

It analyzes how much oxygen your body is consuming, how much carbon dioxide it is producing, along with 12 other biomarkers in your breath. And based on that analysis, it scans the three most important physiological systems in your body. Your metabolism, your heart function, and your pulmonary function. In simple words, cardiometabolic analysis will tell you in the most efficient and accurate way how your metabolism is working. That is how many calories you're burning, how many fats you're burning, how many carbohydrates you're burning. it can also tell you if you have a cardiovascular disease and can also tell you of a respiratory disease it is what elite athletes use as the basis for developing diet plans and workout plans and it's also a very valuable tool in the world of a cardiologist or a pulmonary expert

and so the question that most people have at this point is okay if this is such a foundational assessment that is so important and so holistic why isn't everyone doing it? Right. And the question, and the answer to that question is actually simple. First of all, until today, cardiometabolic analyzers were very expensive. You needed to spend anywhere between $40,000 and $60,000 to buy a clinical-grade cardiometabolic analyzer.

Until you guys came along. Until we, exactly, until we came along. Also, they were pretty big. Right. You needed a cart to move them around, and that's why a lot of people are familiar with term metabolic cart yeah it comes from the fact that you actually needed a cart right to move the device around uh they were very difficult to operate like a lot of training required uh by the practitioners and then probably most importantly no device until the day was uh providing the practitioner with

any sort of support in translating data from raw cardio metabolic information into actionable diet and workout recommendations or diagnosis. And that brings me to my next point, which is why is Pneau unique? In Pneaui, we've built the world's first cardiometabolic analyzer, that is 10x cheaper compared to competition, but still delivers medical grade accuracy. It is portable enough that you can put in a backpack and take it anywhere you go and test outside.

Simple to use that you only need a smartphone to operate it, And then most importantly, it comes with a data interpretation service that allows any practitioner in the clinical or fitness world to translate cardiometabolic data and acquire diet and workout recommendations without the skills or time needed to analyze cardiometabolic information, which, by the way, is notorious in the clinical world for being probably one of the most intricate data sets to analyze. So that's a summary of what cardio metabolic analysis and why spinole is unique. And paint a picture for our audience. Like what does this look like when you're using it? Sure. So you're basically exercising on a treadmill with a mask connected on your face. We're basically analyzing all of the gas exchange that is happening in your body through your mouth and nose.

and we're analyzing how much oxygen you're consuming, how much carbon dioxide you're producing, your breathing frequency, your tidal volume, and many, many other things, on a breath by breath basis. That means on every breath cycle. The test is a 10-minute test of increasing intensity. You get on a treadmill or a stationary bicycle. You wear the mask, and then intensity increases. until either you reach a specific point, that's the so-called sub-maximal test, or you go into your maximum, like until failure, which is the maximal test.

So this is how, what the cardiometabolic test looks like. So explain the maximal test in a little more detail. I've seen this happening in our office now quite a bit. Yeah. So maximal test is basically continuing to increase the intensity until the person just can't go anymore. So if you're on a treadmill, you're starting at a certain, mile per hour and at what cadence are you increasing that so now we're going into the discussion around the protocol yeah and there are a couple of different protocols that you can follow if you're doing

a cardiometabolic test there is the so-called ramp test where you're increasing intensity every 30 seconds or every 60 seconds the amount by which you're increasing the intensity depends on the fitness level of the person so there are recommendations you know based on how fit you are how rapidly you should be increasing the intensity. So that's one type of testing, the ramp testing. And then there's the step test or metabolic efficiency test where you're basically keeping the person at a specific intensity for longer periods of time.

So maybe five or seven minutes per step. And there's different things that we analyze in both tests. Okay. So let's break that down. In a test where you're going, you're just increasing, right? What are some of the key readouts that Panoi is going to provide to a user? So what we basically determine through a ramp test are the so-called thresholds in a person's physiology. So you get the VT1 and VT2, first and second ventilatory thresholds.

These are the thresholds that we use in order to develop training zones for a person. and these are the thresholds that ultimately become the basis for a person's cardiovascular training. On the other hand, when you're doing the step test, you are actually able to measure a person's substrate utilization. That means what is the fuel consumption of the person in terms of caloric expenditure in different intensities, but also what is the substrate that the person is using at these different intensities. That means what is the breakdown between fats and carbohydrates in different intensities? So for example, if you have a triathlete that wants to understand how many carbohydrates his body is using at different intensities in order to pace his nutrition

during the race, he would need to do a step test and measure his substrate utilization in different intensities. Another incredibly important metric, that you can measure through a step test is the so-called mechanical efficiency. Mechanical efficiency is the ratio between your mechanical power output over your metabolic power output. So think, for example, your car, right? Your car is transforming energy, which is found in a chemical form and the gas you put in, into mechanical propulsion.

Mechanical propulsion is basically movement going from point A to point B. pretty much the same concept applies in the human body, right? Because you have energy found in chemical form in the nutrients that you consume, basically the fats and carbohydrates that you have in your body. You're burning that fuel, and you're burning that fuel in order to generate energy that will lead your body to go from point A to point B. So you can measure your mechanical propulsion. If you're on a bicycle, for example, you actually measure the watts.

that's mechanical propulsion. Sure. You can use a device in order to measure power output when you're running. And so that is the numerator of your ratio. And then in the denominator, what you have is the energy expenditure, the amount of chemical energy that your body used in order to generate that amount of mechanical propulsion. So you want to generate as much power as you can with the least cost. Is that one way to think about it?

and that depends on who you're talking to. And that brings me to a very important, to the very important point about mechanical efficiency. So if you're talking, if you're talking to an athlete, any type of athlete, especially an endurance athlete, you are correct. You want to be as efficient as possible. Why?

Because you want to get as much movement as possible for the least amount of energy consumption. Now, would the test potentially jeopardize the readout here? So a runner, for example, is going to be much more mechanically efficient at running than, say, if you got a cyclist and put them on a treadmill. Absolutely. So that's where... Form is an incredibly big contributor. So if you did this test for, let's say, two people who have the same exact mechanical efficiency, right? But they happen to be doing protocols in a case where one person's doing something that they're less comfortable with.

That is going to be an incredibly big contributor. So one takeaway here is if you're if you're doing the Panoi test, you want to make sure you're doing a protocol that you're pretty familiar with, right? Is that fair to say? Absolutely. And obviously if you're a triathlet, then you're doing both running and cycling. You want to measure how your body is responding in both circumstances because you might be. Yeah. Yeah. So as I said, in the case of an athlete, yes, you're looking at efficiency and you want to maximize efficiency. Now, mechanical efficiency so again just to just to confirm that for audience here right you want to make sure you want to have a high ratio exactly you want the the power to the expenditure to be high exactly right what's an example where you where you actually might not want it to be high so let's take weight loss for example okay and the reality is that there are several recent studies that came to light very recently that show that mechanical efficiency is actually one of the biggest reasons why

most people can't lose weight. So when... Isn't that interesting? Yeah. When our body goes into a state of caloric restriction, basically cutting calories on a daily basis, and you combine that with excessive amounts of cardio, what's going to happen to your muscular efficiency is going to go up.

What that means is that every step that you take is going to burn fewer calories. So think that initially, before you went on a weight loss intervention, you were burning one calorie per step that's actually a lot but you know let's let's make up the numbers okay and then you go on a three-month diet which is pretty intense and afterwards you're burning 0.8 calories per step interesting that means your efficiency went up is that something that you want absolutely not right and uh there are several studies that have shown that the reason why most people can't lose weight is not because they have some sort of pathological lack of willpower to

maintain discipline, it's because their efficiency went up. As a result, they are not burning as many calories as they used to. As a result, the caloric deficit that they're implementing today in their lives is not enough in order to lead to further weight loss. We actually just yesterday put out a blog post about the biggest loser. Are you familiar with the show? Yeah, yeah. Okay, so participants underwent a very intense weight loss intervention like crash diets they cut calories by you know crazy amounts and they were able to shed incredible incredible amounts of weight during the program however nearly everyone regained the weight after the show and that sparked the interest of of scientists who looked at their metabolism and they actually found out that because of the acute nature of the intervention, people were burning significantly fewer calories compared to what it was expected for their size, gender, and age. And as a result, for these people now, eating normally means weight gain because their metabolism

has dropped. They're burning fewer calories for everything that they do. In order to maintain their weight, they need to be always eating significantly less. they need to be restricting that they're eating and in order for them to lose weight they need to go into absurdly low levels of coloric intake which is almost impossible so efficiency is an incredibly important thing that's so cool both for an athlete and for someone who wants to lose weight and this is the real value of metabolic analysis and weight loss understanding

if the type of intervention you're doing for example the type of workout that you're doing in combination type of diet that you're doing is actually leading your body to metabolic adaptations that you don't want to have there because what's very important is that which was actually shown in the biggest loser

study that was done after the show and has also been shown in several other peer-reviewed articles is that these metabolic adaptations are long-lasting and very hard to undo so once you get your body into a state of reduced caloric expenditure, that's not going to go away easily. And even if you regain weight, still, in many cases, your metabolism will remain in a dormant

state. There's so many interesting ways to take that. So let's start just with this idea that if you're trying to lose weight, you actually want to not be calorie efficient. Absolutely. That as a core concept seems pretty fundamental. I bet you if you talk to most people who are trying to lose weight, they're not aware of that.

Yeah, yeah, yeah. Because it actually doesn't, it doesn't sound that good. Yeah, yeah. You want to be inefficient. Yeah, I'm also thinking about different, you know, different athletes who you can obviously tell are on one side of the spectrum or the other. I forget the, Mark, what was the boxer's name, the really heavyset guy? Yeah, look that up.

So there was this boxer, and Mark's going to pull the name of it. I mean, if you look at this guy, he just did not. look like a professional boxer and he got subbed in last minute to fight the heavyweight champion and he won and on one side you've got this guy who's 250 pounds of just sheer muscle and on the other side of it you Andy Ruiz so Andy Ruiz and who did he beat remind me but it was it was pretty amazing because so this guy Andy Andy Ruiz I mean I've never seen a boxer who looked like this he looked like a contestant on the biggest loser honestly and he yet he beats this guy who you know his sheer muscle in in boxing yeah

andy reese beats anthony joshua andrews is this guy who's like doesn't look fit at all uh anthony joshua's all muscle heavyweight champion and loses and that's probably an example where you have a guy who's a really talented athlete but uh andy ruse but did he blow up his calorie inefficient right I mean, that could be one factor that led to him losing. No, no, so this guy won? No, I mean, I'm talking about the person who lost. Oh, sure. Yeah, so he's very calorie efficient, right?

If you have an athlete who's super cut and, you know, four or five percent body fat or whatever, isn't it highly likely that you are calorie efficient or not? Not necessarily. So you might be low in body fat, but you might be because body fat is, determined by several other factors, but still as a person, your muscles might be both inefficient or efficient. It's not a direct correlation there. But to answer your question about athletes who are unexpectedly efficient or inefficient, we see that every day. For example, I think CrossFit is probably the most interesting case because it's a sport

where people have traditionally focused on doing excessive amounts of very explosive movements, excessive amounts of weightlifting, which will lead a person to be more of a type 2 muscle fiber person, and that makes you more inefficient. And they usually tend to overlook and neglect the amount of cardiovascular and low-intensity training that they should be doing, which will ultimately lead you to become more efficient. And so you can have both worlds in a specific. Caloric inefficiency that's going to lead towards you burning more calories to do the same amount of work.

Correct. Yeah. Which for someone who's trying to get really cut or bodybuild or, you know, the vanity look, is actually a good thing. It's actually a good thing, but it might not be a good thing if you want to win the race. Right. Yeah. Yeah, by the way, you don't hear people talk about this stuff all that often, which I mean, this to me seems so fundamental.

It's the most fundamental thing. If anyone wants to look that up, it's the concept of adaptive thermogenesis. This is the scientific term. And we'll include some show notes on that. Yeah. So basically, it's the concept of how efficient your body is in transforming energy found in chemical form into mechanical form into mechanical. electrical propulsion, which is what we do all day, every day. Yeah, it's pretty fundamental.

Yeah. Okay, so the next question, I just want to focus on this concept of caloric efficiency for a second. Let's say that you do the Pneaui test and you find out that you're caloric, you're caloric efficient, right? And you want to lose weight. And you want to lose weight. Oh, what do I do about it?

How do you change that? So there's a couple of things which are. important when it comes to driving efficiency so um and you know it helps a lot to see that from the perspective of a person that ended up being efficient so literature has shown that uh what's going to lead to increased efficiency is uh caloric restriction so people that have been restricting uh their diet have tried to lose weight multiple times and haven't been able to do so uh tend to be more efficient also excessive amounts of cardio training without complementing it with the adequate amount of strength training will also lead you to be more efficient and so in our sorry just to spend a second on

that if you if you let's say run and cycle a lot yeah but you never weight lift you will most likely be efficient because your body is getting trained to conduct a movement which is perpetual takes place over long periods of time right and is it's more aerobic and as a result it will try to adapt to that type of movement right and in that case you're actually training your body not to to lose weight as quickly correct and yeah ultimately this is what happened for so so for someone listening who only does cardio sports yeah right one learning from this and by the way you're trying to lose weight yeah yeah yeah yeah you only do cardio sports uh or activities and you're trying to lose weight maybe introduce weightlifting absolutely what what i always like

to say is that at the end of the day weight loss starts under the squad rack because love that yeah it's it's it's it's basically where we build the muscle mass which and and and the low efficiency that is required yeah right for our body to be burning calories uh on a daily basis throughout the day at a significant level okay and that's why you see that every sustainable weight loss intervention has some sort of weightlifting component in it, which is pretty substantial. Now, what about the diet side of this, right? We know that all calories aren't created equal. What do you mean by that? Because that's that, that's a, that's a controversial statement. Well, okay. If you talk to someone who's on the keto diet, for example, they'll tell you the

fact that they ate nothing but meat and vegetables today and I had a bagel with my you know eggs and bacon means that even though we consume the same calories those calories are going to have a a different effect on my body now I want to be clear I know very little about nutrition and I'm not I'm not endorsing any diets or the keto diet but like that's what they would they would say so yeah what's your rebuttal to that which I imagine is a good one yes so it's not a personal rebuttal I I would direct these people to a very recent study that was done at Stanford, which basically aimed to clear the misinformation that exists in the debate between the different types of diets. They actually took people on a low-carb diet.

They divided their group into two categories. One group went to, they went ahead and did a low-carb diet. The other group did a high-fat diet. And what ended up happening was that both groups ended up losing pretty much the same amount of weight. Calories are equal in the sense that if you create a caloric deficit of a specific amount, then your body is going to lose pretty much the same amount of weight. What is better for you? That is a much broader question.

it has to do with your psychological adherence to a diet you might prefer to be eating more carbs than less carbs and there are so many other factors that come into play but when it comes to judging how much weight you're going to lose it is only a matter of how many calories went in and how many calories went out and would you and and that's it remains true no matter what your activities are obviously activity is very relevant because as I said it's all a matter of calories in versus calories out so how many calories you're ingesting versus how many calories you're burning activity oh understood I just I mean to be very very clear about it right like if you if you consume nothing but ice cream versus nothing but meat just to frame this in a very extreme way And you do the same exact activities in each case. You're saying you'll have the same net weight loss. Now, we obviously go into the specifics of how much protein you're eating.

And as a result, what is your ability to maintain muscle mass during the intervention? But provided that you're consuming the right amounts of micronutrients and the right macros in the diet in order to sustain a health. healthy state, then you should obviously lose the same amount of weight in both cases. So it sounds like you're probably someone who's skeptical of all these different diets that are out there. Oh, absolutely. And it's not a matter of being personally skeptical. As I said, it has been proven.

There is no debate around that anymore. I mean, obviously, there's a big reason for a lot of people out there to be. advertising and advocating for a specific diet because they have some sort of financial interest. But at the end of the day, people should know that it has been proven that a low-carb diet versus a low-fat diet, provided, of course, that we are within reasonable boundaries of macronutrients, will pretty much yield the same weight loss result. Got it. And what do you think of intermittent fasting?

Intimidant fasting is more of a psychological strategy. In the sense that, you know, again, the principal idea in losing weight is creating a caloric deficit during the day. So you've got to figure out a way to cut calories. Yeah. And what has worked for a lot of people is that if they skip a meal, they end up consuming less calories. There is some literature out there that suggests that staying in a fasted state has. as specific health benefits, but, you know, but you're skeptical. But obviously, like to make a solid statement around such things, you need to do so much studying

and there has to be so many review meta-analysis studies in order to be sure around a specific statement that I think what's fair to say at this point is that intermittent fasting for some people is a great psychological strategy to cut calories. Do I like doing it? Yeah, absolutely. You know, sometimes. You personally do it. Sometimes, yes.

Because sometimes I wake up and I want to do some cardio activity in the morning. And it just doesn't suit me well to have yogurt with oats. However, there are cases where I weight train in the morning. And I need to fuel up before I go and I lift heavy. So in these cases, it makes tons of sense to eat. Another important piece of information is that there was, some recent research that came to light that shows that it actually makes a lot of, it's actually pretty valuable for people who are older to be eating protein before they go to bed

and right after they wake up because during sleep is when we shed most of the muscle that we've built because our body goes into a negative, but basically, it's the muscle deterioration process, the muscle deterioration window, if you like. And so there was some research that showed that it's actually valuable in some cases to be eating protein before you go to bed and right after you wake up. So there's pretty much a lot of debate around, you know, what's good and what's bad. But at the end of the day, the key drivers in someone's ability to lose weight or attain better performance is actually, you know, getting the basics right, which is eating the right

amount of calories, eating the right macronutrient distribution, and then obviously doing the right type of training. Now, how would Nipanoi tell you that you should eat a certain number of calories in a day? So we measure your basic metabolic rate, and then we also measure your caloric expenditure in different states of activity. sure and that's how we can uh very accurately tell you how many calories you should be eating now the uh interesting how many calories should you eat a day personally yeah uh i'm around 2.5 and 2.6000 calories the days that i so 2 500 to 2,600 correct yeah and does that and for you when you when you say

that that's like to stay even yeah correct yeah right you're not trying to gain way you're not trying Correct, yeah. If I want to go on a mild weight loss process, I would need to drop down to around 2,000 calories, 2,000 to 2100. And yeah, but again, the very interesting application, which a lot of people have looked into is, you know, how you can actually calibrate a wearable based on Panoi information. And... Well, that's a good whoop tie-in right there. Yes, exactly. So Obviously, you can imagine that I can test you with a cardio metabolic analyzer and I can see how many calories you're burning in different intensities, but then I don't know exactly what is happening during the day because you might be engaging in different types of activity and

different level of activity throughout the day. And the only way to keep track of that is by using some sort of wearable device, some sort of activity tracker. And the reality is that activity trackers today do provide you with an estimation of your calories. However, that estimation is not very accurate. There was a recent study done at Stanford again, which basically measured the accuracy of commercially available wearables when it comes to measuring calories. Well, I think wearables are wildly inaccurate, obviously, as someone who's been developing one, you know, part of what we pride ourselves on here is being really accurate. And so I think what we're excited about in partnering with Panoi is how we can potentially

provide an additional service for WOOP members to get calibrated with the PNOI technology. Correct, yeah. And then in turn, have their WOOP calorie analysis be that much more accurate, that much more prescriptive. Absolutely. And I think this is where this is the great window of opportunity for cardiometabolic analysis to become a truly impactful source of information for the everyday person. Yep.

No, I completely agree. So explain to people how Whoop and Panoi are going to be able to use this together. So the whole idea is that you were whoop when you're doing the Pnewee test. and uh well hopefully you wear who 24 seven but no no no yeah yeah exactly exactly so so it's so you calibrate your whoop when you're doing the plnoi test yes exactly by uh basically measuring uh how your body is responding from a cardiometabolic perspective when you're wearing and then at the same time uh whoop is recording your movement and your heart rate data and by emerging the two data streams were actually able to calibrate

whoop based on your personal cardio metabolic profile. Yeah, and I'm set up to do this, I think, next week or in a couple of weeks. I'm excited to do it personally. Yeah. You know, I think what you've built is really, really amazing. And for us, you know, we're always on the lookout for other technology that is super accurate. It comes from a position of research and science, which obviously yours does. I mean, the way you talk about this stuff is obviously very informed.

And the reality is there's just a lot of stuff out there that's not grounded at all in science. It's not grounded in research. It's snake oil. And it's selling, you know, I think it's selling something that's maybe easy to explain, but is not actually going to help people improve their lives or, you know, achieve their goals. So this idea that by better understanding your breath, which is really, I think, the core of Pinoi, you can you can unlock these secrets about caloric expenditure and efficiency and uh i mean we haven't gotten into a couple of the other pieces too right cardiovascular disease detection yeah so how will

that work so um first of all cardiovascular disease the most expensive uh disease in the states and the developed world also claims it only kills like 30% of america yeah yeah yeah yeah And it's really probably, yeah, it's, it's, it's the most expensive and the most deadly disease, not just in the States and the developed world in general. You're, as I said, much more likely to die of cardiovascular disease than you are to die of cancer, you know, pretty much any other thing. And so how does the, how will the test signal that that you may be at risk? So here's the deal. 85% of cases of cardiovascular disease are categorized as is hemeic heart disease.

Eschemic heart disease is basically there's a blockage in one of the arteries of the heart, which ultimately leads to a heart attack. We get heart attacks because there's a blockage in the heart. And so there comes the question, how do we actually scan for cardiovascular disease? How do we actually scan for eschemic heart disease? And there are a couple of methods that are known to science at this point. What most people are familiar with is ECG stress test. which is basically you go on the treadmill much like you would do with

pnowy but instead of wearing the mask you have these electrodes which are connected on your chest and what we measure with this is the electrical signal of the heart as intensity increases the big problem with ECG is that it's 50% accurate so sensitivity and specificity is 50% approximately that means that you might have a blockage in the heart and it's a coin flip whether the system is going to pick it up And as a result, there are official statements by health organizations that say that it doesn't really make sense to be screening people with ECG. And the other method that is widely used is nuclear imaging.

This is the so-called nuclear stress testing. It is much more accurate, has sensitivity of approximately 90%. But the big problem there is that we're talking about an assessment that calls. costs around $5,000, they will inject you with radiation, and as a result, there is a likelihood of developing cancer because of the examination. And in general, it's a very intricate and expensive and difficult examination. And obviously, you have some other methods like ultrasound, which require a special doctor to monitor the exam. So if you look at the current spectrum of available, technologies and methods, they all have significant drawbacks. Either they're very difficult or expensive

or they are inaccurate in the case of ACG. Now, the only assessment that has been shown to have sensitivity very close to that of nuclear stress testing and is easy to conduct is cardiometabolic analysis. And that is why there's a very huge strand today in Europe where cardiologists are using cardiometabolic testing more and more in order to detect eschemic heart disease. The reason why it hasn't picked up in the States, unfortunately, is because of how the healthcare system is structured. It's all about reimbursement in the United States. And because a hospital is going to get reimbursed $5,000 for nuclear stress testing versus $200 for cardiac testing, it's pretty much a no-brainer. Yeah, it's the wrong incentive. Exactly, exactly. But on the

other side of the Atlantic, cardiac, cardiometabolic testing has gained a lot of traction when it comes to... So in the actual test, what shows up? So what we're looking at when we're screening for a systemic heart disease is basically your VO2 in relationship with work rate. So how your oxygen consumption is increasing as your mechanical power output on a cycle or agometer on a stationary bicycle is increasing. think that the

the job of your heart is to pump oxygen-rich blood to the working muscles, right? Yep. If there is a blockage in the heart, the heart is a muscle. If there is a blockage in the heart, after a certain point,

the heart will not get enough blood. As a result, it will not be able to perform its work, its job of providing your muscles with oxygen-rich blood. So what's going to happen is that intensity on the bicycle is going to go up

because that thing is programmed to, you know, increase intensity every one minute or every 30 seconds. But after a certain point, when ischemia, basically provision of blood and the heart stops, that your oxygen uptake is going to drop or plateau. That's one indication. The other indication that will have to happen concurrently is your so-called O2 pulse. This is how much oxygen you're consuming per heartbeat will also. plateau or drop. Combined these two indicators with certain other biomarkers, which are a little bit more complicated for this discussion, can detect ischemic heart disease with roughly 90% sensitivity.

Now, the other very important application of cardiometabolic analysis is the so-called differential diagnosis in the case of chest pain. So chest pain is one of the most frequent symptoms in primary care, not just in the United States, in the developed world in general. So people show up in primary care with chest pain. And because most doctors are familiar with ECG stress testing, they're going to put you on the ECG, they're going to most likely not detect anything wrong with your heart, and they're going to send you back home, when in fact you might have a cardiovascular problem or you might have a pulmonary problem. So the absolute goal standard for triaging between cardiovascular or pulmonary limitations in people that

show up with chest pain and angina is cardiometabolic analysis. So the beauty of this assessment is that you just need 10 minutes on a treadmill to get all of the information you need to build a diet plan, all of the information you need to get a workout plan, but also screen for all the conditions that account for roughly 90% of health care expenses today. And you can do that using just a treadmill it's pretty amazing man yeah i mean i think the other thing that you know is a takeaway for me in this conversation is just how important breathing is yeah right yeah like your breath yeah it to me it doesn't seem like something that you know when people talk about health they're often talking about buckets of like exercise and activity and sleep and nutrition and you know maybe

there's a couple other things, but people don't often add breath to that list of things. And it's so fundamental, isn't it? It is. It is. And the other very interesting application that is starting to pick up for us is posture assessment. Oh, interesting. Yeah. So if you think about it, like, chiropractice. Cell phones are ruining posture. I know, I know, I know. I don't think people fully appreciate how, like, much worse our generation's posture might be than other generations. Yeah, because you see people pivoted forwards staring at their cell phone.

Yeah. But, you know, when it comes to lower back pain and meoskeletal problems and body imbalances, breath is actually a very, very important indicator because efficient breathing means good bowel control, means engagement of your abdomen, and as a result means good posture. That's why for a lot of physical therapists and chiropractors, one of the most basic things is assessing how efficient a person's breathing is.

But then the big question that arises is, how are we able to objectively quantify whether a person's breath is efficient? And it turns out that if you look at your CO2, your entitled CO2 in your breath and your breathing frequency, Entitle CO2 is the highest concentration of CO2 during exhalation. Interesting. Yeah, so if you look at Entitle CO2 and breathing frequency, these two happen to be two of the strongest predictors of whether a person is going to develop meoskeletal problems like lower back pain. Isn't that amazing?

Yeah. And this comes up in the test as well. Yeah, exactly. So one-stop shop for everything. And that's really the vision of the company, is, you know, as you have understood, like, cardiometabolic analysis is widely accepted as one of the most, if not the most holistic assessment, a person, clinical-grade assessment that a person can do outside of a hospital. And it can, and it should be, the health assessment

of the future. And our job here is by making it accessible by hardware that is easy to use and a service that makes people's lives easier, we want to make that happen. Well, look, a lot of our partnership together also is to, you know, try to expand your market and get WOOP members, you know, to do these tests because I think it's super important, it's super interesting. You can tell I find this whole thing,

a whole thing really fascinating. Let me ask you this. Is someone who, okay, well, wait a second. If you took this test, if you were wearing a Panoi when you were meditating versus exercising, how might the actual just pure breathing data look different? I mean, obviously there's the heart rate stuff and all that that's going to be very different. But in terms of the things that you're talking about, in terms of the efficiency of your breath, might someone actually be, I guess what I'm getting at is can you train yourself to be good, not just at a peak? state or a high performance state, which would be, say, exercise. But what if I want to be able to figure out how it can be as optimal as possible sitting at my desk? Yeah, that's actually

a concept that, are you familiar with Brian McKenzie? He's one of the most famous breath coaches in this country. I think I've heard of him. Yeah. So he does a lot of work with us as well. He has been using Pinotteno for quite some time now to test different protocols. And his work and the work of other people have shown that there are definitely, you know, many different exercises, breathing exercises that a person can do in order to improve his breathing and as a result, his overall health, his posture, his mind state, both in, you know, both when the person is sitting in his desk, but also when the person is exercising. Yeah, I bring this up because I started meditating maybe like four or five years ago.

go and I know it's just fundamentally changed my body and changed my mind and yet I would love to actually be able to understand some of the measurements associated with that and I imagine put up no yon well of course I'm going to but it would

what I'm wondering is if I had taken the Pneaui test at rest or even during exercise before having falling in love of meditation versus now like what what sorts of things might yeah so I have seen Yeah, so the things that we would look at in order to assess the delta, yeah, the delta and physiology would be, first of all, certainly, and tidal CO2, so how much CO2 are you able to clear per breathing cycle?

Breathing frequency has your breathing frequency gone down and then tidal volume? Are you able to exchange a greater amount, a greater volume of air between your long? lungs in the environment per breathing cycle. So these are just some things that we would look at in order to assess whether your breathing is heading towards improvement. And Title CO2, we talked about that. Breathing frequency, that makes a lot of sense because obviously if you can feel the same way or accomplish the same things with less breath, your body is behaving more efficiently,

your heart's performing its mission more effectively. title volume explain that one a little more title volume is how much volume of air we can exchange between our lungs and the environment per breathing cycle so um so a smoker right yeah it's going to have it's going to have a bad title volume yeah exactly um someone who is not a smoker but is breathing incorrectly because he's breathing with his chest and not with his belly uh so you know uh doing You know, big, deep breaths, which basically fill up the entire body can also have reduced tidal volume. Isn't that interesting?

So title volume is also a very, very important metric to see, based on which we can assess the breathing efficacy of a person. Now, if you took someone like Brian, the breath coach, and let's pretend for a second that he was mostly focused on breathing, he wasn't big on exercise. Right? Are there ways that he might stand out at rest in your test? Like, let's just say you do the test and the person's mostly at rest or they're just doing something light versus, you know, sprinting up the treadmill. And then they do the maximal test. I could imagine in the maximal test there's a lot of readouts where someone who's purely focused on breathing in their day to day doesn't perform as well, but potentially looks good at rest. Or would that, would the training of getting better at breathing actually apply to both tests? Good question. So is a person who's a bad breather at rest?

Could that person be a good breather during exercise? Yeah, or vice versa. Or vice versa? Generally, no. If a person is a bad breather at rest, he will definitely not do a good job when he's expected to breathe well. under physical stress. Well, let's flip it, because I think, I'm curious, can you be someone who's maybe not cardiovascularly fit, right?

But be a good breather at rest. You could, you could. Yeah. And potentially even look better than someone who is cardiovascularly fit at rest. Yeah, so, for example, you might have a person who is breathing well at rest. Yeah. but is very poor when it comes to cardiovascular training. Just based on fitness level.

Based on fitness level. Based on the type of muscles. And their heart probably, right? Yeah. You guys train your heart too. Correct, correct. So you should think that there are three different gears when it comes to our body. The first gear is the lung, second gear is the heart, third gear.

year is the muscles. So when we're performing, and this is a schematic that was developed by Professor Wasserman. Wasserman was the guy that did most of the work in cardiometabolic analysis and developed this schematic which very eloquently describes the interplay between the different physiological mechanisms in the body. So when you're trying to understand how body is performing and whether the body is performing well, it is always helpful to have these gears in mind because you understand that it's three gears working sequentially. So if something is failing in the body, if your body is failing, it could be any combination of the three. So yes, you might be a great breather at rest because you've done meditation, because this is how you were

born, because like you're a calm person, whatever. but then you have very untrained mitochondria and then the third wheel which is muscles ends up giving up when you start to run yeah you might have a pulmonary limitation you might have asthma or you might have some sort of cardiovascular problem or your heart might not be well trained because you never jogged so or it could be any combination of the two so that's and that's i would say one of the other, it's the other important point about cardiometabolic analysis that it is able to discern what is actually the problem and what is the limiting factor. Yeah, the thing I was thinking about while you were describing that, so you've got lungs, heart, and muscle. When I play squash competitively

now, squash is a very cardiovascular sport, but it requires a lot of lunging. When the season first begins, you have this situation where your lungs will go but your legs will be able to keep playing through a match and you just get to a point where you're winded and you can't keep going. Exactly. And for example, that's something that you're able to tell by integrating Pneau with Moxie. Moxie is another company we work with that does muscle oxygenation. So that's an example where your muscles aren't being oxygenated. And that's why they're, you know, sore and...

Yeah. This is what you would need in order to identify if the limitation is on a muscular level versus on a cardiorespiratory level. Now, the flip of it is later in the season, once my lungs have gotten trained up a little bit. The limitation starts to be oxygen delivering the muscles. Exactly. Yeah. Yeah. Yeah.

Yeah. And so it's... And then you're playing with heavy legs. Mm-hmm. But from a pure strain standpoint in terms of what whoop measures, it's easier to have a high strain in the latter case because you're able to, you're able, it's easier to push your body when your lungs are still there than it is when your legs go, at least in a sport like squash is the point and sooner. Correct. Correct. Correct. Yeah. So anyway, this is all, this is all very integrated. Now, is there anything in the Panoi test that we haven't touched on? I feel like we've touched on a million things in there. Yeah, I think we've covered most of it. Now, V-O-2 Max and anaerobic threshold.

Yeah. Give a quick spiel on what's important about those. So these are just two metrics that we derive from a cardiometabolic test. They're super popular for athletes. I know, I know, I know. They come up all the time. Yeah, yeah. Do you think they're overrated?

Yes. You seem a little bit like extremely overrated. Offended by my question. No, no, no, no. I actually it's it's very interesting that most people are familiar with that you're like the the Panoi test it measures V-O-2 max if it's like oh yeah it's a real test yeah so so actually you know most people are familiar with the term VO2 max and and they often associate V02 max with cardio metabolic testing thinking that VOTOMX is pretty much the only thing that I take away

when I do a cardiomotabolic test, when in fact it's just the tip of the iceberg. Totally. V-O-2-Max is your peak oxygen consumption. That's it. It's how much oxygen your body is able to consume at maximum. It is a great indicator of health, cardiorespiratory health,

also a great indicator of overall health. A lot of clinicians are now using V-2-Max in order to predict outcomes and surgery. series. So that's another, yeah, cool. And also a great indicator for athletic performance. However, it is not prescriptive in the sense that it cannot tell you whether it doesn't give you training zones. Training zones are developed based on your substrate utilization, your VT1 and your VT2. VT2, by the way, is another term for anaerobic threshold. People are familiar. Think that you have two thresholds in human physiology which determine your intensity zones. First threshold, VT1 or other people call it ierobic threshold. Second threshold, VT2, most people know it as anaerobic threshold.

And these are thresholds that we derive based on our RAM test. Now, the really rough calculation of this, right, is someone just takes their max heart rate and as a percentage of it right now often that's inaccurate but like just for people who want to understand aerobic threshold versus anaerobic threshold approximately what are those percent heart rates oh it's impossible to say it's literally impossible to say like because they can be so different oh really yeah yeah any any sort of attempt to uh give an estimation based on percentages is i mean it doesn't really make any sense okay so it's useless yeah um Now, if someone has a high anaerobic threshold, what does that mean?

Okay. So, first threshold is where your body starts to build up fatigue, but still in a sustainable level. This is the aerobic threshold. Iroby one. VT2 is the anaerobic threshold, is a threshold above which your body goes into the red zone, and it starts to build fatigue at an unsustainable rate. this is where you will very soon blow up

and back to the oxygenating your muscles if you're operating above your anaerobic threshold for a long period of time eventually your muscles are going to go what's going to give up first we don't know we need to test something's going to go but something is going to go first

will it be the first gear lungs second gear heart or third gear muscles we need to test there's no way of knowing until we test Now, this is why high-performing endurance athletes measure their anaerobic threshold and then, in turn, try to train below it so that they can try to build up more endurance without running out of gas. Or do you disagree with that concept? No, no, no, no. Knowledgeable endurance athletes and coaches will test different intensities, will pretty much map out the entire spectrum in order to understand how much am I burning. in different intensities

what is the anaerobic threshold is already too much too high for an endurance athlete yeah way too high yeah way too high endurance athletes usually focus on on mapping

out the area around the first threshold because this is the area where they perform and train most of the time it's like 60 70% of your max heart rate typically roughly roughly but again it's yeah yeah yeah yeah uh so how did you get into all this personally personally so um the idea started from my uh co-founder and childhood friend apostolos okay uh we started the company together

so he was working uh during his phd in cambridge uk uh on uh breath analysis The reason why he got into breath analysis is because he went to a conference, and they were talking about breath analysis in general, and he got fascinated by it with. And he started looking into the different applications of breath analysis, and cardiometabolic testing is actually the most mature application of breath analysis. Breath analysis has some other areas, which are very, very different to what we're discussing now, for example. you can detect lung cancer from analyzing your breath. And there's other companies which are doing these things. But he saw that cardio metabolic analysis is something that is extremely interesting and very few people do it.

And the primary reason is, as I said earlier, very expensive devices and no support for the average practitioner on how to use the data in order to provide actual and actionable programming for his friends. So he comes to you, says, Panos, this is fascinating. Sort of like that. Back then, I had just graduated from Stanford. I was working at a tech company in the Valley. And because we've known each other since the age of six,

I go back to Greece, we go on vacation together, and he started to talk about this idea, this prototype that he had built. and I was like, dude, that's awesome. Like, we've got to do something about it. So having drinks and make a nose and talking about it. It was actually Kufonisia. Okay.

People who don't know Kufonisia should definitely go to Kofonisia. But anyways, so yeah, we were Kufonisia. And, you know, at then, like, he was still doing his PhD. He wasn't sure. He was, you know, entertaining the thought. I was working. I was also entertaining the thought. But after a certain point when, you know, he brought the prototype to a,

pretty mature state, we're like, okay, we should try and raise money and turn this thing into a company. And that was late 2016. And yeah, late 2016, we started doing, we started building the team. We started to perfect the product. Initially, what we had built was a handheld metabolic analyzer because we were focusing more on rMR testing resting metabolic rate testing and very soon however we realize that there's so much incredible value in measuring a person's cardiometabolic response during exercise and that's when we started to transition into a exercise device and you know we did a lot of R&D for quite some time and here we are now it's amazing man i think what you've built is really cool and uh and i'm excited to be partnering with you guys

same here um what what else should people know how can people learn more about uh panoi if they want to yeah uh definitely follow us on pnoe analytics on instagram uh also check out our website uh mypnoe dot com and uh yeah these are the two main portals for us and look i'm i'm sure uh for folks listening right now like you'll you'll be hearing more from panos on our channels and you know i think this is just the beginning of of integrations absolutely thanks so much yeah thanks so much thanks for coming on man this was fun yeah thanks again to panos for coming on the podcast and i'm very excited to be working with pnoe going forward if you're not already a whoop member you can join our community for as low as 30 dollars to begin we provide you with 24-7 access to your biome

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