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Peter Attia: Why Your VO2 Max Will Decide How Long You Live

How VO2 max, muscle, and strength training shape the marginal decade; falls after 65 carry a 15 to 30 percent mortality risk for older adults.

Peter AttiaguestSteven BartletthostGuest audience memberguest
Apr 7, 20251h 49mWatch on YouTube ↗

EVERY SPOKEN WORD

  1. 0:00 – 2:04

    Intro

    1. PA

      Death is inevitable, but the rate of decline is very much up to us. But the drawback that young people have is they only begin to realize the inevitability of the decline when it besets them. So your team that came in for testing that are in their 20s, when I'm looking at these results, there were issues that were uncovered that were of concern, and ignoring it doesn't lead to a good outcome when you're 65. But a lot of people have this issue, so it's okay to speak freely about this?

    2. SB

      Yep.

    3. PA

      The biggest concern is that... Dr. Peter Attia is the go-to physician... For high performers, celebrities, and anyone serious about unlocking the science behind a longer, stronger, and healthier life. I had a big epiphany at a funeral of a friend of mine, who I realized had declined so much during their last decade that when they couldn't do those things that gave them pleasure because of injuries, aches and pains, they weren't enjoying life. I call it the marginal decade.

    4. SB

      Wow. Okay. So what are the most important parts of my health that I should be thinking about for longevity?

    5. PA

      So there's muscle mass, muscle strength, but we don't have a single metric that we can measure that better predicts how long they will live than how high their VO2max is, which is the maximum amount of oxygen you can consume. And if you compare somebody who is in the top 2% to someone who is in the bottom 25%, there is a 400% difference in their all-cause mortality over the coming year.

    6. SB

      But how do I know if it's an issue or not?

    7. PA

      We'll go into much more detail around that, but the way to avoid this is to train specifically for that marginal decade. And there's so many things that we just do wrong. The sooner you start, the better. So rule number one: (music fades)

    8. SB

      This has always blown my mind a little bit: 53% of you that listen to this show regularly haven't yet subscribed to the show. So could I ask you for a favor before we start? If you like this show and you like what we do here and you wanna support us, the free simple way that you can do just that is by hitting the subscribe button. And my commitment to you is if you do that, then I'll do everything in my power, me and my team, to make sure that this show is better for you every single week. We'll listen to your feedback, we'll find the guests that you want me to speak to, and we'll continue to do what we do. Thank you so much. (upbeat music) Dr.

  2. 2:04 – 6:39

    What Is Peter Focused on at the Moment?

    1. SB

      Peter Attia. What is keeping you busy at the moment in terms of the subjects that you wrote about in Outlive, but the work that you do online and the work you do in the variety of businesses that you have? What is keeping you fascinated at the moment? Like, what is, what does one's mind focus on?

    2. PA

      I wish I could say one thing. There's probably a few things, and maybe that's, um, not good. (laughs) Uh, maybe the most successful people in life only think about one thing. I would say one of the things I'm thinking a lot about is how to translate Outlive into a delivery system, uh, obviously digitally, that basically operationalizes what is in that book in a manner that allows people to, with as little friction as possible, implement the solutions for themselves. So basically, how do you live a longer life? How do you age, uh, as gracefully as possible and maximize your health span? I think the other thing I'm focused on that is related to that, of course, but distinct, um, which I know your team got to participate in a little bit this week, was kind of how to train people for their marginal decade, right? So this idea of we're all gonna have a last decade of life. I call it the marginal decade just so that we can get comfortable talking about something that people don't like to think about. And, um, I'm convinced that ignoring it and not thinking about it doesn't lead to a good outcome. Instead, if you prepare for it and train for it like an athlete trains and prepares for their sport, uh, you'll have the best version of that possible.

    3. SB

      Marginal decades and centenarian decathlon. Did I say that correctly?

    4. PA

      Centenarian decathlon, yep.

    5. SB

      Centenarian decathlon. Can you explain these two terms to me?

    6. PA

      Yep.

    7. SB

      S- so the marginal decade is the last decade of life.

    8. PA

      Last decade of life.

    9. SB

      Yeah.

    10. PA

      Again, it's this weird thing where most people don't know the day they've entered it, but most people also realize at some point when they're in it. Um, I thought a lot about it. This was sort of a big epiphany that I had in 2018 when I was sitting in the, in the church at a funeral of the parent of a friend of mine whose. who I realized had declined so much during the last decade of their life that even though they were alive, they weren't enjoying life. The things that they loved to do, in the case of this individual, play golf and tend to the garden, they couldn't do. They just physically couldn't do it, right? They had injuries. They had aches and pains. And when they couldn't do those things that gave them pleasure, they retreated from life. And I, I, I don't think there's a person listening to us who can't appreciate that because they ha- they've witnessed it, right? They've seen it in a parent, a grandparent, a loved one, and I don't know, there was just something about that moment, which is often the case, right? It's usually like years and years of thinking about something, and it crystallizes in an instant. But in that moment, I realized, "Aha, the way to avoid this is to train specifically for that decade." And the best model for how to do that is to look at athletes because every athlete trains with specificity, right? So think, think of like all the different types of athletes you would know. So if you think about like a, a sprinter or a basketball player or a football player, they are so different, and very little of their training looks like the other guy.

    11. SB

      Mm-hmm.

    12. PA

      And the reason for that is they're doing something very specific, right? The sprinter has a goal, which is to move 100 meters as fast as possible. That's it. And that requires a certain set of skills. And the footballer has a totally different goal. Yes, he has to be able to run fast for short distances, but just being able to run fast would not produce in-, you know, superior results. And then the basketball player would be different, and then the skier would have a totally different set of skills. So I said, "Well, who's the most well-rounded athlete out there?" It's the decathlete because that guy's gotta do 10 different things really well.Now, he or she doesn't have to be the best in the world at those ten. In fact, they never are. But overall, they're considered the best athlete because of the diversity and breadth of what they can do. And so I said, "That is our model." So, what is the centenarian decathlon then is, I say to you, "Stephen, one day you are going to be in your marginal decade. What do you want to be able to do physically, athletically, in that last decade?"

  3. 6:39 – 10:08

    What Steven Wants to Be Able to Do in His Last Decade

    1. PA

    2. SB

      It's (sighs) ... The answer's so clear to me because it's associated with all the things that make me happy.

    3. PA

      Mm-hmm.

    4. SB

      So it'd be being able to explore the world still with my partner, my romantic partner. It would be-

    5. PA

      But I would even dig further. Tell me what that looks like.

    6. SB

      Okay, so I went to Bali.

    7. PA

      Mm-hmm.

    8. SB

      And me and my girlfriend wanted to go white water rafting. And to get down to the white water rafts in Bali, we had to walk down and then up again-

    9. PA

      Mm-hmm.

    10. SB

      ... about 100 meters of stairs. And as I went down those stairs, I had one of those moments that it sounds like you had at the funeral, where I realized that my dad could not walk down these stairs. He couldn't walk down them and he couldn't walk up them, so-

    11. PA

      And by the way, it's a different reason. I'm gonna point this out and then I wanna come back to your story. Walking down is not about endurance. Walking down is about eccentric strength in the quads to be able to, uh, decelerate the body as it's moving down. Very important. Coming up is about concentric strength in the quads and glutes, and endurance.

    12. SB

      Ah, okay.

    13. PA

      All right, but continue.

    14. SB

      No, that's a really good point because they're two different-

    15. PA

      Yep.

    16. SB

      ... training systems. And then the reason why that was so important was because of the great time I had in the white water raft with my girlfriend. So going down that lake through Bali, and I thought, "Gosh, it was so... If I hadn't... If I'm not careful and I don't think about this, I won't be able to have these experiences when I'm 60."

    17. PA

      What was involved in being in the raft?

    18. SB

      Well, yeah, so a lot of strength required to, like, row-

    19. PA

      Yep.

    20. SB

      ... um, to keep us away from the rocks-

    21. PA

      Yep.

    22. SB

      ... um, to push us off when we got stuck. Um, fall in the water, get it back in the boat. (laughs)

    23. PA

      Abso- Think about the scapular stability that's required, think about the upper body strength you need to lift yourself back into a boat if you fall.

    24. SB

      Yeah.

    25. PA

      I mean, the list goes on and on and on.

    26. SB

      And it was, it was... It took a long time, we were out there for two hours-

    27. PA

      (clears throat)

    28. SB

      ... going through this lake, so. The other thing I think about is Christmas, and I, I think about my nieces. So my brother's a year older than me and he has three kids under the age of f- six. And you know what that's like, these kids just sprint off in every direction. And they'll say to my dad, they'll say, "Come and play in the garden," and my dad, um, wouldn't be able to play with them in the garden the way that they would want to play in the garden, running around, um, being chased around, so my dad just watches them from the kitchen. And so I, uh, these are just... Obviously all the emotional things come to mind first because those are the things that stay with us. And I'll give you one more: Um, the other thing that comes to mind as a man is just being able to protect my family.

    29. PA

      Mm-hmm.

    30. SB

      And I don't necessarily mean wrestle an intruder, but I mean, like, lift things and, um, if something falls, being able to pick it up and move it. So those are the things that come, come to mind first and foremost, it's protection, it's memories, it's activities that create relationships and connection.

  4. 10:08 – 15:04

    Ageing Is Inevitable

    1. PA

    2. SB

      Part of the reason why I think people don't care enough is because they see aging as inevitable.

    3. PA

      Mm-hmm.

    4. SB

      So they look at their, their parents, their grandparents and go, "They're immobile. They can't function properly. That's my destiny. It's genetic."

    5. PA

      Obviously, I don't agree with that-

    6. SB

      Mm-hmm.

    7. PA

      ... though I have tremendous empathy for people who might feel that way. It's, uh... When you see something as ubiquitous as the decline of untold numbers of people as they age, it would be very easy and tempting to say that that is the inevitability of our species. Death is inevitable, despite what some biohackers may tell you. Um, decline is inevitable, but the rate of decline is very much up to us. And the preservation of strength, stamina, movement capacity, uh, those things are largely up to us. In fact, there are actual data that demonstrate quite clearly... In fact, I was just reading a paper yesterday in, in the journal Cell that looked at the role of exercise in aging individuals to preserve mitochondrial function. So, this is a study that looked at older individuals and it randomized one group to a significant amount of exercise and the other group was just sort of business as usual, being largely sedentary, and then using pretty elaborate techniques where you biopsy the muscle, they look at the mitochondria, which are the, kind of the powerhouse of the cell, in these individuals, and it turned out that in the people who were exercising, there was very little decline in the mitochondrial function compared to what happened in the people who were not exercising. Now, just because your mitochondria continue to function well doesn't mean all aspects of aging are offset, but it's a very important one to demonstrate. And this is also true, by the way, of strength and endurance. There's a big difference in the rate of decline of muscle mass, muscle strength, and cardiopulmonary fitness in people who exercise versus who don't.So, it's all kind of a, a long-winded way of saying, um, you have as an individual so much more under your control than you realize, but you have to sort of begin to compounding the gains.

    8. SB

      I'll do it when I'm 50.

    9. PA

      Well, look, the good news is 50 isn't too old, and, uh, I've met many people who don't begin to do this until they're 50. But again, the analogy I would use here is comparable to that of investing for retirement.

    10. SB

      Mm.

    11. PA

      The longer you wait, uh, the less money you're probably gonna have at the end.

    12. SB

      Springs to mind this graph I saw the other day, which I'd sent to my friends, which shows that, um, the, the decline, I think it was in muscle mass from when you're 30, and it makes the point that there's this line which, on this graph called disability. And it shows that people who didn't have enough muscle mass when they were 30 cross the line of disability when they're 70. Uh, and those that did have more muscle mass at 30 don't, don't get close to that line. Um, so that for me was shocking 'cause it goes to show that what I do now is gonna determine whether I'm, you know, by all intents and measures, disabled when I'm 70 or if I'm able.

    13. PA

      The sooner you start, the better. The drawback that young people have is, I mean, you've had a, you've had a great experience 'cause you're, you're introspective about it and you've been able to observe it in somebody older, so you've been able to gather motivation without having to experience the decline yourself.

    14. SB

      Mm-hmm.

    15. PA

      Um, so that's a, that's a wonderful position to be in. For many people, that's not the case. They only begin to realize the inevitability of the decline when it besets them. But the way to think about this, again, is another analogy is that of a glider. So gliders eventually all have to come down.

    16. SB

      (laughs) Yeah.

    17. PA

      Right? Our health span is basically a glider, but we have a lot of control about how long it stays in the air based on how high we can start it. So if you think about, you know, would you rather take a glider off a really high cliff or off a low cliff? That's the, that's the decision we get to make, and, and we sort of call that concept physiologic headroom. So the example you gave is a great one, right? So muscle mass, muscle strength provide an enormous amount of physiologic headroom, as does cardiopulmonary fitness. These are huge variables that make all the difference. And everyone's coming down, but the fitter you are, the slower the rate of decline, and therefore the longer it takes before you cross below a threshold. And that threshold differs by different metrics, but once you're below that threshold, it's very difficult to engage in activities of enjoyment.

    18. SB

      Peter, you're 51 now.

    19. PA

      52.

    20. SB

      52.

  5. 15:04 – 17:02

    What Peter Wishes Someone Had Told Him in His 30s

    1. SB

      What do you wish someone had told you when you were 32? I'm 32 years old. What do you wish, um, someone had screamed in your face and told you (laughs) when you were my age?

    2. PA

      It wouldn't have been much about exercise. It would have been more about other aspects of life for sure, um, because for whatever reason, I've always gravitated towards exercise. That's always been s- a very high priority for me. So I think my advice to 32-year-old Peter would be much more about, um, relationships and emotional health. But if I could go back and speak to 14-year-old Peter, he, A, he wouldn't have listened, but I would have begged him to go a little bit easier on his body and back off on certain things that probably have led to injuries I have today that could have been prevented.

    3. SB

      Can I ask what those certain things are?

    4. PA

      S- Sure. Um, I think I, I think I lifted far too heavy, far too often, and probably without enough coaching on technique. And so, you know, I, by the time I was 27, I had a devastating back injury, but it's one of those things that happened without any incident, which, which is often the case, by the way, for a back injury. When you really blow out a disc in your back, it's not necessarily something you did in that moment. It's usually something that's been built up from the past. So this injury I had at the age of 27 w- really was the result of years of unnecessarily heavy axial loading, uh, loading done with probably insufficient technique, you know, or technique that was at times sloppy and under fatigue, because I used to do a lot under fatigue, you know? I sort of believed in training under a lot of fatigue, and, and I'm, I think that that's a mistake. I think that training under very heavy load should not be done under great fatigue.

  6. 17:02 – 17:48

    Men's Health

    1. PA

    2. SB

      Interesting. We'll talk about that as well. On that point of advice that you gave me there about emotional health, one of the things that's been very front of mind for me at the moment is men's health.

    3. PA

      Mm.

    4. SB

      Specifically men's emotional health, because I read a report that came out in March called Lost Boys, and it just d- details this pretty horrific picture of men's emotional health in the UK at the moment in particular, but the trend holds around the world. And it came out in, at the start of March. It's been in all the newspapers in the UK, and it details a couple of sort of headline stats, the reverse gender pay gap amongst young men, so women are now earning more. You know the stats probably around, um, soon for every-

    5. PA

      Suicide.

    6. SB

      Yeah, suicide, and one in seven young men are unemployed or out of work. All these sort of horrific stats, and then it compounds with things like suicide, s- suicidal ideation,

  7. 17:48 – 18:35

    What Is It to Be a Man?

    1. SB

      et cetera, et cetera. I was thinking about this this morning when I was listening to some of your, your work. I was thinking, "I wonder what Peter's perspective is on what it is to be a man." Actually, it does kind of dovetail into some of your work around test- testosterone and the decline in testosterone, and 'cause one of the things I was thinking about is how testosterone plays a role in what it is to be a man, but if you look at the stats around testosterone, um, it appears to be declining.

    2. PA

      Yes.

    3. SB

      And it, I say this in part as well because testosterone causes a certain set of behaviors, um, in men that...... define and shape what a man is, and what they want, and how they show up. And, uh, even when I said earlier on protection as one of the three things I cared about, that's probably in part because of the testosterone in me.

  8. 18:35 – 23:20

    Is Testosterone on the Decline?

    1. SB

      This debate around testosterone, this conversation around testosterone, um, and its decline, is it declining?

    2. PA

      It is.

    3. SB

      It is. Why is it declining? And what, and is this- does it matter?

    4. PA

      Well, I think the second question's easier to answer than the first. I do think it matters. Um, the, the, the why is probably multifactorial, and the why is just as important as the fact that it is. In other words, the fact that it's declining is both relevant for the fact that a very, very important hormone that has incredible benefit to men, uh, and women, by the way, is going down, and we have to come up with a m- an answer to that, right? Like, so how do we address that? Do we address it medically where we replace that hormone exogenously, meaning we give you that hormone directly? Or do we try to fix the underlying problem? So if you wanna do the latter, you have to know what the underlying problem is. Now, at the population level, the best answer as to why testosterone levels are declining... and, um, unmistakably they are, so th- the data here are unambiguous, there's no debate on this fact. Um, the debate is around the why. I believe that the best answer probably has to do with two things: uh, one is, uh, increase in body weight and fat, body fat specifically, in men; um, and, uh, some combination of, uh, reduced quality of sleep and, um, and, and, and s- s- sort of disruption to sleep. So, so why are those two things relevant? So when you increase body fat, two things are happening: one is you're increasing inflammation and you are reducing the amount of testosterone that gets to stay in the form of testosterone, because part of the testosterone gets converted into estrogen. So with body fat comes more of this process called aromatization, or converting testosterone into estrogen. So if you think about what those two things are doing, if you have more inflammation, that reduces your ability to make testosterone, and you have more capacity to turn the less testosterone you make into estrogen. The net result of that is both of those things are reducing your total pool of testosterone.

    5. SB

      Mm-hmm.

    6. PA

      If you couple that with p- less, you know, lower quality sleep, and I'm not talking about over the last three years; I'm comparing, like, now to, say, 40 years ago, and what are all the reasons that people might have poorer quality of sleep now? I think there are many, but obviously phones and social media and, uh, just the stimulation of the world we live in probably plays a greater role in that. Sleep is when we make these hormones, right? So, so, so we, we make follicle-stimulating hormone and luteinizing hormone at their maximum amount during sleep, and those are the hormones that are driving the production of testosterone. So what we've seen in many of our patients when they have low testosterone... 'cause there's a test you can do to see if their testosterone is low because their body can't make it or because their brain isn't receiving enough of a signal to make it. This is a very easy thing to determine medically. Unfortunately, most people aren't subjected to that level of testing because they go to these testosterone shops on street corners that are just giving everybody testosterone. But if, if, if a physician is curious enough to understand that, you can give a patient a drug or a hormone called hCG. hCG is luteinizing hormone, which is one of the hormones made by the brain. So if you come in and you see a man who's got very low testosterone and you can't understand why, you give him luteinizing hormone. If he still has low testosterone, you know that he has what's called primary hypogonadism, which means his testosterone is low because his testes can't make testosterone. Conversely, if you give the man luteinizing hormone and all of a sudden his testosterone goes up, he has secondary hypogonadism, or, I mean, it, you could mix the primary/secondary there, but really what it, m- the, the terminology doesn't mean anything. What matters is he can make testosterone, but for some reason his brain isn't giving his body the signal to do it.

    7. SB

      Mm-hmm.

    8. PA

      And that's, that's a classic finding in a person who's under high stress and/or not sleeping well. So that's a long-winded answer to your question, but w- I think that those are probably the greatest contributors to this. Now, people have talked a lot about, what about microplastics? What about other environmental factors? What about other factors in nutrition beyond just the ones that would contribute to excess body fat? The evidence there is less compelling, but I don't think we should discount it. But I, I think, I think that, that if those things are playing a role, it is probably much smaller than, than what we just talked about.

    9. SB

      I was thinking as you

  9. 23:20 – 26:39

    Sleep and Bad Choices

    1. SB

      were speaking about sleep and testosterone, about how... and also the link there with bad diets, how if I've not slept well, I wake up and make worse food choices.

    2. PA

      For sure.

    3. SB

      And I was like, is that, like, dopamine dysfunction? Like, what's causing that?

    4. PA

      No, it's probably more due to insulin signaling. So, um, we know from ex- really good experimental studies that when you sleep deprive people, they become insulin resistant, and the more insulin resistant a person is, the less they're able to access their stored f- uh, energy. So higher insulin resistance means greater difficulty accessing stored energy. So if you're, if you wake up and you're, if, you know, you have successive days of poor sleep and you're becoming somewhat insulin resistant, um, you're gonna want to eat more because you're not able to access your own natural stores of fat, which is where we wanna go for energy. So if you look at one e- experiment that was done outta the University of Chicago, they, they took, uh, healthy subjects, young, young subjects and sleep deprived them for...... somewhere between 10 and 14 days, so not a huge period of time. And they only let them sleep four hours a night, which by the way, I know a lot of people who were doing that for-

    5. SB

      Yeah.

    6. PA

      ... years at a time. In, in that 10 to 14-day period of time, their insulin resistance was worsened by 50%. This is, in other words, they, they do an experiment called a euglycemic clamp where they inject them with glucose to see how effectively they can put glucose into their cells-

    7. SB

      Mm-hmm.

    8. PA

      ... which is, that's the, that's the hallmark of insulin sensitivity, is how well you can put glucose into your muscles when it's infused in you. (clears throat) And their capacity to do that was reduced by 50% after such a short intervention. Um, so I think sleep, uh, restriction and unhealthy sleep is a, is a very underappreciated cause of metabolic health and weight gain, and then by extension, these other things we're talking about.

    9. SB

      It seems to me, to be the thing furthest upstream in my life that then causes this cascading effect to how I show up, uh, in sort of cognitive performance, how well I can articulate myself-

    10. PA

      Yeah.

    11. SB

      ... if I go to the gym, how hard my workout is, if I choose healthy options versus unhealthy options. So it feels like the, the-

    12. PA

      And, and mood in general.

    13. SB

      Yeah.

    14. PA

      Yeah, I mean, look, I, I, I've said this before, and I'm not the first to say this, so I'm paraphrasing others, but if you really stop to think about it, sleep doesn't make a lot of sense from an evolutionary perspective. Like, if you go back in time a few hundred thousand years, why would we have spent a third of our life unconscious? It didn't serve our purpose. You can't mate, you can't hunt, and you can't defend yourself. So you have to believe that if we could've evolved out of it, we would have done it, and we didn't. So that means that whatever it's doing, it must be really important. I mean, core essential to our existence. While I will completely acknowledge that different people have a different necessity or requirement for how much they sleep, I still think that many people underestimate how much they need.

  10. 26:39 – 28:37

    What Peter Wants to Do in His Marginal Decade

    1. PA

    2. SB

      You know you asked me at the start, you said, um, "What are the things that you wanna do when you reach your marginal decade?" And I gave you my answer. What's your answer to that now that you're a father and-

    3. PA

      Yeah.

    4. SB

      ... have, are in a different season of life?

    5. PA

      Well, they're very similar to the types of things you're thinking about, and I love how you've got specific examples. So I really like playing with my kids, right? So I can imagine that in my marginal decade, I'll have grandkids that are the age of my kids.

    6. SB

      Yeah.

    7. PA

      Right? And, and, you know, maybe a bit older, but as I'm even getting towards that marginal decade. Okay, so playing sports is really, really fun. I really like playing, especially because when I grew up, like, I played hockey 'cause I grew up in Canada, and then I immediately went into kinda boxing and martial arts, and those became my life. So now, playing sports that I didn't play much as a kid is really fun. Like, I'm really enjoying baseball, I'm really enjoying soccer.

    8. SB

      Mm.

    9. PA

      And, um, and so when you play these things, you realize this is not an easy thing to do when you get old. Like, to sit in the, you know, to play, to sit in the goal and actually, like, stop a ball when a kid is blasting at you full stop, you have to be able to move around. So a- again, like, I would love to be able to play soccer, throw a football, throw and hit a baseball as long as possible. You can get into movements that are much simpler, uh, but if I can do all of those things, I'm in great shape. Now, of course, to be able to do that, I also need to be able to do a lot of things that many people also can't do in their marginal decade, like sit on the floor, get up off the floor under their own power, um, you know, walk up X number of flights of stairs, having the strength to do that. I like doing certain things, like I like archery a lot. So it's, you know, I wanna be able to pull a bow back. Obviously not at the same poundage as the current bow that I pull back, but I would still like to be able to pull a 50-pound bow back in the final decade of my life.

  11. 28:37 – 32:00

    How to Prepare Now for the Marginal Decade

    1. PA

    2. SB

      And when you think about all those things you wanna accomplish, if we were then to sort of codify them into a bunch of exercises or areas of your health that you had to now be thinking about, that I needed to be thinking about, what are the most important things? So I'm a 32-year-old. What are, what are the most important parts of my health that I should be thinking about if I want to achieve all the things that I said to you in my final decade?

    3. PA

      No one in the final decade of their life ever said, "I wish I had less strength, and I wish, I wish I had less endurance." So you cannot be too strong, and you cannot be too fit. The only time that one would throttle back on the pursuit of those is, A, if doing so is coming at the expense of something else, either with respect to your health or your life, and two, if the pursuit of that at such an extreme level produces risk of injury.

    4. SB

      Okay.

    5. PA

      So in other words, could I be stronger than I am today? Yes. Uh, I'll give you an example. We know that in resistance training, the sweet spot for pure strength is one to five reps. When your goal is to maximize strength, you need to be pushing one, two, three, four, five reps. Once you start thinking about hypertrophy, muscle size, we're starting to think about 7, 8, 9, 10, 11, 12 reps. Once we start thinking about muscular endurance, we start thinking about north of 15, right? Those are the general patterns of resistance training.

    6. SB

      So if I wanna build my muscles because I'm going for aesthetic goals, then I need to be aiming above five reps, so it needs to be 10 or 12.

    7. PA

      Yeah.

    8. SB

      But if I'm just purely thinking about strength, ah, bigger weights but lower reps.

    9. PA

      That's exactly right.

    10. SB

      Okay.

    11. PA

      Yeah.

    12. SB

      And then for muscular endurance, we've just-

    13. PA

      Gotta be even higher reps.

    14. SB

      Oh, okay.

    15. PA

      Yeah.

    16. SB

      Lower weight.

    17. PA

      Yep.

    18. SB

      Okay.

    19. PA

      So again, we could go into much more detail around that, but, uh, just to finish the point here, why do I not do much training at one to five reps? In fact, these days, I don't do any training at one to five reps anymore.

    20. SB

      Why?

    21. PA

      Because to train at one to five reps comes at a risk.

    22. SB

      Ah, okay.

    23. PA

      Especially for heavy compound movements. So, like, I'm, you know, I'm okay getting a little bit less of a strength benefit while still, of course, getting stronger, but training at a higher rep load. So I'm typically... So I'm targeting eight to twelve reps with one to two reps in reserve is basically how I'm doing my resistance training. That means every set I'm doing, I would expect to get to within about one rep of failure somewhere. So today, when I lifted, I don't think I did less than seven, I didn't do more than twelve. And the weight was always titrated so that I was either failing, almost failing, or one rep away from failing, somewhere in there. And I was adjusting the weight constantly on every exercise to get there, with the exception of one exercise. I did push-ups, was one of the things I did. Push-ups are kind of more in the muscle endurance. Obviously, I'm doing more reps when I was doing push-ups. But pretty much everything else was in that range. So again, I'm not fully maximizing strength anymore because the cost of it might be a little bit high in terms of injury risk. Similarly, I'm not strength training 24/7 because I need to make time to do my endurance training and other types of training.

  12. 32:00 – 35:28

    Peter's Workout Routine

    1. PA

    2. SB

      How often do you train, uh, resistance training?

    3. PA

      I resistance train three times a week.

    4. SB

      And how often do you train generally? And...

    5. PA

      I train every day.

    6. SB

      Every day?

    7. PA

      Yeah.

    8. SB

      Why?

    9. PA

      Because, you know, again, the, the intensity of my training is not that high at least three days a week. So the three resistance days are pretty hard 'cause I'm really only doing each body part once a week. So when I'm doing it, I'm really... I'll spend that 90 minutes really kind of hammering those body parts. Three of those days are just zone two. So, so my three, three of my four cardio days are zone two days where I'm doing, you know, I'm on a bike and I am riding at a level of intensity that actually allows me to still talk some... You know, n- not talk like I am now, but talking in a sort of a strained way. So for me, that's about a heart rate of 140 beats per minute and that's just not, that's just not taking a huge toll on me. Like, that, those are almost like recovery days for me. And then one day a week, I do a, a, a really, really hard VO2 max day and that's, that's a really hard day. That burns a lot of matches. That's tomorrow. Not looking forward to it already.

    10. SB

      (laughs) Do you do cardio on your resistance training days as well?

    11. PA

      No.

    12. SB

      No.

    13. PA

      I don't. So it's a seven-day... It's four days of cardio, three days of, uh, of resistance. Now, that's gonna change in the summer when I'm gonna add three days of swimming, um, and I will end up doing sw- some swims on some resistance days.

    14. SB

      So before you do your resistance workout, you don't go on the stepper for 20 minutes or cycle for 20 minutes or something?

    15. PA

      I don't.

    16. SB

      Is there a particular reason why?

    17. PA

      It wouldn't really serve a purpose. Um, I... So I n- I know a lot of people do that. I know a lot of people will say, "Hey, I'm gonna do a little bit of a warmup on the s- treadmill or the Step Master before I lift." But I actually have a pretty strong point of view on how we should warm up to lift and I don't think walking on the treadmill or running on the treadmill or being on the StairMaster or on the bike is a great prep for the lift. I think it's better to warm up for a lift doing movements that prepare you to lift. So for example, like if it's a leg day, so Monday's leg day, right? So what am I gonna do? I'm going to start by doing a bunch of core stabilizing stuff, so I'm gonna do a whole bunch of this dynamic neuromuscular stabilization stuff. So you get into basically these baby positions and you really learn to activate your core as you move around in a six-month position and stuff like that. I then do a whole bunch of, um, like do you know what a 90/90 is or a shin box exercise is, um, where you're, you're kind of on the ground in a position where you're really ei- you know, uh, you can start out doing it isometrically but ultimately going through a, a slow eccentric and concentric ph- phase of movement that's kind of activating glutes. So I, I go through basically a whole DNS sequence. Then I get into a dynamic movement prep. So then I get into a bunch of bouncing, a bunch of footwork, um, and then I start with really light weights. So I'll go to a leg extension machine and do very, very light leg extensions, very, very light leg curls, come back and do more jumping and moving and lunging and go back and forth. So I'll spend 20 minutes doing a warmup, but the warmup is geared for me to lift. Whereas if I had just sat on a bike and pedaled around, that doesn't actually replicate any of the movements I'm going to do when I start loading myself.

    18. SB

      I've got

  13. 35:28 – 37:34

    What Causes Injury in the Gym?

    1. SB

      particularly concerned about injury-

    2. PA

      Yeah.

    3. SB

      ... now that I'm 32. Because when I was early 20s, I could do almost anything, it seemed, and nothing would break. But I, I had a couple of injuries when doing, like, shoulder presses and things like that, and one of my friends had a similar injury recently which took him out for three or four months, where he did a shoulder press, pulled something in his back or something, his, like, neck?

    4. PA

      Yeah.

    5. SB

      And then he couldn't, like, turn his head anymore. In terms of injury, if I wanted to get injured, am I right in thinking that the, the thing that leads to injury is basically just walking straight in and trying to lift something heavy? Or is there things further upstream that cause injury in the gym?

    6. PA

      No. There's th- I mean, that's one way to increase your risk of injury, for sure. Uh, but, but yes, there are other ways that it can happen, and I think about it a lot. I mean, one of the injuries I think a lot about are calf injuries, achilles injuries, sort of tendon injuries. This is, I think, one of the things that...... becomes a real problem for people as they age. You know, you, you often hear about people my age, uh, tearing an Achilles.

    7. SB

      Yeah.

    8. PA

      Uh, it's a devastating injury. Now again, it's not devastating in that you won't recover from it, but boy, it's gonna take you out of commission for six months. So, a lot of these injuries happen because the individual still has strength, um, but they've, they've kind of lost some of the pliability in the tendon because they've kind of lost some of the jumping. That's why I always start these workouts with low level of jumping. And I'll progress to higher levels of jumping, but jumping is actually a very important part of training and it's one of the things that we take for granted, but boy, when your ability to jump is gone, and jumping by the way, can mean like just initiating a jump, but it can also mean jumping off something and stopping yourself. Those are really important skills and so e- like something like jumping rope is really important, right? Your feet are just kinda moving like that. They're sh- they're acting as shock absorbers. Calves and Achilles have to constantly change in length, and that accommodation is a really important part of resilience, and I think that should, that should be an important part of everybody's warmup at a minimum, if not part of their workout.

  14. 37:34 – 38:17

    Why Building Muscle Mass Is Important

    1. SB

      One thing I'd love you to do is to persuade people listening that muscle mass matters for longevity because, um... And also if you can within that, that leg day matters- (laughs)

    2. PA

      (laughs)

    3. SB

      ... because we all avoid leg day, including me, and sometimes I need to be told again why, why it matters (laughs) for me to add it.

    4. PA

      Well, I mean, I think, look, muscle mass, um, is, is probably the second most highly, uh, correlated finding, uh, or third most to longevity after strength and cardiorespiratory fitness, VO2 max. So, why is that? Um, so first of all, I think that

  15. 38:17 – 40:32

    Training on Fatigue

    1. PA

      muscle mass is both directly a proxy for strength. In general, the more muscle you have, the stronger you are. We all know exceptions to that. We know wiry little people who are insanely strong, and I have patients like that. They're just naturally, you know, thin people, but when we put them through the testing protocols, you know, they're remarkable in terms of their strength. And I tend to not worry about the fact that they're slight in build when, when I see that they're strong across the board. There is another benefit of muscle mass, which is it's the place where you dispose of glucose. So from a metabolic perspective, the more muscle mass you have, the more glucose, uh, buffering capacity you have.

    2. SB

      And why does that matter as I age?

    3. PA

      Because, you know, one of the hallmarks of aging is a reduction in the capacity to metabolize and buffer glucose, and so as, as glucose levels become less and less regulated, all sorts of bad things happen. Uh, bad things happen to microvessels in the body. So we... If you think of the ec- most extreme example of this is type 2 diabetes, so once a person has type 2 diabetes, what are they at risk for? They're at the risk of reduced vision and ultimately blindness, a- amputations of their digits, impotence, right? The penis has tons of tiny blood vessels in it, and the more that, you know, glycosylated proteins accumulate there, the less they get blood flow, and obviously damage to the small blood vessels of the brain as well. So, all of these things are hugely problematic when glucose is dysregulated. And again, the most important thing that you can do to regulate glucose, uh, in addition to the obvious, which is eating an energy balance, not eating too much, is making sure you have large, insulin-sensitive muscles, which means large muscles in the context of an individual who's sleeping well and exercising, and you're gonna basically have a great place to put all of that glucose when you consume it.

    4. SB

      And is that gonna stave off me getting belly fat because my glucose is gonna be stored in the muscles as opposed to somewhere else, or-

    5. PA

      Again, it all depends on the total energy balance, but yes, it's clearly going to make a difference, right? So one of the surest ways to, um, reduce your capacity to store fat is to add more muscle.

  16. 40:32 – 42:34

    Grip Strength Test and Longevity

    1. PA

    2. SB

      Okay. Um, I, I did the grip strength test. I've done it twice now, and th-

    3. PA

      Meaning you did one of the, like, grip meters or you did a hanging test?

    4. SB

      The, uh, one of the grip, grip meters.

    5. PA

      Okay.

    6. SB

      I actually did it at Bryan Johnson's house, and then I, but I also did it with Andy Galpin, and people tell me it's a indicator of longevity, but I've never really understood why. Is it just testing my strength?

    7. PA

      Yeah. Um, grip strength, of all the strength metrics, it's one of the most highly correlated with longevity. We actually prefer to do it, like at Ten Squared-

    8. SB

      Yeah.

    9. PA

      ... where your colleagues tested yesterday, we prefer to do it on a dead hang, so we make them hang from a bar, um, and we just time how long they can hang. So that, that's a really good metric of your grip strength because it's also normalized to your weight.

    10. SB

      Mm. Okay. Ah.

    11. PA

      So, uh, so we, we wanna see that people can hang for at least two minutes on a bar, and so the question is, why is that so highly correlated with longevity? And it's what you said, it's, it's, it's strength, uh, and the reason for it is it's really hard to be strong anywhere in the upper body if your grip is weak.

    12. SB

      Ah.

    13. PA

      Like, if you think about being able to push, specially being able to pull, like, all of the real metrics of upper body strength require a strong grip, and if you have a strong grip-

    14. SB

      Mm.

    15. PA

      ... you have a strong hand, you have a strong forearm, you have a strong scapula that is connected to your ribcage, like, it goes up the whole chain. And that's another reason why we like the dead hang as a way to test it, because the dead hang is testing everything. It's testing your actual grip. It's testing your scapular stabilization, the stability of your shoulder. It's basically testing that entire chain. And then I also think there's a practical side of this, right? When, when p- you know, uh, it's very underappreciated what frailty does to an aging individual, uh, and what sarcopenia, loss of muscle mass, does to an aging person, and, and what it is about falling that is so devastating to an older person, and the stronger your grip, the easier you're able to navigate a lot of those things, right?

  17. 42:34 – 45:21

    Danger of Falling After Age 65

    1. PA

    2. SB

      It just seems unthinkable that falling is something I should be thinking about at 32 in the future, like 'cause w- 'cause my mobility-

    3. PA

      It seems ridiculous.

    4. SB

      It seems ridiculous. Yeah.

    5. PA

      Yeah. And yet, it is devastating. So once you reach the age of 65...... which that ain't that far.

    6. SB

      Mm-hmm.

    7. PA

      I mean, if you v- you know 65-year-olds-

    8. SB

      (laughs)

    9. PA

      ... all day long.

    10. SB

      Yeah.

    11. PA

      That d- that's not a v- that's not a very old person.

    12. SB

      Yeah.

    13. PA

      Once you reach the age of 65, your mortality from a fall that results in a broken hip or femur is 15% to 30%. Th- just think, it's such a staggering number. So you're over 65, you fall, and that fall results in the break of a femur or hip. There's a 15% to 30% chance you'll be dead within a year.

    14. SB

      W- what kills me?

    15. PA

      It could be something very acute like you ban- you know, the fall that's significant enough to do that also bangs your head. It could be that you get a fat embolism, you get a blood clot. It could be that, you know, during the recovery process of this, you just never really get better, you never thrive again. I think a more disturbing statistic is that of all the people who survive, 50% will never again regain the level of function they had before the injury.

    16. SB

      Wow.

    17. PA

      So they will require a cane for the rest of their life or something like that. Um, now there are lots of things that account for that. Andy Galpin, who you mentioned a moment ago, talks a lot about this, but it's- a lot of it comes down to foot explosiveness, power. So the reason you're not really afraid of falling, like when was the last time you were walking and you- your- your foot caught something and you s- you slipped. Like yesterday?

    18. SB

      Yeah, quite often.

    19. PA

      Yeah, exactly.

    20. SB

      Yeah.

    21. PA

      Why don't you fall when that happens?

    22. SB

      Because I can quickly readjust.

    23. PA

      Right. That's power.

    24. SB

      Okay.

    25. PA

      So you have the power in your foot to readjust when you lose your step. You step off a curb not realizing it, it doesn't matter, you readjust.

    26. SB

      Oh, God.

    27. PA

      Okay. Those are a very, very specific muscle fiber that is responsible for that. It's called the type IIb muscle fiber. That is the first fiber that atrophies when you age.

    28. SB

      Really?

    29. PA

      In fact, you're already at your peak. It's all downhill from where you are now.

    30. SB

      Thank you so much. (laughs)

  18. 45:21 – 46:36

    Training Power to Prevent Falls in Older Age

    1. PA

    2. SB

      So what do I have to train now at 32 to ensure that specifically the example of hitting something and quickly being able to adjust, um, I'm able to do that when I'm 70?

    3. PA

      I think jumping is a great way-

    4. SB

      Jumping.

    5. PA

      ... to do this, right? So- so, I mean, I use ce- certain specialized pieces of equipment that actually have power built into it, 'cause power is different from strength, right? So strength is really the ability to m- is- is just the ability to move a force independent of the speed at which you move it.

    6. SB

      Mm-hmm.

    7. PA

      Power is the maximum combination of force and speed.

    8. SB

      Okay.

    9. PA

      So if you- on the- on the- on the, um, X-axis, if you were to put force, and on the Y-axis, if you were to put power, the curve is an inverted U. So as the force or the weight that you're moving goes up, and you're trying to move it as fast as you can, you're getting more and more and more and more power. But then at some point, the weight gets so heavy that even as you continue to move it, it's going slower and slower and slower, so your power is going down. So there's a sweet spot there. So one of the things I do is there's certain specialized pieces of equipment that allow you to train in that way. So I definitely rely on a lot of those. But even if you don't have access to that machine, jumping is a really important way to generate power. So if you're just doing a vertical jump, that's a- that's power.

  19. 46:36 – 47:35

    Is Balance Training Important?

    1. PA

    2. SB

      What about balance? I- I was at Bryan Johnson's house and as he was cooking his, I don't know, breakfast or lunch, whatever, he was balancing on a half ball. You've seen one of those things.

    3. PA

      Yeah, yeah.

    4. SB

      I- I don't think I asked him why he was balancing on it, but I assume it was to do with balance and the c- certain muscles in the- in the leg?

    5. PA

      There are lots of exercises that are great for balance. Um, anything that produces instability is great because it's, uh, you know, for lack of a better term, uh, I've heard it described as problem-solving for your foot.

    6. SB

      Okay.

    7. PA

      Right? So- so if you think about being on any unstable surface, even if you're just walking on an unstable surface, so if you- if you were to look at a person's foot, their lower leg actually, as they're walking on a surface that's constantly changing, so like a gravel path or something like that, you're going to see, like if this were my lower leg, you would see the musculature of the lower leg constantly adjusting to it.

    8. SB

      Mm-hmm.

    9. PA

      And so, yeah, uh, I'm- I really enjoy things that force that type of

  20. 47:35 – 51:54

    Peter's Flexibility Training Approach

    1. PA

      training.

    2. SB

      Do you do flexibility stuff? S-

    3. PA

      Yeah, so I'm actually naturally a pretty lax person, so I don't do any stretching, if that's what you're asking. But all of the sort of stability and dynamic stuff I do incorporates movement at end ranges. So, um, I- I'll give you an example of why I think the notion of flexibility might be a little bit misunderstood. If you ask a person to stand up and with their legs straight, touch their toes, most people would say that's a great test of flexibility in the hamstring.

    4. SB

      Mm-hmm.

    5. PA

      Right? And most people can't do that. What they don't realize is everybody's hamstrings are long enough to allow them to do that. The reason they can't do it is their central nervous system will not release them to do it. Does that make sense?

    6. SB

      Interesting. Their central nervous system won't release them to do it.

    7. PA

      That's right. It doesn't feel safe for them to do it. Now, how do I know this? Because if you take a person under general anesthesia, you can put them into almost any position possible. So if you took a person under general anesthesia, laid them on the operating room table, you could lift their leg up to here-

    8. SB

      Hmm.

    9. PA

      When they're awake, you couldn't get it past here. When they wake up from surgery, will they have a torn hamstring? Not at all. They won't even know their leg was moved. The difference is when they're under general anesthesia, their brain is not sending a signal to the leg that says, "Don't lift." So why is the, why is the leg, why is the brain doing that to the individual? This is how I learned it on a personal level. So about six years ago, I had tweaked my back (clears throat) and had just done a, you know, unnecessarily heavy set of deadlifts and just pushed it a little too far, and I was kind of nursing this, this sort of, you know, just very, very tight QL. I was completely jammed up. And I came in to, to do some training with a friend of mine who's one of the guys that... Actually, he is really the guy that introduced me to this thing called DNS, dynamic neuromuscular stabilization, and, I mean, I was stiff as a board. I couldn't, you know, get past my knees bending forward, and I'd been hurting for, like, three days. And we went through a series of exercises for 40 minutes, which included me laying on my back with my legs up, him leaning on top of me, so my feet are here on his chest, and doing isometric pushes while working on, uh, generating intra-abdominal pressure. And after an, yeah, maybe 40 minutes of this type of exercises, I was palms on the floor. Now, how do I go from not being able to get to my knees to palms on the floor in 40 minutes with three days of horrible back pain? The difference is when, uh, my back was hurting, it was... my body was not going to let me go down, right? The body was saying, "No way. You're back? I'm protecting you because you are, you are not stable. You're not gonna go any further." And what we went through with this exercise and a series of exercises was basically, I mean, I'm oversimplifying this and sort of anthropomorphizing it, but letting my brain know, "It's okay. You're stable. You're stable. You're stable. The back is safe. The back is safe. Let him go," and then, ah, I'm palms on the floor. So I love testing this. Sometimes I'll just wake up in the morning and do five minutes of breathing exercises when I'm stiff as a board and just get into a, a, you know, a position on the floor.

    10. SB

      Why the breathing, breathing exercises?

    11. PA

      Cause that's really how... It's the, it's the... The breathing is how I kind of create this cylinder in my abdomen to sort of push the, you know, push the, the, the, the floor of the cylinder down as the pelvic wall. The diaphragm is the c- cylinder, uh, the top, and then the, the entire, you know, en- entirety of my abdomen is the wall of the cylinder. And so I kind of go through these exercises every single day, usually on my back, actually. That's kind of, like, part of my warmup. And, and it's just a way to kind of ground myself around creating, uh, concentric pressure in the abdomen.

    12. SB

      Just to get

  21. 51:54 – 52:56

    Peter's Strength Training Routine

    1. SB

      some tips from you around your, your strength training regime, um, how many exercises do you do? What does... I'm really curious. So you train three days a week doing strength and resistance stuff. Do you do, like, shoulders and back and, um, as, like, a pa- like-

    2. PA

      Yeah, yeah. It's just-

    3. SB

      ... you know people talk about pairs and stuff?

    4. PA

      Yeah, yeah, exactly. So on, on Monday, Monday is, uh, is pure lower body.

    5. SB

      Okay.

    6. PA

      And, uh, uh, Wednesday is arms and shoulders.

    7. SB

      Yeah.

    8. PA

      And Friday is, uh, chest and back.

    9. SB

      Okay.

    10. PA

      Super simple.

    11. SB

      Okay.

    12. PA

      Like, nothing, nothing, no rocket science.

    13. SB

      An hour?

    14. PA

      Uh, I mean, it's, it's a li- like an hour and a half of lifting play- plus maybe 20 minutes of the warmup stuff.

    15. SB

      So on the chest and back day, how many chest exercises are you doing?

    16. PA

      Four.

    17. SB

      Four, okay.

    18. PA

      Yeah.

    19. SB

      And then four on back?

    20. PA

      Yeah.

    21. SB

      Okay.

    22. PA

      And I just, I'm just super setting them, and I'm gonna do maybe five sets of each, so five working sets. So there's a lot of warm up in there too.

    23. SB

      Okay.

    24. PA

      Um, and I'll also do some other stuff, like some med ball slams or things like that as well.

    25. SB

      There's been this

  22. 52:56 – 53:48

    Why Endurance Exercises Are Gaining Popularity

    1. SB

      huge rise in people doing these, um, Hyroxes and sort of elite, uh, endurance events and, and such.

    2. PA

      Mm-hmm.

    3. SB

      It's really interesting that it's become so popular. Even things like running clubs, I know, but-

    4. PA

      Yeah.

    5. SB

      ... the fact that people are... more people are doing marathons now than ever before. Why do you think this is happening?

    6. PA

      I don't know. I mean, I think it's a very net positive thing though. I mean, I, I, I, I do think that there's, um, more and more people that are taking up things like rucking and running and, and, you know, finding camaraderie in these things. The only thing I hope is that, that people are doing it in a manner that's sustainable and safe and allows them to do it indefinitely. So I, you know, I just... I'm always hopeful that whatever thing that people are doing, they're not injuring themselves, 'cause again, rule number one is don't get injured. So, so you're, you know, you're, you're, you're playing, uh, you're play- you want... The game, the name of the game is to play the game.

    7. SB

      Yeah, yeah.

    8. PA

      As long as possible.

  23. 53:48 – 1:03:49

    What Is VO2 Max and Why It Matters for Longevity

    1. SB

      In front of me, I have a bunch of different graphs and images, um, and they... some of them relate to a word you said earlier on, which is VO2 max. And this is something I've heard you talk about previously, but for anyone that doesn't understand what VO2 max is or why it's important, um, can you explain what it is and why it's so critical to longevity and health span?

    2. PA

      I think most people will be familiar with the idea that we are obligate anaerobes, which in English means we cannot survive without oxygen.

    3. SB

      Mm-hmm.

    4. PA

      Okay. So why is that? So oxygen is absolutely essential to catalyze the chemical reaction that turns food into a currency for energy called ATP.

    5. SB

      Mm-hmm.

    6. PA

      So everybody's probably heard of ATP. ATP is the money, the currency of energy in our body. Anything that interrupts the production of ATP is fatal. An extreme example of that is cyanide. Everyone's heard of cyanide as a poison. If you take cyanide, you'll be dead within seconds because cyanide blocks one of the transporters in the production of ATP.So it just gives you a sense of how critical it is to have an infinite and abundant supply of ATP. Oxygen is also essential for that. That's why without oxygen, you can only survive for a couple of minutes. Longer than you can without cyanide, but not much longer. So, how does it work? So we breathe in air, and that air goes into our lungs, and that air goes through our lungs into these distal things called capillaries where hemoglobin is bringing the waste product called carbon dioxide back to the lungs. And there's a gradient of, of partial pressure between oxygen and carbon dioxide such that a switch takes place. The air that we breathe in delivers some of its oxygen to the hemoglobin molecules, and the carbon dioxide diffuses off that into the air and we breathe out air that is lower in oxygen and higher in carbon dioxide than what we breathed in. Mm-hmm. So if I go (inhales deeply) , that was high oxygen, low carbon dioxide (exhales deeply) . That was low oxygen, high carbon dioxide, and that's the, that's happening every second of every day. That oxygen, that hemoglobin molecule that's carrying oxygen is carrying it to every cell in my body, because every cell in my body needs oxygen. And that cell in the body is taking the oxygen to run that chemical reaction to make ATP and it's shuttling back carbon dioxide, and it's just the most incredible thing in the world to imagine how frequently this is happening. And the more you exercise, the more you consume oxygen. So oxygen consumption is a proxy for energy demand. So, we can measure this. Now to do so, you have to put a mask on because I have to be able to measure very precisely two things. I have to be able to measure exactly the flow rate of air going in and out of your mouth, and I have to be able to measure very precisely the concentration of oxygen coming out. If I know those two things, I can calculate how many liters per minute of oxygen you are consuming. So you and I sitting here right now are probably consuming less than half a liter a minute. So call it 500 cc a minute of oxygen right now, because you have to consume some to be alive. And look, I'm moving my arms around and you're nodding and taking notes. So, you know, if you're sleeping, you might be consuming 300 milliliters of oxygen per minute. That's, that's the lowest level. Mm-hmm. If you were to get up and we were to walk around here, that number might go up to 800 milliliters, uh, per minute. If we were to walk a little more briskly, we might be at a liter per minute of oxygen. If I said, "Let's go out in the parking lot and jog," well, we might get up to, like, 1.5 liters per minute. We pick up the pace a little bit, we'll get to two liters per minute. If I start really, really running us hard, we're gonna get to three and a half, four liters per minute. Well, at some point, I am going to push you so hard that you will achieve your maximum level of oxygen consumption, and if I push you any harder and faster, you won't extract more oxygen from the air. You may go faster, but you will do so through a process that does not involve the consumption of oxygen. You will do s- do so through an anaerobic glycolytic pathway, but you will have achieved your maximum consumption of oxygen, and that number has a very special name. It's called VO2 max. So VO2 max measured in liters per minute is the maximum amount of oxygen you can consume. And the only way you can measure that, again, is to have this mask with very, very fancy apparatus that measures both of those things I said, and you have to be stressed hard. So we typically do this on a treadmill or on a bike. So your, your, your colleagues that came into Ten Squared yesterday, they did it on treadmills. They ran, and they ran them, and ran them, and they ran them until they couldn't go any faster. And then we measured how many liters per minute of oxygen they were consuming. Now, that answers what VO2 max is. So the next question is, does this matter? Well, the short answer is we don't have a single metric of humans that we can measure that better predicts how long they will live than how high their VO2 max is. And it's not even close- (laughs) . ... to be completely clear. So if you compare somebody who is in the top 2% to someone who is in the bottom 25% for their age, uh, the difference in mortality is 5X. 500%? Yes. 400% technically, because with hazard ratios, you, you, you go two, two, a 2X hazard ratio is 100%. Okay. Fine, yeah. Fine. Yeah. So let's look at you. So y- I see you've pulled this chart out, which is one of my favorite charts. Okay. So you... Oh, by the way, there's one other thing I should state. We normalize this by weight. Okay. Okay. So we always divide that number of liters per minute by how many kilograms you are, so the number is actually reported as milliliters per kilogram per minute. Okay. Okay. All right. So if we look at somebody who is your age, male, 30 to 39, if their VO2 max is below 35 milliliters per kilogram per minute, they are in the bottom 25%. Conversely, if they are at 53 milliliters per kilogram per minute, they are in the top 2.5%.So to be clear, if you take a 35-year-old man, and one of them has a VO2 max of 53, and the other one has a VO2 max of 35, there is a 400% difference in their all-cause mortality over the coming year.

    7. SB

      Wow. Okay, so all-cause mortality, anything killing them over the coming year.

    8. PA

      That's right. Now, this becomes more and more profound as you age, because the all-cause mortality ratio for a 35-year-old is incredibly low.

    9. SB

      Yeah.

    10. PA

      It's like 1%. So that means you're comparing 1% to 4%. It's not that big a deal. But when you get up to my age, so I'm two decades older than you, so now, the low bar, the bottom quartile is less than 29. The high bar is more than 50. Well, my relative mortality in the next decade is probably 2 to 3%, so now multiply that by 4. Okay? When I get into my marginal decade, the low bar is 18. The high bar is 36. That's a 2X difference in VO2 max. A 4X difference in mortality is huge when the all-cause mortality for an 85-year-old is going to be, you know, the one-year annual, you know, the one-year mortality for that person is, you know, more than 10%.

    11. SB

      Yeah.

    12. PA

      So, one of the things that we do is we sort of think through this, not just through the lens of mortality, which is what I just walked you through here, but also health span, which is kind of what you were talking about earlier with the graph of strength and disability. So, we have another figure that we show people that, um, on the X axis shows age.

    13. SB

      Yeah.

    14. PA

      And on the Y axis shows VO2. And it has a whole bunch of lines that come across that show various activities. You know, if you want to be able to run a six-minute mile, you have to have a VO2 that's very high. If you want to be able to run an eight-minute mile, a 10-minute mile, if you want to be able to climb a flight of stairs without getting out of breath. Like, it shows all of these different things, and you see what the required VO2 is.

    15. SB

      Mm-hmm.

    16. PA

      I think, in fact, we might even have these graphs in here. Yeah, right there. So, we put your dot on the graph and we say, "If you stay where you are, you're," meaning right at the green curve, "you're in for a great life." Why? Because even when you're in your 80s, you're still going to be able to do all of those things.

  24. 1:03:49 – 1:05:30

    Jack's VO2 Max Results

    1. SB

      So the, the results you're looking at here are Jax's results.

    2. PA

      Yep.

    3. SB

      Who runs the production here. He came to your center?

    4. PA

      Yep.

    5. SB

      Came to Ten Squared in Austin, he did the test. I think he was on the treadmill for, like, an hour or something like that. And can you explain to me exactly what his results say as it relates to what you were just describing?

    6. PA

      Yeah. So, he did both a zone two and a VO2 max test. So, Jack got on the treadmill and, you know, there's a protocol for how you warm somebody up. You really want them to be able to get to a maximum effort. You don't just put them on a treadmill and crank it up. You take, you take your time getting them up there, and he had an amazing result. So, his VO2 max was 4.1 liters per minute, and he achieved that at a heart rate of 204 beats per minute.

    7. SB

      Mm-hmm.

    8. PA

      Which is higher than what was predicted for his age. If you normalize it by his weight, he was at 56.5 milliliters per kilogram per minute. So, when you look at his age, 'cause he's in his 20s, he was at about the 97th percentile for his age, meaning his VO2 max was higher than 97% of people his age. And, uh, so out of the gate, that just tells us, from a longevity standpoint, our goal is to keep him there as long as possible. I mean, we're so ambitious with our patients and clients that we actually want them to be as, as an aspiration, to be two decades younger at the top 2%.

    9. SB

      Mm-hmm.

    10. PA

      So if you're 50, you want to be VO2 max north of 53.

  25. 1:05:30 – 1:06:21

    Jack's Heart Rate Recovery Results

    1. PA

      And then the other thing we do is we check on something called heart rate recovery, so in 60 seconds post VO2 max, how long does it take, uh, how many beats does their heart rate come down in one minute? This is also a very powerful predictor of mortality because it's a huge indication of what's called parasympathetic sympathetic balance. So, it's basically a question of how does the, how, how much is their autonomic nervous system in favor of sort of a stress response versus a recovery response? And so the gold standard here, we want to see people that can recover at least 30 beats in the first minute. He did pretty well. He recovered 28 beats. You know, if you're really, really fit, you're going to be 40, 50 beats of recovery within the first, um-

    2. SB

      Wow.

    3. PA

      ... one minute. It's incredible.

    4. SB

      Incredible.

    5. PA

      Then,

  26. 1:06:21 – 1:08:24

    Jack's Zone 2 Test Results

    1. PA

      we tested his, um, lactate levels and we ran him for what we called zone two testing, right? So zone two is his aerobic base. This is where he should be spending 80% of his train- 80% of his cardio training time should be in this energy system. So it's hard enough that it's not just pure recovery, but not so hard that it's, you know, uh, pushing energy systems that are, that are higher. This is, this is a pace he should be able to hold for an hour and he should certainly feel like he's working, but not feel it too much. Technically, it's also a place where he's pro- he's got maximum fat oxidation. So, we do this also in the same measure on a treadmill. This is a bit more of a complicated test 'cause you're titrating between how he feels and what his blood lactate levels are.R- maybe not to get too complicated in the weeds on that, but we're simultaneously looking at the ratio of how much carbon dioxide he produces to how much oxygen he consumes.

    2. SB

      Mm-hmm.

    3. PA

      That tells us how much fat he is using in his own body, and we look at that number, and he maxed out at .77 grams per minute, which is very good. One gram per minute of fat oxidation is exceptional. So .76, 77 is pretty darn good. His lactate hit about two millimole, and he achieved this running at 7.3 miles per hour. So, so again, that's, there, there's a lot to unpack in there, but that gives us a pretty good sense of his level of fitness. And for a guy in his 20s, um, that's, that's really good fitness.

    4. SB

      He does a lot of running.

    5. PA

      Yes. Yeah.

    6. SB

      Yeah.

    7. PA

      Yeah, yeah. And, and, but even this test is a body of work. We normally would separate these two tests on two separate days.

    8. SB

      Okay.

    9. PA

      So people, you know, the, the, the people who come to 10 Squared are not from Austin, they're from all over the place, so they come in for two days of testing, and you got to sort of figure out a way to take a person who's not necessarily that fit and, and allow them to do these tests. So th- it's kind of broken up over to a couple of days so they can mix it with the strength testing and all the other stuff.

    10. SB

      And

  27. 1:08:24 – 1:09:00

    How Jack Can Improve His Results

    1. SB

      if you were advising J- Jack on how to improve some of these scores here, what would you say?

    2. PA

      So the truth of the matter is, looking at his stuff here, I would say I think you've got the endurance thing really covered. In his case, there were other issues that were uncovered during his intake that were of more concern, and this is a matter of, like, now what we think of as portfolio management, right? So when your VO2 max is in the top 2%, when your fat oxidizing .7, you know, almost .8 grams per minute, and he's got a heart rate of 165 to 170 when he's, um, in zone two, I mean, this guy's cardio is dialed in.

  28. 1:09:00 – 1:11:18

    Ads

    1. PA

    2. SB

      Bad skin, I've had it, and I'm sure many of you listening have had it too. Or maybe you have it right now. (paper rusts) I know how draining it can be, especially if you're in a job where you're presenting often, like I am. So let me tell you about something that's helped both my partner and me and my sister, which is red light therapy. I only got into this a couple of years ago, but I wish I'd known a little bit sooner. I've been using our show sponsor's Bon Charge's infrared sauna blanket for a while now, but I just got hold of their red light therapy mask as well. Red light has been proven to have so many benefits for the body. Like, any area of your skin that's exposed will see a reduction in scarring, wrinkles, and even blemishes. It also helps with complexion. It boosts collagen, and it does that by targeting the upper layers of your skin. And Bon Charge ships worldwide with easy returns and a year-long warranty on all of their products. So if you'd like to try it yourself, head over to boncharge.com/diary and use code Diary for 25% off any product site-wide. Just make sure you order through this link, boncharge.com/diary with code Diary. (paper rusts) I've got a story that I think you'll be interested in hearing, and it's brought to you by my show sponsor, Fiverr. About six months ago, my team and I sat down to try and work out how we were going to build the most valuable newsletter for ambitious entrepreneurs ever. And after hours of discussion, we finally agreed that to tip the odds in our favor, we needed to be constantly experimenting. But to do this, we needed man power, or woman power, so we hired a group of freelancers through Fiverr and tasked them with testing different elements, which are, like, the visuals in the newsletter, the subject lines, the copy lengths. And even after launching 100 CEOs, the new newsletter, and getting 93,000 signups on the first day, our experimenting hasn't stopped. I'm confident we wouldn't have seen the same success had we not experimented in this way, and our freelance support from Fiverr was critical to that. So next time you're launching something, find your failures and fix them fast with Fiverr freelancers. Visit fiverr.com/diary today and use code DOAC for 10% off your first order. (paper rusts) These are Jack's results. So I've invited Jack in because I feel like he might have some questions and you might have some questions, so you guys go ahead.

    3. PA

      All right. (laughs) Well, uh, first off, Jack, thanks for being an awesome guinea pig yesterday. You hit it out of the park, um, as far as your cardio training. So tell

  29. 1:11:18 – 1:13:21

    Jack's Cardio Routine

    1. PA

      me a little bit, like, what are you, what are you doing for cardio? How often are you running?

    2. SB

      So I actually stripped it back quite a lot. I probably started maybe, maybe like two years ago going really heavy on running, and that's all I did, and then I started getting a little bit injured. So now I've cut it back, but I'd say I do, like, one long run a week, and that's like 20K. Outside of that, I don't really do much other cardio.

    3. PA

      Interesting. I, I know that the team talked to you about your left foot.

    4. SB

      Yes.

    5. PA

      And did, did they show you the pictures on the treadmill?

    6. SB

      They did, yeah. That was super interesting.

    7. PA

      Okay.

    8. SB

      Super interesting. I sprained my ankle really badly like six months ago.

    9. PA

      Yep.

    10. SB

      So they said that could have been something.

    11. PA

      I think it's very likely that the ankle sprain has not, has changed your gait such that you probably are going to develop an injury over time with your running if the, if your pattern is not corrected. So you're overcompensating on the left, and did, I, I assume that, I assume you noticed the difference in the height of your shoulders and your head and everything while you were running.

    12. SB

      Yeah.

    13. PA

      So even though the engine is working insanely well, this test only measures the performance of your engine.

    14. SB

      Mm-hmm.

    15. PA

      Your chassis, which is a subjective assessment, to use the car analogy, uh, shows that the chassis is a bit weak.

    16. SB

      Okay. I'll give a bit of context on what that actually was. So when I was running on the treadmill-

    17. PA

      Yep.

    18. SB

      ... um, I think it was Kyler, was it?

    19. PA

      Yep.

    20. SB

      He, he showed me a picture afterwards of me running, and basically my head was right in the middle when I went on my right side.

    21. PA

      Right foot. Yep.

    22. SB

      But then when I went on my left, my whole body was, like, a bit lopsided.

    23. PA

      Yep.

    24. SB

      So yeah, that's kinda what you're talking about there.

    25. PA

      That's right. And again, like, the good news about running is each step is very light.

    26. SB

      Mm-hmm.

    27. PA

      But if you're running 20K, that's a lot of steps. So even something that's a light impact but done thousands of times will produce a problem. Okay. So let's shift from how well the engine is, which is exceptional, at both ends, by the way. To be clear, your peak engine output, which is VO2 max, was awesome, and your engine efficiency-... which was your zone two, your fat oxidation, exceptional.

  30. 1:13:21 – 1:19:52

    Measuring Bone Density and Muscle Mass (DEXA Scan)

    1. PA

      We do have this issue in the chassis that needs to be addressed, or you're going to get a repetitive strain injury. Mm-hmm. Um, so then the next thing that, that, the team did was just a very simple test called a DEXA scan. But we, we do a more comprehensive one, so we're looking at all the bone density, left hip, right hip, lumbar spine, and then total body fat, total muscle mass, and then visceral fat, which is fat around the organs. I think the most surprising aspect of the test was your bone density. So, um, a DEXA scan, uh, measures bone density very accurately and both, uh, sort of across the board in terms of your, your lumbar spine and your right hip and your left hip, you were, in your, in your lumbar spine, two standard deviations below the mean for someone your age. So, that means basically you're in the bottom 10 percentile of bone density for a guy your age. And for your hips, you're not much better. Mm-hmm. Both on the left and right hip, you're about one and a half to 1.7 standard deviations below the mean. So, what does that mean? That means that you're at... You, you already have something called osteoporosis. So when your T-score, which in your case is almost the same as your Z-score because of your age, but the Z-score compares you to someone your age, the T-score compares you to someone 30 years old. So, when your T-score is minus one, um, you have osteopenia. And when it gets below minus 2.5, you have osteoporosis. Those are just technical definitions of bone density. The problem is your risk of bone fracture goes up really significantly. Now because of how young you are, it's not like I'm worried you're gonna walk out of here and something's gonna go wrong, but the risk of you sustaining an injury in sport is, is not trivial, right? So if you were out skiing, and Stephen was out skiing, assuming he had normal bone density, and you guys both took a tumble, I would be infinitely more worried about your bone density. And we have patients in our practice who do. They're young, healthy people, and they get these freakish fractures while skiing or playing sports and things like that, and they have really low bone density. So, so one, it's just something we want to address. The bigger concern is that what's go- what, what is the, what is the story of this gonna be when you're 60 and 65 and 70? And that's, that's the one where we really want to mitigate it. So, I know that the team talked to you about making sure you follow up with an endocrinologist. You wanna make sure that there's nothing here that is medically obvious to be treated, such as vitamin D deficiency, anything that has to do with parathyroid hormone or calcium and things that are, you know, medically obvious to treat. Um, the most important behavioral thing that a person can do with low bone density, beyond correcting all the nutritional deficiencies that can lead to it, is applying heavy load to the bone. So bones are active pieces of tissue, even though we don't think of them that way, and they respond to deformation. So, you have to put strain into a bone for it to respond and strengthen. And it's counterintuitive that running is not amazing at doing that. It's not bad. So on, in general, runners have better bone density than sedentary people, but not by much, believe it or not. Uh, swimmers and cyclists, believe it or not, te- (laughs) actually have lower bone density on average. But s- resistance training with heavy weights is, is actually kind of what is necessary. Grappling as well, by the way. So people who do jujitsu, strength training, resistance training, those are, those are the ways that you're gonna, you're gonna increase this. So I would say that was the first finding that, that, that is, you know, important and worth discussing. Y- do you have any questions on that? 'Cause I've got a couple.

    2. GM

      Uh, well, I think my first one was, so I, I only actually started lifting weights like properly maybe two years ago.

    3. PA

      Okay.

    4. GM

      So that's probably why you're seeing that.

    5. PA

      Maybe. I mean, I guess, d- w- did you have asthma as a child or anything?

    6. GM

      No. I know when I... My mom says something about like when I was born, I had low calcium, something about low calcium and they had to put something in my teeth. But I don't know what that is exactly.

    7. PA

      Well, if you had low... If, if there's something that was impacting your calcium levels when you were little, that would certainly be a potential risk for it.

    8. GM

      Mm-hmm.

    9. PA

      Um, the, the... Our bones are mostly formed f- for males in their early 20s, for girls, typically in their late teens. So anything that disrupted calcium metabolism when you were young could have played a role in this for sure. Um, the reason I asked if you had asthma is a lot of the times we see folks that, you know, had any medical condition that required corticosteroids, prolonged use of corticosteroids would be another big risk factor. Of course, there's also genetics, so probably worth knowing if your parents themselves have low bone density. Um, but, but it sounds like there's something going on with calcium metabolism as a, as a kid that might have played a role. Um, the reason it is really important to connect with an endocrinologist now is there are actual medical, uh, treatments that can increase bone density in addition to all of sort of the total optimization of the nutritional stuff, vitamin D, calcium levels, things of that nature. And of course, the training.

    10. GM

      Hmm. Are there specific exercises I'd do to increase that? Or is it just an all around kind of thing?

    11. PA

      No, I mean, I think the, the... If you think about the long bones of the body, which are the, the, the ones that we're basically measuring here, I mean, the short bones in the spine, but the femurs and hips, anything that puts those things under deformation. So anything from a farmer's carry to a step up to a box squat. I mean, you know, it's whatever you can do safely that's loading you and placing these bones in a manner that, that forces them to, to actually undergo deformation. The way, the way... And then the other thing I would also make sure of is that someone's checking your blood levels to look at things like testosterone and estrogen. So estrogen, believe it or not, probably the most important hormone besides vitamin D in bone health. So you can think of a bone as something with a strain gauge in it. And as the bone is deformed, the strain gauge sends a signal, a chemical signal to cells that build the bone. The chemical signal is estrogen.

    12. GM

      Mm-hmm.

    13. PA

      So the reason women are so susceptible to osteopenia and osteoporosis is once they go through menopause, many of them...... lose their estrogen if they're not placed on... Well, they all lose their estrogen, but if they're not placed on hormone replacement therapy, they don't get it back, and so they lose that chemical signal. So women see a rapid drop-off in bone density at menopause.

    14. SB

      Peter, is this graph accurate, roughly?

    15. PA

      Yes, this would be accurate.

    16. SB

      So if this is broadly accurate, what is the game then for someone like Jack? Is it, is it building bone or is it preventing loss?

Episode duration: 1:49:08

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