How To Improve Sleep Quality, Muscle Growth & Daily Mood - Dr Peter Attia (4K)

Chris Williamson 0:00 What's this story about your son going to hospital and getting some insane medical charge for a tiny procedure?

Dr Peter Attia 0:09 Y- yeah, well it's- it's unfortunately a very common story, right, where anybody goes to the ER and, you know, they end up needing a bag of IV fluids or something like that, and then they- they get a bill for thousands of dollars. And you actually look through the line item and you realize this is comical, right? You literally charged me $1,400 for a bag of normal saline that costs, I don't know, somewhere between $2 and $3. Um, but it sort of speaks to a lot of the breaks in the, uh, specifically in the American healthcare system.

Chris Williamson 0:40 What is it... Why is it so broken? What... Is it because it's a commercial enterprise? Is it because it needs to be, uh... additional funds need to be brought in from places where they shouldn't? What's going on?

Dr Peter Attia 0:52 It has to do with the complexity of a multi-payer system, and basically the way contracts are negotiated between payers and hospitals. And you have to decide in those negotiations who is in network and who is out of network. Um, that's, like, one sliver of one problem. Uh, this- this exists on- on so many levels. Um, but in- in that case, I think the issue came down to, you know, some very high deductible that wasn't met coupled with, you know, some out of network thing. But the- the truth of it is, there's also ridiculous pricing. So- so there's a... sort of a false sense of how much things cost in hospitals. It's sort of funny money. Like, "We're gonna really, really mark up the price so that we can give you a big discount if you're in network."

Chris Williamson 1:37 Right.

Dr Peter Attia 1:38 Y- y- you know, so you- you see this across the board with all sorts of things in medicine.

Chris Williamson 1:42 And to rehydrate your son, it costs, like, six grand or something.

Dr Peter Attia 1:46 I can't remember the dollar amount. It was so egregious. Um, and again, I... It- it's infuriating to me when you keep in- in- in mind the fact that, you know, probably the average American would have a hard time on short notice producing $1,000. And yeah, I'm fortunate enough that I can produce $1,000 without, uh, too much difficulty. But for the average person, maybe 50% of the population, that's a really big deal and that's a huge inconvenience, right? That means... that changes your plans-

Chris Williamson 2:17 Yeah.

Dr Peter Attia 2:17 ... dramatically. It means you're not taking a vacation that summer. It means you're not, you know, not able to go out with your family for a movie night.

Chris Williamson 2:24 How long are you paying off that-

Dr Peter Attia 2:24 Yeah, exactly, exactly.

Chris Williamson 2:24 ... credit card debt for, et cetera.

Dr Peter Attia 2:26 And it totally... It's totally inexcusable.

Chris Williamson 2:28 I went to a ghost tour in New Orleans five years ago, and the guy that was taking the tour finished up afterward, and I was asking him about the American healthcare system, and he said this thing, it's really stuck with me. He said, "If you get hit by a car, you'd better walk it off." His point being that there are medical emergencies that can happen that can ruin your life by you having to fix them, not by you not fixing them.

Dr Peter Attia 2:57 Yeah. Um, healthcare is the number one cause of personal bankruptcy in the United States.

Chris Williamson 3:05 No way.

Dr Peter Attia 3:05 Yeah.

Chris Williamson 3:06 (clears throat) It's strange for me as someone who's coming from the UK, right?

Dr Peter Attia 3:10 Yeah.

Chris Williamson 3:11 There are problems with the NHS, don't get me wrong. I have had my share of problems with the NHS, but there's a social safety net that picks people up.

Dr Peter Attia 3:18 Yeah.

Chris Williamson 3:18 And it feels, to me, it feels barbaric to not... Uh, you- you don't get the privilege of healthcare. Like, it's just, "Oh, you're so sick? Sorry." Like, "Not for you." It seems- it seems very bizarre coming from the UK.

Dr Peter Attia 3:33 Yeah, and it's a little counterintuitive. The people who are most impacted are not the people at the very bottom of the socioeconomic ladder here, because those are individuals who are gonna qualify for something called Medicaid, uh, which is meant to sort of, you know, provide for the people who truly have nothing. Um, but if you go one level or two levels up from that to people who do have health insurance but they're grossly underinsured, or they can't afford health insurance because, yes, they're working, and yes, they have these other expenses, but they can't afford that. Um, it... Those are the people that are absolutely devastated by, uh, the system here. And- and again, on the flip side of that, I think on some metrics, the US healthcare system is hands down the best in the world. It's not an accident that when heads of state, you know, kings and queens, royalty, you know, whatever, need the best procedure, they're gonna come to the United States. Um, and- and so on the one hand, the US has the best to offer in terms of, you know, the tip of the spear in quality, uh, for medicine 2.0, but at the other end of the spectrum when it comes to cost and when it comes to coverage and accessibility, it's- uh, it's the... You could argue it might be dead last in the developed world.

Chris Williamson 4:50 Look at where it all began, uh, the Wild West of America, though. Your cardiac machine being powered by a nice water wheel or whatever it is (laughs) . Yeah, you talk about this. I- I really love this conception between, uh, medicine 2.0 and- and 3.0. Uh, you've got a quote, "Longevity itself and health span in particular doesn't really fit into the business model of our current healthcare system. There are few insurance reimbursement codes for most of the largely preventative interventions that I believe are necessary to extend lifespan and health span." And after our episode last year, I went to Fountain Life in Dallas. Preventative medicine, right? Full body MRI, brain angiogram, heart angiogram scan with contrast, and a DEXA, and a microbiome, and all this stuff. And it made me realize, uh, why... It's so... Medicine's backwards. You're trying to fix a problem after it's happened as opposed to working out what's going to happen and getting out ahead of it. It's wild.

Dr Peter Attia 5:44 Yeah, yeah.

Chris Williamson 5:47 Lots of people, I think, want to improve their mental clarity. One of the things that is top of mind is my attention, my focus, my ability to pay attention to the stuff that I'm doing. Everyone's a knowledge worker in some form or another now. What do you focus on when it comes to improving cognition for yourself?

Dr Peter Attia 6:09 Um, I think, you know, there, you, you can, I sort of put these into different categories, right? There's sort of the, the, the things you do to improve the environment of your mind, so I, I think probably at the top of that list is, is sleep. Uh, so it's very difficult to cognitively perform well when you are sleep-deprived. And I realize that many people listening to us will think, come on, I can think of all the examples in the world. I mean, look at all these people who don't sleep and are still out there clearly doing very well. Um, and the point is, you never have the counterfactual for those people, right? What you don't know is, imagine that person sleeping eight hours a night instead of three hours a night, um, I, I am positive that they would be performing even at a higher level. Um, I put exercise probably at number two. Uh, I think it is, again, just a remarkable way to provide not just the obvious metabolic and circulatory, uh, food, if you will, to the brain, but, but also kind of think about the, the endocrine side of that, right? So BDNF and things of that nature, uh, play such an important role in brain health. Um, nutrition clearly plays a role, and managing nutrition is important. Um, I think anybody who's, you know, especially people who are really carbohydrate-sensitive will, will appreciate that the, the, the big peak, the big valley that follows, you know, a big carb-rich meal, uh, is gonna, you know, negatively impact cognition. So again, we could build out a few more of those things, but then I think there's kind of the environment with- within which you work. And, and I think for me, this is the bigger struggle. So I've, you know, luckily, I think I've sorted out the sleep, nutrition, exercise side of it, so my limiter tends to not be those things. It tends to be distraction and busyness and doing too many things at once. That's probably the thing that limits my capacity for, uh, high-quality work or deep work, as Cal Newport would describe it, right?

Chris Williamson 8:06 What are the rules or techniques that you set yourself to try and maximize deep work time?

Dr Peter Attia 8:12 Well, I mean, one of the things is I don't actually have any notifications on my phone except the phone if it rings. And you know, in this day and age, nobody actually calls you. So basically, I'm never really interrupted by my phone. It, I don't get a, I don't get a-

Chris Williamson 8:24 (laughs)

Dr Peter Attia 8:24 ... even a vibration if there's a text message, an email, or God forbid, anything stupid like social media. So I have basically a phone that does nothing except vibrate if it rings. That's it. Um, and that turns, uh, uh, in talking with people, I realize that's actually seemingly rare. A lot of people look at me like I have three heads when I explain that I don't have any alerts on my, on any aspect of my phone. Um, the other thing I try to do is set aside larger rather than smaller blocks to get work done. So I try to schedule big blocks of time early in the day that are my quality work time. So typically, that is 7:00 to maybe 9:00 in the morning is always uninterrupted. So there's never anything that's gonna be scheduled during that period of time, and I focus on doing whatever's... So this morning, I did the most important things I had to do during that period of time, knowing that from here to my next meeting to my next call is only going to kind of dissipate my cognitive capacities.

Chris Williamson 9:27 Yeah, I, uh, I went to Dubai. I fled the UK during lockdown and went to Dubai, which I think is four hours ahead of GMT, which meant that I could get up at 7:00 or 8:00 and I had four hours before anything happened, and it was bliss. It was insane. It was what it feels like to be Jocko Willink for a while. And, uh, I now, being in the US, I'm six hours behind the UK, which means that I wake up to the, just this cacophony of, you know, things that need to be sorted, and there's video going out, and there's emails, and there's all this stuff. Uh, but yeah, I think for me, choosing in advance what you're going to work on and then blocking off a little bit of time, even if it's just an hour, to be like, right, I'm just going to do the one thing that is going to move... And if you actually look at your day and say, "What would have had to have happened? What's the one thing that would have had to have been done by the end of the day for me to look back and go, 'Success'" It's probably not that insane of a thing. It's maybe the thing that you have a bit of hesitation or resistance to doing. It's usually not that insane.

Dr Peter Attia 10:27 Yeah.

Chris Williamson 10:29 It's not a massive list in order to be successful. Okay, so, uh, what about when it comes to working environment? Have you, are you sit-stand desk? Are you take, are you doing Pomodoros? What else from the productivity focus side?

Dr Peter Attia 10:40 Oh, it depends what I'm doing. Um, but again, I'm, I, I also need quiet to work. That's another thing. So I always kind of look at my daughter, who seems to be able to do homework with music on, and I did as well when I was in college. I always had music on when I was doing homework. I, I wonder if I could have done better if I didn't, but for whatever reason, when it comes to whatever I do now, which is usually writing, um, I wouldn't be able to do a great job with any distraction, sound-wise or otherwise. Um, sta- yeah, I like to be standing if I'm not on Zoom. Uh, my, the way my office is set up, it's just a lot easier to be sitting if I'm on Zoom. I also, you know, I think, you know, people ask me all the time, like, "Do you, you know, do you count your steps or how many minutes you're standing or sitting?" And the truth of it is, I don't at all, right? And the reason is I'm doing so much other stuff that I don't really need to be particularly attentive to those things.

Chris Williamson 11:32 Mm-hmm.

Dr Peter Attia 11:32 All things equal, of course I'd rather be standing or walking than sitting. Um, but, but I don't tend to fixate on it.

Chris Williamson 11:38 You're ignoring dollars to pick up pennies if you're thinking about how much time you're s- spending standing throughout the day.

Dr Peter Attia 11:45 Yeah, and by the way, I think that is valuable for an individual who can't make two hours a day to exercise, but fortunately, I've just made that an unbelievable high priority where, yeah, it's, I'm always gonna be doing the really important stuff during dedicated time.

Chris Williamson 11:58 What about supplementationally or pharmacologically? What are you using if you need to dial in focus a little bit more?

Dr Peter Attia 12:05 Nothing, um, I do, well, I shouldn't say nothing. So I love caffeine, although I, I'm not convinced I'm really getting a benefit from h- from it. I am a very, very fast metabolizer of caffeine, so I probably consume 300 to 400 milligrams a day.... but if I don't, nothing happens. Like, I, I can't appreciably tell the difference. So for me, it's, I love the taste, I love the ritual, I love making coffee, my wife loves coffee, it's the one thing I can do first thing in the morning that makes her happy.

Chris Williamson 12:33 (laughs)

Dr Peter Attia 12:33 Uh, you know, so it's like, y- you know, you know, it's, it's... So I don't, I, I don't... Even though people would argue that caffeine, of course, is a cognitive, uh, booster, um, I'm not convinced I appreciate the, the metrics of that. Um, I do occasionally, uh, put a nicotine patch in my mouth. I probably get more benefit from that. Um, truthfully, and maybe I'm just not aware of other products, the product I use I think is too high a dose, so you have to... It's a 7 milligram pouch.

Chris Williamson 13:00 Mm.

Dr Peter Attia 13:00 So you have to kinda time it, because as you probably know, nicotine is a very unusual molecule, where at low doses it provides a heightened sense of awareness, so it's actually concentrating you, but then you actually cross over a hump and then nicotine becomes actually quite relaxing and sedating.

Chris Williamson 13:17 I didn't know that.

Dr Peter Attia 13:17 Yeah. It's an, it's an unusual molecule in, in that, in that it has behavior. So, um, both of those properties are ideal. It's great to be focused when you need to be focused. It's also great to be relaxed when you need to be relaxed. It's just you don't want those at the same time.

Chris Williamson 13:29 Yeah.

Dr Peter Attia 13:30 So with these 7 milligram pouches... And again, there's people watching this that I'm sure are gonna be like, "Come on, you idiot, don't you know all this other set of products that are out there?" Um, I used to, I used to enjoy gum more, 'cause you could chew two milligrams at a time, which was really the right dose to just induce the focus. Um, again, nicotine is an addictive compound, so I sa- I don't say this lightly, um, but for whatever reason, I don't appreciate any of that. So in other words, I might have it three times a week for a month and then forget about it for six months, and I don't seem to miss it in any way, shape, or form.

Chris Williamson 14:03 Mm.

Dr Peter Attia 14:04 Um, and obviously, the mode of delivery matters, so, you know, I'm not r- remotely interested in, in-

Chris Williamson 14:09 Vaping it.

Dr Peter Attia 14:09 Yeah, I'm not, I'm not at all interested in, in, in that. Um, it's, it's gotta be basically gum or a, a lozenge or something.

Chris Williamson 14:16 It's so interesting that the dose can take you from where you want to be to where you really don't want to be, but it's the same drug.

Dr Peter Attia 14:23 Yeah, or it depends. Like again, sometimes i- if, if a... you know, and I don't use it in this capacity, but if you really need to relax, se- a 7 milligram slug of nicotine will relax you in a remarkable way.

Chris Williamson 14:31 That would just make me wanna throw up. That would make me want to throw up everywhere. I'm very nicotine sensitive.

Dr Peter Attia 14:36 R- yeah. No, that's a real issue.

Chris Williamson 14:38 So what about... W- we're

Chris Williamson 14:40 talking about-

Dr Peter Attia 14:40 Th- th- there's one other compound that I add to the list, although I rarely need it, but if I'm doing a lot of timezone movement, I will also lean on modafinil.

Chris Williamson 14:51 Okay, and how would you use that for yourself?

Dr Peter Attia 14:54 Just use it as a quick reset on circadian rhythm in the new timezone, right? So for exam-

Chris Williamson 14:58 Take it first thing in the morning?

Dr Peter Attia 14:59 Yes. So take it first thing of the morning of the new timezone, which is not the new... which is not my morning internally, right? So if I had to go to London tomorrow, um, and I had to be there for 48 hours and then come right back, my strategy is, let's say I'm leaving Austin at 2:00 PM. So 2:00 PM Austin time is... What's that? 9:00 PM?

Chris Williamson 15:21 8:00 PM. 8:00 PM.

Dr Peter Attia 15:21 8:00 PM, depending on daylight savings. So I would g- put myself to sleep on the plane within two hours so that I go to bed London time, even though it's 4:00 PM Austin time and I don't wanna go to sleep. And then-

Chris Williamson 15:33 What would you do to induce sleep, given that you're in the middle of your day?

Dr Peter Attia 15:35 Uh, I have kind of a whole long protocol, but basically it comes down to how early did I wake up in Austin the day of, when did I exercise, what did I eat? And then I'm going to try to shut off my adrenal glands with phosphatidylserine, um, I'm gonna take trazodone, a dose of, a high dose of melatonin, which is not something I normally use to sleep, and that's gonna put me out.

Chris Williamson 15:56 What were the first two things that you mentioned there?

Dr Peter Attia 15:57 Uh, phosphatidylserine and trazodone.

Chris Williamson 15:59 And what do they do?

Dr Peter Attia 16:00 Phosphatidylserine, uh, in- inhibits, uh, uh, cortisol output from the adrenal glands. And trazodone is a funny drug. It's, um, it's actually, it used to be used as an antidepressant in the '80s, but it never really took off because it had this, um, nasty side effect of making you tired. So as SSRIs and the like came on board, it sorta fell by the wayside. We now use it as a remarkable sleep drug. It's incredibly safe. And more importantly, it doesn't just induce sleep, it induces stage-appropriate sleep. It's a very helpful drug for people who, um, don't suffer from any initiation insomnia but who do tend to wake up intermittently at night, either due to anxiety or, you know, just any- anything that kinda gets people up. Trazodone basically buzzes over that.

Chris Williamson 16:40 Smoothes that out.

Dr Peter Attia 16:41 Yeah.

Chris Williamson 16:42 Okay. So you've then taken that. Melatonin, what sort of dose?

Dr Peter Attia 16:45 Again, normally I don't take any, but if I'm looking for the hammer, I'm gonna take 3 milligrams.

Chris Williamson 16:49 Wow. Yeah, that is a lot. I mean, h- here's, just before we go onto how to then wake up when you get to London, the levels of dosage that you can buy in CVS of melatonin-

Dr Peter Attia 17:00 It's crazy.

Chris Williamson 17:01 ... is wild. Can, can you just give the overview of how the dose curve works for melatonin with humans?

Dr Peter Attia 17:09 Well, I mean, it, w- what's interesting is, physiologically, the pineal gland doesn't make that much melatonin, right? It's making, um, micrograms of the drug. So I think the smallest dose I've ever seen that you can buy might be 300 micrograms. Like, maybe there's someone out there that makes a-

Chris Williamson 17:28 It's 0.3 of a-

Dr Peter Attia 17:29 0.3 milligram.

Chris Williamson 17:29 Yep.

Dr Peter Attia 17:30 Yeah. That's probably the smallest I've seen. Maybe there's a, a 0.1 out there.

Chris Williamson 17:33 I've got a, uh, a spray, and each spray, sublingual spray of it is 0.3.

Dr Peter Attia 17:39 Okay. Yeah.

Chris Williamson 17:40 And so unless I can like-

Dr Peter Attia 17:41 Yeah, milligramfully.

Chris Williamson 17:41 ... mini to half trigger it, there's no way I could get less.

Dr Peter Attia 17:43 But most of the time, you're looking at 1 to 5 milligram, i.e. 1,000 to 5,000 micrograms of this stuff, and even 10 milligrams. And the problem with that is, uh, uh, it seems if, if, if you look at the literature, um, and I haven't looked in a while, but the last time I did, doses north of about 6 or 700 micrograms, 0.6 to 0.7 milligrams, tend to really suppress melatonin receptors in the brain. And so as a long-term strategy, it's probably a bad idea.

Chris Williamson 18:18 So would that create basically a physiological dependency?

Dr Peter Attia 18:20 Dependency, yep.So m- my, I try to get patients off melatonin, truthfully, and reserve it for jet lag and for travel only, and, and not rely on melatonin as a, as a nightly sleep aid.

Chris Williamson 18:31 But for a single use-

Dr Peter Attia 18:32 But if you're going to, I w- I want them to be as low as possible.

Chris Williamson 18:36 ... I've got a short amount of time, 48 hours, I can't mess about here, I need to hit it with a hammer.

Dr Peter Attia 18:39 Yeah, if I- if, uh, using this example, if I- I wanna fall asleep at what feels like 4:00 and wake up in seven hours, and then two hours later land in London, and-

Chris Williamson 18:49 And be functional.

Dr Peter Attia 18:50 ... and be 100% functional, and then take that, uh, me- uh, modafinil upon landing.

Chris Williamson 18:54 What sort of dose of the modafinil? Is that immediately upon waking?

Dr Peter Attia 18:56 Yep.

Chris Williamson 18:57 Right. And what sort of dose? Any idea?

Dr Peter Attia 18:59 I mean, I usually take 200 milligrams if I'm gonna take it, but-

Chris Williamson 19:01 I don't know...

Dr Peter Attia 19:01 ... modafinil can be dosed. Typically the low end is 100 and the high end is 600.

Chris Williamson 19:05 Okay. Uh, what about armodafinil? I've heard about that.

Dr Peter Attia 19:08 Comparable.

Chris Williamson 19:09 Right.

Dr Peter Attia 19:09 Yep.

Chris Williamson 19:09 Same thing?

Dr Peter Attia 19:10 Yep.

Chris Williamson 19:10 What i- I'm- you're speaking to someone that's never taken modafinil. What's the sensation of it like?

Dr Peter Attia 19:15 Uh, it depends on the individual. So I perceive nothing, I'm just more awake, and I'm- I feel fantastic. But I don't get a high from it, I don't get any stimulation from it. I know there are some people, I can't tell you what fraction of people, but- but a non-trivial fraction of people actually experience a negative sort of stimulation effect from it. In- in the c-

Chris Williamson 19:34 What do you mean? What do you mean?

Dr Peter Attia 19:34 Oh, like they feel like, uh, it probably feels like what ephedra used to feel like back in the day.

Chris Williamson 19:38 Oh, it's rushy?

Dr Peter Attia 19:39 Yeah.

Chris Williamson 19:39 Wow.

Dr Peter Attia 19:40 Yeah. And now- now again, I would argue that in those people, they're simply taking too much and that they're very sensitive to it, and they might get the benefit without that negative side effect if they down the dose.

Chris Williamson 19:49 Wow.

Dr Peter Attia 19:49 My wife, for example, can't take it, but that's probably because she's only ever tried 200. And I would bet if she ever really needed it, I'd probably give her 50 or 100.

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Chris Williamson 20:57 Talk to me about... So that's mental clarity in the now. What about, uh, reducing cognitive decline over the long term?

Dr Peter Attia 21:07 I think it's the... Uh, th- the two big ones by far, I- I think first and foremost is, is exercise. Um, clearly the most efficacious data, right? So if you just look at clinical trials, if you just look at mechanistic studies, um, exercise is the best intervention for the brain. Um, I think metabolic health and high-quality sleep would probably be next in line. So metabolic health meaning being insulin sensitive, good fuel par- fuel partitioning, right? Being as far away from the diabetes end of the spectrum as possible. Um, again, if you have type 2 diabetes, your risk of, um, neurode- neurodegenerative disease goes up significantly. Um, and then it's all things that pertain to vascular health beyond what's already been stated, right? So if you look at... You know, w- again, it's important to understand when we talk about dementia, we are talking not just about Alzheimer's disease, but the other forms of dementia. Alzheimer's happens to be the most prevalent, um, but it's by far, you know, not the only one. And so when we think about vascular dementia, uh, frontotemporal dementia, and obviously Alzheimer's disease, all of the risks for cardiovascular disease carry right over there. So what are the things we wanna do to maintain, um, low risk for cardiovascular disease? Low burden of lipoproteins, low blood pressure, uh, low inflammation. Those are the big, big, big three in metabolic health.

Chris Williamson 22:27 Lipoproteins, how do we get to low lipoproteins?

Dr Peter Attia 22:30 Um, usually pharmacologically, truthfully, because for most people, to ta- to make the lipoprotein level low enough that it- you can factor it out of the equation is not really achievable dietarily unless you're willing to go on a very extreme diet that I think for most people causes more problems than it- than it solves. So you have to- you'd have to be really, really fat restricted to do that.

Chris Williamson 22:53 Mm-hmm.

Dr Peter Attia 22:53 And there are some people who can do okay on that, but most people end up also being too protein restricted, they end up, you know, eventually getting sarcopenia later in life. There's a whole bunch of other imbalances that come along for the ride.

Chris Williamson 23:04 Right. Okay. Uh, blood pressure. What are the big movers when it comes to keeping that in a good range?

Dr Peter Attia 23:11 The big two by far are weight and exercise. Weight meaning weight loss and, uh, and cardiorespiratory fitness.

Chris Williamson 23:18 Right. So you're not... Uh, th- this could be the gym bro, as many of my friends are, that probably overweight in terms of what body mass they're carrying, uh-

Dr Peter Attia 23:30 Not doing enough cardio training.

Chris Williamson 23:31 ... and not doing anywhere near enough cardio. Getting out of breath going up a set of stairs-

Dr Peter Attia 23:34 Right.

Chris Williamson 23:34 ... struggling to touch their toes-

Dr Peter Attia 23:36 Yeah.

Chris Williamson 23:36 ... etc., etc.

Dr Peter Attia 23:37 And so while-

Chris Williamson 23:37 Looking really great kind of.

Dr Peter Attia 23:38 Yeah. An- and so while we have a lot of great drugs to treat blood pressure, just as we do for treating lipids, your ability to impact blood pressure with, uh, quote-unquote "lifestyle" is much greater and should always be first line.

Chris Williamson 23:51 What... Does VO2 max or, uh, resting heart rate make a bigger impact on when it comes to... I mean, t- are you looking more towards zone 2 or toward maximal work to bring that blood pressure under control?

Dr Peter Attia 24:03 Both. The to- just total cardiorespiratory fitness. And you can't really be very high in one without the other. In other words, if you really, really, really have a profound aerobic base, you're gonna have a decent VO2 max. And if you have a really high VO2 max, you have to have a pretty significant aerobic base. And, and I do think that most people would benefit from training those two in a ratio of 80/20 in favor of zone 2.

Chris Williamson 24:28 Wow. Okay. Yeah, I think, you know, again, for the gym bros out there, of which I am, you know, a card carrying member-

Dr Peter Attia 24:36 (laughs)

Chris Williamson 24:36 ... um, just throughout your 20s, it's so, if you, if you know what a push pull leg split is, and if you're enjoying going to the gym and getting jacked with your boys, it is so low down the list of priorities for you to care about doing cardio.

Dr Peter Attia 24:52 Mm-hmm.

Chris Williamson 24:52 Like, unless you're going to Ibiza in two months time and you're a bit fluffy and you think, "I'm gonna get up and I'm gonna do intervals f-fasted first thing in the morning," that's it. Like, cardio's just not on the table.

Dr Peter Attia 25:03 (laughs)

Chris Williamson 25:04 It's true.

Dr Peter Attia 25:06 How many days did you spend in Ibiza?

Chris Williamson 25:08 Oh, w-

Dr Peter Attia 25:08 Was that, like, if you live in the UK, that's like Cancun, right, for living here?

Chris Williamson 25:12 Kind of, yeah. Yeah, so you've got, obviously we, Europe's on our doorstep, so it means that, uh, Majorca, Magaluf, Malia, Zante, Ayia Napa, Ibiza. So, Ibiza's the coolest one of the lot because it's s-sexy house music and it's cool and whatever, whatever. Um, but there's a-

Dr Peter Attia 25:28 (laughs)

Chris Williamson 25:29 They said th- there's a rule of you can ruin any European city by putting direct flights from the UK there. Uh- (laughs)

Dr Peter Attia 25:38 (laughs)

Chris Williamson 25:38 It's so true. You hear these stories about, uh, planes that need to be turned around in the sky because, you know-

Dr Peter Attia 25:43 They're too rowdy in the, yeah.

Chris Williamson 25:44 Yeah, way too rowdy. And you think, look at any British airport. If you go Easter holidays, look at any British airport, 5:30 in the morning, everyone's got a pint. Everyone.

Dr Peter Attia 25:56 (laughs)

Chris Williamson 25:56 Parents have got a pint as they're going away 'cause it's, drinking is just such a in-built part of British culture. It is-

Dr Peter Attia 26:04 (laughs)

Chris Williamson 26:05 ... in our blood, literally. But I think, you know, we spoke about this last time, I think we're turning a corner with alcohol. I think, I really think we are. I think that the way that people see it as this sort of go-to coping mechanism, like, the relaxation mode of choice, the thing that alleviates social anxiety. Perhaps this is because people aren't putting themselves into social situations quite so much, they're able to sit in the house a little bit more. Um, but my previous industry was nightlife. And, you know, I speak to my, uh, ex-business partner and all of the guys that I used to work with, and the loutish, lairy sort of drinking culture has now been wildly supplanted by much more chill sort of brunches, and, and it seems to have matured a little bit more. So, maybe we-

Dr Peter Attia 26:47 W- when I was in London last summer, um, I went to, uh, you know, n-near around the Parliament and stuff, and there was this great statue of Winston Churchill outside of a park. What, do you know the name of the park I'm talking about? It has a, a statue of Churchill facing out.

Chris Williamson 27:01 Okay.

Dr Peter Attia 27:01 He's the only one facing out, I think all the other statues of great folks are facing in, and it's facing, um, I'm blanking on the name of the tavern, like Stephen's Tavern or something like that? And, you know, so the lore is that that's where Churchill held shop, right? 'Cause you had to be within a certain distance of Parliament, so that if you got called back to Parliament, you could go. So basically Churchill lived there. He was always eating and drinking there and holding court. So, of course, I had to go there, and there's no way I wasn't having fish and chips and some pint of whatever. And I mean, I just did this every day-

Chris Williamson 27:32 (laughs)

Dr Peter Attia 27:32 ... even though I couldn't stand the beer. But I was like, "I'm going to have fish and chips and a pint of whatever your finest s-"

Chris Williamson 27:39 Unspeakable, warm lager.

Dr Peter Attia 27:40 "... horrible piss water is."

Chris Williamson 27:42 Yeah, yeah, yeah.

Dr Peter Attia 27:43 "But if Churchill did this, I'm doing this."

Chris Williamson 27:45 I got, from my tour manager, I got a, a Christmas present of the champagne that Churchill used to demand was at every lunch meeting. And he made this company create a new sized bottle because a half bottle was insufficient and a full bottle was too much and he couldn't think. So, they made a pint bottle-

Dr Peter Attia 28:06 (laughs)

Chris Williamson 28:06 ... of champagne, and it's this, and it's got the lore on the back, and it's beautifully designed and-

Dr Peter Attia 28:10 Oh, man.

Chris Williamson 28:10 ... apparently it tastes like fizzy... I haven't opened it yet, I need to wait for a good occasion. Um, but it tastes like fizzy apple water or something. And, uh, yeah, he made them. I- imagine being the guy that goes to a high class champagne establishment and says, "Uh, this, I- I- I, it's not quite enough with the, with the half bottle."

Dr Peter Attia 28:29 (laughs)

Chris Williamson 28:29 "I don't need a full, m-m-make me a new one."

Dr Peter Attia 28:32 (laughs)

Chris Williamson 28:32 And that's the, that's the power that you've got.

Dr Peter Attia 28:34 Yeah.

Chris Williamson 28:36 You say that striving for physical health and longevity but ignoring emotional health could be the ultimate curse of all. What do you mean by that?

Dr Peter Attia 28:47 Well, um, y- you know, there's a, there's a, there's this Greek mythology of a, a fellow I write about in the book, Tithonus, who, who r-requests of the gods, uh, immortality, and he gets granted eternal life but not eternal health. And so he has this horrible curse where he's alive but he's physically decaying all the way into this decrepit never-ending state. And so, I think an extension of that is, well, i-if you're, if your, um, emotional health, which encompasses many things, happiness, the quality of your relationships, any sense of purpose, any sense of happiness, if that is in a bad place, why would you want to live longer? I mean, you, you're abjectly suffering, so why would extending that suffering be of any value? Um, and again, like, you can th- you can play sort of thought experiments all day long. So, uh, let's, let's play one. So, um, you know, the little bit I know of you, Chris, you enjoy people, right? Like, you're not an antisocial human being. So, if I told you, um, "Chris, whatever number you think is the dollar amount that it's gonna take to make you happy, we're gonna double it, okay? That's how much money you've got. And whatever metric of your own physical health, defined by how big your muscles are, how low your body fat is, how well you can perform, let's give it to you plus 20%."

Chris Williamson 30:15 Sounds good so far.

Dr Peter Attia 30:16 Yep. And, um, the only catch is you're the only person on the planet now. Now, don't worry, I've created a bunch of bots that will do everything, so your standard of living won't go down. Like, you're gonna have bots that will do anything, and they'll provide your food and everything. H-how, how happy is your life? Like, how long until you kill yourself?

Chris Williamson 30:36 (laughs) Not long.

Dr Peter Attia 30:37 No, because think about it, like, what are you doing, right? So, that just gives you one-... example of, wow, if you took away my ability to interact with other people, I, th- life is not worth living. Very, very few people, I could imagine, could tolerate that for a long period of time. Um, so sure, that's extreme but it's a great way to illustrate a point, which is, if you have every single thing imaginable but you have no connection to other people, what do you have? Um, so of course it doesn't have to be that extreme for the point to still remain.

Chris Williamson 31:11 One of the things that I've been thinking about a lot recently is, um, integrating of emotions because a lot of us that come from a productivity background or a biohacking background or a strength and fitness background, we try to reduce the human experience down to metrics and numbers and reps and sets and stuff like that. But the actual phenomenological experience of being a human is emotions. It's what- w- what does, what is the texture of your mind as you move day-to-day through the things? When you look back at the day, sure, you might be able to say how many words you wrote or how much weight you lifted or how far you ran, but the actual moment-to-moment experience of that isn't you logging things on a spreadsheet. It's how your mind feels, what- w- what's going on internally. And I really think that that point about emotional health being... everything else kind of being subjugate to that is really true and it's something that I think people gloss over. So when- when you conceptualize emotional health, what are you- what are you talking- how do you think about the component parts of emotional health or an emotional health regime?

Dr Peter Attia 32:19 You know, some of it depends on definitions and semantics, and I don't for a second suggest that the way I do it is the right way or anything like that. The- the way we talk about it with our patients, 'cause we do, um, because it fits into a hierarchy of all the things we care about managing in terms of longevity risk. So longevity risk is anything that is a threat to the length of your life or the quality of your life, and this has to be one of those buckets. Broadly speaking, there are seven. So within this bucket, I would say it's, um, sense of purpose, satisfaction and joy, achievement, quality of relationships, self-regulation, distress tolerance. Tho- those are probably the biggest buckets that fit into that. Um, and again, you know, Arthur Brooks, who I don't know, have you had Arthur on the podcast?

Chris Williamson 33:04 He's coming on in a couple of months.

Dr Peter Attia 33:06 Oh, yeah. So you'll have a great time with Arthur because this is really a big part of what he talks about is the subset of this around happiness.

Chris Williamson 33:12 Mm-hmm.

Dr Peter Attia 33:13 Um, and, uh, I think he- I think he has a very elegant way of- of thinking about happiness, right? Which is that happiness is not a feeling any more than the odor of the food you're consuming is the caloric macronutrient benefit of the food. Uh, and- and therefore people tend to get a little bent out of shape if they don't, quote-unquote, "feel" happy in a sort of positive valence, emotional sense. Um, and- and I think that's actually one of the most important things I've learned in the last couple of years, is that I shouldn't confuse my feelings with my state of happiness, and that- that when I- when I'm evaluating the- my emotional state through the lens of happiness, I really want to go through these- these more nuanced metrics around, like, am I- am I living in a manner that is congruent with what I believe my purpose is? My purpose, first and foremost, as a father and husband, but then secondly my- my- my purpose as a doctor, and then maybe my purpose as a public figure. But- but I feel like I do have a purpose in all those things. Okay, and then, like, what is the state of my relationships? Whe- where are my relationships good? Where are my relations under strain? Where are my relationships lacking in my attention? Um, and then what am I pursuing that is giving me a- a- a- a sense of satisfaction which- which really requires, um, doing something hard and achieving a result? Like, and I... You know, some people are more wired to need that than others.

Chris Williamson 34:39 Mm-hmm.

Dr Peter Attia 34:40 Uh, you probably are. I know I certainly am, and my entire life has been built kind of around hard things to do as little, you know, side projects (laughs) . You know, physical challenges sometimes, sometimes business challenges, writing a book, something like that where you toil and it's hard, but at the end there's something you're- you're proud of. So anyway, it's- it's- it's about accounting through all of those things, um, and I- I... Look, for some people it's easier than others. There's some people that just naturally tend to find ease within those things and others who don't, just as there are some people for whom it's much easier to do cardio and they enjoy it, and there's others who maybe gravitate more towards strength training or maybe others who don't want to exercise at all as their natural default state.

Chris Williamson 35:24 Do you think there's a difference between emotional health and mental health or is this just lexical wishy-washy?

Dr Peter Attia 35:29 Um, you know, I used to use the two interchangeably, um, but I- I don't know. I mean, w- I think in the book I talk about them as- as sort of slightly different, and I talk about emotional health as this thing that we are talking about now and mental health as the pathologized state of disease.

Chris Williamson 35:47 Mm-hmm. Mm-hmm.

Dr Peter Attia 35:48 So depression, anxiety, bipolar disorder, those would be mental health things. Uh, uh, again, I- I don't think there's a right or wrong to this as long as one is clear in what they're saying.

Chris Williamson 35:59 One of the things that I really appreciated about you was your openness. You've spoken about this a number of times, your openness about your own, uh, sometimes negative castigating inner monologue, something that I'm incredibly familiar with as well myself. What would you say to the people who have poor self-talk, uh, uh, a scolding inner voice that reminds them of how they fell short way too often? What have you learned about dealing with that and also about balancing that with your high standards for yourself, about wanting to make a mark in the world but also needing to be able to give yourself self-love?

Dr Peter Attia 36:36 Yeah, it's an interesting question. Um, I don't know that I could provide generic advice on the topic because it probably depends on where the person is in pain right now. So I know that for me-... the message, the- the reason I was willing to engage in the discussion around changing the behavior was because the output of it was- was- was made clear to me, right? So once I recognized the link between my self-talk and my rage, and I fully accepted the fact that I wanted to rid myself of rage, then I accepted the fact that I had to go and fix the self-talk. So my guess is, the only way to really try to convince somebody that, um, you're having an inner Bobby Knight, which is what my guy was, having an inner Bobby Knight that screams at you all the time is harmful, is by helping them understand a clear path between how that behavior links to something that is hurting them in another way that is more obvious. And I th- I think if you can't do that, it's probably a little too abstract to just say, you know, "You should be nicer to yourself."

Chris Williamson 37:53 I listened on recommendation from a friend to a 20-year-old, nearly 20-year-old Tony Robbins Awaken the Giant Within work book on Audible. It's about an hour and a half. And I had never read the original book. And in it, he talks about pain and pleasure principle, and he talks about bringing, uh, with decisions that you want to make or with habits that you want to change, bringing as much pain to bear. Look at what this has cost me in the past, look at what this is costing me now, think about what this will cost me in the future, and then turn that up to a thousand. So my friend wanted to stop biting his nails, so he thought about all of the times in the past that girls had sort of made an icky sort of move when he put his hands on them, and they'd seen them, and how ashamed he felt about it at the time, and about how this was going to hold him back in the future, and how it made him feel like a juvenile, and it was immature. And then he went online to turn it up to a thousand and he looked at the worst photos that he could find of people that had bitten their nail, these awful, you know, like bloody stumps of fingers.

Dr Peter Attia 38:52 Mm.

Chris Williamson 38:52 Uh, and then he thought about the opposite. He thought about, "How much pleasure could I bring to this? How proud I would be if I'd overcome this thing that I- I'd done for 20 years, about how much more attractive I would feel, about how much more confident I would feel when I shake someone's hand or when I put my hand on my girlfriend's leg," and these sorts of things. And, uh, I have to say, it's incredibly powerful, like to do that, to bring to bear. And what you're talking about is, there is a inner tormentor that kind of does a thing, but it's all inside of your head, and it's upstream from some things that actually manifest that you can kind of hold onto and do a thing. So how do you get, how do you get back up, and how do you point the finger at what's actually going on? Well, you bring to bear so much of what's happening in the real world. But yeah, it's, I- I think this is one of the most common issues, especially people that listen to this sort of a podcast, you know, they're high achievers. They want to do things, they wanna leave a mark on the world, they wanna improve themselves. But so much of that comes from like whipping themselves into submission all the time. "I'm gonna castigate myself until I, I like bow under the strain of how much torment I've given to myself." And I...

Dr Peter Attia 39:58 But, uh, uh, a- as you know, it- it, there's a real myth that you have to do that to perform well, right? Um, and the- and the myth is that, you know, there are plenty of great coaches who extract remarkable performance from their athletes without that behavior. So, and it doesn't mean you're not firm, and it doesn't mean you don't have high standards, and it doesn't mean that if the team absolutely shits the bed and doesn't show up, that the coach isn't going to let them have it. But that's, you know, that's very different from the constant berating. And also, I- I think there's just a real difference in terms of, um, you know, differentiating kind of, um, a negative behavior or a negative outcome from the individual themself is the- is the- is the problem, right? So- so it's one thing to say, "I don't like that I wasn't able to do X, Y, and Z." That's a different statement from, "I am a worthless person because I didn't do A, B, and C."

Chris Williamson 41:00 It's a comment on my- my self-worth, on-

Dr Peter Attia 41:02 Yeah.

Chris Williamson 41:03 ... h- how much respect I am owed by the world. Okay, so t- take me through how you reprogrammed that self-talk. I understand that you can have this thing, the rage is downstream from the whatever, but what- w- w- what did that look like? What did going in and fact-checking your, uh, very stern inner voice look like?

Dr Peter Attia 41:25 Uh, it was a, it was actually a very deliberate set of actions, 'cause I think you have to do actions. And the easiest way to reprogram is through voice. So, uh, I think you have to audibly reprogram a system. I don't think thoughts are enough. And so, uh, the exercise that I undertook, uh, about four years ago to reverse a pattern of behavior that was in place for more than 40 years was to every single time I had a moment of self, uh, what was about to amount in a sort of self-cursing, um, situation, I would, I was to, I was instructed to take out my phone and record audibly a- a- a- a description of what I would say to a friend had they just committed the same, quote-unquote, egregious act. Okay, so example would be if I'm shooting my bow and arrow and I'm really doing a lousy job of it, instead of jumping into self-loathing, I would take out my phone and record a memo speaking, but not to myself, but to my friend. You know, like, if it was you, "What if you had just shot as poorly as I did? What would I say to you?" And it, I would- I would be much more gentle. Now-

Chris Williamson 42:51 What were the- what were the sort of things that you would say?

Dr Peter Attia 42:52 Oh, it would be, it would be...You know, and again, you have to understand how strained some of these discussions are, 'cause in the moment, you're so angry.

Chris Williamson 43:00 Yep.

Dr Peter Attia 43:00 Right? It would be, "Uh, hey, Chris. I know you just finished trying to shoot today, and it, it just didn't go well at all. Um, you weren't able to accomplish any of the things you wanted to accomplish. I, I know it's frustrating. Um, I think you just have to accept a couple of things. One is, um, you're probably a little distracted today, if you're being honest with yourself. Um, 'cause you have a lot on your mind and... You know, truthfully, it's a little windy today, and I, I, it's just hard for those arrows to fly straight when the wind is blowing at 10 miles an hour. Um, and, you know, as you know, from prev- previous experiences, like, tomorrow will be a new day. Like, y- you're gonna come out here and do this again tomorrow, and it'll be better. And we're just gonna go back to process and we're gonna get it right, and we're gonna, we're gonna do a couple of drills tomorrow to, to instill that." That was it. You know, it might be a one-minute little voice memo. I'd send that to my therapist. And then, I don't know, five hours later, something else would come up that would piss me off.

Chris Williamson 43:57 (laughs)

Dr Peter Attia 43:57 I'd burn a steak or something, 'cause I tur- you know, I got, I'd got distracted-

Chris Williamson 44:01 Distracted, yeah.

Dr Peter Attia 44:01 ... and left the barbecue. And I, and inside I'd want to immediately eviscerate myself. But instead, I would pull it out and pretend that it was my brother who had just burned the steak. And what would I say to him if we were at his house and he had just burned the steak? How would I make him feel better about it, while acknowledging that it sucks we don't have dinner tonight? (laughs) You know? And, and y- I would do that. And after four to six months of doing this, I don't know, three to five times a day, lo and behold, I couldn't hear Bobby Knight talk anymore.

Chris Williamson 44:33 Wow. So it can, it really turned the volume down?

Dr Peter Attia 44:37 It is, in my life, the single greatest example of neuroplasticity that I have ever witnessed.

Chris Williamson 44:46 And how old are you? Or how old were you when you were doing this?

Dr Peter Attia 44:48 I'm 51 now, so 47.

Chris Williamson 44:53 Dude, that's wild.

Dr Peter Attia 44:54 Yeah, you wouldn't think it could change.

Chris Williamson 44:56 I think especially when you're talking about self-talk, it is the internal physics of your system. It literally is the texture through which you interact with your own mind. And it's the fish underwater thing. Like, you just-

Dr Peter Attia 45:10 Yeah.

Chris Williamson 45:10 ... you don't know that it could be different. And to think that it's as malleable as that. And how sticky has that been? Do you need to drop, are you having to go back and do this, or is-

Dr Peter Attia 45:19 No. I've, I've never had to go back and do it, and I've never heard the voice again. Now, I wanna be clear. This doesn't mean I don't get angry. What it means is, A, the frequency with which I get angry is a fraction of what it used to be. The, um... And the duration or the blast radius is much narrower. So, the last time I got really pissed at myself, or pissed at my inability to do something, was I was in the simulator. I'm trying to learn a, I'm trying to learn a new F1 circuit in the simulator. And, um, for whatever reason, there are certain tracks that are just very hard. Silverstone is a very hard track to drive. Uh, it's very hard to put a perfect lap together, and it just really gets under your skin. And so is Imola. So, Imola is a circuit I'm learning right now, like, learning in great detail, right? Like, I wanna come up with a really cracking time on Imola. And I was down in the simulator, and I was going through it, and I just couldn't nail the last, uh, the second and third last corners. And I would have these epic flying laps, and then I would absolutely shit the bed in this corner, and either off-track, spin, or just lose so much time that I couldn't put a lap together. And, you know, after, I don't know, an hour of this, I just got super frustrated, got out of the simulator, and was, like, absolutely ripping pissed off. But because I didn't indulge in any self-talk, it wasn't like, "You suck, how can you not do this?" Which is exactly what that voice would've said in the past. It was just, "Oh, I am so pissed that I am not able to do this right now. Like, I'm gonna come and do it tomorrow." And by the time I got from my simulator room upstairs, I had forgotten about it. And that's the difference. Whereas before, that would have stayed with me, and I, it's, I'm embarrassed to say this, it would've stayed with me for the rest of the day. I would not have been able to shed that anger for the rest of the day, and it would've leaked into everything I did. Uh, whereas now, in 60 seconds, I, it's not that I didn't remember it happened, it just, the emotion of it was, had dissipate already.

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Dr Peter Attia 48:42 (laughs)

Chris Williamson 48:43 Um, but presumably that means that if they were to go through a period of this rewiring, that dose could be less, intensity would be less, difficulty would be less. Like, if you're patient zero for having a really, really bad inner voice, that means that people who just want to make it a little bit better because it's a bit bad should be able to get there. Have you got any idea what...... what was happening when you're going through it. Like, what is it about speaking to the friend? What is it about that increase of distance? What is it about the saying it out loud and, uh-

Dr Peter Attia 49:11 Yeah. You know, I've never really, I've never really thought about what's happening from a, from a neurobiological perspective. It would be, it would be an interesting discussion to, to have with someone who's smarter than I am-

Chris Williamson 49:22 (laughs)

Dr Peter Attia 49:22 ... um, and, or at least understands that more, but it is... Again, I, I, I didn't do this because I thought it would work. I really was like, "This is kind of a dumb idea. There's no way this is gonna work, and I'm gonna just be doing this for the rest of my life. And maybe the fact that I have to do this for the rest of my life is the penance-"

Chris Williamson 49:42 Mm.

Dr Peter Attia 49:42 "... like, for, for my sins." But I was like, "It can't work." Like, again, I just thought-

Chris Williamson 49:48 (laughs)

Dr Peter Attia 49:48 ... like, it, it's so ridiculous that I'm gonna do this, because, like, you don't... Y- y- y- what is the next thing you're gonna tell me? I can be a foot taller if I think about it every day? Like, if I s- talk to myself, I'm gonna make myself taller? Like, I, I thought that this trait was as immutable as a physical trait.

Chris Williamson 50:07 Yep. Yeah.

Chris Williamson 50:10 You did a insanely long or intense period of therapy at one point. Can you tell me about that?

Dr Peter Attia 50:17 Um, yeah, I've done two. Uh, so these were, like, residential therapy p- programs that I went to, where I spent, uh, two weeks in the first one, three weeks in the second one, where you're, you're in a full-time residential place doing therapy 12 to, you know, probably 12, 13 hours a day.

Chris Williamson 50:34 That's like, um, mind rehab. It's like mental rehab.

Dr Peter Attia 50:38 Yeah, it's immersion, right?

Chris Williamson 50:40 Right.

Dr Peter Attia 50:40 So, so it's diff- you know, the way I, people say to me, people who have felt the need or wondered if it was something they would benefit from have asked me, and they said, "Look, you know, is it the same as just doing X number of hours of therapy?" And I say, "It's not," because it's, it's, it's sort of the same of saying like, "Look, if you really wanted to learn Spanish, would you be better served doing an hour a week with a tutor, or would you be better served moving to Spain and not letting anybody speak English to you?" Like, the, the, the, the difference in speed with which you're going to get there based on total immersion, uh, is, is very separate.

Chris Williamson 51:15 I've never heard of this before. I didn't know this ex- it's like a meditation retreat, but for therapy.

Dr Peter Attia 51:19 Y-

Chris Williamson 51:19 I'd never heard of it.

Dr Peter Attia 51:19 Yeah. And again, these, these programs, and there's probably many of them, you know, they're very well-structured, right? So it's not just... It's some group therapy, some individual therapy, you know, EMDR for trauma, family history stuff. You know, i- it's very uncomfortable. Like, there's nothing about it that's enjoyable. So it's, uh, w- which, you know, o- obviously is sort of like a silent meditation retreat where you have moments of profound misery, um, and then moments of (laughs) of, of bliss. This is probably more painful than that, 'cause you don't really have any bliss. Um, but, you know, the, the people who, who, who lead these kinda programs are very special, and they really, they really understand how to, how t-... They think, they can pattern recognize it. You know, the other thing that I think is pretty, pretty valuable about these experiences is none of us are really that special. Like, we all kinda think our problems are super unique, like, "No one's as fill in the blank as me," and it's just not true. Like, we're all pretty ordinary, and, you know, um... I don't know. I, maybe that's an... Maybe people hear that and think that, "No, come on, I am a special flower."

Chris Williamson 52:24 Yeah.

Dr Peter Attia 52:25 But it's like, no, we're not special flowers. We're just kind of trying to optimize for our own, you know, wellbeing and the wellbeing of those around us in our tiny little world. And, um, if I can suffer a little bit less, that's great, but there are lots of people who have seen my problem before, and, um, and if they haven't seen it exactly, they've seen a version of it.

Chris Williamson 52:43 It's an uncomfortable realization, but it's one that I've arrived at as well, this sort of... It's kind of narcissism to believe, "Look at how special and unique and, and, uh, difficult to understand I am. You could never-"

Dr Peter Attia 52:57 Mm-hmm.

Chris Williamson 52:58 "... I, it would, it would take you an-"

Dr Peter Attia 52:59 (laughs)

Chris Williamson 52:59 "... easily a decade for you to be able to get inside the cathedral of my mental pathologies."

Dr Peter Attia 53:05 (laughs)

Chris Williamson 53:05 And it's not.

Dr Peter Attia 53:07 Yeah.

Chris Williamson 53:07 It's not. It's n- y- you know, and I'm, I'm deep in the, I'm in my therapy era at the moment as well. And, you know, the ease with which someone who is trained can see your patterns and call them out for what they are, and sometimes they have a name, and you go, "I don't have that." It's like someone accusing you of having a disease, and you go, "No, no, no, it's not that. It's something, it's not that. What you just described to me is the name of this disease." And as soon as that happens, the kind of veils fall from your eyes a little bit about you being personally cursed. I often think about that term, personal curse, that you can understand why the ancients used to believe that the gods used mortals as their playthings, because the phenomenon of, of, of rage or of lust or of whatever, it doesn't just feel like some neurochemical imbalance. It, it's imbued with meaning, right? There is a phenomenological experience of doing this thing. It's not just a thing. It's, like, more. And (laughs) to sit down with someone and for them to see you, to really see you, and to observe what's going on, and this is why, you know, so much of my transition from absolute adult infant to, like, man child or whatever I'm at now was... i- it came about from listening to podcasts, because for the first time ever, I got to hear people that were being completely open and honest about their experience. And me going, "Oh, wow. Like, other people have that thing. This isn't just me." I haven't been, you know, imbued with some unique army of one pathogen that, like, affects me in this way. Other people have a, a very, like, cursive internal self-talk. Other people hold themselves to high standards but then also feel bad because they're not enjoying life. Other peop- b- b- b- b- b- and, uh, yeah. To, to realize that you're not as special as you think you are, or your problems aren't as special as they think that they are, I think-

Dr Peter Attia 55:04 Yeah, or as unique.

Chris Williamson 55:05 Yes.

Dr Peter Attia 55:05 Yeah.

Chris Williamson 55:05 Yeah.... and there is usually a pathway, a pretty well-laid-out pathway of, "Okay, well, where does this come from and then how do we look at it and then how do we move forward?" It's not that hard. I wanted... I- I don't know whether I'd be able to do two or three weeks of, of full-time therapy. Uh, two hours a week is, is, uh, heavy enough for me. So coming out the back of that, what... Was there an immediate change or was this something that required integration, like going on an ayahuasca retreat?

Dr Peter Attia 55:37 Um... The- the- the two were quite different and occurred at sort of d- they were separated by a few years. Um, I think the second one was more, was more successful, um, based on the fact that the first one I left, uh, kind of against their advice, right? So they wanted me there for another four weeks. At a minimum, another two.

Chris Williamson 56:02 You'd done two?

Dr Peter Attia 56:03 I had done two, and they wanted... They... Everybody believed I needed a minimum of two more, but likely four more.

Chris Williamson 56:09 Feels like, "This is the worst case that we've ever seen. Bring in the doctor." They're like, "Clear." That's like the mental equivalent of that.

Dr Peter Attia 56:16 Yeah, and I was like, "Guys, I'm definitely better." And they're like, "T- yeah. You're better than when you walked in, but you're not better-better." Uh, and they were right. I didn't know it at the time, uh, and I was wrong. And I left, and I left... This was in 2017. And I left, and I largely held it together until 2019, and then I kind of fell apart again. And by 2020, I was completely apart, and at the beginning of 2020, I had to... I had to go back and pick up the pieces of what I should have done the first time at a different place. And here, this is a place that's a little more intense, and they get most people out in a week. And after a week, they said, "You... You really need another week." And I- I sort of saw them. I- I di... I- I was like... One, I had in the back of my mind the experience the first time, and I thought, "Okay, I can do it." And at the end of the second week, I really thought I was there, and they were like-

Chris Williamson 57:18 (laughs)

Dr Peter Attia 57:18 ... "You're not there." And I was like... I was a little anno- I mean, I was a lot annoyed, actually.

Chris Williamson 57:24 Yeah, yeah.

Dr Peter Attia 57:24 Um...

Chris Williamson 57:24 It feels like you're working hard, you're making these sacrifices, you're trying to do better.

Dr Peter Attia 57:28 Yeah, I'm like, "I don't know what else you would want from me." Like, what would it take for you to say, "I'm better"? And it's really interesting. I... Oh no, you know, I ended up staying for another week, and on the... The weeks there run Saturday to Friday is a week. So it's seven days, but the- the... It starts on the Saturday is the program, right? And on the Wednesday of the third week, which was the 19th of 21 days I was there, was the, was the real breakthrough. And, and, and so they were right, you know. That's the point, right? Like, they... I on- but I only realized it then. And so th- to leave then on the 21st day, like, you know. And this was in, you know, it was in Phoenix, so it was a long drive back home, which was a lot of time to reflect. Um, it was, it was... It was very, very different coming back. I didn't make any of the mistakes I made the first time, and I had a great system in place in terms of therapy, which, which, uh, uh, i- i- still exists to this day.

Chris Williamson 58:34 Mm-hmm.

Dr Peter Attia 58:34 So I'm still doing therapy once or twice a week, and, um, it's a... It's, you know, it's the perfect cadence because there are times when things are going... When there's really nothing to talk about and it's just easy to say, "Hey, I got nothing to talk about today." "Okay, you sure?" "Yep." "What about this?" "Nope, all good." "Great." But I l- having those meetings always on the calendar, um, makes them the priority.

Chris Williamson 58:59 How do you think about pulling yourself out of a negative mood? If someone wakes up on a morning and... Wrong side of the bed syndrome. What would be some of the places that you would say, "Look, here's a few things that you can do that can reliably change your mood alongside all of the other stuff that you need to do within a day"? You can't just take the day off and fly to Cancun or something.

Dr Peter Attia 59:20 Yeah, so remember a few minutes ago I said one of the most important things I learned in the last year with respect to this was, was that I don't wanna confuse the feelings of happiness with the ne- I don't want to include the... I don't want to confuse the scent of happiness with the macronutrients of happiness, borrowing from Arthur Brook's language. Um, I think the other equally important thing I've learned in the last year, and I... I mean, I've learned this maybe sooner, but, but I've really been better at implementing it, is, um, feelings exist for a reason. So to be clear, I'm, I'm not a person who believes that your feelings are right. I think they're wrong most of the time. But the point is, they're, they're never accidental.

Chris Williamson 1:00:01 Something caused them.

Dr Peter Attia 1:00:02 Yeah, and I have to explore the something. And, and this is where I've become, I think, more savvy in the past year, which is when I get into a funk, which I do, I start to... I don't ignore it. I... And I don't judge it. Those are two very important things. So thi- that used to be my playbook. Ignore it or judge it, ignore it or judge it. Be critical of it, or pretend it's not there and power through. Now it's... And I hate to do this 'cause you sound like an idiot, like Ted Lasso.

Chris Williamson 1:00:32 (laughs)

Dr Peter Attia 1:00:32 It's just be curious and non-judgmental about it. Like, literally just say, "Huh, Peter, it... You seem to really be irritable and you really seem to be lacking interest in things that normally interest you. You, you don't even feel like going out and playing with your kids. Like, you're very sullen," and this, that, and the other thing. Like, what is that about? Let's, let's, let's just think about this. Like, do you feel a loss of intimacy with this person-...are you afraid of this thing? Is there something that's af- you know, that- that is causing fear? Are you afraid of losing something? Are you a- are- do you feel humiliated? Like, you start to go through very basic emotions that tend to be negatively valenced, and you- you go one layer beneath them. And interestingly, I mean, again, it's one of those things where if you told me this five years ago, I would have said that's impossible that I could ever figure it out. But I tend to stumble into the why. And- and then you can start to problem solve. "Oh, I'm actua- all of this is due to my fear of this thing happening." And then you can start to say, "Well, how rational is that fear?" And if it is rational, is there something you could be doing about it? And if there's not, how can you brace for this outcome? Like, so, again, it's the, um... And so- so going back, the feeling itself might have been totally ridiculous and totally false, but it was a very important clue that took me back to figuring something out.

Chris Williamson 1:02:12 It's really cool to hear you talk about feelings in that way. This is something I'm trying to learn a lot about at the moment. I'm aware that it sounds like the most sort of performatively autistic thing to- to say. Like, "I'm trying to learn how to feel feelings." But, like, here we are. And, uh...

Dr Peter Attia 1:02:27 (laughs)

Chris Williamson 1:02:27 (laughs) I really think that it's an area that is ripe for people who like to improve themselves, guys and girls that are type A, go-getters, that want to try and achieve things, and they're completely missing one of the huge elements of this, which is what's the day-to-day experience of your mind like? Not from a mindfulness standpoint, because even mindfulness, you can use that to not feel feelings very well. Like, a thought arises, and we let it go. It's like, okay, fine, but where did that come from? Why did you feel that way?

Dr Peter Attia 1:03:01 Mm-hmm.

Chris Williamson 1:03:01 And are you really applying all of the equanimity that you can to just release, relax, and allow these thing- uh, that's like, uh, taking a paracetamol to stop pain. It's like, the pain is gonna continue to be fed up to you. What's causing that?

Dr Peter Attia 1:03:17 Yeah.

Chris Williamson 1:03:17 And, um, it sounds so, like, fluffy and unscientific. And I think another- another part of it is, especially coming from, like, a health and fitness side, people want to be able to control the system. If I eat this many grams of protein and lift this much, I can expect this amount of muscle gain over a year, given the ba- ba- ba- ba- ba-. But with emotions, it's just this... It's chaos, right? You don't have the same rigor when it comes to assessing them and when it comes to- to dealing with them. Uh, but yeah, I- I, certainly for me, it is the area that there is the most room for growth, to be able to understand feelings, feel them, integrate them, work out where they're coming from. Uh, it's cool, it's cool to hear that you've got a practice like that. I think it's- I think it's something that we need to be talking about an awful lot more.

Dr Peter Attia 1:04:07 Well, it's a journey. I mean, it's, um, I hope to be a lot better at it in five years, but, um... A- a- and I think the other thing I would really hope is that, um, I hope to be able to teach my kids, because I think it would be more valuable than most things I could teach them, right? Like, I- I do think that had I learned this in my teens, uh, I would have saved myself, and by extension, a lot of other people, a lot of pain, um, and a- and a lot of that, you know, the- the detonation. So, um, yeah, I- I- it'll be interesting to see, like, at what point is- is a- is a child sort of mature enough to- to sort of start to, you know, metabolize that.

Chris Williamson 1:04:52 Learn how to emotionally-

Dr Peter Attia 1:04:53 Yeah.

Chris Williamson 1:04:53 ... self-regulate and all the rest of it.

Dr Peter Attia 1:04:54 Yeah.

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Chris Williamson 1:05:54 One of the other things that's been happening a lot recently is the rise in TRT usage among young s- me- young men, um, m- maybe in part due to, well, hoping to elevate their mood, to improve the way that they feel. What's your opinion on the what appear to be increasing numbers of young men using TRT?

Dr Peter Attia 1:06:12 Uh, I'm- I'm greatly concerned by it, truthfully. I- I think it's, um... I- I- I think, uh, again, a lot of men, I think, don't understand the risks of TRT. And while testosterone is a very safe therapeutic, I mean, uh, uh, i- i- if done correctly, it's as safe a hormone as there is. Uh, but, you know, if you're talking about a young guy who doesn't actually understand the impacts of testosterone on fertility, for example, later in life, uh, doesn't understand what a physiologic dose is versus a supraphysiologic dose, and especially in the cases where guys have to get this stuff illegally, um, then- then you introduce a whole new layer of contamination and, uh, all sorts of things like that. So, so net-net, I'm a little concerned, um, maybe a lot concerned. I also think, you know, there are lots of clinics opening up that are kind of trying to circumvent some of these issues. And again, I- I- I think they're...I, I think their, their motivation is to capitalize on an obvious interest, but they do so without, uh, a, you know, necessarily a, a nuanced approach to how to do this.

Chris Williamson 1:07:23 Take me through the risks of TRT. What are they, high level?

Dr Peter Attia 1:07:28 So it depends on the... On, uh, if we're gonna talk about TRT done correctly, do you mean literally TRT, testosterone replacement therapy? Or the-

Chris Williamson 1:07:35 That and its more, uh, malignant offshoots where people start to push dosages and stuff. Take us through, you know, the range.

Dr Peter Attia 1:07:42 Well, I would say, let's start with what's sort of known in the medical world, right? So we'll start with kind of appropriate physician-administered testosterone replacement therapy.

Chris Williamson 1:07:51 For an appropriately aged individual.

Dr Peter Attia 1:07:53 For an appropriately aged individual at an appropriate physiologic dose.

Chris Williamson 1:07:56 Cool.

Dr Peter Attia 1:07:56 Okay, so the two big risks that people have historically been concerned with are prostate cancer and heart disease, so an increase in the risk of prostate cancer and an increase in the risk of cardiovascular disease. Both of these have been studied extensively, and I think we can make a very strong and compelling case that testosterone replacement therapy is not increasing the risk of prostate cancer at all, and it may in fact be decreasing the risk slightly. Um, I've done an entire podcast, I think two podcasts, on just that topic. That's how nuanced it is. Um, but again, we... Uh, to give you just one example, when we have a guy who has undergone a prostatectomy for prostate cancer, he's had his prostate removed, um, we will still use testosterone replacement therapy in that guy. So think about that. You have a guy who had prostate cancer. You will still give him testosterone replacement therapy if it's warranted or indicated post-prostatectomy. Now, do you do it and shut your eyes and never look again? Of course not. You're still monitoring his PSA every three months, and you're gonna look for any sign of recurrence, and if there is in fact a recurrence, you would immediately cease it, because what we do know is testosterone would feed prostate cancer. But the point I'm making is around initiation. Is there any evidence that testosterone replacement therapy initiates prostate cancer? The answer is no, there is not, and there is some evidence to the contrary. The cardiovascular disease question is a little bit more difficult, and the data are a little bit more muddled, but on balance, they come out in the direction of TRT does not increase the risk of cardiovascular disease. Now, there was a big trial that was completed last year called the TRAVERSE Trial that gave men, uh, uh, Androgel, so topical testosterone, and followed them for, I wanna say three or four years, and there was no increase in the incidence of ASCVD, atherosclerotic cardiovascular disease. But there is... So, so at face value, that study was taken to mean, look, we have one more study, the biggest and best, that demonstrated no increase in the risk of cardiovascular disease with TRT, so w- the debate should be settled once and for all. Um, I did a podcast on this, wrote a long newsletter on this, and the long and short of it is that's a, in my view, that's a slightly premature conclusion, because I don't think the TRAVERSE study was done perfectly. Uh, most importantly, it, um, did not give men a high enough dose in my view. So the men started out very hypogonadal, with a total testosterone of somewhere between 1 and 300 nanograms per deciliter, but they were only replaced to about 600 nanograms per deciliter. And while that's a reasonable rate of replacement, I don't think it represents what's happening in the world.

Chris Williamson 1:10:45 Yeah.

Dr Peter Attia 1:10:46 I mean, we replace patients to higher than that. We replace patients to 800 or 900. We're technically tracking free testosterone and not total testosterone, but usually to get somebody in the range of where we think a good free testosterone is, we will see a total testosterone, uh, that's easily in the 800, 900 nanogram per deciliter range. So it's possible the TRAVERSE trial only answered the question, does low dose, or as one of my analysts put it, does testosterone light replacement therapy increase the risk of cardiovascular disease? And I think there we can say the answer's probably no.

Chris Williamson 1:11:18 Okay, and what about testosterone replacement therapy when it's done badly?

Dr Peter Attia 1:11:21 Yeah, so I think if you even think about it in the medical setting, I think th- testosterone can be given to very super physiologic levels, and I see patients getting super physiologic levels all the time. They come into our practice, they've been treated at some T clinic, and they walk in with (clears throat) a free testosterone of 35 nanograms per deciliter, um, w- you know, which is, like, twice what you would consider reasonable. And, you know, part of the problem is we don't really know what the long... Eh, everything goes out the window with what I said earlier. Now can I say that that doesn't increase the risk of prostate cancer initiation?

Chris Williamson 1:11:56 Mm-hmm, mm-hmm, mm-hmm.

Dr Peter Attia 1:11:56 I can't say that, 'cause I don't have the data. Can I really say that doesn't increase the risk of cardiovascular disease? No, I can't. It's also, by the way, creating a lot more erythrocytosis. So those people are making red blood cells at an alarming rate, and they need to be monitored very closely for increased blood viscosity.

Chris Williamson 1:12:11 Is, is that... Uh, I have a friend of a friend who donates blood every month.

Dr Peter Attia 1:12:16 (clears throat) Yeah.

Chris Williamson 1:12:16 Is that-

Dr Peter Attia 1:12:17 That's why.

Chris Williamson 1:12:17 Because they're just making too much and it's too thick?

Dr Peter Attia 1:12:20 Correct.

Chris Williamson 1:12:21 Wow. I mean, good for the blood donation people.

Dr Peter Attia 1:12:24 Yeah, and again, the question is, if you have to give blood every month, if your bone marrow is so revved on that you have to give blood every month, do we run the risk that you're gonna convert into polycythemia vera at some point, which is a disease now where all of a sudden you can't shut that process off? So again-

Chris Williamson 1:12:40 Oh, it becomes self-sustaining even once you've come off the TRT.

Dr Peter Attia 1:12:42 Yeah, again, I, I'm not suggesting that that's happening. What I'm asking is we don't know, right?

Chris Williamson 1:12:46 Yep.

Dr Peter Attia 1:12:46 And, and there's just a big unknown there. The other thing is once you start to get into these super physiologic doses, you start to run into other issues around a lot of estrogen and a lot of DHT. So you'll see these men who are on these super physiologic doses of testosterone also showing up on 5-alpha reductase inhibitors, which we could talk about why I'm not a huge fan of those, and on aromatase inhibitors, which I'm also not a fan of th-

Chris Williamson 1:13:11 Is that to stop gyno and hair loss?

Dr Peter Attia 1:13:12 Yes.

Chris Williamson 1:13:13 Right.

Dr Peter Attia 1:13:13 And, um...... obviously I'm not very (laughs) I'm not a guy who takes hair loss very seriously.

Chris Williamson 1:13:19 (laughs)

Dr Peter Attia 1:13:19 But, um, you know, I, I think it's a mistake, uh, to take a 5-alpha reductase inhibitor for hair loss. I think there are far better strategies if it matters, and, um, I think, you know, even though the risk of, uh, finasteride syndrome or post-finasteride syndrome is low, it's not zero, and it's potentially irreversible. And this is, uh, this is, uh, I think in a young man taking finasteride, w- who... Again, if you've been take... If you're listening to this and you, you're on finasteride and you have no issues, you're fine. It's something that if you... hasn't kicked in within, you know, six months, it's not gonna kick in. But, um, we do, we do see men who have like a permanent loss of libido. This is reported in the literature.

Chris Williamson 1:13:58 That's, that's what finasteride syndrome is?

Dr Peter Attia 1:13:59 Yeah.

Chris Williamson 1:14:00 Okay.

Dr Peter Attia 1:14:00 So, so basically there's something about blocking DHT that might not be a great idea.

Chris Williamson 1:14:05 Permanent loss of libido would be bad. Um, what, what else haven't we spoken about when it comes to exogenously increasing testosterone levels? Fertility?

Dr Peter Attia 1:14:15 Yeah, well, there's another thing that I, I think is when you... Yeah, fertility for sure, right? So at, um, once you give exogenous testosterone, um, you're going to cut down on androgynous production, including sperm production, and therefore you're gonna see a reduction in fertility. And at some point, that's re- retrievable, uh, and at some point it becomes more and more difficult to retrieve. So it depends on the person's age when they start and what their testicular reserve is, but, you know, generally speaking, two years of exogenous testosterone can spell the end of androgynous production and therefore a lifetime dependency, which, again, we do that all the time. Like, if a guy is old enough and decides it's time to go on TRT, we fully accept that, and there's no risk of being on lifetime T for life within physiologic doses. But for a guy who's young, that might be an enormous risk, and, and we s- you know, we see this all the time where guys who are doing this in their 20s decide they wanna have kids in their 30s and they can't.

Chris Williamson 1:15:19 What else haven't we said about the risks of TRT?

Dr Peter Attia 1:15:22 Um, I think there's another method of delivery using, uh, clomiphene and, and clonoph- enclomiphene, and these are drugs that have the advantage of preserving fertility. Uh, they work by inhibiting estrogen receptors in the hypothalamus that trick the brain into thinking you need more testosterone, so now the brain, uh, via the pituitary starts producing more follicle-stimulating hormone and luteinizing hormone, and you end up increasing androgynous production. Um, and, uh, again, I, I might be a, an unusual skeptic in this regard, but my concern with that approach typically centers around, yes, you raise testosterone, but are you getting the full benefits of testosterone? Because I think one of the benefits of testosterone is the benefit in the brain. And if you're now blocking-

Chris Williamson 1:16:10 Mm.

Dr Peter Attia 1:16:10 ... estradiol's impact in the brain-

Chris Williamson 1:16:12 Mm-hmm.

Dr Peter Attia 1:16:13 ... um, certainly anecdotally, there's questions about whether you're taking away some of the benefits of testosterone, including mood and libido.

Chris Williamson 1:16:21 Would you have any concerns for people being on Clomid for a long amount of time? Is that something that you think shouldn't be used?

Dr Peter Attia 1:16:29 Um, I would feel very strongly about people not being on clomiphene or Clomid for a long period of time for another reason, which is it really increases the production of esterol called desmosterol. Um, interest- So, and the reason for that, there's a lot of problems with that, including p- potentially an increase in the risk of atherosclerosis, increase in the risk of cataracts, and things of that nature. So I think long term use of clomiphene is probably not a good idea. The drug was never intended to be used long term. It's a fertility drug.

Chris Williamson 1:17:03 Mm.

Dr Peter Attia 1:17:04 So it's intended to be used short term, and I think short term, uh, rises in desmosterol are not problematic.

Chris Williamson 1:17:10 Mm.

Dr Peter Attia 1:17:10 But lifetime increases or many years of increase I think would be, and th- there's a drug that was... There's a drug that increased desmosterol levels in the '50s and '60s that was actually pulled from the market because of the increase in cataracts and the increases in cardiovascular disease.

Chris Williamson 1:17:27 What, what about these... I, I went to, uh, uh, Prospera in Roatan, which is one of these network states. There's no FDA, uh, uh, jurisdiction there. People are doing experimental follistatin gene therapies. The dudes from Tiny