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Before my hands start shaking the millions, you a personal question. Now we're just
living tissue over metal endoskeleton.
Hello boys and girls ladies and germs. This is Tim Ferriss. Welcome to another episode of the Tim Ferriss show. Where is my job to interview? World-class performers to deconstruct, how they do, what they do Lessons, Learned, tools, Etc, that you can apply to your own lives. Nowhere. Is this more true than in this episode, where I interview my friend and Doctor Peter Atia? MD, you can find him on Twitter at Peter, Tia MD. He is the founder of early medical, a medical practice, that applies the principles of medicine 3.0,
A patients with the goal of lengthening, their lifespan and simultaneously improving their health span. He's the host of the drive. One of the most popular podcast covering the topics of health and medicine. Doctor, Tia received, his medical degree from the Stanford University School of Medicine in train for 5 years at the Johns. Hopkins Hospital in general surgery, where he was the recipient of several prestigious Awards including resident of the year. He spent two years at the National Institutes of Health as a Surgical Oncology fellow at the National Cancer Institute.
His research focused on immune based therapies for melanoma, his new book is out live subtitle the science and art of longevity. And on the book page, for outlive, you can find quotes from Steven, Levitt who is the best-selling author Freakonomics from Esther perel, who no doubt. Many of you will know New York Times bestselling author, psychotherapist and podcast host of where should we begin Andrew huberman? Who many of you will know also Hugh Jackman. And
And others. This is an Incredible Book. It's taken a long time for Peter to put together and I'm very excited to have him on the show to discuss, not just the book. But everything that went into the book, many different approaches and Frameworks, you can apply to navigating in improving your own health and health span. You can find him online. I'll give just a few on Instagram at Peter. Atia MD, that's Peter, atti a MD and on the website Peter Tia, m.com you
Find links to the book and many other things and the practice website is early medical.com. And now without further Ado, please enjoy a wide-ranging conversation with my friend Peter, a TIA
Dr. Tia Peter, nice to see you
Seema. I want
to start with the personal, we're going to get into all sorts of topics, many different aspects of your practice Lessons, Learned etcetera. But I went to your house recently, we had some Topo Chico and a bite to eat and a few other things and I commented on how much larger you were and not larger as in obese, but muscularly larger. So, I thought we would begin with the
in of how and why not necessarily in that order. You added so much muscle mass
in the fall of 20 21. I had sort of hit a relative low in wait. That wasn't quite as low as where I was, as a cyclist, which was probably about 165 pounds, but was still pretty low for me, kind of in the low-to-mid 170s and I did a dexa, scan which I do periodically. Probably a couple times a year but I
Done one in a few years and when I get my dexa scans, you know, I always plot the data, right? So I'm not just interested in body fat but also, you know, bone mineral content and many other metrics, but one of them that's really important. Is something called appendicular lean mass index or a LMI. Another one is called FMI fat, free mass index and it's probably worth explaining a little bit about what these are. But the Alm I takes what the dexa scan imputes as the lean tissue.
And your arms and legs and kg divides that by your height in meters squared. So, it spits out a number like 8 kg per meter squared. This is a pretty accurate representation of how much muscle you have in your arms and legs because the dexa scan can really only identify three things, bone fat and other. And since things in your arms that are not bone and fat tend to be muscle, it's pretty good at identifying muscle. Whereas the fat free mass index looks at the entire body and just subtracts out fat. That's also a
Proxy for lean mass but there are many other things like organs that are taking up some residents there. Anyway, when I looked at these metrics, I was shocked. I was shocked at how much less muscle I had than 10 years earlier. Almost exactly 10 years sooner and, you know, I attribute it to several things, but I really thought that Chief among them was just how much fasting I had been doing over the previous three years. I had really kind of Taken fasting to a pretty extreme place, you know, doing up to 10.
Days of water, only and routinely just busting out, seven day water only fasts, certainly doing three days every month would be something I would do without hesitation.
When you say ten days of water only over what period of time is that
meaning like how frequently would I do that?
Yeah, I'm just wondering what the Cadence was
probably quarterly probably every quarter and while I certainly think there are some benefits from doing that. I think what I was sort of confronting was wow. There's actually a
Pretty big cost as well. And I would go out of my way while fasting to still exercise. I was lifting weights every single day, which was difficult sometimes. But doing everything I could, to sort of try to stimulate muscle protein synthesis. But at the end of the day, if you're not providing any nutrients, including amino acids, you're basically just tearing down muscle to try to rebuild with that muscle, but your net effect is a loss. So I just said, like, I got to fix this. I got to do something about this, and I want to have my Alm, I be in the least the 90th percentile.
If not above the 97th percentile as I age, the data are pretty unambiguous that people live longer better lives with an Alim. I north of the 75th percentile. So not one to just clear. The bar. I want to be considerably above are so basic. I just change things around and said nutrition and exercise are going to change a little bit so we can talk about those changes. But basically, I'm a big changes with exercise and nutrition to make those
Corrections how much lean mass
Did you gain over? What period of time? Would you say once making these
changes? So, in a span of God, I'd have to go back and look at the exact data. I believe it was 13 or 14 pounds of lean mass in about 12 months, which is again. That's not Herculean. These are not insane and numbers not taking anabolic steroids.
This is relatively doable for someone who is making it a high priority to eat. The right amount of protein, the right kind of protein and space sitting it and consuming it at the right times. And then also focusing training on a little more
hypertrophy. So for people listening I'm asking these questions not simply because I'm interested in lean muscle mass but also the implications for longevity. So I'm guessing you did not put all of that lean muscle on your biceps.
Oops. And that there were other movements that were Incorporated for very particular reasons if I'm getting my read on dr. Peter Tia, right, as I think I am. So perhaps you could just describe some of those changes and also protein and how you suggest people think about protein, how you began thinking about protein
I'll start with that and we can talk about the training. So the protein basically went to a very conscious and concerted effort to increase protein to one gram per pound of body weight. People are going to ask is that 1 pound of actual body weight is that 1 pound of lean body weight is that 1 pound of Target body weight. The answer is for someone, my size, and weight, and my body fat percentage. I think, at the time, I was about fifteen percent body fat, it really doesn't matter. It could be basically call it 1 gram per pound of current body.
It is sufficient. So that's what I did. The next question then becomes timing and this is something that until a couple of years ago I wasn't really paying enough attention to. So it wasn't enough to just say well Peter you got to have 180 grams of protein in a day because for example, 290 g boluses of protein doesn't accomplish nearly the same thing as 4 45 G servings spread out over the course of a day. So there is kind of a sweet spot with protein where
We need to be north of about 20 to 25 grams to ensure that those amino acids aren't, just going into what's called a gluconeogenic pathway, so we can turn protein into glucose but we don't really want to, you know, protein should be thought of as a structural nutrient, whereas we want to really think of carbohydrates and fats as energy nutrients. So you have to have enough protein in a given serving that you don't just have the liver, take it and use its bit for gluconeogenesis at the same time. You don't want to have
Too much and too much is a bit of a, an unclear limit. But my best reading of the literature is that you're starting to hit too much at about 50 grams, in a
serving and what type of protein are we talking about? Just in terms of, I'm thinking of bioavailability and protein efficiency ratio, how should people think about quality or type of
protein?
So the first decision, I think everybody wants to make as you know, am I getting this from plant or animal? And unfortunately this has become sort of a contentious topic and it's, you know, got it sort of political religious overtones to it. But if you don't concern yourself with any of those things and you just think about biochemistry, there's really no ambiguity here. Protein derived from animal sources are more bioavailable so you can overcome some of that by cooking the plant. So once you start to cook the plant and free it up from the fiber, you can liberate more of the plant protein, but you're still always going to be struggling with a bit.
Bioavailability problem, that can be anywhere from 20 to 30 percent haircut, you're taking just on the net consumption of the amino acid. The second issue comes down to amino acid quality. And if you're really concerning yourself with hypertrophy, I think the three most important amino acids would be leucine lysine and methionine. These are amino acids. That also, you don't tend to have as high a quantity main plant protein. Now, you can get them.
And it gets especially hard if you can't have dairy or eggs. So if you have someone says, look, I'm a vegetarian. I'm not going to eat beef or chicken, but I'm willing to have eggs and dairy it gets a lot easier, you know, eggs for example are very high source of methionine.
so, what we typically will tell patients is
Rather than just fixating on the total number of grams of protein, you need to eat which you may have a hard time hitting. If you focus on the number of grams of leucine Lysine and methionine, you're getting in a given meal or a given day that will almost assuredly, get your total protein quantity to the right place. So for me that really meant, I just wanted to make sure I was getting gosh, probably 6 to 8 grams of leucine, add a comparable amount of Lysine at least two grams of methionine a day.
And you know, I use an app to track what I'm eating just so that I can see where my protein is coming from and how much I'm getting and when and where, and that tended to work out pretty well,
what is the name of the app? If you're willing to mention it.
Yeah, it's called carbon. I have no affiliation with it. But a friend of mine, it's his app and I like
it
I guess. My affiliation is that it's my friends app.
I'm glad you brought up the leucine lysine and methionine because I was
Into asked earlier if while you were fasting but losing lean muscle mass over time, you were supplementing with say branched chain, amino acids in any fashion.
I was, I used to always drink BCAAs during workouts. And for folks listening, there are three branch chain amino acids, and leucine is hands down the most relevant of them. And we know from the work that our mutual friend, David sabatini has done in his lab. That leucine is a very, very potent Mt.
Or stimulator. In fact, it might be the single most potent stimulator of mtor. Mtor, of course acutely. You want that thing stimulated. It's promoting growth. You don't want to chronically stimulated, but you wanted acutely stimulated the problem with branched chain amino acids. And I got to tell you Tim, I think it's largely fallen out of favor, so I don't even consume branched-chain amino acids anymore during a workout, I'm literally just consuming an electrolyte drink. That's it. The problem is one. They don't stick around long enough and they're free form until you're just not getting enough of them.
And the third thing is, the temporal nature of when you take them in being in the workout or a couple hours after that workout doesn't really seem to matter our window in which we can synthesize new muscle is sufficiently broad that. Even for an untrained individual who has a narrower window, it's totally reasonable to say, look, just make sure a couple hours after that workout you get in your big protein meal. So instead today, I just use high-quality whey protein post-workout and I
Trouble myself with consuming any protein in workout.
So just want to mention a few things for folks. So number one, there's a huge difference between no animal products and lacto-ovo vegetarian. And one example of that would be Bill Pearl who became mr. Universe as a lacto-ovo vegetarian. So it does make a huge difference. The second, I'll just mention, we may come back to this and discuss key to at some point. We have discussed it at length in previous conversations, but the gluconeogenesis is one
What is the pathway by, which you can knock yourself out of Quito? If you consume too much protein, and not enough fat liver, just loves to convert that into glucose and then but a bing bada, boom, you're out of ketosis or leased out of the range. That one would be aiming for. So, let's come to the book. So you and I have had many offline conversations about the book will probably not repeat some of them. Why did it take so long? And I believe there were three iterations over six years and the
First, iteration had a zero translation into the final version. Something along those lines, maybe you could correct me if I'm getting that wrong button, so that's why. If you taken so much time to work on this
book, I think there are probably several factors some of which are related, some of which are not. I think on one level. My appetite for how good quote unquote, I needed this book to be was very high, so on like you Peter. Yeah, look, I think there were some people out there who can turn
now to book a year and more power to them. But the way I viewed this book was that this is sort of the one and only book I ever want to write will ever write another book. It's hard for me to ever. Imagine the answer that question is yes, but again, maybe and maybe at the end of my life, I'll have something else to say. But as I'm 50 years old now and I'm at the midpoint of my life or slightly past the midpoint of my life. I feel like everything I ever want to say on this particular topic is in this book. And therefore, it was just a very long book. The final version is probably a hundred and forty.
Thousand words, the version I ultimately submitted, was 200,000 words. Like, this has been chopped way down by thirty percent into. What is still, obviously a book. That is quite long. So that's part of it. I also think part of it is
And maybe you can relate to this him, I don't know. We've never actually talked about this but I think there's just a vulnerability that comes with writing in this manner that is unlike all the writing of done in the past. So I've been blogging insanely for 12 years, that's different. The you're not really putting yourself out there when you write a blog post, you don't have to read the comments that people, right? You don't have to pay attention to any of that stuff. I think when you write a book,
You are really saying to people, like here, I am tear me down and I just think there's on some level it. Maybe it's embarrassing to say this, there's just been a little bit of a reluctance to be. I got it for lack of a better word vulnerable, just to sort of say, okay, you know, I'm, I'm willing to say everything I have to say on a subject matter and now let the arrows come flying. And that's again, I don't know that that makes sense, but I'm sure that anyone who does something very public feels that way, but it's different with podcasting, which I don't have a problem doing, and it's different with blogging, which
I don't know if I'm doing but this strikes me as maybe what an actor feels like when they make a big film, or a director or again, like an author, like you. So I think there was a little bit of subconscious dragging my feet and hey, maybe I can just keep working on this book forever but it'll never actually come
out. So I do identify and I would say, for me at least part of that is when you put out a book, it might be one of the 20 books, the Publishers working on that. See
And but especially if it's a book of this depth and also I will second vulnerability, not just on the personal side when discussing physical health, but also in the chapter or as it's a section really on Mental Health, psycho, emotional health and so on. I mean, you really show sides of yourself that are
uncommonly shown, I think in some of your other formats and
Unlike a blog post. It's very hard to just delete a book from the world once it is published. So I number one, think it was right to take it seriously and however long it takes to do a book of this quality as the time that it takes. And I think that's the way it should be. And I will say, just as a side note, I mentioned this to you and you know this that my dad who has struggled in various ways with health for decades now.
Picked up your book, which I had at home when he was visiting me and Austin and could not put it down. And that is, I won't get into all the details of why this is the case. But like, if if that isn't a testimonial, I cannot imagine what is at to the extent that I ended up giving him my copy. So he could take it home. That should tell everybody
something. I didn't know that. Tim thank you because I will, you guys came over. He mentioned how much he was liking it. He had just picked it up but I didn't realize he'd finished it and he enjoyed it. So thank you. That means a lot. Yeah.
And with that let's talk about perhaps this is a good place to start objective. Strategy tactics. Why are these three pillars important and why all three?
You know? I learned about this stuff about a decade ago, when I was working on a problem, that is irrelevant now. But I think the message was important, which was, I think I had a vague sense of what the objective was, and my immediate tendency, which I think is normal. And I think we all do because I don't
Think anyone's hardwired to go through the middle. Step was to go from objective to tactics. In fact, I think most people just kind of go to tactics without even thinking about objective and certainly not having that strategy piece in the middle makes life really complicated. So, the first thing I think is to understand what's the difference. So objective is pretty straightforward, it needs to be stated. It should be very clear though. So, for example, my objective might be
You live longer, okay. If you said well, what are the tactics now? What should I eat? How should I exercise? You know, do I need to take this supplement or that supplement the probability that you were going to come up with the right set of instructions is vanishingly small.
Even if provided this list, this laundry list of
tactics? Well, I guess the question is, how do you come up with the list, right? Like how are you filtering on that list, right? So there's no shortage of tactics that one could think about because the world is Rife with everybody off,
Offering their tactics. It's not like I'm not suggesting tactics but what I really want to do is say look let's anchor to a strategy. So for example, if one of your objectives is okay, I'm going to live longer, it's like not a let's deconstruct. That what is living longer mean? Well, to understand what it means to live longer. You have to understand what ends life. Well, what ends life is a very clear and easy to understand data set. So let's look at it and let's look at it in. Great detail, we call this the death bars analysis. So what are the death bars?
Well, it turns out if you're over 40, you don't smoke, we can really clearly tell you that. There's an about an 80% chance you're going to die from atherosclerosis, cardiovascular disease, cancer neurodegenerative disease or metabolic diseases such as type, 2 diabetes and things like that. Probably, I would include accidental death in there so falling or Automotive accidents. So that's an important Insight because now you start to work backwards from there. So if so who anything I want to live longer, I have to avoid those things.
Ah, okay. How do I avoid those things? Well, let's start with the chronic disease bucket. There's two ways to think about that. I love when things turn into somewhat binary decisions is one way to live longer to live longer with a chronic disease or live longer without a chronic disease. So might not be entirely obvious, which of those is true, but if we look at the data, it's pretty clear the data unambiguously make it clear that you will live longer. If you can extend the period of time,
That you live without a chronic disease rather than extend, the period of time you have the chronic disease. So in other words, it's better to get cancer later in life than to live longer with cancer. As one example, it's better to have your first heart attack very late in life than have an early in life and then be right on the verge of having another one as time goes on. Well, just by going through those very simple questions. All of a sudden you start to formulate a much clearer strategy for living longer that points. You much more clearly towards
This idea that I talk about the book called medicine 3.0 rather than medicine 2.0. And once you iron all that out, then you start to get into the tactics. Oh, all right. Okay. So how does nutrition layer onto this? How does pharmacology layer onto this? How does exercise layer onto this Etc?
I wanted to share an anecdote, which will not surprise you. But when I published the 4-Hour Body and no doubt, you're going to get a lot of these types of requests. If you haven't already, I had a number of not morbidly obese, but
Out of shape. CEO friends. Say look I just want the index card. Just give me the index card with the seven things I should do and I'll do those seven things. Can you guess what the compliance rate was with that Peter? What's your, what's your guess, very
close to the success rate of skipping the strategy step
zero percent? Not a single one of them actually implemented, any of it. Just as a quick side note which you might find our Channing. I had an amazing Mega successful. Investor named ed Thorpe on the podcast.
Choose if not over 90 90 right now, he's in excellent shape and he plants his travel around minimizing time in automobiles and he's sort of run through the numbers just as an
anecdote, very underappreciated cause of morbidity and mortality. I think about it a lot.
Yeah, we might come back to as I think about it different seat belts that you can use in life which initially I don't want to turn this into a Tim Ferriss, Ted talk. But initially thought about
Out with respect to covid early. Which was like, what minimally inconvenient easy to do things? Can you do to dramatically mitigate risk even though you've never had a head-on collision? The downside of having a head-on collision is so high that most of us will wear a seatbelt when driving on the highway, most of us will have a fire extinguisher in the kitchen, even though there's never been a fire in your kitchen at cetera. So where else can we take very small steps that are easy low cost.
That prevent dramatic downside risk. So we may come back to that, but I want to bring up a graph that you have in your book page, 28, for those who want to find it, where if you remove the top eight contagious, / infectious diseases, meaning we're counting for the Advent of antibiotics least. As I understand it, we haven't really seen a material or at least large change in mortality rates since what 1900 few sort of account
For some of these variables. Why do you think that is? Because certainly most people don't want to die.
Yeah. So you're absolutely right. So life expectancy since 1902 today, has increased by twofold. It's remarkable. It's gone from about 40 to about 80 plus or minus, but that's directionally the change. We've seen in call it a hundred and twenty years. And I do think that understandably it's tempting to tout that as the marvels of modern medicine and
You're thinking well, oh my God. We went from 40 to 80 in 120 years. The next 40 just based on Moore's Law. That's got to get us to like 160, right? Okay. Maybe. But let's take a closer look at the data. So you do this, very simple analysis, which is. Okay, let's go back to 1900 and March forward, but when we go through the mortality tables just strip out the top eight leading infectious disease.
Causes of death. And what you see is exactly what you described there is now no change in mortality from then until now effectively, there's a little bit, it's been a little bit better and I think what it speaks to is.
Two things. One is the remarkable success of medicine 2.0 in solving acute care and infectious diseases and the remarkable failure of medicine 2.0 in addressing. The chronic diseases that sat under the surface of the water, waiting for the tide to go down.
And those would be presumably the four or five likely causes that you mentioned earlier. Perhaps is a good place for you just to define or describe briefly web two point, not web to try that. Again for you to describe medicine to, I'm not gonna be the only interview or fucks that up medicine. 2.0 and Medicine 3.0.
Yeah, so it's probably easiest to just for the completeness.
Art with medicine 1.0 medicine. 1.0 was basically everything that occurred prior to the transition period of the late 17th century into the late 19th century. So that 200-year period marks the transition from, when medicine had absolutely no basis of science whatsoever. I mean, we can mock it now but truthfully, they did have a scientific method or a scientific tools so that
All they could do was sort of think about the gods. Think about Bad humors come up with the best rationalization they had for what was going on. In fact, arguably the most insightful thought that occurred in medicine 1.0 was thousands of years ago on the part of Hippocrates who was the first to believe that diseases Were Somehow caused by nature and not the gods. That was truly remarkable inside. Now beyond that, he had no clue what was going on, but that was a remarkable insight and that was probably the
of medicine 1.0 with Francis Bacon in the 17th century. We had basically the first push towards the scientific method. This became really important and no one has done a better job explaining this than our mutual hero. Richard Fineman there's a great video which I'm sure you guys can find for the show notes where it's an old grainy black-and-white. We're finding is talking about the scientific method and he's saying, look, you make a guess you design an experiment. It's good. I guess is called a hypothesis by the way. It's
The fancy word for a guest, you design an experiment to test that hypothesis, you do the experiment, you compare the results of the experiment to your guests, and then you decide to either discard or update your hypothesis, this was such a profound concept that it basically propelled us into medicine 2.0 and the place where that Sean greatest was unquestionably in the world of microscopic organism. So if
viruses and bacteria. And so it's a brutal bloody slog to go from semmelweis to Coke to Lister but that transition effectively brought us into the modern era where, hey, all of a sudden doctors were washing their hands and not operating on people with dirty hands. And, of course, eventually we had antibiotics and eventually we had vaccines and taking smallpox and polio off the table and reducing the mortality.
Body of influenza, and having anybody's all of that stuff had such a profound impact on human health that it cut mortality rate down by a half and doubled our life expectancy. So now, we're into the maturation of medicine 2.0. We saw these other amazing success stories. I think, the two most notable by far would be hepatitis C and HIV. I mean to think that we're at a point now, where a virus that is, as tricky as HIV can basically be rendered a chronic disease.
He's on the back of Highly active antiretroviral therapy is nothing short of amazing when I was in medical school. Tim, we're not talking like a long time ago, I was 25 years ago, we were told hep C will never be cured and it will break the back of the US and Global transplant infrastructure. Meaning we're going to need so many livers to put into all these people with hep C that by 2030 the system will break.
And lo and behold, we have a drug that within a matter of weeks will eradicate this thing. So again, huge successes
Now counter that with what we've done against cancer when Richard Nixon declared the war on cancer before you and I were born was more than 50 years ago. The goal was to eradicate this disease by the bicentennial in 1976. Well not only that, not happen. But here we are more than 50 years later and survival for cancer is barely 5% greater than it was in 1970.
I could go on and on, but let's just look at neurodegenerative disease. So you were talking about six million people with Alzheimer's disease in this country. If you add up those with Lewy Body, dementia and Parkinson's disease were talking about gosh, another four and a half million. So we're looking at more than 10 million people in this country with very, very significant neurodegenerative diseases and that says nothing about, you know, ALS and Huntington's and things like that. We don't have a single thing that we can do to cure these people.
We have barely a few things that can slow the progression of their diseases but we've made hall tree steps against chronic diseases when you and I were born the prevalence of type 2. Diabetes was less than 1% today. It's 10% effectively, right? So we've seen a log fold increase in type 2 diabetes.
100 to 120 million people in the United States are metabolically sick. Meaning have metabolic syndrome or pre-diabetes or type 2. Diabetes out, right? So something's not working, and the current system of medicine 2.0 doesn't really seem equipped to address it. It intervenes late and by the time, it's intervening. It's not really fixing this thing. I'm proposing. This idea that of course, I'm not the first person to suggest, maybe I'm the first person to talk about it, this way is, we want to kind of pivot to this newer way of thinking about things.
Things which deviates from medicine, 2.0 in a couple of really important areas.
The first is in its timeline. So medicine 2.0 is largely focused on treating disease and it's really interesting when I think about it because it's so obvious that I can't believe. I didn't notice it earlier, but when you're in medicine, when you're in medical school, when you're in residency, when you're in, practice, you sort of need a code for a disease, you need a code for a disease that you Bill for and you treat and prevention doesn't really fit into
So when I went to medical school, I didn't learn a single thing about nutrition or exercise or sleep, or stress management, or emotional health. I learned a lot about pharmacology and it's tempting at this point to say, well, pharmacology is either good or bad. No, it's both pharmacology is good and it's really valuable. But over indexing it is bad. And ignoring all those other things is problematic, those other things. Turn out to be far more efficient tools of prevention. If no doctor learned about them, then why are we?
Prized that medicine 2.0 is unable to cope with that. So one we have to understand prevention and we have to understand the timeline for prevention, must start much sooner. You have to start doing these things. Long before diseases are kind of ravaging the system. The other big difference is that as I talked about it, the scientific method was such an important part of medicine 2.0 and with it came something that I'm sure you've talked about many times, which is the randomized, controlled experiment. This is the
Tool that allowed us to do that thing. That Fineman described, the randomized. Controlled experiment is really wonderful. It is insufficient by itself to solve the problem. So medicine, 3.0 needs to go from what we call evidence-based medicine. You only do what the randomized control trial says to evidence-informed Medicine.
Which is you take the insights from the randomized control trials, but you have to then modify them and specify them to a given patient.
So those are
really the huge
leaps that we have to kind of take two. Now make this next
transition.
Could you say a bit more expand a bit or give an example hypothetical or otherwise of moving? From the? I don't want to say Seoul but extremely strong focus on only making decisions for patients based on our CT data to what you're
describing. Exercise is a great example. So exercise would say the recommendations would be too, I'm gonna give you two examples by the way. So this one's kind of a simpler one and then a more
It's sort of nerdy or one. But the nameplate recommendation around exercise is something to the effect of two and a half three hours a week of moderately vigorous activity. But no one is like parsing these data down. And actually looking at what metrics matter like how much strength do you need to have the absolute lowest risk in mortality? How much cardiorespiratory performance do you need to absolutely lower your risk? Literally fourfold relative to
In the bottom quartile. So, do I have a randomized? Controlled experiment that tells us that I don't? No one's going to do that experiment which is I'm going to take a group of, you know, 10,000 people randomize them to different levels of training. Increase each of their Fitness has to relative levels and follow them prospectively for the remainder of their lives. Never going to happen, right? So instead, we have to be able to triangulate between these other sources of data. Another example, maybe a bit more glitchy might be
Be the way we might use different forms of lipid lowering medication. So this is kind of a whole other tangent we could potentially dive into which is if you're really interested in preventing heart disease which by the way, number one, cause of death in men and women in the United States and in the world it's the 444 champion of death. It's such the champion of death that for every woman who dies of breast cancer there's like eight to twelve women who are dying.
Heart disease, so pink ribbons matter. Red ribbons matter more. This disease would be largely preventable. If people didn't smoke control their blood pressure and had a poby levels that were equivalent to the levels. They had as children, no one will do the clinical trial that will get us there. Yet we have all the mendelian randomization we have all the mechanistic data and so an evidence-based approach says, look, we're going to Target LDL
Are all 200 milligrams per deciliter. This approach is going to say actually that's probably insufficient for this individual because their risks are higher. And by the way their appetite for reducing the risk of this disease is higher so we're going to take a more aggressive posture even though the recommendation of the literature is going to be far less aggressive.
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So medicine 3.0 seems to comprise a number of different elements, one of which is early intervention or a certainly much earlier intervention. Hence early medical. I can only imagine and another is medical literacy and a more perhaps proactive approach to education and intervention on the part of the patient. So it's not
A passive experience of being shepherded through a system by a doctor or team of doctors. You take a much more active role and I wanted to chat about medical literacy because what I've noticed just to give personal example, long ago wanted to potentially become a doctor and certainly became fascinated by competitive Sports and performance enhancement that led to doing my best to read studies and dig into the science and understand.
As much as possible. I was unsure of the value of that once I shifted courses and decide to do other things. But in the last, I would say decade as my parents have gone older as more and more of my friends have run into issues. It is astonishing how valuable this minimum effective dose of medical and scientific literacy has become mean, it's astonishing how much it helps you to navigate things and make decisions and parse signal from noise.
So I'd love for you to speak to Medical literacy and how one can become more, medically / scientifically literate and certainly, I would highly highly recommend. I'll just double down on this that everybody read this book because I think that your book does a good job of this very, very good job and I'll just add a maybe a sidebar note. So I can hear myself talk a little more, which is that
There's a, I think I have very common Trend among people who are well educated in some areas, but not in medicine, or science to succumb to scientism with a capital S. They'll know the term randomized, controlled trial, and they will insist that. If you say anything outside of the purview of that, that it is unsubstantiated nonsense. And there are other examples of this or they're over index on one thing as you mentioned.
So pharmacology, it'll be either good or bad but the fact is like anything totally over indexed, sort of the paracelsus. The dose makes the poison type of problem, but could you speak to Medical literacy somebody's listening? They say, you know what? I recognize that I don't know much about this. I would like to go about it in a really effective way. How do I do it?
I think you. And I have even talked about this once before Tim and I don't think I had a great answer for you then and I don't know that I have a great answer for you now. It's really not
a simple thing to do. Let's just start with the nomenclature. A my first day of medical school. I still remember one of the professors saying and I don't remember the numbers. So the story is not as cool because I don't remember the actual numbers, but I'm making a numbers up, but not the point. Okay. He said, well, all of you were smart pot, shots, that just graduated the first year class in college. You have an average vocabulary of X words an ex was, like, whatever number I do honestly, I remember I was Callin, 20,000 words said in the next two years.
He just in the first in the preclinical phase of medical school. We are going to add why words to your vocabulary and why was bigger than x by like 20 percent. And those are mostly going to be Latin Greek words by the way, and he was right. I mean, it was sort. It was like learning a new language. So part of it is just the semantic problem. Now, do you have to know all of that? Of course not. But what's proximal? What's distal? All of these things? Kind of factor into this. Do by far, the biggest issue, though,
This is the one that we try to solve the most for on a weekly basis. There's a reason that we go to Great Lengths to write a newsletter every single Sunday, it's basically a Class. A lot of times it's like such and such a study is published and the News picks it up and writes a take on it that we think is the monstrously wrong or a paper gets published, that gets a lot of attention that says this. And we think it's an important paper and we want to highlight it. So we kind of try to use those things as case studies. And I honestly think that
Most efficient way to go about learning this. Now we did write a Series 6 years ago I think called studying studies which is I think a five-part Blog series that Bob Kaplan and I wrote and I think it's probably a great Foundation to just get the basics. What is a case cohort, study? What is observational? Epidemiology what types of bias exists and how do you look for them? Consider that sort of your basic foundational knowledge set but thereafter.
It becomes reps in the more you can do this. I think Lane Norton also has a course that he just launched and I think it's actually called reps but I can't remember what reps stands for. But it's basically a scientific literacy course in how to read studies about nutrition. In his case, it's about exercise and nutrition. Again, we try to cover everything in our newsletter that you know we'll talk about a drug study, will talk about a supplement study and exercise study, all those sorts of things. So those to me are the ways you go about doing this, you just have to dive into it and
A little bit overcome the fear of it. I suspect it's not unlike what you would say if I was asking you Tim, I really want to learn Japanese. Is there a particular app that I should look at? Or this other thing I think in the end of the day? You'd say look man you got to like learn it. Here's the way to get the foundational skills and then go and find people to speak Japanese
with. Let's actually use that example. So learning Japanese because I do think there are parallels here, I think it comes back to objective strategy and tactics and I just want to share a quote, that's one of my favorite quotes that also might help folks, which is from
Um, Ralph Waldo Emerson. And the quota is the man who grasps this is, of course, people. But the man who grasps principles can successfully select his own methods, the man who tries methods ignoring principles is sure to have trouble. This applies, as much in medicine, developing scientific literacy or learning Japanese, read it applies in all these places. And so, what I would say, please feel free to pick this apart is that to learn. Japanese is a very Broad
Add objective. So, I would encourage someone to refine that substantially and they might refine it to. I would like to be conversationally fluent, which means I understand and can convey, maybe 80% of what I hear or want to say in a conversation that does not include Specialists terminology. That is abstract like economics or
Art fill in the blank, right? So you're discussing what happened to whom when I was born here, I went to school there, I have two brothers, whatever it might be. And with that goal, then I would say, for the vast majority of people. If and this is a big, if they were willing to make it a part-time job, let's just say with three or four hours per week, spread across four consecutive.
Days that if they layered things properly within three to six months, if they then added in a couple of kind of larger sessions for bulk memorization and you can use spaced repetition tools but the tools don't matter as much as being really clear on the objective that you could become functionally fluent, conversationally fluent, as I described it, which omits reading and writing completely in Japanese scripts, probably within three to six months. If you took it super seriously and there are some adjuncts, I would add to that. So to
If people may be a glimmer of hope on the medical literacy side, I would say if people started with your am a number 30 this is episode 188 how to read and understand scientific studies if people listen to that first and assume folks before you listen to it that you're not going to understand at least 30 percent. Let's just make that an expectation. So you don't get frustrated and if they further maybe read some of the case studies from your newsletter made that sort.
Out of one of the hours that they spend per week just like the Japanese. If they may be read book like bad science by Ben goldacre who's an MD British to some of the cultural context. And examples may not resonate for u.s. readers but he runs through some of the basics and they read outlive that making this literacy, your part-time job a very light part time job. For three months is
One of the best investments you will ever make in your life. I really feel like the payoff is so tremendous. That it seems almost crazy to not learn and you don't have to learn a hundred thousand words, but you need to be familiar with, let's just call it a few dozen Concepts that you'll be able to look at PubMed or databases of studies, or at least abstracts, not going into all the supplemental stuff and make some sense of a b or c. Are there any
Any suggestions you would have for just becoming familiar with what the scientific method actually entails. I could think read the Wikipedia entry as a starting point. But for instance, where a lot of smart people or seemingly, smart people screw up with the scientific method is your guess. Although it is a gues, aka the hypothesis needs to be falsifiable for a, and a lot of people start with completely impossible to falsify guesses. And it's just, you know, you're painting yourself up shits Creek.
Without a Paddle, any suggestions for how people could at least become familiar with like the scientific method and what that means as far as structured thought and
process. I don't off the top of my head have a resource that I can point to I agree with you that there's so much more Nuance to it than just understanding kind of the character trade version that I explained earlier. For example, how you design an experiment is essential. So even if you have a hypothesis, that can be falsified, if you
Sign the wrong experiment to test it. You can miss out. This becomes very important. By the way, as you start to look at studies, if a study is quote, unquote - how do you know if it's a negative? Because it was too small in size and what we would describe as underpowered versus it was adequately powered but there was no effect at the other end of that Spectrum. Sometimes a study will find a statistical significance but it was overpowered and that difference while statistically.
It is clinically irrelevant. Now that kind of stuff, we do cover in the studying studies stuff, but I think what you're describing are, these more important heuristics, that truthfully, maybe there is a great book out there and I'm just ignorant of what that book is that kind of goes through this, but that's the kind of stuff that I think you learn with practice then unfortunately, if you're not doing experiments, I mean, again, I think I learned most of this stuff not in medicine, but in the two years that I spent at the NIH where, you know, as a fellow but
Doing research. So I was a like a research fellow not a clinician that's probably where I learned more than anything about how to do science. And so I think anybody who's been in a lab is just learning that but it's very informal, you know? It's not at least for me. It wasn't a
structured thing.
In terms of priorities, I would say, folks, man, I've seen so many people lost in the medical system especially when they, suddenly have a serious diagnosis with some form of cancer or otherwise and they are absolutely helpless because they do not have a handful of Concepts that they've become comfortable with and just a basic set of terminology. So the very least. Look up Sir, Francis Bacon. I'm sure there's a biography, an excellent biography out there somewhere and it will no doubt track that.
Development of the I guess baconian approach,
you know, one thing I'll add to this Tim before we leave. This topic is also for folks to look up, Austin Bradford, Hill. So Austin Bradford Hill scientist of the kind of middle part of the 20th century to him. We owe the Bradford Hill criteria. So there are, I believe nine, Bradford Hill criteria which are the criteria that we use to scrutinize observational data. So when you
You have epidemiologic data, how can you scrutinize them to understand and change your confidence in the likelihood that these data are causal? I mean, causality is one of the most important Concepts in
science. Could you also justify an observational study versus randomized control trial. So, people have that
just isn't so an observational study. Yeah, it doesn't have an intervention so you can observe things, either looking backwards. So things that already
and you can go back and look at what happened. You can even observe things prospectively, but without intervening so saying, hey, we noticed that, you know, there are group of redheads over here and their group of brunettes over here. And we're just going to follow them for the next 10 years and see if the color of their hair predicts, their life satisfaction, making this up, of course, and so you might get an answer from that. And then say, oh my God, the people with red hair were so much more likely to get melanoma.
I mean, this is devastating and it must be that something about red hair is causing skin cancer, but it must be that brown hair must be reflecting the Sun and those people aren't getting skin cancer. So there's a correlation. So, another question is, do we know if there's a cause they're do? We know if they're red, hair is causing those people to get more skin cancer than the people with brown hair. And the answer is probably not write the answers. Probably that red hair is associated with fairer skin. And that that's the issue. Because if you really want to know,
Ed hair was causal, you would randomize people to different groups and you would actually dye that hair in one group, one color and dye the hair in the other group another color and then you would follow them. So what Bradford Hills criteria allow us to do is look at nine factors such as the strength of the observation. So what's the actual magnitude of the observation? What's the reproducibility of it? What's the biological plausibility of it? Is there an analogy to it? Is there a dose effect to it and as you go through these nine criteria, which actually I think I should do.
A
couple of times in the book because so much of the data we look at around nutrition and exercise are unfortunately epidemiological, we can't do the controlled experiments but it's what allows us to say when I read a study that says 12 hazelnuts will reduce your risk of death, 12 hazelnuts, a day and consumption reduces risk of death by 10%. I can look at that and say total nonsense that's just epidemiologic nonsense. Conversely. When I look at epidemiologic data that's a people who are really really strong.
Long live longer than people who are really, really weak by going through those nine criteria. I can be much more confident. That that is actually
causal.
So unless you two things, the first is, if you're going to get because we're mentioning a number of different books and this is not just to blow smoke up Peters ass which by the way, was a real thing. I found a menu from the wild west and it was like all these various things you could have done to you and blowing smoke up your ass was like, $50 was the most expensive sets a real thing. So it's not just that I'm doing that. But if you're going to buy one book on this stuff, get out. Lift because it covers a broad spectrum and I want to also mention because I think this is really critical and we'll probably
Back to this, but it isn't just about extending lifespan but extending Health span and having like full optionality physically or trying to preserve that to the greatest extent possible for the longest period of time possible. I will add though, that people will see for instance and a lot of this Medicals, our scientific literacy is so you don't get fooled by misinterpretation or sensationalism in media because you'll see a headline that says, something like bananas increased.
Your risk of colorectal cancer by 100% And what that means though if you dig into the data is like, alright, your risk goes from 1 in 5 billion to 2 and 5 billion. So it's just from a behavioral standpoint it just does not matter at all. There's a book called How to lie with statistics by Daryl Huff, which I think is a very fast read and that will also complement everything that we're talking about. So let's look a little more closely at
some of the content and interventions and tools in the book and I'm not sure this is a great way to kick it off. But there's a expression I've heard at least applied to Medicine quite a few times which is fifty percent of what we know is wrong. We just don't know which 50% and so I'm curious to know what you have seen kind of peeking behind the veil at what is not working and what you have then
Designed to address that misfire in your practice and by extension in the book, you mentioned a few things, right? Like a poby levels. You mentioned being very specific with exercise prescription being extremely specific and the, the possibility of lowering certain types of risks for fold. So I'll let you tackle that, however, you want, we can start, wherever makes sense.
We could probably talk about different things within different buckets. So, starting with sleep. I think that with sleep, I
Of like to simplify things a little bit sometimes. So one thing that I think is happening a lot right now is people are getting probably at least some people overly anxious about what their sleep trackers are telling them. And so, you know, we've got a problem where the pendulum has sort of swung a little too far to the other side where maybe 10 years ago, nobody thought at all about sleep. And now you've got a class of people me among them who maybe think too much about sleep and all of a sudden it becomes a little bit.
Productive and we see this in a subset of our patients and the first and most important prescription for those people is stop tracking. Take the tracker off. Let's just focus on the fundamentals. What time are you getting into bed? And what time are you getting out of bed? If we can within 15 to 30 minutes on either one of those completely fix that and completely toggle on the basic blocking and tackling aspects of sleep hygiene which have to do with food, alcohol? Light
Temperature noise, Etc. You're going to be okay and I don't really need to know what your sleep score is. And how many minutes of this sleep versus that sleep, you hatch? So, you know, I personally go through this myself, I'll go through phases of time where I'm not looking at any sleep tracking device and if I know I'm going to be in an environment where sleep is compromised, which is basically a lot of the time if I'm traveling I don't even take a sleep tracker with me. Because why do I need something to remind me of what's probably happening? How about? I just do the best job I can and be a little less data.
and so that's an example of where I feel like
You know, a couple of years ago I would have just said like more data is always the answer and now I think I'm a bit more measured in, I say look. Sometimes more data is not always the answer. Now, the flip side of that is there's nothing that will demonstrate to a person how much late-night food and alcohol are ruining their sleep than a sleep tracker. So I do think it's really valuable to see that and I think for many of my patients that has been the most decisive thing that has reduced their alcohol intake for sure. And despite what a lot of the
Epidemiology will tell people alcohol is not good for you in any dose. Doesn't mean we shouldn't drink it at all, but let's not delude ourselves into thinking. It's actually healthy at some low dose. It's not so understanding that. It's a toxin. I think help you have a more measured response in my response to alcohol. While we're on that topic, is if I drink something that doesn't taste incredible. I pour it out. I'm never going to tolerate a bad glass of wine ever. It's just not worth it.
So since we're
on it, I'm going to pull us back to this question of data, probably through the lens of continuous glucose monitors and the best uses and maybe the most common misuses for people who do not have type 2, diabetes, or type 1 diabetes. But let's just sit with the alcohol for a second. So what are your personal rules for alcohol? Consumption? Outside of the if it tastes mediocre or shitty, it gets poured out.
Which is a great rule, but what types? What are your favorite types of alcohol? How do you personally navigate
that? Well, I'll start with like kind of quantity. Yeah. So I would personally just say there's going to be an insane reason to have more than two drinks in a day. So it's sort of somewhere between zero and two and it's got to be a really good reason to drink on more than three days a week. So in the back of my mind, I'm keeping a tally which is I really shouldn't be having more than about seven drinks in a week.
And again, seven drinks in one day is very different than one drink a day for seven days. So it's the frequency, and it's the dose and that defines the poison. The second thing is I really have to make sure that that drinking is a good three hours away from sleep. Again, when I say these things, people say Peter you must be a robot. No, I'm just saying. These are general principles. There are going to be times when I violate that. I think I posted something on Instagram, a little while ago which was like the most rancid night of sleep nicely.
Data were comically bad. And the reason was, we had friends over it was very late, we drank, we ate, you know, I basically went to bed that, you know, by the time they left at like 10:30, I went to bed and we had just finished eating sort of thing and not surprisingly, my sleep suck. The point, I made in the post was I do it again. It was a fantastic night. The four of us hadn't had dinner together in a long time. So you just have to be very thoughtful and deliberate about the choices and trade-offs that you make as far as the type of alcohol.
You know, I think at least people, I
think love to this isn't again, an example of something. I think we tend to over index 20, you know? It's I drink a lot, but let me tell you, it's just vodka and tequila, so, but it's got to be good for me, right? It's like no. Alcohol is alcohol, right? So I love tequila. I love Mezcal. I love really good wine. And I love really dark Belgian beer. I'm not deluded to think that any of those are healthy. And I know that there are some people who have a horrible reaction to certain types of alcohol while I would put that in the same category.
These people who have a horrible reaction to certain types of foods, don't consume them, but I think mostly where I focused him is on, how much am I going to drink? How close is it going to be to bed? And What's the total tally per week and never exceed a certain tally in a given day?
You know, I was waiting for the right time to bring this up Peter. But, you know, I know that people say, cookies are bad for you, but I've only been eating Nutter Butters and I feel like, I feel like that's the equivalent, although it's less of a neurotoxin.
I do love Nutter Butters by the way.
They are good. There's I don't know. I had one but oh my God. Now that you reminded me of that, that's horrible if you do that
so well that will combine nicely with the see GM's so all the jeebies and the see GM's. So my guys, you inside joke, could you speak to continuous glucose monitors? Because for a long time, even still. Now these are broadly thought of as something. That one might only use if they have some form of diabetes.
However, there are people who do not fit in those categories, who use them, and I would love for you to just wraps, give us a bit of an overview on see GM's and and what you have seen as the best uses and how you use them in your
practice. So a continuous glucose monitor is a device. There were really two big ones on the market right now. One is made by a company called Dexcom and one is made by a company called Abbott in the latter is called the freestyle Libre. So, I think it's a company that I've acquired many years ago. These are devices that are worn.
And usually on the tricep, they can also be on the abdomen and they have a little tiny filament that is quickly shot in with a needle into the subcutaneous space. So the filament remains after the needle comes out and the filaments, it's in a part of the body where it can sample, something called interstitial fluid. This is basically the fluid between cells to be clear. It's not sampling the blood
So it's samples, the interstitial fluid and it measures glucose level there and it's basically calibrated to know, based on what the reading is there what the glucose level is in the blood. So a continuous glucose monitor as its name, suggests, is a way to give you real-time information about what your blood glucose is.
as you said for people with type 1 diabetes which was the first use case is a very important innovation because people with type 1, diabetes are by definition dependent on insulin so they are using insulin exogenously to do the job of their pancreas which is no longer working
and the pancreas of course is Like This brilliant organ where it's the one that's Auto regulating glucose via insulin and when that goes away they have to be the one to do it. So now they have this device that is at least giving them real time glucose information and they can adjust insulin injections as needed. It obviously didn't take long for that to expand into a much much larger market. IE 10 times the size which is people with type 2 diabetes some of whom do require
This insulin some of whom do not but all of whom by definition have a carbohydrate and glucose tolerance disorder. Very definition of type 2. Diabetes is based around unregulated peripheral glucose and this tool is therefore helpful, right? It's helpful in first and foremost I think knowing what to eat. I think. Historically, we have given people with type 2, diabetes, abject lie, horrible
News and insight with regard to what to eat, you know, we just haven't really help them think through this problem. So, the CGM makes it pretty clear that not all foods are created equal when it comes to managing glucose homeostasis, everything I've said so far, is relatively straightforward. I think, where we now, this is a great example by the way, of medicine, 3.0 versus medicine 2.0. So everything I've said so far more or less makes sense. If you're in medicine 2.0. In fact, I think we're finally at the point where even medicine 2.0 is starting to accept the
The carbohydrate restriction is a really good idea for people with type 2 diabetes. It's not the only way, by the way. So caloric restriction, in general, will work to improve insulin sensitivity, which therefore improves glucose regulation. But it does seem that carbohydrate restriction as a form or a gateway to caloric restriction, has greater efficacy than other methods. Once we now talk about people without diabetes medicine, 2.0 would argue a CGM.
Plays no role. Okay? Is there a randomized control trial demonstrating the efficacy of CGM in anything outside of patients with diabetes? There is not but now we have to get into the leap of faith. That one takes when you start triangulating between other pieces of data. So we want to start with one, which is in a population of non-diabetics, is there any evidence that glucose levels matter?
So type 2 diabetes is defined as having a hemoglobin A1c above 6.5 percent hemoglobin A1c is just a way to measure how much glucose is stuck to hemoglobin. And by knowing what that number is, you can impute, what the average blood glucose is in that individual over the preceding three months. So, six point five, which is the cutoff translates to an average blood glucose of 140 milligrams per deciliter,
So the question then would be if you take two people who don't have diabetes, one of whom has a hemoglobin A1c of 5.0. And one of whom has a hemoglobin A1c of 6.0, neither of them are diabetic. Is there any difference in their outcomes?
So to put that in perspective, the guy at 5.0 has average blood glucose of about 100 milligrams per deciliter. The person at 6.0 has an average blood glucose of about 120 milligrams per deciliter. So they're both outside that diabetes range.
Well, the answer here was actually pretty clear it is that there is a difference, in fact, for a non diabetic population, the lower the average blood glucose as estimated by hemoglobin A1c, the lower the all-cause mortality. Okay, so what's the implication? Now, we'll see. Implication is, if you take a group of people who don't have diabetes, but want to live longer IE, they want to lower their risk of cancer. They want to lower the risk of cardiovascular disease. They want to lower the risk of neurodegenerative disease. I think we can make a pretty reasonable.
The faith that having a lower average blood glucose is better than having a higher average blood glucose. Even if at higher average does not put you in the range of a diabetic. So now the question becomes are there tools to help us manage? That is the one tool would just be the A1C. You could say, well I'm just going to my hemoglobin A1c measured every six months. The problem with that, as we know, is that hemoglobin, A1c is very easy to mislead. It's very dependent on red blood, cell turnover,
so, the more rapidly red, blood cells, turn over, the more artificially low, the hemoglobin A1c will be and conversely the longer the red blood cells sticks around the higher, artificially the hemoglobin A1c will be this for that reason that we like to use CGM to actually get true measurements of average blood glucose when a patient who doesn't have diabetes puts on a CGM for the first time, they're invariably
Surprised. There's this real learning phase. That comes. You've done this Tim you were doing this probably 10 years ago you were your first one everybody goes through this. I remember you know for me it's been about eight years since I started at first, you simply cannot believe the things that drive your blood glucose up. You can time, it sounds some of it sounds
dumb. Could you give some
examples? Yeah. I mean, like, I remember the first time I had raisinettes, I was like, it's not like, I didn't expect it to go up, I didn't expect it to go up like that.
Exercise, certain forms of exercise. And by the way, I'm not saying this is pathologic. There's nothing wrong. When you're exercising for your glucose to Skyrocket. If you're doing to badas or you're doing hit workouts, again, it's not pathological, but it's super interesting. And other things that I think are pathological is how much your blood glucose goes up. If you had a poor night of sleep, if you have a horrible night of sleep, your insulin sensitivity gets crushed to the next day and your glucose levels go up. Well, that's actually very interesting. Maybe you could argue that adds too much stress to the
fire, but it's an Insight. Nevertheless, that can help drive a behavior change. I think, in the book, I cover my ten. Best insights from years of CGM, in myself. And patience, it's about different foods and foods, high in fiber are going to have one effect, lean sources of protein versus fatty sources of protein. All those sorts of things. Ultimately, I think CGM becomes a really helpful tool for compliance. It becomes a behavioral tool. We tend to gamify it a little bit. I know that when I'm wearing CGM, which I just happen to be right now, by the way.
I'm going to think twice before eating something stupid. And again, it's purely just because my personality likes to gamify things. It's like, yeah, I'm tempted to go and eat all the leftover waffles on my kids plate, but I just know. It's like a, it's going to shoot my blood glucose up and I like not doing that. Where I
think people
get into trouble and where the counter-argument is
Which is a fair argument is look, if you only index on blood glucose, you could still end up doing a bunch of things that aren't healthy. If you ate bacon for every meal every day, your blood glucose would not go that high but it's probably not the healthiest choice and I would agree with that. But by that logic we shouldn't look at body weight either because by smoking cigarettes, your body weight will go down. So does that mean body weight is a lousy measurement? Know
No, it just means that any measurement and isolation can be ridiculous and can be game. So we shouldn't ignore blood glucose any more than we should ignore body weight or body fat or body composition.
We just have to understand that it's one of many tools that we can look at and the CGM. Again do I think this is like necessary to live a longer healthier life? Of course not it's simply one tool that we have to help us understand how to regulate one of the you know for
macronutrients
So like to add two things to that. So the first is people listening who have not experienced a CDMA here, puncture filament and imagine something out of you know hostile to or something like that I will say that in 2008. I want to say was the first time I used a desk on which was the size of the cell phone is like Gordon Gekko and Wall Street is huge and the experience of putting what felt like to me subjectively
The kind of barbecue tongs into my abdomen was very unpleasant at the time I have however, tried the latest generations and you basically feel nothing. I mean, it's so easy in my experience. I mean, I don't know how many of your patients report a lot of pain with that but I was shocked by, how completely innocuous the whole procedure was, I mean, is very, very mild, very quick, very easy. So I just wanted to mention that. And then
Lee. This is probably applies more to your patients, then to you. But in the book, you mentioned, the Hawthorne effect which I think was first coined in manufacturing and looking at worker, Effectiveness or output. But that is the phenomenon. Whereby people modify their behavior when they're being watched. I think that is another selling point for some form of accountability. Is there anything you'd like to add to that?
At.
No, I mean I think we there are some patients of ours who actually want to utilize the Hawthorne effect and if we agree mutually to do so we can see all their data. So they can just say look I want you to be looking at my CGM data every day and that's going to hear an accountability partner for me. So I'm going to eat less junk food. So
what are some of the other perhaps underemphasized or underutilized metrics that you think are important? This could be in
Realm of metrics are tools, right? So it could be forms of screening. It could be blood, markers of different types. There are a few that come to mind that I imagine are on this list could be physical performance, markers of sometime. What are some of the come to
mind? If we're going to just talk in magnitude vo2max and muscular strength, stand in A League of Their Own. So there's really nothing that's within the zip code of those.
Two metrics. So having very, very high vo2max for your age and sex and being very strong, they have more of a positive impact than any single thing. We can think of has a negative impact and that includes having end-stage renal disease, like being on the wait list for a kidney while you get dialysis. Being a smoker having high blood pressure, having type 2 diabetes, being obese. The downside of those things is relatively small compared to the
I'd of having a high vo2max and being very strong. So we almost shouldn't even talk about things until people are willing to accept that fact and take the steps necessary to address them. Now, you might say well okay how many people can become very very strong or have a very high vo2max and the answer is, I don't know, like, I don't know, especially on the vo2max side, you know, to get into that top two point five percent of the population where you really start to see an enormous.
Armas gap between you and everybody else. In terms of lifespan, may be only a quarter of the population, has the potential to get there. But the point is everybody has the potential to be more fit than they are outside of people who are already doing everything they can. And so just going from being in the bottom, 25% of the population, to the 25th to 50th percentile of the population, Cuts your risk of all-cause mortality in half at any point in time. There's nothing that compares to that.
Like there's no drug out there that's going to do that. So again, I think you talked about drugs all day long and how I think they're really important and how we could think about controlling a poby and you know, rapamycin and Metformin all these other things, all that stuff is Pixie Dust compared to what these things are on the strength side. The same thing. Anyone who's got older parents knows this?
If you really want to watch somebody suffer when they're aging you watch them losing their cognition and you watch them losing their physical body. You watch them lose the ability to move around with ease to have balance to be pain-free. All of these things, while a big part of that is being strong strength, is something we can actually hang on to as we age. You know, we lose quickness long before we lose strength.
And that's the good news. The bad news is you have to be very deliberate and how you train it. I'm sure on the podcast you've discussed type 1 and type 2 muscle fibers. So people are probably familiar with that want to reiterate that our muscles are made up of these fibers that are very unique properties. So muscles are these multicellular things where the the cells are these long sort of fibers that can track past each other, and that's what creates the contraction of a muscle. But if you dig a little bit deeper, you have different types of fibers. So, you have type 1 fibers, which are fueled
Mostly if not entirely by anaerobic process so they can use fat, they can use glucose, but they do. So in the presence of oxygen primarily, they're very slow to fatigue, which is mostly where the name comes from but they don't generate that much force. So these are the muscle fibers that are mostly on display when you're walking or just carrying out activities of daily living
commonly called slow-twitch as you alluded to stretch.
So
you can you can you can do things for a long period of time and these things, don't fatigue, conversely. Another subset of these fibers are type 2 fibers and they're called fast, twitch muscle fibers and they're fast to fatigue. Now they're much more powerful, so when a type 2 fiber contracts far more is happening. It's generating far more Force, but it's doing so with a different metabolic strategy. So it's glycolytic it's just using glucose or, you know, broken down glycogen and it's going
Fatigue quickly. So it's accumulating metabolic byproducts that are leading to fatigue. So there's a reason why if I say Tim jump up and down as high as you can, as many times as you can, this is not going to be a long exercise, right? We do have to sit and wait, two hours for you to finish that. You're going to fatigue pretty quickly. If you're doing maximal jumps, whereas, if I say jump rope, you could do that for 30 minutes easily and if you're relatively fit person. So you get the sense of the difference. Now, as we age,
we lose
Lose
power and explosiveness more than anything else. And we lose that the soonest, and that's due to the type to fiber, the atrophy of the type to fiber. This again this comes back down to strategy. So that's why. If you want to live a longer better life, you have to have a strategy in place for maintaining type two fibers and you're not going to get that without resistance. You know, you can't say. Look, I play tennis every day, I walk every day. Those things are great. They're not doing something for your
Two
fibers. Yes, let me hop in for a second because I want to get specific on that because I think some of the approaches are tools. Might be counterintuitive for folks. So first just some random trivia for folks who might be interested. If you've ever carved a chicken or a turkey, neither of those like to fly very much and the breast meat tends to be white and then you have the dark meat. Well there you have type 2 type one fibers respectively. So just for the next time
You're cutting up a bird.
Yeah, the reason the legs are dark is they have much more mitochondria. Those are their slow-twitch muscles there that are heavily dependent on oxygen delivery and oxidative phosphorylation whereas the white meat, the breast meat is very fast twitch quick quick quick. Quick flapping doesn't have the mitochondria so that's, you know, has far less of it. And therefore, that's kind of a less oxygen rich muscle. When you dissect us, of course, you don't see that difference are type 1 and type 2.
Two fibers are less clearly separated.
So if someone wants to improve strength, correct me if I'm wrong, but you have a number of, maybe they're not. Just sure it sticks. I mean, the direct indicators, but you have a number of things that you focus on, and I'm sure there are many others. But in the strength category, I would love to know how you define very strong and perhaps this would be a place to talk about, or at least include.
Hand strength Farmers carry or anything else that you'd like to add. That might not immediately show up on someone's kind of mental radar when there's thinking of
strength. Yeah, I mean, there are a handful of strength categories that we think really matter and just ideas that are important when you think about strength. So one of them is the importance of understanding eccentric, versus concentric strength and how both are very important. I actually put something up on Instagram the other day about this where I
I just explained that the concentric phase is basically the go and The Eccentric phase is the slow. So you accelerate through concentric Force, which is the force a muscle. Generates, as it is shortening, that moves you forward the eccentric phase, which is equally important. But often ignored is the strength or the force that a muscle is exhibiting. As it is lengthening, that's what's decelerating, that's what slowing you down.
Andy Galpin. I think recently talked about a great metric and I agree. This is a fantastic metric something I'll check mine constantly is how far a broad jump, can you do? So I want to make sure that I can do a standing broad jump, that's higher than my height laying down. So you know if I'm 5 foot 10, I want to make sure I'm jumping at least six feet on a broad jump and a broad jumps are really interesting test. It's a profoundly extreme example of concentric and eccentric strength in the same movement. If your
Just standing there and you want to jump six feet in front of you, that requires an enormous explosion. That's a very high concentric load. But guess what, if you want to not break your nose, when you land and destroy your knees, you better be able to decelerate yourself and slow yourself down. That's an unbelievable eccentric asked. So, while that's a very extreme example, consider walking up and down stairs, walking up the stairs is very taxing, concentric lie,
But where do most people get hurt in life? It's actually walking downstairs. And if you watch, especially as people age the difficulty they have in slowing themselves down. When they're coming down stairs or taking a step off a curb. This is where people are falling and breaking their hips. It's far less that they're falling due to concentric weakness and far more that they're falling due to Eccentric weakness. So therefore principle number one in our strength,
Meaning is always be doing both not necessarily in the same movement, not necessarily focusing equally on a given day, but everything we want to do. We want to make sure that we are hitting the concentric and eccentric phase. Not just the more obvious which is the concentric
Now does that take the form of Simply accentuating? The lowering in the case of say a trap bar deadlift or something like that where you have something like two seconds up for seconds down or does it take other specific forms?
I mean there are other ways there are very specific exercises that you'll do. So, for example, like you know, a Nordic roll out, you know, Nordic fall, you know, for a hamstring exercise where you're, you know, what I'm talking about when you're kneeling on a mat and your feet are held in position and you sort of allow yourself to slowly come down. That's just
A purely eccentric
misery choirs quite a bit of starting strength to
do well and truthfully, we wouldn't have people do that out of the gate. You'll do that with assistance to start because most people simply don't have the hamstring strength to do that. Yes, it can be accomplished greatly by using slow what we call negatives. So focusing just as much on the negative as the positive. So for example, one of my favorite exercises to do our step-ups because one it's a single leg exercise, it's a beautiful hip. Hinge we can talk about,
Some detail in a moment because the hip hinging is another one of the big principles and it allows you to do a very nice isolation of The Eccentric on the step down and you really have to be able to control that. If you can't control it, you're using too much resistance. Obviously, so hip hinging is another big important principle. And, again, hip hinging. When people think about that, they think that doesn't have to be a squatter, a deadlift. No, it doesn't have to be, it can be a hip Thruster, it can be a lunge, it can be a step up. I mean, I think the Step Up might be the single most important one for people to do.
Because it doesn't have any axial,
loading. Could you explain what you mean by that
when you're doing something like a squat or a deadlift? There's weight that is basically pulling your spine down to your hips. In the squat. It's because the weight is actually sitting there in the deadlift. It's because the weight is being. The force is being transferred through your arms there. But in either case, you are loading, the axis of your spine,
And that's fine if you know how to do it safely but as you know you know, having done these things, that's not just something you can walk in off the street and do you really have to be coached how to do that stuff, safely. And stepping up onto a block is something that's much safer to do. And it's also something that you can do with a single leg at a time and therefore, you get to see where your asymmetries are because we all have them. I mean, I am so deep down the rabbit hole of step-ups that I can't even explain the nuances.
In oblique compression pelvic, angles, in the difference between my left and right leg, do it, tinkering with that stuff allows me to work out. So many Kinks with how my body works. You mentioned another one earlier which is being able to carry heavy things, you know this is just such an essential skill for our species, it's something we do better than anything. There is no animal that can carry with their hands. What we can do, certainly a strong male but history and even a strong female
L can carry their body weight in their hands half their body weight in each hand, is not an insurmountable task for us
with that. Be a hypothetical Target for your
patience. Yeah, we would like to see our patients carry half their body weight in each hand for a minute. So walk around with half your body weight in each hand for a minute. Yeah. And having strong hands is one of the most correlated findings with longevity. So, we talked earlier about, like, what does it mean to be really, really strong? Well, unfortunately, the data on this are based on what the studies show in the studies are
Testing interesting things, but they're not exhaustive, right? So they're usually looking at grip strength, leg extension bench press or the most commonly tested things but grip strength comes up over and over and over again, in studies, as such a proxy for longevity lower risk. I think there's a figure in my book that talks about the unbelievable, monotonic decline in both the risk of onset of dementia and death from dementia as grip strength increases again.
Kind of go back to the Bradford Hill criteria and you look at the strength of the association's. You look at the consistency of these associations. You look at the dose effect of these associations, very hard for me to believe that there isn't causal relationships here and that being stronger training to be stronger, will actually improve outcomes, not just, that strength is a marker of Health which is obviously correlated with living longer if that makes sense. I mean there's a distinction there. So yeah, we think that carrying things is very important. I'll
Two different phases, you know, I love rocking. So that's another thing that I think is just a great all-around way to kind of now, combine two different types of exercise. Something that's part of strength. And something that's part of endurance also wrecking gives you because it's so just for people who don't know, rucking is just basically carrying a really heavy weighted backpack. Probably one of the most important tools used in the training of special forces in the military. I mean you know you we have so many friends that have been through that and I'm amazed at how much they rocked like it's sort of like eight hours a day.
They're just walking around with 75 pounds on their back, if not more,
what is your protocol or like methodology look like for
Wrecking? So I use 55 to 60 pounds and I'll typically do an hour Ruck and because of where I live. It's really hilly. So I really like that going up the hills. I'm going hard. I'm really pushing my cardio up the hills and I'm trying to find the steepest Hills possible to come down because that's working that huge eccentric gear. It's really forcing me to be
able to decelerate on the way down those Hills with a lot of weight and you're not getting the pounding. I mean I think that's the beauty of it. Right. Is your back pounding your knee with the impact you would if you had to run to produce that effect
Yeah, that's probably the most compelling reason that I started rocking a few years ago and especially in preparation for for certain Alpine hunts and so on have did a ton of rocking and the collateral benefits? I mean, they're not really collateral mean, the direct benefits where this sort of holy shit effect that sometimes I've seen with kettlebell swings and other things where this translation that you wouldn't expect pops up in all sorts of ways and I used to be a runner but
I ended up you probably didn't know this, but I used to be a cross country Runner. When I was say up to it but age 15 and then through poor choices like doing lots of wrestling and other Impact Sports developed knee issues. And so stopped running. But I always missed the sensation of getting a good workout while walking or moving in some Fashion on ground and rucking salt that coming back to vo2max. So vo2max, I've always wondered to what degree someone can.
VO2, max already spoke to the benefits, even if you're moving from, say 25th percentile, the 50th percentile, huge benefit, right? I mean, how I think you said housing housing, having cutting in half certain mortality risks, what have you found to be the best approaches for improving, VO2 max
well. First off, it can actually be improved quite a bit. I think the research out there understates how much it can be approved because the research studies are relatively short. So
So, you know, it's true that in a 12-week study, you might see, you know, kind of an 8% Improvement or 10% Improvement, I would say that's just the tip of the iceberg, right? We're not talking about 12 weeks of training here. We're talking about a lifetime of training and we're talking about 25, 50 percent Improvement in vo2max that anybody who's been involved in serious, training will see all day long. So the how is also very important, the analogy. I like to use which I'm sort of borrowing from one of my old cycling coach.
Ouches is that think about building a pyramid, the VO2 max is the height of the pyramid. So if you want to build a really high pyramid, it also has to have a really wide base.
So the key for building a high VO2, max is saying, I'm going to spend about 80% of my aerobic training time in zone 2 and this is counter-intuitive, right? A lot of people think, oh my God, if I want to build a high vo2max, it has to be all intense training. No, you have to first and foremost build that huge aerobic base, that is the pyramid that allows you to make the peak higher. So once you have that aerobic base, that other 20%
One of the time is used, you know? So basically most people are training too hard to build the base but not hard enough to build the peak. So they're in when I kind of think of as garbage training Zone
and not the kind of rip on it not to get too technical.
Yeah, but it's like, that's sort of the problem with doing a lot of, you know, sort of fun classes and stuff. Look, it's absolutely better than sitting on the couch for sure, but it's not specific enough to achieve this goal. So you really
I want to kind of separate that zone to from that zone 5 and when it comes to vo2max, you basically have to be in the 328 minute range is the sweet spot. So it's got to be intervals that are about three to eight minutes. So, three minutes at the low end, meaning you're doing something that is so hard. You can do it for about three minutes and at the high end, eight minutes. If you can do it for more than eight minutes, it's not doing a lot for your VO2 max. If you're to be good, if you can't do it for three minutes. It's also not doing the maximum out of your VO2 max
and just
For clarity that's the zone 5 that you're referring to
build. Yeah yeah exactly. And here you're typically doing about a
one-to-one
work to rest recovery. That's how hard these intervals are. If you do three minutes at that whatever that output is you're going to need about three minutes of recovery before you can do it again. So we typically say like a good starting point is four by four four on four off four times.
That's just a great workout to start just doing that work out once a week. Let's say, three days a week you're going to do your cardio and it's going to be kind of the low end zone to cardio one day a week. You pick an exertion level that you can barely get through four minutes of it. You can do it. But you have a little bit left in the tank, but not much and that that you need four minutes to recover. And then you do that four times sandwiched between a warm up and a cool down. What would the film understand correctly? That would be the building of the peak. What does this?
Into training look like
long and slow. So for me it's all done on a bike
aside from subjective perceived exertion is their heart rate range, or anything else that you can use as sort of a proxy indicator so people can have something to aim
for. Yeah, once you get fit enough lactate becomes really good. So measuring lactate with a point-of-care, like a finger prick devices. What I do, you're looking for a lactate level of about 1.7,
22 mmol for most people is the zone. For people who aren't yet fit enough. Their lactates are usually going to be way higher than that, while they're still training that energy system, or if people just don't want to do that. And for those people rpe rate of perceived exertion is really the best way to do it and it's far more accurate than heart rate. So the rpe is you should be able to talk but you don't want to. So today I did a Zone 2
I ride this is very unusual but just because of the way it was today, I spent the entire Zone to on a phone, call my entire workout was on a phone call.
There was absolutely no confusion on the part of the guy in the other end of that line that I was on my bike.
And that I wanted him to talk more than me. I was breathing like this. It was like, okay. So yeah, you know, like, I mean that's, that's kind of how I was going at it. I can nasally breathes, when I'm doing Zone 2. But it's, I'm right at the limits of what I can do and it's very easy for me to nasally breathe. Like, I don't mouth breathe at night or anything like that, so that kind of gives you a sense of it, if you can talk pretty easily while you're doing it. Like if you're out on a walk and you're talking to somebody, that's too easy, if you can't talk at all.
That's too hard and I think that is by far the best
test. Just to give people some more specifics of the for the zone to, how long would a Target session? Be how many times per week and then similarly for the 4x4. Let's just say that you described for these own five building the peak. How many times per week would you do that?
I think if we can do that once a week is great. And again that's 15. Yeah. Zone 5 and I think for Zone 2, we think minimum effective dose. So again, it depends on where
Starting if you're starting with, you've never exercised in your life boy, we'd be happy to get you doing to 30 minutes a week Zone 2 sessions but you very quickly will start to adapt to that. And then I think we start to get into three hours being the Meed and that might be. And that might be kind of 360 minute sessions or for 45-minute sessions,
have you ever tried Peter? And I'm just going to bring this up because we spent a good amount of time together and this has been a bit
of a revelation for me. Have you ever tried skinning on skis? Going uphill with skins on skis,
Lance Armstrong is a good buddy and he moved out of Austin to Aspen a few years ago. I keep giving him crap for it. And I'm like, dude, why did you leave? Why did you leave? And he's like, yeah it's tough. I mean, especially in the winter because he's a summer sport guy, but this is his form of winter exercise, and having him describe it to me, I'm like, yeah, I can see that. That sounds pretty awesome actually.
So, you know this Peter but people listen, amen.
I historically and about as far from an endurance athlete as you could possibly be in the sense that if you look at my sports career such as it was, it's all optimizing for trying to win very quickly, within three to five minutes, generally and anything close to Extended exercise has always been rightly and probably wrongly punishment in my view. I just have really
Liked it, which means I've gravitated towards weight training, things like that. Skinning and rucking are the two things that have changed that my body including like my low back pain. And so on feel so much better when I am doing skinning and rocking, I will say with the rucking and I don't know what your setup looks like, but I really benefit from having a waist strap, there are rucking backpacks out there that do not have a waist strap. And I find those can cause some back pain. If I have either too much
Each weight use them for too long or both.
Can I make a Shameless plug for my friend Jason McCarthy's Company? Goruck please. I have no affiliation but I love Jason and I love the company. So yeah the goruck is the way to go here. You just need a backpack with weight but if you want to invest in it they make amazing packs. You can buy these bolt on waistbands that allow you to support because I'm like you I like to have 80% of the weight on my hips and virtually none of it on my shoulders. I don't even
Link up the little strap across my chest because I want to be able to breathe fully. So I'm very light on the shoulders, incredibly heavy on the hips and their packs and the weights that come with them. Just make this a very elegant solution. So yeah, totally agree.
Yep. So goruck. I also use go Rex. I'll give them a plug. I don't know the founders but ended up honing in on on go wreck. And I will say also, the breathing component aside from the loading distribution that you just met at mentioned. One of the benefits that I find of rocking versus say a weighted vest which are quite popular in the CrossFit community. And so on is the where you are, bearing the weight and also, the ability to breathe those? We two advantages and I'm sure there's a lot to be said for the weighted vests as well. Although
Though funny I'll tell you Peter. I know if I ever told you this this was probably 2009 2010. I decided I was going to try weighted vests and I was like this is going to be fantastic, can't wait. And so I bought this monster which was loaded up, it looked like a suicide bomber vest has just had like all these they look like canisters full of way much that our way. Well, okay, I'll get there. So I thought to myself, it's just walking.
At that point, I was very seriously and I know this is not winning any records, but for me, it was a lot. I mean, I was probably 180 and I was deadlifting 475 for wraps, which is as high as I got. And I thought to myself, I walk all the time, let me get, I think it was a hundred pound vest. So I get this hundred pound vest and I put it on and I decide to go for a leisurely, you know, two or three mile walk and I get a mile out and I'm like, I can't carry this thing. I'm just going to collapse into a puddle.
On sidewalk. So I had to leave the vest on the sidewalk. This isn't like the mission in San Francisco and go back to my house, to get a car to come, get it. And I thought to myself, if anybody steals this thing, they deserve to have it and not surprisingly, the weight vest, did not move it. Stayed exactly where it was. So, yeah, rocking. I suggest we're rocking and start lighter than you think.
Yeah. I recommend people start with a sixth to a quarter of their body weight.
To get you. As you'll end up, dropping it somewhere
and truthfully, I think, you know, Michael Easter, who's written about this extensively. In his book, The Comfort crisis, which if your listeners haven't read that, not that we're trying to give them more books to read, but the Comfort crisis, I can't recommend highly enough, you know, I think he said that even the military right now thinks that you don't really need to go above a third of your body weight. Let gravity help you more than that. But anywhere, from a 6 to a third your body weight is probably the sweet spot where I've
ended up. This will make me sound week maybe.
Is right around 45 and some cases. I've added a bit more weight but I probably weigh 175 right now 45 and then focusing on inclines. Basically, just going for the sort of geographical altitude or not even necessarily altitude, but the incline challenge rather than, than slapping on a ton of weight and walking on flatter ground what are some other for you? Crux we've spoken about strength with we spoke about VO2 max just so I can
I may be explicitly. Explain why I've spent, and we have spent some time on this, it's because the implications are not purely muscular, and maybe this is a place to talk about what you have learned about a neurodegenerative disease and specifically, perhaps Alzheimer 's because I think this will all tie in and show people that these sort of Cartesian duality of body and mind is really a loser.
Could you speak to that?
I think that probably the first time I took a hard look at this would have been 2014 maybe 2015. And at the time I had one analyst is named and palych are look at this in detail and got. It was a, it was probably a six to nine months project. I mean, it was a really, really exhaustive. Look at the literature and the deepest dive, we could do at the time of
What do we know about the prevention of Alzheimer's disease? So, again, we started with a very bold hypothesis, which we were not alone in, but most people thought was crazy, which was that these diseases have some degree of prevention. There is a way to prevent these to some extent, maybe not completely. But luck is not the only thing or bad luck. Is not the only thing that is driving these diseases. We have some control and so to make of her
For short after Dan kind of went through all of this analysis. And after analysis, after analysis, the thing that stood out above everything else was the benefit of exercise. And I just sort of told Dan to go back to the drawing board. I was kind of like, damn. I think he's screwed this analysis up,
buddy. Like there's zero
chance that exercise is actually the best thing here. Are you going to now? Tell me that chicken soup is the best thing for colds. Like I wanted some insight here. I didn't want some
Some stupid platitude but it turned out Dan was right and I was wrong. So I think the data are pretty unambiguous, you know. In fact I'm doing a podcast on this but a time this one's out. It might be out, I don't know, but I've got a podcast coming out on sort of brain health and here we are back again. Now with many more analysts and much more tools at our disposal to kind of understand the literature and still exercise Remains the most important modifiable Behavior. We have
To reduce the risk of Alzheimer's disease and probably Parkinson's and Lewy Body Dementia, by the way. So we can't say that for every single neurodegenerative disease, right? I can't. I don't have any real insight into how you prevent Lou Gehrig's Disease, which is an absolutely horrific disease. That is fortunately much more rare, but when it comes to the big three Alzheimer's, Parkinson's and Lewy Body dementia exercise, exercise, and exercise matter. And part of that has to do with movement Reserve. So,
When you think about Lewy Body and Parkinson's, these are primarily movement disorders. So they're kind of on a spectrum. You got Parkinson's at one end, pure movement disorder, little bit of cognitive Lewy Body kind of bit of both and then Alzheimer's much more cognitive having a higher movement reserve and having a higher cognitive Reserve are protective.
What do you mean by movement Reserve? Just greater range of motion ability. Suspect remove movement patterns that they can
sustain greater physical capacity. So people who are really good dancers who are
Really good at doing complicated coordinated problem, solving things with their body, who have kinesthetic awareness. They're going to have a much slower decline even when diagnosed with Parkinson's disease, for example, so we want our cognitive Reserve High, we want our movement Reserve High and then on the other side of that, you get the kind of hormonal vascular metabolic benefits that come from the actual exercise. So, one is the benefits you get from being in the state.
81 is the benefits. You get accruing, the
state, could you expand a bit on the hormonal effects? And otherwise mean, I think this is probably just because it has words in the acronym that I like, but brain-derived neurotrophic Factor etcetera. I mean, to what extent can you? Wait, some of these
factors? I don't know that. I could tell you a relative waiting, but certainly bdnf is a very important one. So it's a very important growth factor for neurons, but also, of course, when you think about the metabolic,
The effects and the hormonal effects that come from what is exercise doing to cortisol levels? What is exercise doing with glucose and insulin levels? I mean we see an unbelievably strong association between Type 2 diabetes and Alzheimer's disease. Again, here's an example of where medicine 3.0 I think gives you a little bit more confidence to make the extension, which is look. If type 2 diabetes is bad, having insulin resistance without type 2, diabetes is also probably bad. Therefore, we want to take all steps possible to maximize insulin.
Activity, glucose, disposal. All of these things that fit under the bucket of metabolic health, and again exercise is not unique in its ability to act on those things nutrition. Absolutely does as well. But boy, does exercise have a profound effect on those things?
Let's talk about
training the trainer, Maybe by that. I mean the vast majority of people listening to this will not be able to work with you or a practice like yours. What types of requests can they make of their Physicians? What types of tests might they ask for this baby? A clumsily worded question, but how can they make their doctor and their
Health Plan per se better. Are there any recommendations you
have? Yeah, look I think that kind of comes back a little bit to your medical literacy question at the outset right which is I think part of it is also just being a bit more clear about what your objectives are. When you're finding a doctor and understanding a little bit about what their style is asking them, what is their philosophy on something? How much time do you spend learning about things that you did not learn in medical school? I go back to something I said earlier, which was
there's almost nothing I do today. Tim that I learned in medical school. I can't think of one thing and it's not because what I learned in medical school wasn't valuable, it's just that and maybe that's the wrong example. By the way, let's be a little less glib. If I look at the physicians in my practice who trained in Internal Medicine and ask the question. What did you learn in residency that you're using today? The answer is probably like 10 to 15 maybe 20.
Percent max.
So, where did that other 80% come from? And I'm arguing that if you want to participate in medicine 3.0, you have to be able to learn outside of your training. And I think that's that's a discussion that should be had very deliberately and not obliquely. So I think understanding where they sit on prevention, understand how they're educating themselves, what are they reading? What are they learning? And if the answer is, hey, it's not a good fit, great better to find that out.
Out before you jump in.
As we're talking about this, two things came to mind and please feel free to dismantle this. But the first is to be able to assess medical literacy. You have to have a certain base level of medical literacy yourself. So I would say kind of Step number one is developing a working vocabulary and also Frameworks, many of which you provide in outlive such that you can actually assess other people to some
That's kind of step one. The second is that if we think about many Western trained or I shouldn't say, Western trained Physicians, who are schooled in a western Paradigm as those focused on the sort of addressing of disease, rather than prevention of disease, broadly speaking, it may be may be unfair to paint, so broadly, but let's stick with that for a minute. That as you think of your health care, it goes beyond just your primary care physician and could vary.
Well, and probably should include people like exercise. Physiologists are people who are trainers, given how much overlap and integration. We've discussed in the course of our conversation, and it just occurred to me that and this I think is quite true that. It's a lot easier. Not that you shouldn't look for concierge doctors if you have the means and that's a possibility by all means do that, but you can find. Excellent, excellent strength, coaches.
Has I would say much more easily than you may be able to get yourself into a economic position where you can for concierge medicine and the payoffs. I'm not saying they're comparable but the payoffs of having a good strength coach or an endurance coach go a long way. So those came to mind also. So let's just say they're asking these questions of their doctors, they find a doctor. Are there any particular?
Recommendations, you would have a couple of things. Come to mind that I have in my notes Here. Related to tests to request. For instance, I don't know where you stand now on Grail, which I guess would be considered, sort of a liquid biopsy, right? Scans like, pre Nouveau for instance, and perhaps more intelligent approach to family. History is something that I know you cover in the book. Would you like to speak to to anything that might fall in that category of things?
To consider
requesting. We think it's really important to be testing, you know, as I said apoe is one thing for sure. We really do want to know that genotype and again, if you believe that Alzheimer's disease, has some element of prevention baked into it, then knowing that your high-risk should be a valuable thing to understand when it comes to understanding cardiovascular disease, you know, we care deeply about a poby apob again, being a more important metric than LDL cholesterol or not.
HDL, cholesterol or HDL. Cholesterol. This apob is the concentration of all atherogenic particles. So includes all the hdls vldls, ETC. Also knowing LP little a which is a genetically determined very high-risk article that while it can't be modified will allow you to understand how much more you need to optimize. For example a poby. So knowing LP little a knowing apob knowing apoe, there are other biomarkers obviously that we care deeply about, you know, uric acid homocysteine.
Dean insulin, liver function tests, Statin see, is one that I think is largely under appreciated. So most doctors are using creatinine as the measure of kidney function. Creatinine is a joke actually, actually, at some point I wish I had the time and maybe I will make the time to do a deep dive into how it became the de facto gold standard for measuring and estimating. Glomerular filtration rate, it's an absolute atrocity. So for a person who's very low in muscle mass, it really overestimates kidney function for a person with
Muscle mass or who's just exercised, it really underestimates kidney function but it virtually never correctly, estimates kidney function, whereas Statin see which is another blood test, probably costs a few more dollars but certainly not much you know it might be the difference of one dollar versus seven dollars or something completely more accurate and unlinked to these
issues. How do you spell? Systen C,
Cy s t a cyst at like it says it sounds phonetically. I
Never. I could do the spelling
bee but it kicks. See people find it on Google. Let's see
what I asked. Yeah, exactly don't. I don't don't ask me to spell anything longer than
all right. How about on the early cancer? Screening side.
Well again the cancer chapter is probably a very long chapter for a reason but I think one of the big takeaways on that chapter is the overwhelming evidence that treating cancers when they are detected early has significantly better.
Comes in treating the exact same cancer later on down the line, even using the same cocktail of drugs. I think the two examples in the book, I use our that of colon cancer and breast cancer. And looking at, you know, for example, using the full Fox regimen of chemotherapy to treat a patient with adjuvant treatment meaning. So a person that had a stage 2 or stage 3 colon cancer, that is respected. And at least surgically you don't see any gross disease. They just have microscopic disease. You treat those people with the full Fox
Chemo regimen, which is a multi drug regimen and you compare that to people who have metastatic disease.
The outcomes are vastly different right in the latter group, nobody's going to survive for 10 years. And very few of them will make it five years. In the former group, 80-plus percent are going to survive 10 years, go through the similar example with breast cancer. The point here is the fewer tumor cells. You have the smaller, the burden of cancer, the fewer, the mutations, the fewer, the Escape mechanisms that are in place to evade, the immune system, the more likely you are to survive treatment and therefore
Until we figure out ways to completely eliminate cancer, which I don't think are going to happen. Anytime soon, we have to take a much more aggressive posture towards screening and acknowledged. By the way, the downside of that, there's a significant downside to more aggressive screening. But if you can, if you can come to grips with that, you have a better chance of beating cancer by far and to your question. Now, Grail becomes one of the tools. We would think about doing that. So
Rail is a company. I guess it's currently or now probably owned by Illumina. It uses something called cell-free DNA. So, it takes a blood sample, tubes of blood, and looks in there for tiny, tiny, tiny amounts of DNA that are out of the cell. So most of the DNA if, you know, Tim if you win did a DNA test and they took blood, they would take the DNA out of cells in your blood, they break down red blood cells and white blood cells and take the DNA. But this technique looks at all the DNA, which is not in cells, which is
Is a fraction of a fraction of a fraction of a percent. They look at that DNA and by looking at the methylation pattern of it, so these little methyl groups that are stuck to it, they impute two things, one is cancer. Likely to be present, yes, or no. And if, yes, can we figure out what organ it is? Where did it come from? So these tests have a relatively low sensitivity,
Meaning, if a cancer is present their ability to detect, it is not that high.
They have a very high specificity, which means if no cancer is present, they are very likely to tell you that every screening test has to be tuned towards sensitivity versus specificity. And this test is tuned to very high specificity. Very low, sensitivity. So the implication of this is for a low prevalence.
Cancer. So for General, screening by General screening. Okay, so let me take one step back knowing the sensitivity and specificity of a diagnostic test is only slightly useful. If you don't know, the prevalence of the condition you're testing for which is called the pretest probability, you can't actually impute what's called positive and negative predictive value. In other words, what you really want to know? When you look at a diagnostic test before you take it is if it's positive. How likely is it that
Have the condition. If it's - How likely is it that I don't have the condition that's positive and negative predictive value respectively. And you can only answer that question when, you know, not only the sensitivity and specificity but what your pretest probability is. And if you don't know that, you would just say, well, what's the prevalence of the condition and where I'm looking? So when you take cancer screening in a general population, the prevalence is very low. We're going to be 1% 2% 100 people that walk into for a random cancer. Screening you wouldn't expect more than
one or two of them have cancer. So with a low sensitivity and a high specificity test. You have, if you do the math, you'll see very low positive predictive value and very high negative predictive value. And for that reason, I think initially was not blown away by the test because of how low the sensitivity was for low stage cancers, like stage 1 and Stage 2. The sensitivity was like, 20%. That's the metric that I cared most about. I don't really care about your sensitivity at detecting stage 4 cancer.
So we've blown it if we're waiting until that point, what is very interesting to me though, is when you start to look at this by histology and this to me is interesting, if you look at all breast cancer, the stage, one stage, two sensitivity for detection is 20-ish percent, but if you look at hormone negative breast cancer, it's 75%.
If you look at hormone positive cancer, it's 20%.
Basically, what do you mean by hormone negative and positive?
So one of the most important ways that we identify breast cancer is by its hormone profile. So is it estrogen progesterone and or her to new positive? So, triple negative breast cancer has the worst prognosis. So a breast cancer, that does not express the progesterone. Estrogen or her2/neu receptors has the worst outcome. It's the most aggressive breast.
Cancer.
And those cancers even at the same stage are far more detectable. They have a 75% sensitivity in low stage cancer.
this tells us that we need to think of liquid biopsies in a very different way from how we think about quote-unquote anatomic, screening,
So a mammogram or an MRI or ultrasound are agnostic to the properties of the cancer. They are simply looking at its presence in size. What this liquid biopsy? Might be giving us a window into is the behavior of a cancer. Why is it that a triple -? You know, I have a 75% chance of I'm using the terminology looser but let's just say I got a 75% chance of catching it in the bloodstream, even at an early stage. Whereas if it's triple positive.
It has a much better outcome. I'm not going to catch it. Very likely at that stage, might be that because the latter is not that lethal and therefore, it's not shedding and the former is much more lethal and that's why the cancer is spreading. So I think it's super early days on this cancer, screening is definitely one of the most contentious things that, you know, I probably talked about in the book because I do take, I think a very different view from the mainstream, which is that we have to do this aggressively,
All we have to do this early. I mean I'm I'm just 50 years old. I've already had. I'm three colonoscopies in at 50. So to me it's just as it's unacceptable. I think to die of cardiovascular disease in the year 2023. I think it's unacceptable to die of colon cancer and your colon cancer is the third leading cause of cancer death.
Yeah yeah I will just say like a name names but a friend of mine put off colonoscopy for a few years older guy and yeah I know who you're talking about with yes stage 4.
Or so early counts, early counts a lot and I'm just going to leave a couple of gingerbread Trails for folks because I do want them to pick up the book. I mean there's so much we couldn't even scratch the surface in our conversation, but the contrast between say, a CT angiogram over calcium score or calcium scan. I mean, there's so much we could dig into immunotherapy and many other things, but what I'd like to do, you'll probably get a kick out of this. Number one, I think you have some of the best chapter names
I've seen in a long time, so I want to, I want to give you credit where credit is due and then
by the way, some of those might be Bill Gifford might deserve some of the credit. My co-author I was really struggling for some chapters with quotes. You know, we as you probably noticed each chapter has a quote. And I think Bill probably came up with three quarters of them. I was really struggling with the quotes because I had some that were okay but he would always come through in the end with a better one. So
all credit to Bill. But what I'd like to do just to give people a lay of the land is actually
This is going to sound ridiculous, but just read through these briefly. And then what I'd like to talk about is how and why you decided to include the chapter, the high price of ignoring, emotional health. So, if you bear with me here, I'll just do a little recital. So chapter one long game from Fast death to slow death, and I'm not going to give the chapter numbers. I'm just going to go through these medicine, 3.0 rethinking medicine for the age of chronic disease. We touched on this briefly objective strategy tactics. Our roadmap for
This book centenarians is coming into part two of the older. You get the healthier you've been eat less live longer question mark the science of hunger and health one disease to rule them all the crisis of abundance, the ticker confronting and preventing heart disease. The deadliest killer on the planet. That's my chapter. As you know if anything is going to kill me that isn't an accident. It is probably heart disease. The Runaway cell new ways to address the killer. That is cancer. Chasing memory, understanding Alzheimer's disease. Also, something in my family and other neurodegenerative diseases.
Part 3. We're rounding. The bend here coming into home here, thinking tactically building a framework of principles that work for you. Exercise Nature's longevity, drug Training, 101 training for the Centenary and decathlon. Which for those long-term long-term podcast listeners, that may sound familiar and it's certainly been refined and developed in the form that you find in this book, The Gospel of stability, relearning, how to move to prevent injury nutrition? 3.0? You say potato, I say nutritional biochemistry that's the most Peter
Thing I've ever read putting nutritional biochemistry into practice, new rules, for changing the way you eat the Awakening, tap into the power sleep. And then last but not least work in progress, the high price of ignoring emotional health. Why the last chapter
I'll tell you something funny. When I had an early draft of the book, I shared it with a mutual friend of ours, Hugh Jackman and Hugh read it. And his only feedback was that should be the first chapter and Hugh had a really solid argument for why that was the case. The publisher absolutely said no chance in hell. And so it was either nowhere or at the very end of the book. So look, I think that this was the hardest chapter 2 right unquestionably
It's the 17th chapter that has very little to do with the other 16 for reasons. I won't necessarily explain here, but it's a very different format. It's a very different structure and it tells a very different story. But look, I think for some people, it might be the most important chapter in the book, and I think for others, it might be totally irrelevant. But that was a risk. I think that was worth taking and I'll just say this, I think you alluded to this earlier on several occasions.
Longevity without Health span is the greatest curse in the world to live a long life and to suffer is not to live and that suffering that loss of Health span can be cognitive. It can be physical and it can be emotional. And that last one is so squishy. That it's hard to talk about in a medical book.
But that chapter is basically my way of trying to do that.
I just want to have some, if you don't mind I'll give a teaser. Now, there is a lot to this chapter, we're not going to dig into all of it, but maybe we could start with and we won't spend too much time. As I'm watching the lighting and the sun and the moon, and the stars, change your video because I know I've been gone for a while, but are
You open to discussing the 47 affirmations that you had to write and the context a little bit of the context around that because I think a lot of people listening to this will identify with certainly that particular instance of your experience.
Yeah boy. It's hard to explain that without explaining where I was when I was being asked to do that but
sure you can say whatever you'd like
to again the sun is low. So let's just say I was in a rehabilitation center where one of my homework?
Assignments. On the first day was to write and affirmation for each year. I've been alive at the time. I was 47. This was three years ago so it was you got to come up with 47 things to say about yourself that are positive and I couldn't come up with more than a few. I was sort of stuck at four or five until the 19th day.
and then, I really kind of had an enormous breakthrough that honestly, in the book is
I don't devote a lot of real estate to it as profound as it is, but I think, if you're really of person reading this who's been where
I'm taking you will understand it. But I think once I reached that point, once I had that breakthrough, as I described in the book, I was able to write the remaining 43 of them in 20 minutes. Those 47 affirmations then became a very big part of my kind of recovery contract. And for a period of about six months, I would read those twice a day every day, standing in front of a mirror, which sounds very sort of Stuart Smalley, whatever that character's name.
Was what was his name? Smiley, smiley smiley enough, people, and people like me. That's right, that's
right. But I think for my problems this was such an important step the term fake it until you make. It has such a negative connotation from Silicon Valley and companies like their nose. But in Psychology can actually be pretty valuable. If you start to say something enough, you will believe it. And that we think about that a lot in the
but it works also in the positive and I think that in some ways that one exercise became a very important Brick in the Wall of
fundamentally altering, my view of myself and fundamentally altering. The stories, I told myself
I must say someone who was there in your life for that period and also watching the steps that you took including what you just described. I am so glad that you
included the chapter in this book because I think a lot of people who would like to optimize lifespan and healthspan nonetheless find it easier to think about the maybe hard measurable edges of something that is physical versus that which is currently giving them the most suffering which is some lack of equilibrium or a set of proper.
Should say proper constructive lenses, through which to view life and themselves. So I think it's a real gift and not one without. I'm sure some trepidation on your part to include this in the book. So I just wanted to commend and thank you for including I think it will help a lot of people and so I hope you. I hope you feel good about ink so much. Yeah, I hope you'll get about a Peter Peter, we talked about a lot. The sun is come, the sun is gone. Is there anything else?
That you would like to mention before we close any requests of people. The book is outlive the science and art of longevity. I'd never say this long-term listeners will know this. Go get the book. This is a very, very solid book that many years have gone into, not just in the writing, but in the living and experimenting and refining and changing of mind that is reflected in this sort of adaptability and principles in the book.
So I do recommend everybody. Check out the book of course early medical.com Peter, Tia, m.com. There are many other places on Instagram at Peter. Atia MD, is there anything else that you'd like to mention Peter before we wrap up
no other than just to really thank people. I think there's a lot of noise out there in the world today and I think that anyone who's going to buy this book and devote the time to read it or listen to it on the audiobook. This is not a to crapper, right? This is not a book, you're going to read on the toilet and taken to crap.
Oops, I've never heard that expression.
Oh, I think of all books is, how many craps it every book is like it's a fork rapper, that's a 2
cup.
It's an amazing honor little things I've been doing for the book prep that would have ordinarily annoyed. Me to no end. Haven't annoyed me at all, because I'm realizing it is sort of a special thing that you have a relationship with someone. You're not necessarily meeting but they're doing something that is giving of themselves which is taking the time to read this thing and in exchange you're giving them something that's you know, hopefully valuable. So anyway, thank you for having me on the show Tim and thanks for people who are going to maybe go out and get this thing.
All right guys, it's no to crapper. That's my quote on the back of the book you'll find it featured prominently on Amazon and Peter. Peter, congratulations, man, I know this has been a long time coming, I'm excited for you, I am even more excited for the people who will read this and hopefully derive from it, some clarity and focus amidst and overwhelming amount of noise and bullshit out there.
So I do see this as a very strong signal in a sea of noise. So I encourage people check it out, outlive the science and art of longevity dr. Peter a TIA nice to see you man to be continued in person soon. Maybe we'll have those two drinks of peace with some red wine and some nice selects of axis deer from your freezer and best of luck with the launch, man. Thanks for making the time.
Thanks man. Appreciate it. Thanks so much.
Hey guys, this is
Tim again, just one more thing before you take off, and that is five bullet Friday. Would you enjoy getting a short email from me every Friday? That provides a little fun before the weekend, between one and a half and two million people. Subscribe to my free newsletter, my super short newsletter called five bullet Friday, easy to sign up, easy to cancel. It is basically a half page that I send out every Friday to share the coolest things. I found or discovered or have started exploring over that week. It's kind of like my diary of cool things.
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