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Language: en
the higher that level the longer you're
going to live there is no number there
is no biomarker there's no finding in
all of biology that is more predictive
of a person's length of life than that
specific number
you have a quote in the book that goes
something like I used to think that diet
and nutrition were the cure-alls and now
I'm not so sure
how is it possible that diet and
nutrition which would have been the
thing and I've said many times in the
show if if you just let me
control a hundred percent what people
eat
I I've got them covered I'll control
their body composition but the one thing
I always caveated was I don't know that
I'll keep them alive longer because I'm
running an NF1 experiment so what made
you start to lose faith that diet and
nutrition were the answer well I think
it's important to differentiate between
a couple of things so I definitely don't
want
um what I've written or what you've
correctly interpreted to imply to people
that I don't think nutrition is
important right what I'm really saying
is nutrition is an asymmetric input to
the equation if we want to think about
it technically meaning it has far more
downside if you get it wrong than it has
upside if you get it right that's
interesting does that make sense yeah so
getting it wrong will really hurt you
getting it right man it's not going to
make you live to 200. that's right I
mean first of all I don't think anything
will but yes that's the right idea no
absolutely not so so if you get it wrong
and let's be clear we are living in a
case study of getting it wrong right MO
the standard American diet is all about
getting it wrong for virtually everybody
so we're we're watching proof positive
what it means to get it wrong but what I
want people to understand is
it's very easy to get to that point
where you think okay I'm going to fixate
on this thing and it's going to get
better and that's wonderful by the way
if you do
but you're if you do that at the
exclusion of some of the other things
namely exercise
um you're really leaving an opportunity
on the table an exercise has more of a
symmetric upside and downside in other
words if you
are not exercising or you're not
exercising sufficiently there's a huge
downside but unlike nutrition if you get
exercise right there's enormous upside
there is true life extension and
Remarkable Health span extension which
might be even more important I'm really
I'm bothered by that and it's bothered
by that because I hate exercise dude in
a way that you can't imagine so
literally while while I was reading your
book which I always do as an audio
format I was doing
um air squats and sit-ups and stuff
because just hearing you talk about the
importance of exercise it really is the
thing that I have always done out of
obligation and never out of Joy so I
always thought again literally until
reading your book that I was way better
off controlling diet and you get this
the classic phrase you can't outrun a
bad diet
can you like are you saying you can well
again we wanted so that's a complicated
answer which we'll take in steps so
there's probably a season in your life
when you can generally when you're young
and if that exercise is at a high enough
level you can so just using my own
personal example absolutely when I was
growing up so in my teenage years right
13 to 19 I didn't pay any attention to
what I ate other than I was always
eating
and when I say I was always eating I'm
not exaggerating right like I every
morning breakfast was a box of Froot
Loops or Captain Crunch or some
unbelievable crap that could only be
consumed in a tupperware bowl bigger
than my head nice and you know with a
liter of milk lunch was usually seven
sandwiches oh my God it's a full loaf of
bread what were you doing I was
exercising six hours a day Jesus were
you a wrestler or something boxer oh yes
so you know running minimum five
typically closer to 10 miles every
morning 25 minutes of rope jump two and
a half hours of weight training sparring
bag work every single day 400 push-ups
before bed every single night with one
exception One Night in high school I
didn't make it happen wow you actually
remember that it was only one time one
night I was so goddamn sick that I
couldn't get out of bed for a whole day
and that was the only night in all of
high school I didn't do my 400 push-ups
before but I was so pissed off that even
now you remember that there was one day
I love it but my point is I didn't stop
eating I was eating french fries crap
all day every day I couldn't gain weight
I was trying to move up a weight class I
couldn't because of the exercise or your
genetic Proclaim oh I just think I mean
that that much exercise you're you can
eat whatever you want
um now could I exercise that much today
could I exercise could I out exercise a
bad diet today no at 50 I can't do what
I could do when I was 15. right I want
to get into the mechanisms of that so
here's another one of my ignorant
statements that I live by uh this is all
a game of controlling your glucose and
that if you let me control your glucose
levels then I basically control your
destiny and I want everybody listening
to know that after reading this book I
know this is probably not only overly
simplistic but maybe even just wrong
correct but uh
in exercising like that it feels like
okay well you're burning all that
glucose so the glucose isn't going in
and wreaking havoc on your system
um are you saying now mechanistically
that
at this age I guess like you either
I think there's two things going on
right one I simply couldn't do
I I don't think I could do in one I
don't think I could do four one day what
I did for five years
every day just two taxing on the system
it's just too difficult like I don't
have the physical capacity to go like
today if I went out and ran 10 miles I'd
be beat for the rest of the day like
that would be my day whereas I had done
that before six in the morning every day
and I was just getting started so I
simply can't do what I used to be able
to do
so I think that's just a big part of it
but also as we age for reasons that are
not entirely clear we do become less
metabolically healthy our mitochondria
become less efficient our muscles become
more insulin resistant part of that's
driven by hormones part of that's driven
by enzymes I mean we know that
testosterone is going down my
testosterone is actually quite low you
know I'm sitting here kind of on the
fence contemplating should I really
start testosterone replacement therapy
because my testosterone has kind of been
in the crapper for a few years but I
know me crap or what what number oh I
sort of hover in the 400 nanogram per
deciliter range and I've kind of been
there for a few years and you've tried
to elevate it naturally and can't
um I mean only in that I'm doing all the
right stuff like I sleep incredibly well
but my FSH and LH are really at the
upper end of normal in other words like
everything from my brain is doing the
right thing my brain is telling my body
to make testosterone but you know I'm
sort of at the limits of what my body's
willing to make right now which is you
know probably I'm at about the 20th
percent tile now one time you and I had
spoken about testosterone replacement
therapy and you said you prefer to do
precursors and not so would you still do
the precursors if you do it I'd probably
start with a precursor or a pre-hormone
like HCG
um I wouldn't use Clomid which is
another one
um and give it a shot and see if that
could really wake things up but you know
eventually you know I'd probably need
testosterone
um but even that like even if you
restored my testosterone levels to what
they were in my 18s or 20s I'm not sure
that that would be remotely sufficient
to address the metabolic changes that
have occurred in me
um you know I probably have less hormone
sensitive lipase or or lipoprotein
lipase rather on my muscle cells and
more of it on my fat cells in other
words my body is probably more inclined
to fuel Partition unfavorably meaning
it's probably more inclined to take
energy and put it into fat cells as
opposed to direct it towards muscle
cells so all of that is to say there's
no way today I could out exercise a bad
diet and as a general rule
again at least if using uh body
composition is the metric yeah it's a
pretty good
um you know rule of thumb that you're
not going to out exercise a bad diet but
there are exceptions clearly
okay so I want to linger on this idea
for a second that because this the
reason that I am really I've always
steered myself towards things that you
say is because you have a really deep
ability to get to the mechanism of
action
and so this idea that a diet is
incredibly important in terms of you
have to do the right thing to avoid
downside but it's not really going to
elevate you now we hand over to exercise
and exercise
is potentially going to now pull you
farther forward but I want to understand
why so is it you talk a lot about in the
book stability is it just that I'm not
going to fall or is there something
going on at the cellular level that
becomes important it's all of the above
so
um
you know generally speaking we think
about this through the lens of Health
span and lifespan so let's just start
with the lifespan side of that and we
can even go back and talk about the
nutrition piece right so if your
nutrition is sub-optimal what does that
mean there are lots of ways your
nutrition can be sub-optimal it can have
too many calories in it it can have too
few calories in it it can have too
little protein in it it can have
deficient micronutrients in it I mean
those would kind of be some of the big
examples of where nutrition can be off
and those will produce different
phenotypes you could be underweight you
can be overweight you can be insulin
resistant which comes hand in hand with
excess nutrition you can be under
muscled which would be a result of low
protein intake so and then you can have
a whole bunch of sort of deficiencies
like B vitamin deficiencies and vitamin
D all sorts of nutritional deficiencies
that come from not getting the right
vitamins and micronutrients on the
exercise side we can go through the same
exercise by the way on on the nutrition
side that mostly impacts lifespan those
deficiencies disproportionately Point
towards a shorter lifespan so as you
increase adiposity you increase meaning
as you get fatter
um you increase the odds that you're
going to start spilling that excess fat
from the safe place that you can store
it which is in your subcutaneous fat
cells as athletic as aesthetically
unappealing as that is but otherwise
metabolically quite inert you start
spilling that into places where fat
shouldn't be
inside the liver inside the muscle
itself meaning right inside the muscle
cell
around the pancreas around the heart
around the kidneys around the organs
itself is visceral fat once you start
spilling fat there all of a sudden your
risk of every disease every chronic
disease goes up and it goes up a lot
right I mean we're talking about a
doubling of risk of cardiovascular
disease cancer and neurodegenerative
disease especially Alzheimer's disease
don't pull past that so I need to
understand this mechanism so it's um
you're filling the fat cells you're also
making new fat cells some not so much
you basically I'm talking about when
it's working well oh no no you're just
filling the fat cells yep and the
subcutaneous fat cells are accommodating
the increase in energy storage so again
even though you know culturally we don't
like that that means you're getting
fatter yeah evolutionarily that's an
enormous leap step forward right this is
what allowed us to basically develop
monstrous brains is the ability to store
lots of energy so we weren't dependent
on meal to meal because our brain is by
far the most energy hungry part of our
body so you have this organ waste two
percent of your body weight consumes 20
to 25 percent of your energy any
interruption in energy is going to
prevent the brain from working so in
order to evolve very quickly and
basically hit escape velocity on all
other species this was our trick how
could we become efficient at storing
energy and fat is by far the most
efficient way to store energy so this is
all very good it only becomes
problematic when you live in an
environment where there is so much
abundant energy that you exceed the
capacity of this system to safely store
it right so the way you can think of it
I think I described it the way the book
is a bathtub
the bathtub that is your the total Depot
of all your fat cells water is energy is
flowing in there's a little drain that
safely drains water out that's your
expenditure of energy the balance
between those two things determines the
water level at some point if the input
is so much greater than the output you
will not only raise the level of water
to the point where it's getting bigger
you'll start to overflow it's that
overflow that's destructive right right
so does your body store visceral fat
without overflow no visceral fat is part
of the Overflow okay so is visceral fat
made up of the same sacs that I would
find in my subcutaneous fat
um it's uh no it's it's actually kind of
a different location altogether and it's
it's it behaves very differently so
visceral fat is far more inflammatory in
fact that's part of the problem you know
if we do a dexa scan on a person which
is how you can measure some of this
stuff
you do a dexa scan on a person that
weighs 200 pounds that has 25 body fat
so by definition based on those numbers
they have 50 pounds of fat
but let's assume that of that 50 pounds
of fat the visceral fat is five pounds
so ten percent of their fat is visceral
that five pounds of visceral fat is
wreaking all the damage in their body
the 45 pounds of fat that is not
visceral
totally inert okay let me describe it in
a lay person's way so subcutaneous fat
is water inside of a water balloon
visceral fat is water on your sweatshirt
yeah and your sweatshirt now is just
[ __ ] wet and nasty yeah think about
the bathtub analogy right the the
subcutaneous fat is the water in the
bathtub is totally fine the visceral fat
or peripancreatic or intramuscular or
intrapatic fat is when it gets out and
starts leaking through your floor it's
the same stuff it's the same just one is
in its rifle container and the other
it's just glommed on to something that's
right
that is really interesting so for
example in the muscle what does that fat
do that's so destructive it impairs the
signal of insulin not to get terribly
detailed but you like the mechanism
right insulin hits a receptor called the
insulin receptor that insulin receptor
triggers a Cascade a chemical Cascade in
a muscle cell that tells a glucose
transporter to move up to the cell and
allow glucose to come in that's the way
it's supposed to work when you have fat
inside the muscle cell that signal gets
broken so that's what the that's the
first sign of insulin resistance
and the body says hey I need to get rid
of this glucose I need to get this
glucose into the muscle that's where we
store glucose I can't I need more and
more insulin to do this and eventually
you run out of ways to do that so
initially you can make the glucose go
away but you need more insulin
eventually all the insulin in the world
doesn't do it the glucose goes up that's
called type 2 diabetes okay so how do I
overwhelm that system if I have a binge
night on a Saturday and I'm going ham on
the ice cream am I going to overwhelm
the system or do I have to fill the fat
cells first is it basically speed or
quantity so two separate things there so
if you're just having one binge night
eating ice cream and stuff you're you're
binging you know you've got glucose and
fat and you may you may well dispose of
those things fine it depends on your
incoming state so if you're a relatively
healthy person an insulin sensitive
person a night of binging really isn't
going to cause any trouble certainly
nothing long term right what we're
really talking about is The Chronic
result of doing that and so the the
glucose these and the fat piece are
slightly different the the glucose piece
is very tightly regulated
um you know if you consider the
difference between a person who doesn't
have type 2 diabetes and someone who
does it's literally only the difference
of one teaspoon of sugar in the blood
that's the I mean it's a remarkable
difference in terms of how subtle it is
that's how tightly the body wants to
regulate glucose so when the body can't
do when the body can't regulate glucose
that becomes type 2 diabetes
long before that's happened you've
usually started exceeding your storage
of fat and it's that excess fat that
spills out of the bathtub that is making
the body dysfunction around glucose
regulation I've recently heard that it's
more dangerous to be a lean diabetic
than to be an obese diabetic do you
agree with that the data absolutely
suggests that that is the case
okay so if I'm a lean diabetic then what
that predicts is that my water balloons
are very small and they just can't take
much water and so they keep spilling
back out spilling back out spilling back
out so if I'm a lean diabetic I probably
have a ton of fat around my viscera yeah
and that doesn't translate to much
weight on the scale because you don't
need much of that visceral fat
peripancreatic fat intra hepatic fat you
don't need much of it in total mass to
cause absolute metabolic destruction
okay and so that's why the lean insulin
resistant the lean person who's
metabolically unhealthy has the worst
outcome
so interesting man so okay before
reading your book I would have come in
uh and said all right let me just look
at the person I'll ballpark you if they
are lean they're almost certainly fine
and if they are obese they for sure no
question they have a problem metabolic
disorder they're in danger uh I get the
feeling from reading your book while
that may sometimes be correct and maybe
directionally at the population level
it's fine but that an individual
actually can be fat and healthy and that
a lean person can effectively have the
blood if somebody is morbidly obese yeah
you're absolutely right at the
population level
we can look at things like BMI and make
General broad statements but at the
individual level to do anything other
than ask the question specifically about
that person is to do a disservice and
you're right up to a third of people who
meet the BMI criteria for obesity
they are metabolically healthy and their
life expectancy is the same as a lean
person Jesus okay so when I read that in
your book I actually had this impulse
I'm ashamed and I would never act on it
but I had the mask mandate impulse of
like you can't tell people that like you
you're just better off telling them that
being fat is going to kill you don't be
fat well so this is where Nuance comes
into uh consideration
everything I just said is more about
lifespan but let's talk about health
span okay there are reasons to not be
obese that go beyond you know premature
cardiovascular disease cancer Etc
think about the impact it has on joints
so it's not necessarily going to shorten
your life if you're metabolically
healthy but there are still other
consequences that's right got it okay
joints just because I'm carrying so much
weight yes every time you take a step
while walking your knees are
experiencing approximately three times
your body weight in terms of force Jesus
when you're running it's about eight
times your body weight
so losing weight has a very non-linear
effect on your joints and similarly
gaining weight in the negative Direction
has a very non-linear effect on joints
there's a reason that now I'm not that
psyched about running the way I was when
I was 25 pounds lighter I was 25 pounds
lighter my joints handled it
effortlessly today
I don't know I'd probably get away with
it but I'd have to really reduce my
volume and frankly I just choose not to
I much prefer to get my cardio doing
things that aren't having impact on my
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impact Theory to get 10 off your first
month yeah we don't want to dismiss the
orthopedic causes of you know reduced
reduce more reduced Mobility
um and weight plays an absolute role on
that furthermore I don't want to suggest
that body composition doesn't matter
lean mass absolutely does matter and
it's really what people should be
focusing on so this gets back to the
point of
you know the reason I'm not a huge fan
of sort of population-based metrics like
BMI is they just don't contain enough
information right like a very very
muscular individual will could have a
BMI of an obese person so obese is
defined as a BMI of 20 a pardon me of 30
overweight is a BMI between 25 and 30 is
overweight I think my BMI is like 28. so
I'm I'm closer to obesity than normal
weight but I'm not based on body
composition yeah so body compositions
we're really not watching he's he's got
some muscle on him this kid no I mean
I'm like just I'm a relatively normal
healthy guy and that's what by what
metric do you consider your physique
normal
like the normal person in America yeah
maybe not maybe not heavy yeah sure
um
so anyway my point being
when we look at our patients we I don't
know my patients bmis I couldn't care
less I want to know how much visceral
fat they have
I want to know how much total body fat
they have I want to know their bone
mineral density and the metric I
probably care most about or at least as
much as bone density and visceral fat is
something called appendicular lean mass
index and fat-free mass index what is
that so appendicular lean mass index is
take the total amount of muscle mass in
both arms both legs in kilograms divide
it by your height in meters squared you
get a number that number we rank on a
nomogram and we care what that
percentile is why arms and legs arms and
legs well we do too so you do
appendicular lean mass index which is
arm's legs and then we do fat free mass
index which is all non-fat mass of the
body and you do the same calculation
each has a pro and con the fat free mass
index has the advantage of including all
the muscle in the body but unfortunately
it includes stuff that's not muscle it
includes organs
the appendicular lean mass index has the
advantage of being a very good proxy for
muscle mass in those locations because
they don't have organs in your arms and
legs so we do both and they usually give
concordant answers but sometimes they're
a little discordant and we have to
evaluate them discordant meaning they
have different percentile predictions
but we want to see people at or above
the 75th percentile for those two muscle
mass metrics and again
you don't have to be super that doesn't
mean you're super jacked right like you
know a super jacked person is off the
chart on those things but again no one
would accuse me of being super jacked I
think I'm at the 95th percentile so
we're this is not a this is not a
standard that is unreasonable and the
reason we care about that is the the
evidence that if you look at a person
whose almi is greater than the 75th
percentile that's one of the ones you're
just describing that's the appendicular
lean mass index and you compare them to
people below the 75th percentile
the mortality difference in those people
once they reach their mid 70s is a
staggering difference so in one study if
you looked at people who were 75th
percentile or higher
their 10-year survival from the age of
72 was 80 percent
if you looked at people who were below
that their 10-year survival was 50
percent
that's a pretty big difference
when you take on a new client that is
coming to you specifically for longevity
reasons
do you start with looking for signs of
degradation the damage that they've done
or are you prescribing the things that
they ought to do no we start we want to
we want to get as much Baseline
information as possible so everything
from your family history in excoriating
detail because it's going to tell you
about the what you call the horsemen in
the book yeah what are your legion of
death that's right what are your what
are your risks at least as your genes
would set us up to believe obviously
lots of blood work body composition
information functional testing so
mitochondrial function VO2 max which is
Peak aerobic strength and movement those
are really big big buckets and we have
very specific tests that we use for each
of those things the strength and
movement tests are tests we've designed
over the past several years
um and and they're I think in many ways
some of our best work really because
they're you know we had to come up with
this stuff on our own because nobody
else really had a test that we felt was
as predictive of you know what we wanted
to believe so it's doing a whole bunch
of that type of testing and and using
all of that to basically come up with
something we called the longevity risk
assessment the lra which is a rank order
of all the things that are a threat to
their longevity there's basically seven
things that are a threat to how long you
live and how well you live yeah and we
just sort of rank them out and get to
work and that's when you start to get to
prescriptive what are the seven uh
cardiovascular disease or the diseases
of atherosclerosis so cardiovascular and
cerebrovascular disease cancer
neurodegenerative diseases inclusive of
all dementias
um accidental deaths including
Automotive accident
uh what do you look at for that fall
risk as you get older yes so it's
basically Falls automotive and overdose
so that would by the way include people
who are using illicit drugs right if
you're using list of drugs nowadays
there's a very good chance you're
running the risk of getting spiked by
fentanyl right last year over 100 000
people died by accidentally ingesting
fentanyl because it's so cheap and so
people are putting it into other drugs
yeah basically drug cartels are now
using synthetic fentanyl as a filler in
drugs because it's insanely cheap okay
um then you get into uh sort of physical
decline so Orthopedic injury and
physical Decline and then there's
usually some special one that'll show up
that's specific to an individual so for
example you know someone might have
hemochromatosis or something like that
or something like that yeah just a
genetic disorder of like iron uh
metabolism or someone might have you
know low kidney function or something
like that once you kind of rank order
those
risks that's what determines the getting
to work part so now you start to get
prescriptive how do you go about
mitigating those risks so then you'll
take on a period of time what are the
things that you start looking at so if I
said hey I the person you want to talk
to you can't ask them any questions but
I can give you any reading you want
would you go immediately there's seven
things we look for in the blood or
um yeah blood testing is very helpful
but it has lots of blind spots there's
no one test that offers us everything so
blood testing for example will give us
great insight into your risk of
cardiovascular disease uh pretty good
insight into your risk of dementia what
are you looking for there I'm gonna
guess glucose yep you're certainly
looking for all things that pertain to
metabolic Health all things that pertain
to lipids and lipoproteins inflammation
things like homocysteine what would you
look for for inflammation C-reactive
protein yeah c-rective protein
interleukins things like that
um you also look for again all the
lipoproteins factor into both
cardiovascular disease and dementia
really fast I want to go back to
inflammation this is the one that scares
me the most when I was a kid you could
write on my skin just by scratching me
and it would welt up
um I ice my wrist in fact this is where
you and I first cross paths I was icing
my wrist for 15 years you had me try
keto which will definitely talk about
your change of perspective on that uh
that changed my life and by introducing
healthy fats my inflammation plummeted
but I still I've not ever done a
C-reactive protein test if you see
C-reactive protein in the blood do you
know that oh that's coming from or is it
just like okay it's very non-specific
yeah yeah so very very high levels of
C-reactive protein which we often see
almost assuredly don't constitute
pathology of concern it's usually an
acute illness
really yeah so normalcy record protein
level is less than one if if I get a
patient's blood back and it's 12 I'm
calling them and I'm saying hey were you
sick around the time we do this blood
and they're almost always saying no but
I got sick the next day or yeah I'm just
I was just coming off a bad cold so
somebody on a standard American diet
won't have spikes not not to that high
usually what I'm more concerned with is
the person who's got a C-reactive
protein of two and a half that never
goes away there's something going on
there
and it could be diet related it could be
autoimmune it could be cardiovascular
it's very difficult to know so again the
problem with most of the biomarkers
around inflammation is the profound
non-uh specificity of them when did your
uh so if my arrogance around diet
started to dwindle uh with your book
when when did your conviction around
diet is is going to be the answer to
everything when did what what began to
shake that
I think just kind of in the process of
writing this book and getting deeper and
deeper into the data I don't know tooth
Circa 2011 to 2012 where I even went on
a whole rant about the non-importance of
exercise relative to nutrition and by
the way I acknowledge up front the irony
of me writing this because this was
still back in the days when I was
exercising three or four hours a day but
I sort of chalk that up to look I have
an addiction and I do this and I love it
and it's like a hobby it's like a
passion like I would do this if it were
harmful
but like don't look at me and think you
need to be doing this right all you need
to be doing is you know controlling your
diet
um so so
it just became impossible for me to
ignore the the literature on exercise
and what what's the thing like you saw
grip strength is tied to a massive
decrease in all-cause mortality stuff
like that like what are the biggest it's
the entire spectrum of it right so it's
the experimental literature the
epidemiologic literature the mechanistic
literature but what's it all saying
Muscle Matters like if we had I know you
[ __ ] hate the I did this whole
note-taking session about how you hate
like people that don't get into the
nuance and then I was like my
Counterpoint to that is if you can't
distill this stuff no look I would say
high cardiorespiratory Fitness and high
muscle mass and strength are more
predictive of a long life than anything
else we know say those again High cardio
respiratory Fitness yes it's measured by
VO2 max okay
High muscle mass high strength the
amount of muscle the amount of muscle
although I would argue it's more
strength and we just see a very tight
correlation between strength and muscle
mass okay within reason interesting that
is more predictive of a long life
than any other metric we have okay so
now we're going to get to I'm going to
test this at the fringes I don't know if
you know who Dr William Lee is but I
just had him on the show and I was
barraging him with questions about sumo
wrestlers
and he made an assertion that I found
just impossible to wrap my head around
which is that a Sumer wrestler may be
perfectly healthy and I was just like
how the [ __ ] is that what that tells me
is that I could ask you and get a
prescriptive answer to the question how
do I get obese in a healthy fashion
so I can't speak to sumo wrestlers I
don't understand anything about them I
don't know but but on its face it's
possible Right In based on what we just
talked about they can as long as they're
hella strong as long well no as long as
they are metabolically healthy in their
obesity there's no question okay
consumer wrestler is profoundly obese
right and it's not like just muscle mass
so a sumo wrestler is extremely high in
muscle mass is extremely high in
strength is also extremely high in fat
if they also happen to have high cardio
respiratory Fitness which I'm guessing
they do to do what they do provided all
that extra fat isn't creating a
metabolic problem okay let's let's
define that so they're not leaking out
so they don't have they don't have
insulin resistance they're able to
uptake their diapers of glucose just
fine they're
um and the reason that matters so much
is because if you don't you're getting
uh the so two-ish glucose is sticking to
things yes so that's that's half of the
equation so half of the damage this is a
bit of an oversimplification but half of
the damage is the excess glucose is
causing a lot of sticking around and
it's damaging small blood vessels the
other half of the problem may be even a
bigger half of the problem is the excess
insulin that is trying to put that
glucose away is causing damage to larger
blood vessels and also it's a growth
factor that is constantly in the on
switch feeding tumors cancer would
certainly be the biggest concern you
would have there and that's probably why
after smoking obesity is the second most
prevalent environmental trigger of
cancer because obesity is a signal that
you've got your body in grow grow mode
well obesity is often though not always
accompanied by high signals of growth
and inflammation which gets back to you
know are you a metabolically healthy or
unhealthy obese person if you're
metabolically unhealthy and obese that
means it's by definition accompanied by
high growth factor High inflammation
high glucose and all of those things are
destructive to your health so is the fat
becoming inflammatory because it sends
out a hormonal signal or it sends out
inflammatory signals when it's not in
the fat cell when it's not in the right
fat cell when it's not in the
subcutaneous fat cell got it so those
visceral those fat droplets that are
around the organs are sending out
inflammatory signals so when we're
looking at an obese person just to beat
this point to death
really the we're just concerned about
I'm going to guess given that you're
obese so you're probably leaking fat
into the system that is becoming
visceral fat which is just loose using
the water balloon analogy it's just
loose fat and sticking to things that
it's not supposed to causing distress
and the liver I know can cause scarring
absolutely causing damage in the liver
then yes can absolutely lead to scarring
and ultimately cirrhosis if it doesn't
goes or go away which is the leading
cause of liver transplantation is fat
accumulation in the liver not related to
alcohol ingestion yeah
um and getting into the pancreas
poisoning the beta cells making it
harder for them to even make insulin so
further exacerbating the problem of high
levels of glucose
um so yeah but the problem is when
you're looking at that person with your
naked eye you don't really know it
okay very interesting all right so back
to strength
um getting back to our sumo wrestler so
we
we would have to look for things to see
if this is fat in a healthy way and it
oh can I say protective instead of
healthy sure maybe I just have something
emotional I still need to work through
with obesity uh but it feels like uh the
reason that a lean diabetic is in a far
more problematic state is it does not
have the defensive mechanism of hey this
terrible diet that you're eating is
causing the leakage of fat uh and when
you're obese it's like hey we got you
you can pump the system full of fat we
can store it appropriately all as well
so
the Obesity then to a point will be
protective
it seems that obesity to a point
is the safest place to put excess energy
which you're better off not consuming
yes but if you are consuming it you're
way better off storing it in
subcutaneous fat cells and getting
bigger than you are just letting it
dissipate into in other words you're
better off having a bigger bathtub
that's full than having a smaller
bathtub that's draining water onto your
floor and down your heat ducts okay let
me ask you another question while I get
as we age we're probably not going to be
able to do it
is there any damage being accumulated to
a Michael Phelps in his early 20s eating
10 000 calories but burning 10 000
calories through exercise yeah great
question
um
probably not in the short run
um and probably not if upon ceasing all
of that activity the energy expenditure
returns back to an appropriate level so
as long as the body's using it you're
fine yeah now again
um there might be a behavioral challenge
there it might not be an accident that a
lot of former athletes who are you know
basically eating as much as is humanly
possible to support their energetic
needs when they're young struggle to
maintain Health when they get older
because the habit of still I mean I
truthfully Tom I think I still struggle
with this like I mean I'm not in a
position now where I can just eat all
the time and yet I think there's a part
of me that's still kind of wired to want
to right but again when you're not
exercising six hours a day you can't so
and I remember you know even when I was
young my parents just watching with
complete befuddlement as I would I was
just constantly eating and it didn't
like I would tear through ice cream I
was just always like it didn't matter it
just didn't matter I was an eating
machine and it was freakish for people
to watch they couldn't believe it and
yet I was rail lean right and they said
I remember my parents saying is like you
know they're like you better be careful
like one day you're not going to be able
to eat like this um
yeah that is uh the Lamentations of the
old looking at the Young yeah no I
definitely get it uh okay so if you
maybe the data already shows us but if
you had to guess or base it on the data
why is why does strength matter so much
is it that cardio Fitness uh means your
heartbeat slower when you're not
exercising and and the differential
between how much you exercise and thus
speed it up but that the amount of time
you spend in that really slow resting
heart rate like that's the deal is it um
you're gonna say all the above but like
grip string so I'm not falling uh I
don't know what else well I'm storing
amino acids in muscle yeah so I think
there's several things going on so let's
talk about the limitations of the
exercise so the limitations of the data
are
your their data are only as good as
things that we can measure
so you know what hemoglobin A1c is yes
okay so hemoglobin A1C for people
listening is a blood test you get that
in a snapshot
gives some prediction over what your
blood glucose has been doing for the
past few months
so in that sense it's what is called an
integrator
right if you think back to calculus for
people who took calculus the integral is
the area under the curve it's the total
ups and downs it incorporates everything
that's happened and so in this case
hemoglobin A1c is an integral function
of the last three months of your eating
at least as it pertains to glucose
doesn't tell you anything about fat
protein overall calories doesn't tell
you any of that stuff but gives you a
pretty good indication of how your body
regulated glucose
okay
integral functions are not common in
biology unfortunately
uh I had a recently a very interesting
guest on my podcast and we talked about
how HDL cholesterol may be an integral
function for recent triglyceride levels
so the fluctuations in your
triglycerides and we know that lower is
definitely better becomes an inverse
correlate with HDL cholesterol so the
higher your ratio cholesterol might
suggest lower previous levels of
triglycerides so that's kind of
interesting that has not been validated
but it's an interesting hypothesis
but for the most part we just don't get
great integral functions
it turns out VO2 max is a really good
integral function of how much cardio
training you do um
so VO2 max have you ever had a test done
I have not but do you know how it works
uh I think so so you run uh all out and
then you go slow get your heart rate
back to 100 run all out again well
that's how you would train for it but
the test is done uh on either on a
treadmill or a bike those are pretty
much the only two ways to do it you have
a mask on and you're pushed so you get a
warm up and stuff but then you're
basically pushed until you fail where
you're like I have to jump off the
treadmill yes got it um and what's hap
what they're sprinting so they're trying
to no no no it's not it's it's
um at the end it feels like you're
sprinting but they'll you know if your
two Max test might take 10 minutes
they're gradually working you up and
watching your consumption of oxygen rise
so this mask is measuring how much
oxygen you consume because it has a
little oxygen sensor on it so it knows
the flow rate of oxygen that you're
putting in and it's measuring the
concentration coming out and it's it
says okay right now you're consuming one
liter of oxygen so you and I sitting
here right now are consuming three or
four hundred milliliters of oxygen per
minute very little
if pushed to your max you might be 10
times that whoa the fittest athletes in
the world you know will get to 20 times
that at they have the capacity to use so
much oxygen so that's what the VO2 max
test is it is measuring your maximum
consumption of oxygen
the higher that level the longer you're
going to live
there is no number there is no biomarker
there's no finding in all of biology
that is more predictive of a person's
length of life than that specific number
and the question is why
and I believe the reason is VO2 max is
such a potent integrator for what you
have to do to have that number you
aren't born with that number being high
there's clearly a genetic component to
that number you know the the highest
people in the world ever measured are
born with a great potential for it but
they won't get that potential without
training and the training you have to do
to get that is pretty hard
so
what the what this tells you is that
that type of training is what's really
valuable
the same is true with strength when you
compare
very strong people to very weak people
you see almost as high a prediction of
longevity as you do with high VO2 max to
low VO2 max
and again
it's important that we are strong for
all the reasons you said it helps you
prevent falling it helps you stand up it
helps you do all of these things that
matter
but I think the reason it's telling us
you're also going to live a long time is
because it tells us what you had to do
to get there when we see that the top 10
percent of people with grip strength
compared to the bottom 10 of people with
grip strength have a 70 percent less
chance of getting Alzheimer's disease
and a 70 chance of dying from
Alzheimer's disease it's not because
grip strength by itself protects your
brain right it's because those people by
definition are doing so much more
physically and it's the doing part that
is protecting their brain
man this is uh very interesting so let
uh I'm gonna ask it so let's imagine a
world where we have uh just insane AI
with VR do you think that I would be
able to stimulate my brain
in a way that because people talk about
for staving off dementia like dancing is
nothing anything so
can I obfuscate the need for the
physical part if I'm stimulating the
brain or is it like nope like you're not
doing the things you would need to do to
make your heart uh and again I don't
know if it's resting heart rate becomes
the thing that's good or because if it
really is just the thing you have to do
and not the outcome of the thing right
right uh how can I fake it uh probably
you would get some benefit in a if you
did this as a thought experiment where
let's assume we can truly above your
neck replicate The Experience that's
probably giving you some of the benefit
but I don't think it's giving you the
majority of the benefits so the muscle
acts like an endocrine organ so when it
is put under the appropriate stress it
is releasing myokines right it is
releasing hormones that are having a
beneficial value for example bdnf brain
derived neurotropic factor is being
released and providing effectively
nutrition to neurons so you actually
have to do the thing to get it not just
thinking you're doing the thing also
let's not forget all of the other
benefits of exercise such as the
metabolic benefits so we talked about
all of this business around insulin
resistance well the number one cure for
insulin resistance is exercise that's
why those sumo wrestlers can be morbidly
obese by most definitions and still
potentially be quite insulin sensitive
because of how active they are and then
of course we get into the structural
piece of this right which is what good
is it to have a brain that works if your
body actually does not
yeah or vice versa yep for that matter
uh okay so
ketogenics was something it really was
transformational and as I discovered
ketogenics through you I'm very curious
to hear
um you no longer feel
the same that you did what changed
well it's a broader topic I think around
that of dietary restriction so I think
my aperture has just widened
significantly
so you have to take a step way back and
ask the question how does one what are
the ways in which one can change their
diet so
let's come back to your example in a
moment because
I think if I recall when you went on a
ketogenic diet it wasn't in an effort to
lose weight no yeah so let's put your
case aside for a moment and instead
discuss it through the lens of how most
people think about ketogenic diets vegan
diets pick your diets it's it's usually
some form of energy restriction
so
I think initially I was like most people
are pretty myopic about my views of
energy restriction
and over time that thinking evolved into
saying look there are really broadly
speaking three strategies to reduce
intake
one strategy is to just directly fixate
on the reduction of energy intake that's
called caloric restriction so
bodybuilders are a great example of this
right like they really know how to weigh
and measure every single thing they're
eating and they certainly understand
during an anabolic phase this is how
much energy I need during a catabolic
phase or cutting phase I need this much
and they've got this down to a science
and it's really remarkable I mean it's a
science optimized for the reduction of
fat that's right that's right and
maintenance of muscle that's exactly
right so longevity that's right
absolutely right so so but but let's be
clear like I don't think there's a
better example of any type of person on
the planet that's figured out how to
control intake up and down and to
produce a perfect result with respect to
that aesthetic well said and for most
people that's really hard to do
um it's hard to do because you can't
really ignore it like you can't just eat
without thinking you always have to be
paying attention to what you're doing
but it is the most direct way to go
about getting the results you want
so that's method one
method two says how about I don't pay
attention to what I'm eating
or when I'm eating
um but I pay attention apparently I
don't pay attention to what I'm eating
or how much I'm eating but I just pay
attention to when I eat
so that's called time restriction people
call that intermittent fasting and if I
make the window in which I eat small
enough
I will reduce energy and take in total
so if I said to you you know you can
only have one meal a day chances are you
are going to lose weight
now people thought that well there must
be something magical about intermittent
fasting beyond the caloric reduction but
that turns out to not be the case it's
been tested in several studies now and
it's clear that if you eat 2 000
calories in one sitting
it's no better or worse for you at least
from a weight perspective than if you
eat 2 000 calories spread out of the
course of a day it's probably worse for
you in another way though which is
you're a little more likely to lose
muscle mass because you won't be able to
get the right amount of amino acids I
don't want to derail your point but we
are going to have to talk about
autophagy because I intermittent fast
like a fiend great 365. yeah okay so
then we get to the third method of
caloric reduction which is the use of
what's called dietary restriction
so here we pick things within the diet
and we cut them out
and the more restrictive that is the
more likely it is to produce an energy
reduction and therefore the more likely
you are to achieve the goal of weight
loss so the glib example I always give
is if you went on the no lettuce diet
you would not lose an ounce right right
it's simply not restrictive enough if
you went on the only potato diet you
would lose an insane amount of weight
you simply couldn't eat enough potatoes
to maintain now the that's not a healthy
diet right no one would think that the
all potato diet is going to produce an
ideal Health outcome but you will lose a
lot of weight right so keto is simply a
very for a restrictive form of that diet
and many people lose a lot of weight on
a ketogenic diet because they are
limiting so many things right they're
limiting so many carbs it's also for
many people much more satiating so it
actually readily reduces their hunger
and so they simply don't want to eat
more so they have fewer food choices and
they don't want to eat as much but you
can gain weight on a ketogenic diet if
you eat a lot you have to be careful
because you're generally eating more
energy dense foods on a ketogenic diet
and I've seen lots of people blow up on
ketogenic diets because they somehow
think it's a license to eat as much fat
as they want
not the case
so now let's talk about so so that's
that sort of coming to that conclusion
made me realize oh well there's nothing
really magical about any particular diet
when it comes to energy balance
but now each of these diets has their
own trade-offs around other metrics of
Health
so for example we talked about the
importance of protein
protein is I think the most important of
the macronutrients I know everybody
wants to argue about fat and carbs but I
think the the game is won and lost with
protein and you know the recommended
dietary allowance of protein is
unfortunately very low so there's most
people are being told to eat 0.8 grams
per kilogram of body weight and that's
literally half what you need to be
eating whoa
yeah that's the amount of report for
body mass that I carry or ideal body
mass total body weight yeah so if I at
six foot weighed 250 pounds
I'm going to be wanting to eat something
like 1.6 X that in protein in kilograms
so yeah so if you were if you weighed if
you were whatever 200 pounds I would
want you consuming
at least 160 grams of protein and maybe
closer to 200 depending on your demand
and depending on your age and depending
on the type of protein you're getting
so
a lot of different diets let's pick two
that I think one has to be they're
doable but you have to be careful about
getting enough protein so let's start
with a plant-based diet so plant-based
diet by definition you can't have any
animal protein so all of a sudden you're
doing away with the best form of amino
acids
you know one could argue that when we
eat
animals or animal protein it is a more
pure synthesis of the amino acids that
are coming from Plants right so like a
cow all it's eating is plant but you eat
a cow or like venison is one of my
favorite things right so I'm eating wild
venison from Hawaii that only eats grass
and yet it's the richest source of amino
acids I can sink my teeth into in other
words its digestive system its
metabolism is doing this remarkable
thing I can't do which is turning grass
into the richest densest source of
protein if I want to go back and eat the
grass it's fine but I just have to
acknowledge I'm gonna have to eat a lot
more of it because it's not a great
source of protein so the bioavailability
of plant protein is about 70 percent
that of a animal protein and it's not as
rich in the most important amino acids
so when we have patients who are
plant-based and they say oh do I have to
give up my plant-based diet I say not
necessarily
um and if it's working for you in all
other ways other than this then there's
a work around here but the workaround
requires you being very deliberate about
your protein quantity
another example is you so we're going to
come back to the case that you just said
which is what about people who are
intermittently fasting do they have to
you know is that a bad thing is it a
good thing well it depends but if a
person is intermittently fasting you're
going to see a lot of muscle loss unless
they're very thoughtful about their
protein intake so it you know if a
person's intermittently fasting 16-8 you
can generally get away with it because
in eight hours you can get usually at
least three good servings of protein
but we have a lot of people who are
intermittently fasting and they're only
eating two meals no snacks
they can't come close to getting the
right amount of protein in because you
can't have let's just say you're on the
160 gram a day program
80 grams twice in your day is not going
to cut it because you can't put 80 grams
to work it's too much protein for the
body to utilize Peter man this is so
different than how I live well nobody
think about it like bodybuilders are
very thoughtful of this right if you
look at bodybuilders I thought we
debunked all the like six meals a day
and you're saying no like I actually do
need to break it back up if you're
optimizing for muscle mass yes and it
can't be too small so this is where it
gets really crazy if you're eating
really small amounts of protein yes like
20 grams at a time you're not going to
get muscle protein synthesis
because the liver is going to the liver
basically takes first dibs on the
protein and undergoes gluconeogenesis
it's just going to make glucose out of
protein so if you just trickle tiny
amounts of protein in you're not getting
muscle protein synthesis I'm turning it
into glucose it's a really inefficient
process yeah you're just the liver is
turning it into glucose if you eat tons
of protein and the limit based on a
literature seems to be
somewhere between 40 and 50 grams in one
sitting okay once you exceed 40 to 50
grams in one sitting the excess just
goes into gluconeogenesis huh
wow okay this is very fast so if you're
trying to get 140 grams a day you really
need to optimize it by 4 times 40. and
ah wow okay so amazing this is amazing
I'm always game to change uh okay so I'm
breaking my protein up 4 by 40 if 160 is
my goal what period of time do I need to
put between them because I would be
happy to do that like it
what's your feeding window what do you
like to eat when to win man I I usually
keep it tight like four or five hours
max okay so if you really want to do it
that way then you're going to have to
have well I don't want to do it that way
if I need to well but but I'm saying
like if that's working for you from a
weight management standpoint and a total
calorie I'm a freak of discipline I will
never accidentally gain weight you don't
have to worry about that with me what
you have to worry about with me is right
now I believe that autophagy is
necessary to avoid cancer I don't want
to die of cancer so I intermittent fast
to make sure that I'm in autophagy but
there's no evidence that 20 hours of
fasting is sufficient to induce
autophagy yeah see I thought there was
man I thought autophagy kicked in at
like 15 16 hours
but mice will die in three days of not
eating well that's bad yeah so in other
words like we're just it's apples to
oranges we have no I mean do we know
where it kicks in for humans no because
we don't have biomarkers for autophagy
my intuition which might be as useful as
a warm bucket of hamster vomit is that
it's probably three to five days
three to four days maybe do you do any
prolonged fasting I don't anymore wow
um and I'm not opposed to it like I
would probably still do you know if you
were diagnosed with cancer what would
you do
yeah I would probably
get back to fasting more
evidence-based or just throwing
everything at it mechanistic
yeah give me the mechanism uh you know
you get a perfect deprivation of growth
factors yeah
very interesting also selective
sensitization of cancer versus
non-cancer cells during chemo right so
there is some evidence from Walter
Longo's work that when you're undergoing
chemotherapy doing so in a caloric
deficit can be beneficial because the
cancer cell is differentially and
disproportionately stressed by caloric
restriction and then the normal cell and
therefore you're because remember chemo
like the magic of chemo is not that it
kills cells or kills cancer cells it's
that it selectively kills cancer cells
anything can kill a cancer cell it's how
do you kill a cancer cell and not a
regular cell right so how do you how do
you enhance the spread between those two
and it might be the caloric restriction
is a way to do it and it renders the
cancer cell even more susceptible and at
the same time that you're hitting it
with chemo it becomes uh more likely to
die at the expense of the healthy cell
that's that's the mechanism and there is
some data to suggest that that's the
case
okay so uh autophagy we know is going to
kick in at much longer we hope is
kicking in it much longer periods uh
deprivation can still help with cancer
from a growth factor remember you're
also kick an autophagy with exercise so
if you're looking for another absolutely
what is autophagy right autophagy eating
well yes yes yes but what it's occurring
in nutrient absence and there's a great
way to induce cellular energy reduction
which is exercise
when you exercise cellular energy goes
down that's why exercise increases amp
kinase activity just as fasting does hmm
so you you don't want to underestimate
the benefit of exercise in tricking the
cell into thinking its nutrients or
scarce
okay then what kind of exercise I'm
gonna guess it has to be the kind that I
hate the most and if VO2 max is the
under the curve revealer uh it's what
we're talking about very high intensity
period of rice high intensity well
that's how you train VO2 max but that's
not what I have to do no because that's
only that's that should only be 20 of
your cardio volume eighty percent of
your cardio volume Should Be steady
state and moderate
okay the 80 I like that a lot better
interesting that's zone two as we call
it yeah yeah and that's done at a level
where you could carry out a conversation
if you had to but you don't want to
right that's the that's the litmus test
that is a perfect description okay so uh
going back to protein so maybe in fact
no you're you're saying just flat out
the intermittent fasting is probably not
helping you at all and if anything it's
probably making it hard for you to get
protein and spare your muscle uh you
need to spread this out you've spoken
kilograms which really threw me off
that's okay how much do you weigh in
pounds uh 185 Okay so
160 to 180 grams per day so four meals
at 40 to 45 grams is perfect for you
okay spread out over ideally as long as
possible and to be clear these don't
have to be meals like two of my four 25
grams of protein that's a [ __ ] meal
it's not though think about it like what
is that 200 calories it's like a chicken
breast it's yeah that I mean you don't
consider that a meal that's a rounding
error um no for me like I'm doing I'll
do like I have these venison sticks that
are 10 like little jerky Venice hot or
made uh they're actually now bought you
can now buy them I like that yep okay
um so each one is 10
grams of protein and 50 calories and I
will have five of those as a snack
there's 50 grams of protein right there
with 250 calories like it's nothing okay
what about are they highly processed
anything to avoid there no problem
because there's a company they're made
by company that I'm involved in so I
mean I love the most obviously as a guy
that only gets involved with things that
I care about I think are real so it's
called Maui Nui venison okay these are
um this is a type of deer called Axis
deer that are invasive to the state of
Hawaii and so they're harvested there in
the most Humane manner fashionable which
is what allows the animal to be
completely stress-free so they're
harvested by sniper at night under night
vision and whoa yeah so if you think
about it like harvesting an animal is a
very stressful thing for an animal like
if you're thinking about how a cow is
harvested yeah even if it has the most
um Wonderful Life
you know it's grass-fed it's out in the
pasture it's not inside like
all of that might be great and it is
certainly better than the alternative
but the very end of its life is still
quite stressful this is a moral thing or
does this moral no I believe I believe I
believe it impacts the quality of the
meat the interest right so think about
the cortisol levels that are surging
through that animal's body right at the
time of its death yeah but from an
evolutionary standpoint everything got
eaten oh yes no no I'm not that's not a
moral question I'm saying from a health
perspective yeah but I'm saying you're a
lion the gazelle you're chewing on is
freaking the [ __ ] out as you eat it
alive so there's no way that I can have
some major no I think deleteriously it
actually probably has an impact on taste
more than anything else
um the other thing is it's very hard I
mean this is more of an argument of why
I love Wild game yeah is Wild game eats
the best plants the best feed right so
when you go to the grocery store and
you're buying
you know irregular grain-fed steak it's
not eating what it evolved to eat like
it's you kind of want things that are as
close to eating what they evolve to eat
and you know for for deer that's like
that's basically grass right so
um anyway these things are processed in
a way that basically has nothing in them
right so you're just I'm just getting
pure protein yeah I don't want to derail
us but this is really interesting so you
snipe the deer at night using night
vision goggles so it basically dies in
its sleep it dies instantaneously dies
instantaneously stress-free
um and so interesting how'd you find out
about these guys
um I met the founder of the company five
six years ago
um and we just immediately became
friends I became completely fascinated
by the problem that they were trying to
solve which was how you know the
Hawaiian government is trying to
eradicate this species because it is
destroying the island so this is a
species of deer that was brought to
Hawaii
in the 1950s for hunting but it had no
predator
it was brought from India where its only
Predator was the tiger you brought it to
Hawaii it had no predator and it has now
run amok so it is kind of destroying
three islands of Hawaii finding a way to
do this sustainably now so that they can
keep having them the goal is by 2030 to
have it be sustainable right now they
are still not able to do it sustainably
in other words right now the deer are
still growing at a rate that is too
significant Jesus
uh headshots yes interesting wow I don't
know why I find that so fascinating but
that's very interesting okay so back to
protein intake right so point is you
could have a weighted wake up I'm like
Chomp Chomp into the event not
necessarily like I mean again it depends
on when you like to exercise for example
so so I should exercise fasted
um it depends if I'm gonna exercise
first thing in the morning I do it
fasted if I'm gonna wait a couple of
hours I'll have a protein meal first but
it doesn't matter because I've always
heard that you've got so much glucose if
you're eating and now you're just going
to get fat and you're never gonna lose
it it doesn't matter no so so
um I generally prefer to exercise fasted
but if the workout is getting pushed
till later a couple hours later I'm
gonna have something before not because
I need to but because I want to make
sure I spread out those protein servings
enough
so at least two of my protein servings
aren't meals they're like again the
jerky is not a meal it's a snack and
then like a whey protein shake again 40
50 grams of whey protein in some you
know would you uh I'm willing to stomach
the venison snacks and or chicken
breasts and or eggs eggs yep great cool
love them uh so if I'm willing to eat
the amount of protein that I need in
eggs venison whatever would I still do a
protein shake not necessarily no not at
all and do you because I have developed
slowly over time a deep aversion to
anything that's processed so I'm trying
to get as close to biting in that's
fantastic the walking animal as possible
absolutely yeah that's great
and then you would have like kind of two
meals right so I'll probably also have
like my lunch would be a salad with
chicken breast or salmon and then my
dinner dinner's the easiest meal to hit
your protein Target right like that's
like falling off a log just because it's
typical to eat at a station or whatever
whatever you're gonna have talk to me
red meat white meat
again I think it matters less the color
of the meat matters much more the source
of the meat matters much more about how
that is a grass-fed grain fed yeah and
and how close can you get it to an
animal that's in its natural state
truthfully it's much easier for me to
get wild game that's red meat like I
much prefer elk and axis deer both Wild
game that either I'm killing or someone
I know is killing and it's the wild
that's the important part yeah it's an
animal that's eating in the environment
it's it's an animal that's not contained
right and the contained is problematic
largely because of the diet that we know
they will need yep okay uh how much meat
how much of your protein comes from meat
by percentage
um
I don't know I'd have to figure it out
but clearly the majority
because the one thing I've I also like
Greek yogurt by the way so that's
another thing that's a hard left so
Greek yogurt has a lot of protein it
does actually it's quite high protein
eat it because of the taste probiotics
just another way to get protein in to
diversify a little bit from boredom or
diversity matters yeah just some diver
no no just for me diversity matters like
I like to mix things up and and it's
just again it's just a function of time
like maybe I don't have time to make an
omelette right now and I'm I got a quick
call I gotta jump on so I can scarf down
a bowl of Greek yogurt with some nuts in
it
this seems impossible it does take for
good no it sounds amazing like I feel
like the way that I live right now would
take a lot more discipline than what
you're describing
I'll be interested to see if that's true
in practice
um
Okay so
let's fit eggs into the mix here uh I'd
love to get an idea knowing that
individual there's a lot of individual
variability here in fact we should
probably talk about saturated fat at the
individual level the one thing in my
diet I do not at all pay attention to
how much saturated fat I eat I'll go out
of my way to consume it but I make zero
attempt to avoid it and because I don't
check my blood levels nearly enough I am
always a little hesitant to push my
exact diet onto people
um
do I need to worry about saturated fat
potentially yeah
um saturated fat can increase your uh
synthesis of cholesterol it can also
with enough of it being consumed the
liver can sense the amount of saturated
fat and basically shut down the
clearance of cholesterol meaning the the
bringing of cholesterol into the liver
can I quote Peter attia on cholesterol
in the book out live if you haven't read
it I highly suggest it he said your
total cholesterol number is about as
meaningful to dying from heart disease
is your eye color that's right so you're
bringing up cholesterol so some
something matters something about
cholesterol matters but not the total
number right total cholesterol is again
not a particularly relevant number APO B
which is the constant which is a
measurement a laboratory measurement
that is the concentration of
lipoproteins that carry cholesterol into
arteries that's what you should care
deeply about
but when someone says what's your total
cholesterol 200 milligrams per deciliter
who cares doesn't mean anything but
there is a type of cholesterol that is
carried in a certain well so cholesterol
for the most part that 200 milligrams
per deciliter is your total cholesterol
is divided into three types of
lipoproteins a high dose has a different
carrier uh no that 200 comes is the
aggregation of approximately three
lipoproteins high density lipoprotein
low density lipoprotein and very low
density lipoprotein so if you look at
your lab
you get you get a blood test done if
it's done correctly a lot of them are
not but if it's done correctly and they
do a direct measurement of LDL
cholesterol you will be able to add up
the vldl cholesterol the LDL cholesterol
the HDL cholesterol and the sum of those
three will equal to total cholesterol so
if the total cholesterol is 200 and the
HDL cholesterol is 70 and the vldl
cholesterol is 20 the LDL cholesterol
will be 110 yep and of those three
numbers
um we would say the most important
Insight you could get would be to take
total cholesterol subtract HDL
cholesterol and that number is called
non-hdl cholesterol that number starts
to become a pretty good predictor of
risk so total cholesterol because those
are damaging in some way yeah that's now
telling you the total cholesterol
content of LDL and vldl and those are
the destructive lipoproteins now an even
better number is not how much
cholesterol is contained in those two
things but how many of those two things
do you have and that's what's captured
by apob
can you explain that more so each of
those lipoproteins the vldl and the LDL
have a protein wrapped around them that
protein is called apolipoprotein B100
which is a very sexy name it's
abbreviated apobee
so if you measure APO B Because LDL and
vldl have one and only one April
lipoprotein B100 on them
the APO B number is the concentration of
those two particles
and the gradient of that the more of
those particles you have the increase
the greater the probability that those
particles are getting into your artery
walls got it so the the number of those
do matter and so if I just subtract out
my HDL subtract your HDL from your total
cholesterol you get the cholesterol
concentration of those two particles
but I'm but and that's predictive of
risk but what's more predictive of risk
is the number of those particles okay
which is how do you
I don't know if it's going to be
fruitful but there's something in that
math that I'm not following so if I got
back my cholesterol account and I look
at them I'd be able to tell of my 200
let's say uh 110 are the two that are
bad uh but there's some total number it
sounds like it's a separate measurement
you don't you wouldn't impute it from
the those clothes you just have to go to
apob you have to get the APO B measured
that's right yeah it's another
laboratory measurement understood
understood because unfortunately rarely
done
is it can you just ask your doctor give
me an apob measurement absolutely okay
it's a relatively inexpensive test it's
about people depending on the test it's
somewhere between five and twenty
dollars do they not do it because they
disagree with you or they just don't
know they don't know what it is
troubling very okay uh so in fact we
should talk at least briefly about this
idea so in the book you talk about
medicine 3.0 versus medicine 2.0
medicine 2.0 is all about curing
medicine 3.0 is all about prevention
um
how do I would call medicine 2.0 more
about treating than curing okay fair
it's largely not Curative right very
good distinction uh okay so if you were
going to give me the
um the little tool kit of medicine 3.0
uh
uh what how would you begin to bundle
that like what are the the things that I
should be going towards
well again to your point so medicine 3.0
really says we've reached the limits of
what medicine 2.0 is good for medicine
2.0 is really good at curing
uh acute problems so it's really good at
curing
um infections traumas acute issues it's
really bad at treating chronic problems
cancer uh you know recurrent heart
disease neurodegenerative disease type 2
diabetes it's really bad at treating
those things and therefore all it really
does is prolong the period of time you
have those things
and
I go through a lot of explanation in the
book as to why that strategy is not the
right strategy
so living longer is not accomplished by
living longer with a disease
living longer is accomplished by living
longer without disease
once you realize that you inevitably
come to the obvious conclusion that a
new type of medicine is needed which
must be focused on extending the period
of time you do not have disease and that
word is prevention which has been
bastardized to mean virtually nothing
because everybody talks about prevention
but it has no meaning right so true
prevention has to start very early
true prevention needs a set of tools
that medicine 2.0 doesn't participate in
medicine 2.0 which is the medical system
that every one of us who's trained goes
through is largely A pharmacologic
playbook if your mission is achieving
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now you're going to get people who sit
here and say
our all pharmacology is Bad Medicine is
bad no no that's not true at all
pharmacology is wonderful pharmacology
has done amazing things in medicine 2.0
and we would want to use all of those
pharmacologic tools as needed in
medicine 3.0 but it's literally you know
one-fifth of the equation where is
nutrition where is exercise where is
sleep where is emotional health those
things are also needed to delay the
onset of chronic disease and none of us
got trained in those tools so if if a
doctor is going to help their patient
with those other four tools they're
going to have to learn about it outside
of Medical Training that makes sense uh
okay so if we know what we're trying to
do is delay the onset of these disease
you talk about that in the book that
basically the thing that centenarians
have in common is that they probably
were able to delay the arrival of heart
disease dementia uh because you say this
cancer that these things are Bill
building for oftentimes decades that you
can see heart disease in teenagers which
is pretty crazy so these are people that
have probably delayed the onset of the
early symptoms of that for decades more
than the people that died I'd say 70 or
80. exactly okay that makes sense so now
then I want to get to and we'll stay on
cholesterol here for a second so you
talk about in the book that dietary
cholesterol does not equal cholesterol
in your body so what does what causes
bad cholesterol being the thing that I'm
certainly more concerned about
so dietary cholesterol is very difficult
for our body to absorb it has a bulky
chemical side chain on it called an
ester and the only way we could absorb
it is if we have an enzyme to cut the
Ester off called the diastarified and
bring it in we don't have much of that
enzyme so most of the cholesterol you
eat
such as the cholesterol in you know
shellfish or eggs you poop out okay so
we should just make sure everybody
understands that eating cholesterol has
almost zero bearing on your cholesterol
levels in your blood
that doesn't mean that your diet has no
bearing on the cholesterol in your blood
but your genes play a very significant
role in the levels of your blood lipids
so we want to always differentiate
between cholesterol and lipoproteins
cholesterol is the cargo
lipoproteins are the boat so
um the term bad cholesterol doesn't
actually mean anything people say LDL is
the bad cholesterol
that's actually very inaccurate right
LDL low density lipoprotein is the boat
that carries cholesterol and LDL is bad
but we should really say LDL is the bad
lipoprotein the cholesterol in LDL is
the same cholesterol in HDL which people
call good cholesterol so you can see why
it doesn't make any sense now every cell
in your body makes cholesterol
so
95 percent of the cholesterol in your
body is cholesterol you made
the reason every cell in your body makes
cholesterol is because it is one of the
most important molecules in the body if
you couldn't make cholesterol you would
have died in utero
and the reason for it is every cell in
your body is wrapped in a membrane and
that membrane is made of cholesterol
most of the
um important hormones in your body
testosterone estrogen progesterone
cortisol
are made from cholesterol so this
hormone is absolutely this molecule is
essential for life but not every cell
can make enough of it so we have to be
able to traffic it between cells so we
have to be able to take it back to the
liver the liver has to be able to
package it back out it has to be able to
move around the system so if your body
is like a big city
the Super Highway of that body is the
blood the circulatory system and the
circulatory system is made of water
so when you cut yourself you know you
see red stuff come out but don't let the
hemoglobin and platelets and things
confuse you it's just water with a bunch
of red proteins in it
um and fat doesn't mix with water
cholesterol is a fat it's a lipid and it
doesn't dissolve in water so we can't
just move cholesterol around in the
blood the way we move glucose or the way
that we move sodium or potassium those
things are dissolving in water they're
called hydrophilic and they move around
freely cholesterol is not it's
hydrophobic it repels water so that's
why we have lipoproteins we have to have
these lipoproteins to move the
cholesterol in and out of the body
and that gets to the point of there are
basically these different types of
lipoproteins some of them are very high
density they have lots of protein and a
little bit of fat in them some of them
are low density
lots of fat less protein and some are
very low density virtually no protein
and lots of fat or cholesterol
and they have different properties and
it turns out that the low density and
the very low density ones are the ones
that are atherogenic meaning they're the
ones that promote the destruction of
your arteries
okay so something is starting to slowly
come into Focus for me so fat in the
blood is bad
cholesterol or fat which one do you mean
I mean fat so when we talk about if if
I'm understanding what you're saying
correctly there are two times now that
fat getting loose is sounded like a
problem ah well let's not so so fat is
rarely floating around the bloodstream
for the same reason but if A lipoprotein
if the very low density is indicated
because it has very little protein and a
lot of fat well just when I use fat
there what I'm really referring to is
triglyceride and cholesterol but they're
inside the lipoprotein they realize it
matter that the ratio of protein to Fat
starts getting low it only matters in
that that's how I'm describing why their
difference in density got it yeah so it
isn't that it is fat that makes them
problematic so what do they do what's
problematic is that the low density
lipoprotein and the very low density
labor protein
are the only ones that seem to make
their way into coronary artery walls or
artery walls in general and they have
the potential to get stuck in there so
the high density thing no we don't
really have a great sense of it it's
something about APO B so HDL high
density lipoprotein doesn't have apob on
its surface it has something called APO
a on its surface and when a high density
lipoprotein goes into the artery wall it
comes back out
when AN apob particle goes into the
artery wall sometimes it comes out but
sometimes it stays in there and when it
stays in there or gets retained bad
things begin to happen the first of
those things is it undergoes a chemical
reaction called oxidation
that chemical reaction called oxidation
creates an inflammatory signal and that
tells inflammatory cells called
macrophages or monocytes to come they
become macrophages and they eat that
oxidized LDL molecule
that's what kicks off a devastating
Cascade in which the body ironically and
paradoxically in trying to fix the
problem creates a catastrophic problem
that ultimately leads to the creation of
a plaque that if it ruptures will block
the blood supply of the artery and cause
a heart attack
you've got the two types that end up
basically they have the apob on them APO
B can get stuck in my arteries once it's
stuck in my arteries my body sends it a
immune response effectively that then
ends up creating a problem uh is that
calcification calcification is the final
stage of the body trying to repair the
problem okay so think of it as the
concrete that gets poured on a melting
down nuclear reactor so when you get a
CT scan that's like what's called a
coronary CT scan to look for
calcification the presence of that
calcification while by itself not
problematic is predictive of something
bad that's happened I describe I think
in the book calcification is like going
through a neighborhood and seeing bars
on the windows
the bars on the windows are actually a
good thing they're going to prevent
somebody from breaking in right but it
tells you what kind of neighborhood
you're in yeah okay now that makes a lot
of sense
going on with my diet one thing that I'm
very curious about and there's a raging
debate online a capri is just a calorie
um
where where do you come down on that in
terms of the quality of the calorie does
it matter if I'm eating Terror like if
you agree that the quality of the
calorie matters but I'm still under
eating do I have a problem
so the the calorie is a calorie
discussion always needs some
clarification are we talking about with
respect to energy balance are we talking
about with respect to nutrition and
health are we talking about with respect
to satiety and and so we have to clarify
which of those we're talking about all
I'm talking about ever is longevity
so so then a calorie is not a calorie
for sure right so in other words if you
took a bunch of people and put you know
one group of them on 2500 calories a day
of Twix bars and another group on 2500
calories of
you know
one food only lettuce you know or
whatever it wouldn't be 2500 calories
but you know 2500 calories of venison
sticks venison sticks and another group
on 2500 calories of some well-rounded
diet that's you know they might all end
up with the same weight they might have
a different Health Quality and they
would I would expect it I clearly don't
expect the guy on 2500 calories of Twix
bars to live as long as the person on
2500 calories of good food nor do I
expect them to feel the same
so if you're totally and by the way they
might end up at slightly different
weights because of how they feel and
while you may in this experiment control
only their intake you might not be able
to control their energy expenditure so
they might actually expend different
amounts of energy because of how they
feel
so
um the the calorie is a calorie debate I
think is kind of a silly one because a
lot of times people are talking past
each other when they're yelling at each
other and they don't understand what
they're talking about and so you know we
just have to understand are we talking
about pure controlled you know
calorimetry or are we talking about in
your case what you're asking about which
is I think more important which is
health
[Music]
okay so uh your book goes into something
really interesting which is the
emotional side of all of this so what
role does that play why does it matter
yeah just in a book about longevity I
was surprised to see that section happy
but surprised well I think
um
it's not a section that would have
appeared in the first five years of my
writing this book right like you know we
talked about this book took six seven
years to write and the first and second
versions of this book were very
different from the third version which
is the version sitting on this table
and
um I think when this book started out it
was a book about how to delay death
that was really what the book was about
like what do you need to know about
heart disease and cancer and Alzheimer's
disease and exercise and nutrition and
sleep and this drug and that drug to
delay death as much as possible
um and the book really evolved into what
do you need to know to live the best
life
and I don't think I could write about
that without talking about a very
important albeit difficult to quantify
aspect of Health span which is the side
of longevity that refers to quality of
life
um without ignoring you know by ignoring
emotional health it's it's what I
consider one of the three pillars of
Health span so physical health right all
the stuff about your body Freedom From
Pain strength flexibility movement all
those things cognitive Health the
ability of your brain to work and to
stay sharp and you know have executive
function processing speed memory Etc but
then there's this piece called emotional
health
and so the last chapter of the book is
really about that and I think that had I
not written that the book would be very
incomplete
so for you is it about identifying why
you do what you do is it about the
example that you give in the book is you
healing your own trauma
um what what is the game there
well the you know there's 17 chapters in
the book and 16 of them are
I I think I'm you know coming across in
some way as an authority right like
that's it's being written as though at
least I know what I'm talking about and
I hopefully I do
um but I'm writing it as the physician
and the last chapter is an area where I
write it as the patient so I talk about
my journey over the last five or six
years in kind of getting better in this
Dimension this was always an area of my
life that I think was lacking enormously
and as a result of that
um I think I you know the book has lots
of patient examples right the book is
written in a in a scientific way but of
course you know you never tell a story
without making a point and you ever make
a point without telling a story well the
last chapter I just happened to be the
patient in it and that's the the way in
which I walk through hopefully a
conveying of the importance of paying
attention to this
what I'm trying to figure out though is
what what is that a category of so one
thing I talk to people a lot about is
meaning and purpose talk to people about
emotional control
um but there's also the angle of there's
going to be a cellular result of your
thinking and this is where it starts to
get cloudy and so I'm there are people
I'll let them remain nameless that uh uh
I don't interview this type of person
because I think they cross the line
between thoughts become physical and
uh getting into now we're just making
[ __ ] up so that you can think something
and manifest it or if you have cancer
you can think it away
and so
I want to know where where is that line
for you you felt it important enough to
bring it up in a book about longevity
was it just though a quality hey I've
told you how to get quantity now I want
to talk quality or well it's there no no
I mean I think there's several things
right so so
start with the the question as posed To
Me by Esther perel have you had Esther
on your podcast I have yeah so so people
listening will be familiar with her so
you know Esther pose this question to me
many years ago which is
effectively why would you want to live
longer if you're unhappy
and that's such a obvious question and
yet I am amazed
absolutely amazed at how much I interact
with people because remember all I do is
interact with people who want to live
longer
that's my job
everybody I'm talking to everybody who
wants to talk to me always wants to talk
about how to live longer how to live
better in some way and yet very rarely
are they paying attention to this aspect
of their life what is their relationship
like with themselves how well as you put
it do they understand themselves what
are their relationships with other
people how well are they able to
regulate their emotions how present are
they what is their sense of purpose what
is driving them all these things and if
that house is in disarray
I would make the argument that living
longer is a curse not a blessing
it's a bold statement
push back on it I mean what's what's the
definition of torture right so let's
let's play a thought experiment if I
said to you Tom
I'm gonna Grant you immortality
in perfect health so it's not going to
be like tethonius where I let you live
forever but you age forever that would
be hell no no I'm gonna allow you to
stay right like you are now you're not
going to get one more wrinkle on your
face you're never going to get a disease
would you take it yes
I'm not going to give it to anybody else
in your life oh yeah I would take that
I'm always shocked that other people my
wife include wouldn't okay all right so
so let's go one step further I'm going
to give it no I wouldn't that's so
interesting do you know how many people
you're gonna watch die wait I'm making
the Assumption that's what bothers you
why wouldn't you take that
um well let's come back to me I want to
keep going with you for a minute okay
okay so now I'm going to make these I'm
going to give you a different experiment
we're gonna do the same thing but I'm
gonna put you on a desert island now yep
and I'm gonna provide everything for you
so you're not going to have to worry
about finding food
um in fact forget the desert island I'm
going to keep you in this beautiful
house yep and I'm going to somehow keep
the lights on and I'm going to somehow
keep the food coming in but there will
be no other human on this planet for you
to ever interact with including your
wife would you take that can I kill
myself no so I have to live forever like
that yes that's the first one where just
what I know about the human psyche
breaking in isolation I I it would be
ill-advised though God I would want to
if you'd let me kill myself at any point
I would take it but if I can't it's too
dangerous no of course you wouldn't take
it right I mean you have not in the
course for me that is not self-evident
and if I didn't understand what happens
to the human psyche when it's isolated
in in my life where I have been isolated
for extended periods of time I have
experienced no suffering whatsoever
I just I don't disagree with that but I
think the question is yeah what's the
longest period of time you've been
isolated yeah exactly and what does
isolated truly mean yeah yeah and if I
have input like if you let me keep the
lights on and I could have entertainment
I've thought a lot about this like uh
how much would that help but like let's
you saw the movie Castaway yeah okay so
if I had any glimmer of hope that I
could get off that Island I would want
to be alive I would want to try and try
but that's a totally different story
right yeah this is what I'm saying is
even the hope that I could one day
recount I'm telling you there's no hope
so then I would not I'm going to let you
live indefinitely in this house all by
yourself yep okay so that's just an
extreme example of one dimension of
emotional health which is connection to
others and I'm I'm telling you that
given everything to excess oh and by the
way I'll even I'll even sweeten the deal
Tom I'll give you all the money in the
world and you can buy whatever you want
well right now by what oh you could buy
Yachts art whatever you want we've we're
going to have robots that do everything
for you that make everything and you
can't interact with these robots I was
going to say complicated the robots are
not enough they're not going to supplant
so there's there's everything I could
ever want except for you can have all
the cars all the Yachts whatever yep
you're not gonna do it if you really
stop to think about it you're not going
to do it because with no connection to
another person it's a meaningless life
yep so we could do the same sort of
exercise going through all of these
different elements of emotional health
and I think if people are really being
brutally honest with themselves they'll
realize that if you you know if your
wife hates you if your kids hate you if
you're you know you're people around you
don't feel good about you and you don't
feel good about yourself and you're not
you know you don't have a sense of why
you're doing what you're doing
I think I think it's a I think it's a
tough I think it's a tough way to live
so it do you think that people asking
that question
of how to live longer is in some ways
not the wrong question but it's just so
incomplete that you need to address the
emotional side
I think it's a very understandable
question
um I can't speak to others but I
certainly
through my own experience can understand
why one would ask that question and why
it's something you would want to grasp
on to I mean I think that for most of us
the thought of not existing is a little
um if not frightening certainly very
uncomfortable
non-existence is very difficult
only on the back side so we all know
what non-existence is like try to
imagine what you were like before you
were born so I don't I it's possible I'm
deluding myself it's also possible that
I really just see this slightly
differently so I have absolutely no fear
of not existing
if
yeah the thought of just not waking up
tomorrow only gives me anxiety around
ooh did I make sure that I sorted things
out for my wife like is she gonna be
okay like the thought of something bad
happening to her I don't like that
um
knowing that I'm about to die would
change my frame of reference so
radically that it would make me
immediately behave differently so
definitely a huge part of the way that I
behave is predicated on that I have more
time I try to operate knowing that it's
certainly not guaranteed I could have an
aneurysm and Keel over and die before
the end of this podcast I'm very aware
of that
um the reason that this feels so
important to me and the reason that I
was so glad you included it in the book
is that I think the only thing
ultimately that matters is how you feel
about yourself when you're by yourself
and if you have earned your own respect
I think that's hugely important I just
found it very intriguing that not a lot
of people are going to cover that topic
in your book and I was wondering if
there is if it's just that like hey make
sure that that it's worth fighting this
hard to stay alive and make sure that
you're not just driven by the animal
instinct to fight or flight and
basically you have a vision of your
mortality that you're running away from
but you're never like figuring out why
you live or is there also a sense of
if you're in that state where you're
very stressed out you're prone to anger
or whatever the case may be you're also
shortening your life yeah I think it's
both Tom and I think that
a lot of people are self-sabotaging
without understanding why
so
we have a lot of agency over living
longer
I mean if there's one thing I hope
someone takes away from this book it's
how malleable their lifespan is and how
malleable their health span is but you
have to do things to get that as you
pointed out at the beginning of the
discussion there is no easy way to do
this
um there's not a pill or a specific
workout or a superfood or a supplement
or whatever that's gonna make all of
this easy it's a lot of stuff that has
to be done over a relatively long period
of time
and your ability to do that is highly
predicated on your relationship with
yourself
and so you know
having sort of
poor sleep habits poor nutrition habits
poor exercise habits on some level
has a component or a root in your
emotional health
and that's not true for everybody but it
is true for a lot of people
and I see this constantly in my patients
right I see patients whose Own Story
whose own narrative is partly an
impediment to their actions and so
they're suffering twice
they're suffering in that they're
failure to take actions or their actions
that they're taking for example drinking
too much are going to actually shorten
their life but they're also going to
decrease the joy of their life and the
harmony of their life for whatever
period they have
[Music]
so let's say that we do everything right
let's say we've got meaning and purpose
We have dealt with our emotional
difficulties we have identified and this
is actually something that's really
important that I took away from the book
you really have to figure out what of
the horsemen is coming for you what
agent of death from a family history
genetic makeup lifestyle all of that
which one is most likely to come and get
you I think that's very important it
might be worth actually recapping who
the horsemen are we've touched on them I
think all of them but we didn't name
them as like these are the horsemen
might be worth doing that
um but so you've you're doing all this
how long can we live like is it really
like we're already there it's like 122
and and I hope you get there my friend
and follow the book and you'll get to
122.
or can we actually push this farther
based on what we have today I don't see
us exceeding the human record for
longevity I think to go beyond that
would require a technological
breakthrough
so I would never represent that you know
doing everything to the max with respect
to perfect nutrition perfect exercise
perfect management of the horsemen
through all means necessary that that's
going to get someone to exceed that
level
um
you know my
thinking of this is that you know we
might have 10 years of stretch
which is a huge amount if you really
stop to think about it right if you're
you know life expectancy is 82 and you
make it to 92 instead in their quality
exactly and that's the point right where
I'm really confident we have the
capacity to change it is on quality and
I you know I said to you everybody comes
to me
on some level and they want to talk
about longevity but when I really probe
them what they really mean is Health
span they don't care as much about how
long they live they really care about
the quality at the end of their life
I care about both to be really honest as
do I healthspan would be if I don't have
that it's all meaningless I totally
agree with you
um I would pay almost any price
to live longer and so the for instance
um the question that that you asked like
I would even if there was an apocalypse
as long as there were some other people
even if it killed everyone I knew and
loved which would be brutal man like I'm
I am into my wife in a way most people
just are not into their significant
other I can tell by talking to them and
even that I would if a meteorite hit and
it was like your wife is going to die
but you can live I'd be like yeah I want
to live
so my wife wouldn't though she's like if
you die I'm going that's so interesting
I can't wrap my I mean it depends on my
kids but but yes if my wife and kids
were not on this Earth I wouldn't want
to be on this what would happen if God
forbid Peter God forbid I don't have
kids because partly because I am so
afraid of how devastating it would be if
they died but if they died
would you want to die
um I mean again I I hope I never have to
contemplate that but if I lost all of my
kids yeah I'd I'd have a hard time
probably wanting to go on Wow Wow I get
it man look it's it is
I I have seen people go through it it is
an unbearable thing that I can't believe
life asks of anybody
but despite knowing how bad that hurts
and I would not want to go through it I
don't know man and and look of course I
might get so rocked I'm just saying hear
from an emotional sobriety standpoint
where it is just the thought exercise
um I don't understand people's response
to be like yeah just take me out but
let's go back to I think what's the more
germane point which is
um you want quality of life and length
of life I hope what comes across really
clearly in the book is those are not
mutually exclusive and what I really
would like people to understand is if
you pursue them both you get them both
in fact if you just focus on health span
if you just focus on preserving
cognition having the most physically
robust body possible as you age and
pursuing emotional health you are
guaranteed to get lifespan benefits as
well
okay so talk to me about the horsemen
let's name them
so there's four three of them basically
account for the majority of
death in the first world
one of them directly doesn't account for
that much of the death but indirectly
probably accounts for the most of it in
other words it's the amplifier of the
other three so the big three are the
diseases of atherosclerosis so heart
disease and stroke second one is cancer
third one is neurodegenerative diseases
inclusive of all dementias so that
includes Alzheimer's disease uh
Parkinson's disease Lewy Body dementia
vascular dementia
Etc
so those those three really they they
show up a lot on death certificates they
kill a lot of people
the fourth one is more of a spectrum
it's not a single disease but it's the
spectrum that goes from hyperinsulinemia
to insulin resistance fatty liver
disease all that metabolic stuff we
talked about all the way out to type 2
diabetes and again not a huge number of
people's death certificate says nafldi
type 2 diabetes a little bit but not not
staggering but when you're on that
Spectrum the further you get towards the
type 2 diabetes side of that Spectrum
you're just doubling your risk
essentially of all the other three
Horsemen do you think that metabolic
disease is causative like is basically
every non
um traumatic death is it Downstream no
it's it's it's uh it's neither necessary
nor sufficient but it is causative so so
you can have causality without necessity
and sufficiency so let's take an obvious
example smoking is smoking causatively
related to lung cancer
100 like meaning there is a causal
relationship between smoking and lung
cancer but 15 of people who get lung
cancer never smoked
I don't know the number but many people
who smoke don't get lung cancer
so similarly metabolic disease is a
hundred percent causally related to the
other diseases but not everybody who
gets met up not everybody who's
metabolically ill is going to
necessarily succumb to those diseases
you could die of something else
um and not everybody who succumbs to
those diseases had metabolic disease
okay that's really interesting there's
at least one example you give in the
book I'm not sure where you put your own
story but you scored a six on the
calcification
uh scale very young 30 35 and then
anahat O'Connor who we bizarrely both
know you know them way way way way
better than I do but I had the Good
Fortune of meeting him
um
he scored like 126 or some ridiculous
thing
so is that the kind of example where you
guys were both relatively healthy but
have this what genetic predisposition
well totally different issues I mean
anahad as I write about in the book had
unbeknownst to him a very elevated LP
little a
um which is genetic and he was otherwise
exceptionally healthy
um and is to this day exceptionally
healthy but had this genetic issue that
was driving
you know rapidly advancing heart disease
and luckily
um you know was caught really early I
mean 125 or whatever his calcium score
was pretty darn Advanced but to be able
to catch that at such a young age uh is
is going to make an enormous difference
in course correction so had he not had
that calcium scan done and acted on it
uh there's virtually no question in my
mind he would have died prematurely yeah
so I was going to ask so if that isn't a
driver or isn't being driven by his diet
is it purely just genetic luck of the
draw yes okay so in the book you tell a
story of somebody that came to you they
had just the worst deck of cards or hand
of cards that you could be dealt around
cognitive decline
well as in the they had the worst I mean
they didn't have the worst fortunately
they had you know a very bad hand dealt
to them vis-a-vis the risk of
Alzheimer's disease so how do you if you
get a rough deck hand oh I keep calling
deck you get a rough hand like that uh
what do you do
um you start acting as early as possible
to mitigate the risks so we know what
one we we have a really good sense of
things that people can do to reduce the
risk of Alzheimer's disease and in this
particular woman's case I call her
Stephanie that's not her real name
um we we undertake a number of things uh
with respect to sleep stress uh
nutrition exercise
supplements that we know are correcting
certain deficiencies such as elevated
homocysteine levels
um and
unfortunately
in her case fortunately because she's so
young but unfortunately for many people
we don't have pharmacologic strategies
yet so we're just I think on the
precipice of sort of some Precision
medicine ideas so for example in our
high risk patients who have this Gene
the apoe4 gene we are using a new test
called the c2n test that measures plasma
amyloid and we're using plasma amyloid
as a biomarker for the first time now to
track interventions so in other words
we're using drugs exercise nutrition Etc
to try to lower plasma amyloid and
high-risk people
talk to me about drugs like this is one
thing statins comes up a couple times in
the book I I the only drug I take is an
antihistamine
and I would stop doing that if I could
figure out what it is either in my diet
or my environment that's giving me the
allergies but I've had it across like
seven different places that I've lived
different states I mean just doesn't
seem to matter I've had wildly varying
diets doesn't seem to impact it anyway
so I take an allergy medication
um and then I'll sometimes supplement
vitamin D but other than that I I just
have a real hesitation to take any
supplementation whatsoever
but you don't seem to have the same fear
I have of an isolated compound so you
get people on statins if they have early
signs of
heart disease not necessarily I mean
when it comes to managing APO B which is
the thing we're trying to manage on the
lipid side
um we have a lot of classes of drugs
statins are one class of drug that's one
way to lower APO B is to use a Statin
statins also happen to have the most
side effects of any class of drug that
lower lipids in fact all the other
classes of drugs that lower lipids have
no side effects statins really have the
worst side effects by far so you might
say well why do we even tolerate statins
like why would we even use them we use
them because we have the most data for
them they are very efficacious though
not the most efficacious
and they may have some other benefits
that go beyond their APO B lowering
benefits so all that has to kind of be
weighed and you have to weigh that
against the downside of statins which
are that a non-trivial subset of people
have at least one of two problems in the
presence of a Statin one they get muscle
soreness
the other problem is paradoxically their
glucose metabolism Goes to Hell
not entirely clear Why by the way but we
see dysregulated glucose metabolism in a
small subset of patients on statins and
again we see in a small subset of those
patients about five percent muscle
soreness so if we have those symptoms or
signs in a person on a Statin and we've
chosen a Statin as part of the solution
in this lipid lowering campaign
we just discontinue it and can it
reverses like that but when you
prescribe somebody a drug do you do that
only when it's like they cannot uh
address this via diet and exercise yeah
it depends so
um it depends on several things so
certain so exercise has very little
bearing on lipids it has no clinically
meaningful benefit on lipids has a much
better clinical benefit on metabolic
health and blood pressure which are also
very important in controlling heart
disease so we care a lot about exercise
because we want to control those other
things that drive heart disease the big
three by the way are smoking high blood
pressure and high APO B so
um again we're trying to do all of this
in concurrent fashion as opposed to just
you know playing whack-a-mole on one
thing
um but nutrition has a relatively
um minor role outside of extremes at
controlling APO B
um once a person once you get a person
sort of insulin sensitive and once
you've normalized their triglycerides
unless you're willing to go on profound
fat restriction it's very difficult to
get apob in the levels that we deem
appropriate for
um true prevention would you rather put
them on profound fat reduction or
generally not because it usually comes
at such a high cost what's that cost uh
usually they end up getting insulin
resistant because you're now putting
them on a very high carbohydrate diet
and they're usually protein malnourished
why would that be true so it just is a
function of what they're eating so for
two years so I used to be 60 pounds
heavier to lose the 60 pounds I
basically just ate chicken breast and
broccoli and while not fun because I was
also calorically calor calorically
restricting so hard uh
uh it was fine yeah and if that works
preference though over a drug here's
what I say
no the answer is no what I say is
diet is a way harder problem to get
right than drug so let's get the diet
right first let's come up with the diet
that works best for your metabolic
Health your muscle mass
your
um your sort of fat distribution and
your sanity
diet is really hard to get right um
maybe not for you you're kind of a you
know a highly disciplined person but for
most of us
we want to make sure that we can put you
on a diet that you're you're able to
stay with for the Long Haul we're not
compromising muscle mass we're not
compromising metabolic health
so if that Diet also happens to produce
very low APO B because it's highly
restrictive in fat fantastic stay the
course
in my clinical experience taking care of
lots of patients that's not the case for
most people for most people the diet
that produces optimal muscle mass really
good metabolic health and is something
that they can tolerate for a long period
of time it's not sufficiently reduced in
fat enough to have a meaningful impact
on their lipids and therefore if we want
to get apob low enough to really get
into major prevention territory we're
going to need a drug
okay uh
I'm not sure if it's more enlightening
to find out what stack of drugs
supplements you take or if based on
Horsemen that is likely to kill you I
have people on these but I am curious
what what do you take are you on
rapamycin Metformin anything like that
um I do take rapamycin I do not take
Metformin
um I do take uh a lipid lowering drug I
take two lipid lowering drugs so one of
them is called rapatha it's a pcsk9
inhibitor so it's an injectable drug
that
prevents the degradation of LDL
receptors on the liver so that's
specific very specific so it's a very
clean drug has no side effects Works
incredibly well it's the most potent
lipid lowering drug we have did you have
a genetic predilection to something that
made this necessary I mean I I just only
that I have a genetic prediction
predilection to heart disease my family
history is abysmal for heart disease so
um you know once that came into Focus
for me I was very clear that I was going
to do anything and everything to at
least take that off the table right
um and that basically means not smoking
not an issue having low to normal blood
pressure fortunately not an issue and
having physiologic concentrations of
apob meaning lowering my apob to the
level of a child
okay and you are you able to get to that
or is that what this injectables for I
use these drugs to do that got it does
rapamycin help with that no so what's
rapamycin about explain what it does to
people
um well I I think that's that's a bit of
a TBD right now I mean we we know what
it does in the on label use so on label
use of rapamycin which is you know
taking kind of a medium dose every
single day is an immuno is an
immunosuppressive dose and that's how
rapamycin was approved in 1999 by the
FDA for use in patients with solid organ
transplants so when you have an organ of
somebody else put into you your immune
system naturally wants to destroy that
organ so patients who get organ
transplants kidneys or livers or hearts
or things like that they have to be on a
cocktail of drugs to suppress their
immune system specifically their T cells
which are the cells that would normally
be going after viruses but now they're
going after the organ so
um that's nothing to really do with how
we're thinking about rapamycin as we're
thinking about rapamycin through the
lens of what's called Giro protection
which means
you don't really have a very specific
disease you're treating you're more
broadly targeting the process of Aging
at the cellular level
and there
um based on a lot of animal data that's
very compelling it appears that
rapamycin does indeed provide Giro
protection
um but it's very unclear as to how to
dose it to get that and how you dose it
in a mouse
probably isn't how you should dose it in
a human but we don't really know
um so if we don't know why am I doing it
yes I guess I I'm
I'm
steeped
reasonably well in the literature and I
have a strong enough conviction that
the way we're dosing it for this purpose
has a much higher probability of being
valuable than not
but I'm gonna be very quick to abort in
the presence of new information just as
the information that you see in the
literature in your blood both all of the
above new studies coming out you know
there's a very important study coming
out in three years
um called the Aging uh the dog aging
project I believe it's called yeah yeah
I had him on the show yeah so so very
interesting so if I remember right from
uh talking to him basically we're trying
to get out of mtor more or less which is
my big fear with my diet because I'm I
eat so much I mean so much has changed
my mind since reading your book but I
eat so much protein animal protein
specifically I imagine I'm in mtor all
the time and so it was is tempting to
try rapamycin but is that what's really
going on uh not really I mean well yes
rapamycin is is an inhibitor of mtor
that's that's how the drug Works
um but it's not when you eat protein the
activation of mtor is relatively short
so but if you're eating it all the time
wouldn't you then presumably just
constantly be soaking that fire not
necessarily I mean even if you eat like
I do which is no intermittent fasting
there's still 14 hours a day I'm eating
nothing right so
um and again amino acids do not stick
around very long in circulation so you
know you're they're coming on they're
stimulating mtor and then they're gone
um if if if
um rapamycin's benefit is through mtor
inhibition specifically
um it's probably more through the
inhibition of chronic elevation
okay and who knows there may be tissue
specificity it may be more about what
it's doing in one part of you know in
one tissue versus another might not be
in the muscle it might be in the liver
um there are a lot of unanswered
questions here which is why I think the
work Matt is doing is really important
if you I'm guessing you have a a
hypothesis at a minimum of what the
mechanism of action is there that is
prolonging life like if we think about
your whole hypothesis on a sense
engineering is that the four horsemen
they're just delaying longer than
anybody else so what is do you guess
rapamycin is doing that causes the delay
of one or all of those
probably some enhancement of autophagy
probably some inhibition of senescent
cells
possibly some reduction of inflammation
is it reducing the creation of senescent
cells or just the ramidity with which
they're cleaned no it might be
inhibiting these secretory factors that
they secrete so senescent cells release
these factors that effectively are their
agents that poison other cells and it
might be the case that rapamycin is
impairing that process
very interesting so that makes me think
about cancer so we talked a little bit
about that before we didn't go into a
lot of detail so
cancer I don't know if people are more
afraid of Dementia or cancer but both of
those are pretty terrifying from in
terms of ways to go out
with cancer we've I forget how long
we've been the war on cancer we've made
precious little progress are we barking
up the wrong tree like what what is it
that either makes that so hard like if
we know what it is why is it so hard to
deal with and if we don't know what it
is why do you think that's evaded our
eye for so long
well it's a really good question
um you're right that we have made scant
process in the most important metric of
cancer which is overall survival
so
think about it for everybody who gets
cancer we should be asking the question
How likely is it that they will not die
of the cancer that they just got um
um another way to think about that is
How likely are they to be alive in 10
years if you're alive in 10 years after
getting cancer that cancer is unlikely
to be the thing that kills you
um and by that metric
we've only made about a five to eight
percent Improvement in 50 plus years
whoa
and that Improvement has been largely in
some very specific cancers so that's not
like across the board we've gotten a bit
better it's like no we got a lot better
in a couple of cancers namely leukemias
and certain lymphomas
a couple of other esoteric cancers like
testicular cancer
and aside from that we haven't really
gotten better now very recently there's
some exciting news that does seem more
applicable to a slightly broader array
of cancers which is the form of therapy
called immunotherapy so unleashing the
immune system to fight Some solid organ
tumors has also proved to be and some
leukemia's lymphomas has proved to be
quite promising but we still haven't
figured out a way to unleash that
against every Cancer
even though in theory it should work
right every Cancer should have at least
some mutations on it that the immune
system could recognize as non-self and
we know for certain that 80 percent of
them do in fact 80 percent of cancers
solid organ cancers so these are the
ones that are killing the majority of
people right so breast cancer prostate
cancer lung cancer colon cancer Etc 80
percent of those cancers have what are
called novel neoantigens on them meaning
they have antigens on them that are
novel to the cancer and recognizable by
the host's own immune system the problem
is there aren't enough T cells to
recognize it to Mount is sufficient
immune response so the real challenge of
cancer therapy today in my view is going
to be enhancing that problem that
process rather in other words
I think most of the attention on cancer
should be on how do we create more
reactive antigens in cancer and how do
we enhance and extend the longevity of T
cells to attract that
um so I'm actually surprisingly more
optimistic now about this than I was
even when I started writing the book
because of what I'm seeing with a class
of drugs called checkpoint Inhibitors
and also for um what I'm seeing with
interesting clinical trials where we're
seeing
the pairing of checkpoint Inhibitors
which are immune modulators and
conventional chemotherapy drugs which
take tumors that are not previously
susceptible to this immune modulation
but then create mutations that then make
them susceptible
really clever and cool stuff I I think I
write about a couple of examples of that
in the cancer chapter so
um
it's it's easy to be sort of pessimistic
about cancer because of how poorly it
has gone for the past 50 years but
I think the next 10 years look a lot
better than the last 50. because of
things that are already in motion yeah
because of these processes that are in
motion so if you got diagnosed with
cancer what would be like step number
one you what kind of cancer is it is it
one that responds to immunotherapy is
there like a protocol that you would
walk down
no it would be entirely dependent on
what the cancer was but you know so that
gets to kind of step two of my thinking
on cancer which is uh is the the
unequivocal unambiguous understanding
that your odds for treating cancer go
down the more cancer cells you have in
your body
so detecting it sooner in the book you
talk about you for your patience you
lower the age of colonoscopy do
everything much more aggressively so
we're you know we're we're doing cult
we're doing colonoscopy much earlier
much more frequently we're doing how
often would you do a colonoscopy oh it
depends on the individual I mean in me I
do it every three years really yeah and
then I do stool-based testing in between
what do you check for on the stool
you're looking for fecal DNA so you're
looking for DNA of the colon cancer yeah
interesting
it has its own DNA what are we looking
for yeah you're looking for the DNA
that's shedding from a tumor
tumors have DNA other than it's not my
own DNA it is your own but it's mutated
I mean by definition every I mean cancer
is a genetic disease right so cancer by
definition has mutations that render it
different from the host cell in a way
that's predictable
uh yeah that's we know what breaks in
DNA well we know yeah we know what's we
we're sampling what's normal because we
see the abundance of that and then we're
looking at what's different is there
anything abnormal yeah very and that's
what electricity how would you do that
like the sequencing of that sounds like
a nightmare not anymore I mean you can
sift through that many samples oh my God
Next Generation sequencing can do this
stuff like it's it's simple how many
sequences would you have to do in a
single fecal sample to figure out if
there's one like is it a thousand a
hundred ten
um I think which maybe a better question
is what's the Frequency with of abnormal
cells that can be detected in the
presence of normal and and that's a good
question I don't know in fecal uh I
don't know in the fecal test I know in
the blood test it could be
one in a million hmm
do you guys speaking of feces uh do you
guys look at the microbiome at all no
really what don't know what to do with
it yet nobody knows what to do with it
anybody who says they know what to do
with it is probably trying to sell you a
supplement
that is probably true
uh okay so I'm startled meaning look
there's no doubt that the microbiome
isn't an is an important part of human
health like we're not I'm not sitting
here denying that or saying the Earth is
flat there's no doubt that your diet
plays an enormous impact on the
microbiome there's no doubt that you
know a course of antibiotics will alter
like all of these things are true but
we're still left with the so what
question
I've yet to see an example of where
someone can show me
that
I have a person in whom I detect a
problem I check their microbiome
I make an intervention in response to it
that I wouldn't have otherwise made that
fixes the problem wow I just don't see
those examples okay so man this is very
interesting and important to my life so
I think we talked about this before my
wife seven years ago now I think had a
threshold event where she went from
having a manageable gut issue to I was
legitimately afraid she was gonna die
her hair was falling out her nails were
breaking she couldn't keep anything down
she was in agony at times on the floor
couldn't be picked up I was just really
really brutal she had to do things like
swallow cameras colonoscopy endoscopy
like I mean she did [ __ ] everything
and this was long enough ago seven years
that uh
a lot of doctors only sort of knew what
a microbiome was like they didn't know
anything about it they only sort of knew
that it existed and so they couldn't
come up with any answers and it was only
through finally getting her tested
realizing she didn't have enough
diversity realizing what we're gonna
have to do to start building that
diversity back it was a very long
journey of figuring out what the things
were that she was responding to
um dietary enzymes probiotics prebiotics
I mean just like this whole arsenal now
it may just be oh we didn't actually and
and to be honest we don't know which of
those things worked and she said many
because she takes like 26 supplements a
day or something she's like uh I don't
know do I still need to take them all
she's like I have no idea so she just
keeps doing what she's doing and we
don't know the counterfactual in these
situations and and I guess what I'm what
do you mean by that we don't know what
would have happened if you did something
different yes very true so that this is
the problem with this space is we don't
have clinical trials upon which to
extract knowledgeable or reliable
information why I don't know probably
because there isn't enough financial
incentive for the industries that
typically want to do this right like if
you're an unregulated industry which is
the supplement industry what incentive
do you have to do a clinical trial you
don't require it to sell your product
all you need is marketing so that's why
no supplement company is out there
trying to run a clinical trial clinical
trials are only run by drug companies
because they can't sell their product
right without a gold standard of a
clinical trial so for as much as people
want to kind of poo poo drugs and AAA
supplements they should really be
thinking about this in the other way the
burden of proof is much higher on a
supplement in the sense that we have no
clue if it works let alone if it's not
harmful at least the FDA for all of its
faults and you won't find many people
that are more critical of the FDA than I
am I think it's on the verge of being a
corrupt organization at least it tries
to hold drug companies to some level of
efficacy and safety it doesn't always do
it but at least it's trying at least
they're going through those motions no
one's even trying to do that with
supplements I mean the supplement
industry is such a filthy disgusting
industry that even though I take
supplements I stress more about sourcing
those than I would ever stress about
sourcing Pharma hmm
okay so in other words you've got to be
really careful where you're getting your
supplements so if I'm using a probiotic
which I do during allergy season hmm
interesting a probiotic why you know I I
live in a part of the world where there
are really wicked allergies and I don't
want to get them so I've talked to a few
allergists and I've said look what can I
do prophylactically during this season
in Austin where Cedar fever is out of
control and they say well we don't
recommend doing immunotherapy until you
actually develop the allergy blah blah
blah but a couple of them have said look
we recommend this probiotic we think it
might slightly enhance you know this
element of your immune response and I'm
kind of like okay I if there's a five
percent chance it works and it's not
going to hurt me I'll take the chance
because the only thing I'm doing is
wasting money but like I don't find that
to be I mean I do it somewhat
reluctantly all right that's so
interesting to me that the microbiome
would play a role in allergies I mean I
get it because so much of the immune
system's there but it's just it's such a
unexpected twist turn of events for me
um even just the discovery that so much
my immune system resides in my gut was
already startling
yeah it's it's it I mean again I think
the microbiome is interesting and I
really hope we get to the point where we
know how to manipulate it um are you do
you look at the research on that are you
waiting for something more stable oh I
intermittently do but but I don't follow
that research nearly as closely as what
I'm following other things so it's sort
of like like every year I'll go back and
do a little dive into it with the team
and say okay what is there anything we
know today and you know year upon year
upon year we kind of come back to the
same conclusion which is nothing to
nothing exciting to report yet I mean
there are edge cases right so fecal
transplantation obviously very
efficacious in some people
um do you worry about fmt
um I mean there are huge risks
associated with it as you know so it's
it's it's it's something that should
only be done when the risks are
justified by the alternative of not
doing it yeah we were maybe a month away
from me doing fecal microbial transplant
with Lisa because I was just like this
is scary yeah understandable but for
reasons of it just felt like blood
transfusions from like the 70s or
something where it's like I don't know
scanning for the right things
very terrifying so what would you have
done if I'd come to you with Lisa and
said hey uh she's always had gut
problems I would have sent you to
someone who who does that like again I'm
not saying that who though like nobody
seems to know like when I say we finally
even I couldn't resolve it for her as
much as I was learning and meeting with
experts like she finally just had to be
like when I eat this what do I feel when
I eat this what do I feel yeah I mean
again this is not my area of expertise
so I wouldn't act like it was
um you know you'd be like I don't know
yeah I'm really happy telling people I
don't know there's there's more things I
don't know than I do know yeah that is
uh that's something that a lot of people
struggle with I definitely fall into the
other camp where I feel like I know just
enough to be like do this come back
report so it was really interesting
reading your book seeing how much of the
things that I felt like uh in fact I'll
say this another way I am I'm I'm I have
a weird emotional hang up like I really
wanna I wanted to say the sentence that
I'm gonna stop doing intermittent
fasting and and start are doing what
you're talking about and I probably
should uh do I have orthorexia this is a
very interesting question I feel it's so
easy for me to maintain my body
composition through intermittent fasting
it's very easy for me to maintain my uh
my satiety through intermittent fasting
it's when I click over into ketosis I
find that my relationship to hunger is
different but you did say that that if
I'm doing it for body composition
reasons fair enough that's very
interesting so one thing that I know I'm
just thinking out loud here one thing
that I um
I do often wonder about with my own
physique is protein intake and muscle
hardness
when you like when I'm being really
consistent with working out and I take
my carbs up my muscles get really hard
will I have a similar effect by and you
know why that is right uh the glycogen
is being pushed with your muscles it's
more water right so more carbs means
more glycogen every molecule of glycogen
is bringing three molecules of water so
you're you're filling up the muscle
okay so then is there none of that
relevance with proteins I was going to
say like it's different right so so
protein is contributing to the sarcomere
the functional unit of the muscle the
the that's that's that's the part that's
Contracting right that's the functional
piece of the muscle so that's what's
increasing the synthesis of the muscle
and that obviously contributes to size
uh but it contributes just as much to
function
um but creatine you know will add size
to muscle through water retention
carbohydrates will add glycogen and
water to muscle these things are
important for performance also by the
way so they're not just an aesthetic
thing so carbohydrates uh creatine water
protein synthesis all of this matters to
muscle
if I were eating more protein would you
expect my muscles to feel more firm what
uh am I going to be able to increase my
strength more like it assuming that I
hold my workouts the same because I'm
trying I'm trying to think through do I
change my diet or do I just keep doing
what I'm doing now what I'm doing now is
easy but I always thought I would say I
don't know how you're working out so I
don't know right now what you're limited
by are you limited by amino acids or are
you limited by Progressive overload or
are you limited by some other Factor so
meaning I'm not overloading the muscle
enough yeah are you over are you putting
enough stress on the muscle or not uh do
you have a high enough testosterone or
not do you have enough amino acid or not
any of those things can be the
bottleneck
um and uh you're at the limit of your
genes right like all of these things
start to matter now my guess is
virtually nobody is at the limit of
their genes except for bodybuilders so
I'm not at the limit of my genes what am
I at the limit of right now probably and
I'm not at the limit of protein anymore
I'm probably at the limit of how hard
I'm willing to train how much I'm
willing to train and actually I'm
probably at The Limited testosterone as
well because my T is pretty low so I
can't answer the question for you what
is more protein going to do because I
would need a lot more information to
understand like how your training what's
your training volume what's your
training intensity and you know all
those factors okay so one thing while I
have you that I I will say is my
limitation when I think about what holds
my physique back I get injured a lot and
I get injured in a very specific
repeatable way which I think has to do
with stability which you cover in the
book so
um I have a very weak middle back and I
compensate for everything by shrugging
my traps so it almost doesn't matter
what I'm doing like brushing my teeth I
will suddenly realize Jesus and I have
to like remind myself to I think it's uh
retract my scapular like I'm pulling
that sort of mid-back girdle down in the
book you go into how you can rewire the
way that your brain has learned to
control your musculature what what is
that process I have injured my trap
you're gonna think I'm exaggerating I've
injured my trap 115 times over the 20
years when you say injured your trap so
you sent it into spasm so where I can't
turn my head or I can't tilt my head uh
literally last night in bed I was
rolling over so just adjusting my
posture and it went and I was like
you've got to be [ __ ] kidding and so
then I couldn't fall back asleep because
I could just feel it tightening and
tightening and tightening and tightening
that is the thing that has has held me
back for forever it's the first injury I
ever received the first day in the gym
doing an overhead press it went and I
thought I was dying at that point I was
like what the [ __ ] uh yeah I've injured
it probably at least 115 times
again it would be impossible for me to
kind of give you the diagnostic here but
I think I think if you think about the
way I kind of go through that stability
chapter
um it starts with respiration so the
first thing we'd have to understand is
what's your respiratory strategy
um so are you over inflated under
inflated chest breathing only abdomen
breathing only all of these things
um are you chest out are you hunched
over like you'd want to go through how
do you correct your your respiration
strategy
um and then you'd want to look at do you
have for example segmental control of
your spine most people do not I can't
imagine yeah so until you have segmental
control of the spine you are always
going to disproportionately put Force at
various hinge points in the spine do you
have thoracic mobility of your spine
sounds like you don't have thoracic
mobility of the spine do you have scap
is thoracic Mobility so are you able to
rotate through the thoracic spine so you
have a cervical spine thoracic spine is
the longest segment and then the lumbar
spine so most people don't have
segmental people that like twist
themselves on a chair that kind of thing
like how would you do that yeah but if
you do twist where are you twisting
through where is the torsion what part
of the spine for me almost certainly
lower back exactly that would be the
most common so most people are
excessively applying torsion in the
lumbar spine and you want to be able to
dissipate it through the whole spine
also when you talk about the flexion
extension of the spine and by the way we
made a bunch of videos like
because you can't explain all this stuff
in words so in the book there's a link
to like videos where I go through what
these things look like but you know
being able to do a segmental cat Cow
exercise is a really good way to see if
you have segmental control of extension
and flexion of the spine from head to
tail
um so you know then we get into sort of
do you have scapular control through the
full range of motion through all four
phases so protraction retraction
elevation depression again very few
people can can control their scapula
through those things so stability and
movement are uh you know intertwined
very intimately and if you you know if
you're trying to unpack these injuries
you generally have to go back to the
breath training how to train yourself
how to breathe properly training
yourself how to move properly and there
are two schools of thought that I have
relied on very heavily in my journey
here and that of my patients and that
one is called Dynamic neuromuscular
stabilization DNS the other is called
postural restoration Institute PRI
bringing everything that I've learned
from this conversation and the book
today tell me if this makes sense so I I
would like to add more muscle to my
frame do you know how much muscle mass
you have right now I don't have you had
a dexa scan I haven't man I'm really
like I love that stuff but because no
one's coming to my house to do it uh I
haven't gotten tested be very
interesting you can't do it at your
house you kind of have to go to the
machine I'm willing to do it I would be
very keen to figure that out one I want
to see if I haven't well you should get
a Baseline and you should you know you
should figure out like where you are
where do you stack up right now in terms
of muscle mass if for no other reason
then you can evaluate your progress if
you let's say you you know you test your
almi it's at the 70th percentile that's
great but do you want it to be at the
80th percentile well this way you can
figure out if the changes you're making
are going to move you in the right
direction or not all right so making my
goal maybe even more broad is something
you talk about in the book which is the
centenarian decathlon uh so what are the
things you want to be able to do when
you're older you better be scoring very
high on them depending on what part of
your age you're in now because it's all
going to decline as you get older so
here are the things I feel like I should
be implementing based on I am 47. okay
and so what do you want to be able to do
40 to 50 years from now I want to be
able to be very independent from a
Mobility perspective so I love the idea
of being able to
when I'm flying to Mars to be able to
hold I guess before we Blast Off be able
to put luggage above my head uh
uh so yeah I want to be able to travel
put things above my head I don't want to
lose a lot of my strength I want to make
if you want to go to Mars by the way
you're going to tolerate pretty high
g-forces so think about the next race
that's going to be required to do that
yes also I would just like to not have
constant trap injuries that'd be amazing
um I want to be able to play video games
okay I don't play video games I do drive
a simulator though so that's probably
similar uh I would guess not from the
perspective of what I struggle with so I
had so much wrist inflammation for so
long I think a lot about inflammation
inflammation keep that down so you thank
you by the way you're encouraging me to
add fat to my diet allowed me to go from
basically never being able to play video
games to I can now play as much as I
want on Saturday which I mean I I'm sure
I could play more than that but that's
just from a Time allocation standpoint
so uh that's been a huge one so being
able to do that sex huge thing in my
life so being able to whatever that
takes so a certain amount of flexibility
I imagine and uh stamina et cetera et
cetera
[Music]
yeah Aesthetics I want to look good I
want to be strong look strong
um
something cognitive like being super
sharp that would be really important
well I mean if you're playing video
games presumably you've got to have
pretty decent cognition right you've got
to have
um certain skills and depending on if
you want to be doing this
yeah also true I don't need to pick up
grandchildren that would be the maybe
one deviation from what a lot of people
want to be able to do but being able to
be physical active I mean take sex is my
like I want to be able to do that to the
fullest
um so given all of those things here's
sort of how I see this now breaking out
um
sleep which we didn't really get into
but I obviously I'm gonna need to get
sleep that's going to be super important
I'm going to need to identify given my
family history I think it's either going
to be cancer or heart disease neither
sort of overwhelmingly prevalent
um but those would be the two where
grandparents died of that so certainly
want to be thoughtful about that so I'd
identify those two Horsemen so I'm going
to be really thoughtful around my diet
making sure that I don't have fat
spilling out that I'm really thoughtful
about the
um
that's the one that gets into my cell
walls arterial walls yeah and you do
need to check your LP little a which is
the thing we talked about as well that
is genetic and occurs in
about eight percent to 12 percent of
people okay so uh paying attention to my
diet uh the adjustment that I'm thinking
about making my diet I'm gonna test not
doing intermittent fasting see what that
does for my muscle mass
um eating more protein I have a feeling
I might be lower in protein though I
haven't counted up the eggs I eat a lot
of eggs
um and then I'm really curious to see
about cycling rapamycin so what is your
cycle on rapamycin
um I just dose it once a week just just
take one dose once a week yep okay very
interesting
um trying that
what other changes you're gonna have to
have a doctor help you with that that's
that's not an that's not an
over-the-counter yeah yeah yeah for sure
for sure I obviously would be doing this
on the back of a lot of blood testing to
make sure that I
um a that I know what my Baseline is B
then I'm actually getting the result
that I want to see
um so yeah looking at the number on the
um
the cholesterol that we were talking
about earlier
grip strength is going to be one again
not
you know not sitting around with a
little one of those like little grip
squeezers because that's not really what
it's about it's how do you develop grip
strength you develop it by carrying
heavy things right so you know this
morning I was dead lifting and because I
was doing it in the hotel and I didn't
have chalk I was failing in grip today
like it's actually funny my hands and my
forearms are still sore five hours later
because I was really at the limits of
what I could do without chalk and you
know I didn't have anything else so so
but so yeah I was dead lifting but think
about how much I was doing for my upper
body even though that's a lower body
activity
um you know doing farmer carries
something I love doing I mean I'm always
trying to figure out a way to use my
upper body to maximize the relationship
between grip and shoulder
so think of it less as like very
specific tests that you do and think of
it more as the the broader activity you
need to do to produce that so grip
strength is just an integral of upper
body strength
all right so if if that is my sort of
fumbly way through the things the
changes that I'm gonna make
um
if somebody wants to outlive and they
come to you that cocktail party and you
just cannot get away from them and you
have to answer the question in a
succinct way
um what do people need to do to maximize
the human life expectancy
there is no sentence I can give any
person to tell them what the
prescription is right I mean if I could
I wouldn't have written a 500 page book
there's no chance believe me I didn't
want to write a I wasn't look I wasn't
looking for things to do right the
reason this is complicated is that it's
complicated and
two people can have two very different
prescriptions you know if I'm at that
cocktail party and the person I'm
talking to after a few minutes I figure
out that their biggest issue is that
they're not sleeping
you know or that you know they're
sleeping four hours a night nothing else
I'm not gonna really waste time talking
about protein with them we've got to
figure out why they're not sleeping
seven to nine hours a night
and how much of that is sleep hygiene
how much of that is underlying pathology
like sleep apnea or restless leg
syndrome how much of that is alcohol how
much you have to get to the root of that
problem but if you're sleeping four
hours a night that's the elephant in the
room if you're not exercising at all and
you're sleeping well and you're sort of
eating okay like none of that other
stuff matters you need to get exercising
if you have type 2 diabetes and
metabolic syndrome you know I we have to
get you exercising and changing your
diet and all those other things so so
again
it I'm not being difficult because I
don't want to give glib answers I I'm
not giving a globe answer because there
isn't one very fair all right where can
people engage with you to get the
non-glib details on all of this uh I
think if you go to our website Peter
attiamd.com and sign up for our free
newsletter you'll very quickly get
brought into our world where every
Sunday we're gonna spit out something
that me and my research team have
written on all these topics I love it
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