Simple Habits That Could Add Decades To Your Life - Dr Peter Attia

Dr Peter Attia 0:00 The reality of it is, having a very high VO2 max, being incredibly strong, that's going to do more for your lifespan and health span than any piece of technology or biohacking, manipulation of gut biome, or any other thing that people are talking about. I mean, it- it's just not even within the same zip code. And you don't need a lot of technology to do those things. You just need to put in the work. (wind blows)

Chris Williamson 0:22 Pete Shirey, welcome to the show.

Dr Peter Attia 0:24 Thank you very much, Chris.

Chris Williamson 0:25 Would

Chris Williamson 0:26 you say that you have a unique or different perspective when it comes to longevity?

Dr Peter Attia 0:33 Uh, I don't know. That's an interesting question. Uh, yeah, maybe in some ways I do, I suppose.

Chris Williamson 0:39 It seems to me that you're focusing on not just lifespan, but also health span as well, not just physical health, emotional health, mental health. That more holistic view, uh, seems to be different to me.

Dr Peter Attia 0:53 Yeah, and also, uh, I think kind of a somewhat low-tech approach as well. Um, and I'm completely interested in, you know, fascinated by, obsessed with all the high-tech stuff and the, you know, the science that hopefully will come through in the, in the coming decades, but I, you know, maybe going back to my background in, in risk management, I really think everyone should always be hedging everything they're doing. So, you know, to just assume that we're going to come up with some amazing technological breakthrough that's going to, you know, start to defy aging while not doing all of the things that we can do with the technology that exists today strikes me as unwise.

Chris Williamson 1:33 What's that background in risk management?

Dr Peter Attia 1:35 Um, I, after I left my first stint in medicine in 2006, I went to work for the consulting firm McKinsey & Company, and, uh, though I was recruited there to do healthcare, I ultimately, uh, wound up in the risk practice because of my background in math. So, uh, I, yeah, I was doing, you know, credit risk and, uh, cool stuff like that.

Chris Williamson 1:56 All right. And how does that inform the way that you show up for your work now?

Dr Peter Attia 2:00 Um, I think it's essential, right? I think, I think everybody should be trained in some understanding of, of risk. Everyone should be trained in probability statistics. Uh, you know, that's, to me, the much more important stuff in mathematics, um, and I, I think that understanding how to think about, uh, symmetric and asymmetric risk, understanding expected value, uh, thinking about how to hedge risk, all those things are, you know, important not just in, you know, thinking through financial instruments, where banks are constantly making mistakes anyway, but as you think about your own life. So I'll give you an- a very silly example. So, uh, uh, two weeks ago, a friend said, "Hey, you want to come, you know, skiing?" You know, he's gonna go to this amazing place and ski, and I said, "No." He's like, "How do you not want to do this?" And I was like, "Well, I don't personally get enough pleasure from skiing to justify the downside," right? "So the upside for me to go skiing with you is this much. The downside is this much. But that's my decision. That doesn't mean you shouldn't go skiing, right?" Because for him, the upside is probably much larger-

Chris Williamson 3:02 Mm-hmm.

Dr Peter Attia 3:03 ... and maybe he's a much better skier than I am, so his downside is much less. But it's thinking through simple things like that. Ev- every decision I make, I sort of put through that matrix.

Chris Williamson 3:12 That makes a lot of sense. I'm interested by this low-tech approach that you've mentioned, and I, I keep on bringing this up, uh, mutual friend Andrew Huberman, uh, yourself, has really been at sort of the forefront, I think, and Kelly Starrett's new, uh, new book, um, is almost sort of stripping things back a little bit. Uh, there was a, a movement, you know, 10 years ago, the sort of advent, the absolute, like, frontier of the biohacking quantified self, and it really seems like that's not being reversed, but being taken back to, um, a much more simple set of rules for people to follow.

Dr Peter Attia 3:48 Yeah, look, I think they're not mutually exclusive, and I'm certainly no stranger to all of those things, and I probably still do things that most people would consider excessive when it comes to, you know, tracking things and monitoring things and incorporating technology into what I do. But the reality of it is, you know, having a very high VO2 max, being incredibly strong, that's going to do more for your lifespan and health span than any piece of technology or biohacking or manipulation of gut biome or any other thing that people are talking about. I mean, it- it's just not even within the same zip code. And you don't need a lot of technology to do those things. You, you just need to put in the work.

Chris Williamson 4:29 Well, it seems to me that

Chris Williamson 4:30 one of the longest levers is compliance on whatever the program is that you're going to do, and one of the problems that I found, certainly, I, I struggled tracking macros, right? I've always struggled tracking macros. So for me, learning what intuitive eating felt like actually meant that I adhered to my diet more effectively than setting the bar for compliance so high that I just constantly failed and then I didn't get any motivation from doing it. And I feel like that is a little microcosm for tons and tons and tons of ways where the bar has been set too high for people to actually access these protocols.

Dr Peter Attia 5:01 Yeah, everybody's got to figure out the system that works for them. I think, uh, using nutrition as an example, so, um, you know, as I talk about in the book, the... there's basically three ways to go about reducing intake. So if you're over-nourished, which is the kind of way I describe people that have too much body fat, especially in places where you don't want it, right? So it's not really the subcutaneous fat we're worried about, it's the visceral fat, it's the intramuscular fat, it's the peripancreatic fat, uh, perinephric fat, all of those things that are metabolically destructive. So not the cosmetic fat. That actually has no metabolic, um, consequence. So let's assume you establish that a person needs to, you know, me, I need to lose, I need to reduce energy intake. I can do it by calorie counting or tracking my macros. I can do it by dietary restriction, by sort of identifying things within the diet that I don't want to eat and limiting them. Or I can do it via time restriction, just narrowing the window down in which I eat. Each of those has its pros and cons, but what matters is that you figure out what kind of works for you. So for me personally, dietary restriction has always produced the best outcomes. If I simply pick certain boogeymans in the diet and say, "I'm not gonna eat those things."... everything falls into line. Whereas when I track macros, which by the way, sometimes produces better results in the short term-

Chris Williamson 6:20 Mm-hmm.

Dr Peter Attia 6:21 ... it can be harder to maintain. Conversely, I have friends who can track macros all day long, every day, um, and they can do it automatically.

Chris Williamson 6:29 Yeah.

Dr Peter Attia 6:29 Like they don't have to be in an app doing it.

Chris Williamson 6:30 I'm not built like that, man. I'm not built like that in the slightest.

Dr Peter Attia 6:33 And, and that's okay. I mean, again, I think the point is I, I, you know, sort of would want my patients, for example, to try all three and figure out which one works for them. Um, and as I always say, like, you're better off being seven out of 10 in performance, but doing it every single day than being 10 out of 10 some days, zero out of 10 other days. And, um, you know, that kind of cyclic performance generally leads to worse outcomes over the long run.

Chris Williamson 6:59 One of my friends, Alex, mentioned to me the other day that most people have a bucket of perhaps between five and 10 meals that they typically eat, and he said that one of the longest levers when it comes to altering your diet is to just look at those five to 10 meals, even forget about everything else. It's like, what do you eat the most? You probably have, uh, uh, for me it's like four recipes that I go back to very consistently. Okay, what's that constituted of and how can you just tinker with that a little bit for it to be closer to what your goals are? I thought, holy shit, like that's such a low-tech solution, and yet in terms of what it does, does it grow any corn? Does it actually work? Probably super effective.

Dr Peter Attia 7:39 Yeah. I, that's one of the things I enjoy most about macro tracking when I do it is, you know, the app I use, which is called Carbon has, you know, and, and I'm sure this is true of any of the apps now, they're all so much better than they used to be 15 years ago-

Chris Williamson 7:51 Mm-hmm.

Dr Peter Attia 7:51 ... when I started trying to pay attention to this. But you basically put in your recipes, so you're not necessarily going to pre, you know, populated things. You're saying, "Look, when I make an omelet, I always do it the same way. It's eight egg whites, it's four yolks, it's half a tablespoon of butter."

Chris Williamson 8:07 You've been doing it for 25 years and you still-

Dr Peter Attia 8:08 The exact same way every time.

Chris Williamson 8:09 Yeah, yeah, yeah.

Dr Peter Attia 8:09 So I just click, click, click, click, click, and now I can know. And you're, and you're absolutely right. There's probably no more than about six things that are constituting 80 percent of what I eat.

Chris Williamson 8:18 Talk to me about

Chris Williamson 8:19 the difference between slow death and long death.

Dr Peter Attia 8:21 Ah, okay. So, um, I mean, as the name suggests, it really comes down to the rate of time between when the onset of the illness takes place and when you demise. So if you think about the greatest successes in medicine, our current medical system, what I call medicine 2.0, uh, medicine 2.0 is remarkably successful in treating fast death. So, um, when you think about trauma, when you think about a person who's, you know, driving down the street, uh, car hits another car and, you know, they suffer a significant injury that 100 years ago would have killed them, we now have, you know, remarkable capacity to save lives in that situation. Infectious diseases, of course, would be the poster child for this. Uh, up, again, up until 150 years ago, we stood no chance against, uh, most infections. And today, you know, some of the most devastating bacteria barely, you know, touch the surface. And, and, and by the way, viruses that once, you know, wiped out civilizations, we can now vaccinate against and all these things. So, um, we've effectively doubled human lifespan, uh, going from about 40 to 80 years by treating fast death. So, big win for medicine 2.0. Um, the problem is, we haven't really made much progress against slow death. So slow death is what most people think of when they actually think of death now. When you think of cardiovascular disease, cerebrovascular disease, cancer, neurodegenerative disease, metabolic disease, those are slow deaths. Even when a person drops dead suddenly of a heart attack, right, a person who's been asymptomatic their whole life and drops dead suddenly of a heart attack, that disease was killing them for 30 years. So unfortunately, we just haven't made much progress there, and, uh, as I argue, that's where we have to make progress. That, that has to be the transition if we want to be serious about longevity.

Chris Williamson 10:14 Why is that not a priority currently?

Dr Peter Attia 10:16 I don't think it's not a priority. I think we just have the wrong strategy. So, um, if you have the wrong strategy, you will fail. And I would argue that we don't have the right strategy for addressing those problems. So it's not due to a lack of trying. I think we've been trying very hard to eradicate slow death, and I would argue that the fact that we've had such little success given the enormous resources that have been put in, both financially and simply sheer effort, uh, I think is proof positive that we need a different approach.

Chris Williamson 10:46 We're gonna go through a lot of insights today that people can apply to their lives.

Chris Williamson 10:50 Before we even get into that, how should someone think about building a framework of how they can take the tactics that we talk about today and actually use them? As we mentioned at the very start, compliance, adherence. You can have the best strategy in the world, if you don't end up applying it, it means nothing. What is your, uh, best advice on how people can form a framework of tools that they can actually use?

Dr Peter Attia 11:13 Well, I think you have to start with the objective. Uh, so, so everything I talk about, I've always talked about this way, uh, or at least, you know, for more than a decade, and I certainly have written a book through this lens, which is, you go from objective to strategy to tactics. So we always want to start with the objective, and I do think it's worth being clear for any individual what their objective is. Uh, and I, I take a lot of time with patients going through this. So, um, you know, when you go to your doctor, it, that's not a common question, what is your objective? Um, and again, it's not the fault of the doctor. I think it's the fault of the system. The system isn't really set up to ask that question. The setup, the system is more set up to kind of play a bit of Whac-A-Mole. Is there a problem right now? Is there a symptom right now that I need to address? But if you're trying to play this sort of long game, you have to work backwards and say, "Okay. What do you want to be true at the end of your life?" And the, the framework that I use for that is called the marginal decade.So, the marginal decade is the last decade of your life. Everyone will have a marginal decade, and that's not a pleasant thought for many of us to think about, right? I don't love thinking about the fact that I'm going to have a marginal decade, but I will. Now, you never know the day you enter (laughs) your marginal decade. Um, but many people know when they are in it. And the question then becomes, what do you want to be true in that decade? So, let, let's play the game with you. How old are you, Chris?

Chris Williamson 12:43 35.

Dr Peter Attia 12:44 Okay. So, let's assume that, you know, fate will smile on you, and, you know, God forbid, you're not gonna have some premature death. You know, you're not gonna die in a car accident next week or be s- stricken with cancer in, you know, 10 years or something like that. So, let's just assume your marginal decade is kind of the ninth to tenth decade of your life. What do you want to be true in that decade?

Chris Williamson 13:08 I would like to still be able to move without assistance. I would-

Dr Peter Attia 13:12 What kind of moving?

Chris Williamson 13:13 Uh, I would love to be able to still walk.

Dr Peter Attia 13:16 Okay.

Chris Williamson 13:16 Uh, I would love to be a- I'm ... adore dogs, so being able to take the dog for a walk, being able to throw the ball.

Dr Peter Attia 13:21 How big a dog?

Chris Williamson 13:23 Golden retriever.

Dr Peter Attia 13:23 Okay.

Chris Williamson 13:24 Is that a big dog?

Dr Peter Attia 13:25 Yeah.

Chris Williamson 13:25 Big for a nine-year-old?

Dr Peter Attia 13:26 Yeah.

Chris Williamson 13:26 Okay.

Dr Peter Attia 13:27 That's okay.

Chris Williamson 13:28 Okay.

Dr Peter Attia 13:28 This is ... You can be ambitious here.

Chris Williamson 13:29 I am ambitious.

Dr Peter Attia 13:30 Yeah.

Chris Williamson 13:30 Big golden retriever.

Dr Peter Attia 13:31 Okay.

Chris Williamson 13:32 Um, I would-

Dr Peter Attia 13:33 So, you want to be able to walk a golden retriever.

Chris Williamson 13:35 Yep.

Dr Peter Attia 13:36 How far?

Chris Williamson 13:38 30 minutes on a morning.

Dr Peter Attia 13:39 30 minutes a day? Okay.

Chris Williamson 13:40 Yep. Uh, maybe twice a day if I could, at best.

Dr Peter Attia 13:43 Hills or no hills?

Chris Williamson 13:45 Uh, not so fussed about hills.

Dr Peter Attia 13:46 Okay.

Chris Williamson 13:47 Hills can, hills can go, but do want to live in a house that's got, uh, a balcony.

Dr Peter Attia 13:51 Okay.

Chris Williamson 13:51 So, would need to be able to go up and down stairs.

Dr Peter Attia 13:53 Okay.

Chris Williamson 13:54 Um, would love to still be able to pick up grandchildren. I have no idea whether that's realistic at 90 years old, but that would be something I'd love to do.

Dr Peter Attia 14:02 Pick them up from the floor, from a crib-

Chris Williamson 14:05 Both.

Dr Peter Attia 14:05 Where? Okay.

Chris Williamson 14:07 Um, would s- love to have still a good quality of sleep. Um, and would love to be able to-

Dr Peter Attia 14:17 Have sex?

Chris Williamson 14:19 At 90?

Dr Peter Attia 14:19 Yeah.

Chris Williamson 14:20 Not something I've considered. Good question. Let's say yes. Let's say, yes, I'm still going at 90.

Dr Peter Attia 14:25 Okay.

Chris Williamson 14:26 Um, and probably most importantly above all of this is still have proper cognitive function. Like, still ... I, I, I value the quality of my thoughts more than anything-

Dr Peter Attia 14:37 Mm-hmm.

Chris Williamson 14:37 ... on the planet. Um, I still want to be able to learn. I still want to be able to satisfy my curiosity. You know, if I was still able to have conversations like this at 90, that would be just, uh, fantastic to me.

Dr Peter Attia 14:49 Uh, I assume you don't want to be in pain.

Chris Williamson 14:52 That would be good.

Dr Peter Attia 14:53 Okay. So, again, uh, we could drill into this a lot further, but I think what would emer- ... And by the way, this is a, this is a valuable exercise because I don't think a lot of people do this. Um, but I, I think everybody needs to do this and needs to go really far down the rabbit hole. And what you'll realize is, um ... By the way, everything you've said is totally reasonable. Like, I have some people when you play this game with them, you know, the first thing they say is, "I want to be heli-skiing when I'm 90." And it's like, I'm not gonna tell you that's not possible, but, like, that that's the first (laughs) thing you would say is a little odd, right? But everything you're saying is, is, is achievable, but is challenging. So, for example, walking a golden retriever, um, at the age of 35, you don't even have to think about it. But if you actually look at the force that's in that leash and the amount of balance and strength and lower leg variability you need to not fall over when that's happening, by the time you're in your 70s, that's going to be very difficult. So, you have to build up an enormous reserve in those capacities today to cope with and anticipate the inevitable decline that's going to come in all of those. Um, so, so that's, that's how you start. You start with the objective. You reverse engineer what the implication of each objective is.

Chris Williamson 16:12 Mm-hmm.

Dr Peter Attia 16:13 And you, you know, you, you under- ... We understand pretty well what the decline of those properties looks like.

Chris Williamson 16:18 I need to stop you there. How realistic is it for some male in his 90s to still be able to have sex without any assistance?

Dr Peter Attia 16:26 Well, it depends how you define assistance. I think the use of, like, phosphodiesterase inhibitors is probably gonna be required.

Chris Williamson 16:31 What's that?

Dr Peter Attia 16:32 Like, a, a drug like Viagra or Cialis.

Chris Williamson 16:33 Understood.

Dr Peter Attia 16:34 Um, (clears throat) but otherwise, I think it is realistic. Um, but again, like, think about what that comes down to. So, a big part of that is going to come down to your microvascular system. So, there's a reason that, you know, having type 2 diabetes, having atherosclerosis, is an enormous cause of impotence. It's, it's not affecting your brain. What it's affecting is-

Chris Williamson 16:57 Blood.

Dr Peter Attia 16:57 ... the microvasculature, the blood flow of the penis. So, th- there's a, there's an argument for being very metabolically healthy. I mean, I see this even in patients who are in their 50s and 60s, who at one point are completely dependent on drugs like Cialis.

Chris Williamson 17:12 Mm.

Dr Peter Attia 17:12 And then you get them metabolically healthy, and all of a sudden, they're like, "Oh, I don't need this anymore."

Chris Williamson 17:16 I wonder how many men who aren't that concerned about getting overweight, who aren't that concerned about losing a foot, but if you told them that their penis would stop working, that would be the final motivation (laughs) for them to look after their diet.

Dr Peter Attia 17:26 Whatever it takes.

Chris Williamson 17:26 (laughs) Okay, so we've got, uh, objective.

Dr Peter Attia 17:29 Yep. Then we have to think about what the strategy is, right? And this is where I think, um, w- ... it's very complicated in this problem, so-

Chris Williamson 17:37 Is this where people get lost?

Dr Peter Attia 17:39 I think so. I think this is the step that most people just skip altogether and go right to the tactics. So, they say, "Okay, I, I hear you on objectives. Now, tell me how to eat, how to exercise, how to sleep, et cetera." Um, and I think you can't skip this bucket. And th- th- there's a reason that there's, like, chapters in the book that are devoted to this. Um, if you're playing ... Um, if you're, if you're trying to ... If you're asking questions that are straightforward, you don't really need a strategy. So, if you said to me, "Peter, my objective right now is not to get a sunburn."... I don't, we don't need a major strategy. Like, it's relatively straight, we can go straight to tactics. You're going to avoid the sun, altogether. If you need to be in the sun, you're going to wear long sleeves and a hat, and then you're going to wear sunscreen, and blah, blah, blah. And it's, it's pretty straightforward. But when you say my objective is to live 10 years longer than I otherwise would and do so at a much higher function, as evidenced by that list of things you just said, well, I can't just jump to tactics. Th- they're not obvious. So instead, I have to go through a whole bunch of indirect measures because I don't have what I really want, right? What I really want is, I'd love to be able to rely on the gold standard, which is randomized controlled experiments that would give me the answer. But for reasons that are self-evident and obvious and not worth explaining, we don't have randomized controlled (laughs) experiments that answer all the questions, um, that pertain to taking a 35-year-old and setting him up to be the best 95-year-old. So we have to have an option B, and option B really rests on a whole bunch of other pillars of strategic insight. So one of those things is, what are the inferences we can make from observational data of long-lived, well-function humans? So looking at the centenarians, for example, who we very quickly figure out are genetically gifted, so their, their, their sp- their superpower was picking the right parents. Um, but we can still learn a lot from them. Uh, we'll put that aside for a moment. The other thing we l- we can look at is short-term human studies that don't cover the hard outcome, such as the full duration of your life, but cover certain things. So for example, there might be heart outcome studies that look at heart disease or stroke, or heart outcomes that look at performance and functional metrics such as strength, resilience, and things like that. We then look at animal literature, or non-human literature, I think to be more accurate, that looks at the full duration outcome. So I think we can look at some of those animal studies and get a pretty good sense of what's affecting lifespan and healthspan, but we have to be careful with it like we do with everything in that we, we want to be very thoughtful that we're not just sort of zeroing in on one model. So we, this is again where, where we look at things that favor lots of models. So you know-

Chris Williamson 20:33 (clears throat)

Dr Peter Attia 20:33 ... something that's consistent across mice and worms and flies and dogs is much more interesting than something that is only going to work in one mouse model in one person's lab. (smacks lips) Then we want to look at mechanistic studies. So how can we understand, for example, the benefits of exercise when we look at the cellular level, when we understand the m- m- you know, when we look at proteomic, metabolomic changes of exercise and how do, you know, what do those things tell us as an example about, say, exercise or sleep restriction or dietary restriction? And then the final tool that I think we look at in our strategy bucket is Mendelian randomization. So sometimes you actually let nature do the randomized controlled experiment for you. So Mendelian randomizations are very elegant types of studies where when you can find genes that are responsible for phenotypes of interest, you can ask the question, as nature shuffles those genes, do we establish causality by the outcome? So when you put all five of those together, that's how you start to cobble together what your tactics are. And that's the final piece of it. So what are your tactics? You basically have five domains. You have all things that pertain to what you eat, all things that pertain to how you exercise and move, how you sleep, all the drugs, molecules, supplements, hormones that you could possibly take, and then all the, you know, call it the bucket of things that you would do to manage emotional and mental health.

Chris Williamson 21:57 (smacks lips) When you break it down like that, longevity seems very simple, that you have these five key areas that you're focused on. Where are people focusing their attention, in your opinion, when it comes to both healthspan and lifespan longevity that have the shortest levers but people are giving undue attention to?

Dr Peter Attia 22:19 Yeah, that's such a great question. I, I think what's, what I find funny is that everybody, and I'm sure, I mean, I'm not sure, I know I've been guilty of this myself, it's w- it's very tempting to just focus on your favorite thing. Like, there was a point in time where virtually all of my attention was focused on nutrition.

Chris Williamson 22:37 Hm.

Dr Peter Attia 22:37 Like, I really felt that nutrition was the, the alpha and the omega of this entire equation, and all you had to do was sort of eat a certain way and everything was going to work itself out. Um, obviously the medical establishment is hyper-focused on the, the medicine side of this, uh, as evidenced by the fact that's the only thing we learned in medical school and residency, right? It's not like anybody taught you how to administer exercise or nutrition. Even if you knew that those things mattered, you had no education in how to actually do anything about it. It would sort of be like an oncologist who knows chemotherapy is good, but doesn't know anything else. Like, doesn't know which (laughs) chemotherapy or what dose or what schedule or what biomarkers to use to track the progress of the chemotherapy in the, um, you know, in the tumor as it regresses. So, um, so each, each, each entity I think just kind of has their own expertise. Um, y- you know, where I stand today, I would say a lot of people are kind of majoring in the minor and minoring in the major when it comes to nutrition is sort of a belief that I have. I, I think once you get beyond the real fundamentals of energy balance and protein intake, I honestly think a lot of people are spending too much time, um, thinking about the finer details of it. Um, and, and, and the evidence at least at this point in time is not really there in an overwhelming way to say that it matters a whole heck of a lot once you achieve that. In other words, there are multiple different ways to achieve energy balance, to achieve, you know, adequate distribution of fats, macronutrients, and things like that. But the belief system that I once had and that I think many others have that, you know,... this exact ratio of omega-6 to omega-3 is what's essential. If that's true, it's not based on any evidence as of this time.

Chris Williamson 24:34 You've mentioned the protein intake, very important. What are your thoughts on this current movement at the moment which is people, um, avoiding and sometimes demonizing meat consumption because of activating the mTOR pathway?

Dr Peter Attia 24:47 Yeah, I think there's a bit of a confusion between chronic activation of the mTOR pathway and acute activation. So we do need mTOR to be active sometimes, right? I mean, mTOR is the most important amino acid sensor we have in our body, and if we want to be in a, uh, in an anabolic state, and sometimes, which we do, it's gonna have to be activated, right? In fact, I would argue that the three most important amino acids, leucine, lysine, methionine will... Mtor is the leucine censor, right? I mean, leucine and mTOR were sort of made for each other. Um, this is very different from the metabolically ill person whose mTOR level is probably chronically elevated. There's also an issue with tissue specificity, and again, part of the challenge here is in humans, we have no way of measuring this. So we can measure this stuff in mice, you can sort of look at mTOR activation in muscle versus liver versus some other tissue. Um, in humans, we can't do any of this. We don't have, uh, what, what David Sabatini, uh, refers to as an mTOR integrator, a signal integrator. So the sort of the way that hemoglobin A1C is an integrating function of average glucose, right? It integrates glucose level over the previous three months roughly. We don't have a tool like that to measure mTOR activity. So, um, a- a- again, I think that the, the belief that we need to limit amino acids to limit mTOR activity is, is a, is a, it's kind of a backwards way to think about it. What that's really going to do is create a situation of sarcopenia, which is-

Chris Williamson 26:21 What's that?

Dr Peter Attia 26:21 ... uh, muscle, like loss of muscle as we age.

Chris Williamson 26:24 Okay.

Dr Peter Attia 26:24 Yeah.

Chris Williamson 26:25 Surely though, if people are consuming three to four servings of 25 to 50 grams of protein per day, is that not just going to continue to just spike mTOR? Does that not end up netting out at mTOR just being elevated throughout the day?

Dr Peter Attia 26:41 Not necessarily. I mean, you have to remember the, the, um, the duration that, uh, you know, free amino acids stay in your circulation is pretty low. Um, you're also probably still spending 12 to at least 14 hours a day when you're not eating. Right?

Chris Williamson 26:56 Mm-hmm.

Dr Peter Attia 26:56 So even, so, so, so I'm someone who probably takes a lot of effort to consume, you know, 1.8 to 2 grams of protein per kilogram of body weight, and that's gonna be spread out over three to four meals. But there's probably still 14 hours a day when I'm not eating anything, and during that period of time, those amino acid levels are gonna be really low.

Chris Williamson 27:19 I heard about you

Chris Williamson 27:21 doing some very extreme fasts over the last few years. Talk to me about those.

Dr Peter Attia 27:26 Yeah. I don't do that anymore, but I used to do a lot of fasting for many years. I would, you know, do a seven to ten day fast quarterly and a three day fast monthly.

Chris Williamson 27:38 That's intense. That seems intense-

Dr Peter Attia 27:41 Yeah.

Chris Williamson 27:41 ... to me. You know, I'm someone that's done intermittent fasting. I sat down with David Sinclair four and a half years ago, I think, in his office at Harvard. Uh, and you know, when David first came onto the scene, which was the first time I'd really, really heard intermittent fasting as, uh, being pushed as a, a longevity lever, uh, I thought, "Well this is great." Like, you know, it's something that I can do, it's for the lazy among us, it actually makes eating food easier because we've managed to, um, reword skipping breakfast as doing intermittent fasting.

Dr Peter Attia 28:10 (laughs)

Chris Williamson 28:11 But I found it incredibly difficult to blend staying fit, staying muscular, and doing intermittent fasting. I really, really struggled to make that work. Um, what have you got... First off, why have you changed your approach to intermittent fasting? I know that you've gained a, a ton of muscle recently. Um, and how have you worked in blending your understanding of intermittent fasting and its positive benefits, with the fact that you want to look good, feel good, perform well?

Dr Peter Attia 28:42 Yeah, so I, I, again, I still think going back to kind of what are the three ways that you can reduce caloric intake, you can calorie restrict directly, so just track and reduce globally. You can dietary restrict which is pick certain elements within the diet, carbs, fat, whatever, restrict. Um, or you can time restrict, create a smaller and smaller window in which to eat. Um, the biggest drawback of that final strategy, which again, is a viable strategy, but the biggest drawback of it, in my opinion, is the, the reduction in protein intake. So, uh, this has been borne out in the literature, so we've seen, we've seen clinical trials that have documented this, that first and foremost, the time-restricted feeding within that 24-hour period doesn't seem to produce any benefits above the caloric restriction that it brings. That's a very important caveat.

Chris Williamson 29:31 Okay, it's, it's just-

Dr Peter Attia 29:32 Meaning there is nothing magical about the time restriction beyond the calories that are being restricted.

Chris Williamson 29:38 Wow, okay. So the hunger signal that people get which is, uh, those of us that have taken like the, the Sinclair Red Pill, um, th- this is a signal that I'm hungry, this is hormesis happening, this is discomfort, this is good for me, has no different impact than small amounts of satiation throughout the day with...

Dr Peter Attia 29:59 There's nothing that has been measured or documented in any clinical trial that suggests that that is beneficial over the caloric restriction. In other words, if you're gonna eat 2000 calories spread out over 12 hours or you're gonna eat 2000 calories spread out over six hours where your, you know, calorie, you know, your time-restricted feeding for 18 hours, we're not seeing any difference.

Chris Williamson 30:21 Wow.

Dr Peter Attia 30:21 Now, and now that's not... Uh, here's what's interesting. That's often not what happens.So what more likely happens is the person who calorie restricts, um, has a easier time, believe it or not, maintaining muscle mass than the person who time restricts.

Chris Williamson 30:36 Why?

Dr Peter Attia 30:37 Probably for two reasons. Uh, although this hasn't been fully teased out in the, in the data, 'cause they're not tracking it this closely. But my, my impression is that when you time restrict, you're just less likely to eat as much protein. And secondly, as you kind of alluded to earlier, um, it's a delicate balance to get the right amount of amino acids into the muscles. You can't have too much and you can't have too little. So what you don't want to do is waste, for lack of a better word, your amino acids down a glucogenic pathway, where they're basically being used as glucose substrate.

Chris Williamson 31:12 What, what would cause that to happen?

Dr Peter Attia 31:14 Either too much or too little. So if you'll-

Chris Williamson 31:15 And what's too much and what's too little?

Dr Peter Attia 31:16 Yeah, sort of 10 to 20 grams of protein, the liver is going to preferentially take that and use it as glucose. And anything over about 50 grams, the liver's going to say, "I'm gonna take that excess and also make it glucose." So it, let's just say your number is 180 grams of protein per day. Eating 18 servings of 10 grams a day, not going to achieve optimal results. Uh, having one serving of 180, also not going to-

Chris Williamson 31:42 I've, I've tried both.

Dr Peter Attia 31:43 Yeah, yeah. Um, so that person really probably ought to be doing four servings of 45.

Chris Williamson 31:48 Right. So you're saying for most people, it seems like roughly a sweet spot is 25 to 50 grams per serving.

Dr Peter Attia 31:55 Exactly.

Chris Williamson 31:56 Right. So in this regard-

Dr Peter Attia 31:58 And that t- that time-restricted feeding guy has a really hard time doing that if he's going to be deliberate about that.

Chris Williamson 32:04 Mm-hmm. H- how big is the gap? When does a feeding window start?

Dr Peter Attia 32:07 Yeah, that's a great, that's a great question. Probably about three or four hours.

Chris Williamson 32:10 So it's basically impossible. Often-

Dr Peter Attia 32:12 For the time-restricted feeding person-

Chris Williamson 32:13 Yes.

Dr Peter Attia 32:13 ... unless they're willing to eat protein outside of their window.

Chris Williamson 32:17 Right, okay, which if you are, uh, dogmatic around-

Dr Peter Attia 32:20 If you're dogmatic, it becomes very difficult.

Chris Williamson 32:22 Correct.

Dr Peter Attia 32:22 But if you're, if you understand that there... And what we do with our patients who want, who want to do time-restricted feeding, because I think it's the easiest one to do.

Chris Williamson 32:30 Yep.

Dr Peter Attia 32:30 Like you just-

Chris Williamson 32:31 I would agree.

Dr Peter Attia 32:31 It's the easiest one conceptually to do. It's the easiest one to be compliant with. So what we would say is, "Look, it's just about the calories, so I still want you to have a low-calorie protein shake in the morning-"

Chris Williamson 32:42 Mm-hmm.

Dr Peter Attia 32:42 "... where you're gonna have 200 calories of, of a protein shake that's basically just proteins, some, you know, cashew milk, and a few frozen berries. Um, but at least you got that protein dose in."

Chris Williamson 32:52 Yep.

Dr Peter Attia 32:53 The other thing that I would say leads to what we experience clinically as a, a lot of people losing muscle mass when they do this is a lot of people exercise in the morning, but their feeding window is in the evening. So now they're creating a little bit of a gap, especially if they're untrained. Um, it's less, less of an issue in a trained individual, but in an untrained individual, we do see some benefits to having the amino acids, uh, restored in greater proximity to the training.

Chris Williamson 33:22 How

Chris Williamson 33:23 worried should we be about artificial sweeteners?

Dr Peter Attia 33:26 You know, I don't know, uh, would be the short answer. I, I think that this is another one of those things where, uh, boy, people really love to demonize these things. Um, but if you, if you really just wanna look at the facts, let, let's talk about facts, right? So aspartame, which is the original, kind of the OG sweetener, uh, everybody loves to demonize aspartame or NutraSweet, but the reality of it is if there is toxicity to it, it's probably impossible to measure at regular doses. This is a substance that, at least the last time I checked, had more data on it from a safety perspective than any other molecule tested by the FDA.

Chris Williamson 34:05 You're kidding.

Dr Peter Attia 34:06 No, it's, it's just... 'Cause again, it's been around since the 1960s, right? So does that mean that if you consume the equivalent of 12 cans of diet soda a day it's safe? Probably not, but we don't know, right? So, um, where do I think these sweeteners potentially wreak the most havoc? You know, one is I, I, I think that they probably increase your appetite for sugar anyway. So if you're, if you're consuming them in an effort to avoid sugar, um, you have to be just mindful of the fact that am I robbing Peter to pay Paul?

Chris Williamson 34:43 Hmm.

Dr Peter Attia 34:44 Um, if you really want to eliminate sugar as one of your dietary strategies, uh, you might just be better off reducing sweet things altogether. And what you'll discover, 'cause I've gone, I've done this myself, I've had periods in my life where I've been, you know, very dogmatic about restricting sugar. I'm not that dogmatic about it these days, right? But when I have been, you know, one of the things (laughs) I noticed was how unbelievably sweet things are that I used to not think were that sweet, like berries.

Chris Williamson 35:11 Mm-hmm.

Dr Peter Attia 35:12 You know, like, you know, raspberries aren't generally thought of as the sweetest thing in the world. But when you completely eliminate artificial sweeteners and regular sweeteners, you know, after a few months, berries become insanely sweet. You know, 85% chocolate becomes mind-bogglingly sweet, as opposed to what most people would think of it as kind of bitter. Um, you know, there was a recent study published that looked at, uh, one particular sweetener, erythritol, and, um, it was a pretty poorly done study. Um, but it... Look, it asked some interesting questions, right, which is, you know, is a metabolite of this potentially atherogenic? Uh, again-

Chris Williamson 35:48 What's atherogenic?

Dr Peter Attia 35:49 Uh, would it lead to or cause atherosclerosis?

Chris Williamson 35:52 What's that?

Dr Peter Attia 35:53 Cardiovascular disease. Sort of the, the, the inflammatory disease of the coronary arteries and, and other arteries. Um, again, I, I think the data are, are pretty underwhelming that artificial sweeteners are harmful, but I also think there's probably a class of differences between them. So my personal favorite of all of them is something called allulose. Um, allulose is, it's basically natural. It is an enantiomer of fructose, meaning it's a molecule that's almost identical to fructose with one very minor structural change.... what's unique about it is it has, in my opinion, the best taste. 'Cause I, the thing I don't like about artificial sweeteners is I just don't like the taste. I actually like the taste of sugar. I don't like (laughs) the taste of, you know, saccharin. I don't really like the taste of aspartame. I certainly don't like the taste of stevia. I mean, that, to me, it makes me want to vomit. But allulose has the same taste, the same mouth feel as sugar, and the only drawback is it's only 70% as sweet, which is not a real drawback because you could always dose it up if you want. Uh, it also has the added benefit of i- it appears to actually reduce blood glucose a little bit. It appears to have a- an effect where it pulls glucose, um, into the kidney and, uh, pre- like, basically increases the filtration, glomerular filtration of glucose. So it slightly lowers glucose. Not as potently as something called a, um, an SGLT2 inhibitor, which is a class of drug that does that, but it's- it's- it's very interesting, nonetheless. So, um, you know, I guess if I were thinking about how I would consume it, I- I would probably consume more allulose than other things. But unfortunately, it's still not that prevalent in foods. You have to- you have to just buy the allulose itself. So if I'm making something, I'll use allulose in it.

Chris Williamson 37:40 What I like about this framing is it gets to one of the reasons why doing a randomized control trial for diet stuff is so hard, because how are you going to be able to control for the psychological training that having a sweet thing, even if it is a zero-calorie sweet thing, even if it's a zero-calorie sweet thing with no downstream risks to your body unless you take it at insane dosages, how are you going to be able to control for what that does psychologically to people's expectations of the sweetness of their foods, of the frequency of having sweet things throughout their diet? Um, yeah, I think that's a really nice little microcosm there. The one- one of the other thing- I'm wearing a-

Chris Williamson 38:17 a Whoop band at the moment. Um, some people are drowning in data now, right? We've gone from a world where we knew nothing to where some people know a lot. But I would guess, on average, that even people who care about their health and fitness are still mostly not wearing a tracker, they're still mostly not getting blood panels done, they're still mostly not going and getting a full-body MRI scan, et cetera, et cetera. What are the most important metrics for someone who is completely, uh, unindoctrinated into the world of looking at vital signs within their body? What are the most important metrics for people to be looking at?

Dr Peter Attia 38:54 Well, I mean, again, I- I have a pretty long list on that because we're- we're holding ourselves to a pretty high bar. Um, so the way I think about this is, what are the inputs to what- what I call the longevity risk assessment? So, um, there are basically about seven or eight things that are a threat to your length of life and quality of life. We've talked about them already, right? So, cardiovascular disease, cerebrovascular disease, cancer, neurodegenerative disease, orthopedic injury, emotional distress, misery, like, all those things, right? So, how do we know how you're stacking up on all of those things? What are the inputs to do them? So yeah, blood tests, uh, family history, selective genetic testing, colonoscopy, MRI, liquid biopsy, VO2 max tests, Zone 2 tests, DEXA scan. I mean, the list is long, and I- I think in our matrix, we have over 40 things that go into that, or f- over 40 inputs that go into our risk assessment. And then that risk assessment leads to outputs. So, what do you do in response to the- the ranking of risk based on those things? Okay, run the matrix, go and do those things, and then let's come back and measure and do again. So, it's hard for me to say what the most important is because it really comes down to an individual. So, if an individual shows up and they have a significant family history of cardiovascular disease, well, look, a CT angiogram is going to be very important, and a blood test that's measuring Lp (a) , lipids, and ApoB is essential 'cause you have to know which, you know, which of these things is responsible for that. Uh, you know, certainly m- you know, a continuous blood pressure monitor, uh, or at the- at a minimum, you know, we would have patients checking their blood pressure at home two to three times a day for a month. Again, super low-tech, right? You might think, "How is that interesting?" Well, it's enormously interesting because blood pressure is one of the biggest risk factors for Alzheimer's disease and cardiovascular disease. So, a- a- again, people are obsessed with things like, you know, their sleep data, um, but don't forget, the really, you know- you know, less sexy stuff that we could've measured forever, such as blood pressure, but knowing how to measure blood pressure accurately is important, and I- I think, you know, undiagnosed hypertension is an epidemic in this country.

Chris Williamson 41:16 What do people get wrong when measuring blood pressure?

Dr Peter Attia 41:18 Uh, the first thing they get wrong is they don't measure it. But assuming they do measure it, um, they're not stationary for five minutes before they measure it, they don't have the cuff on correctly, they don't have their arm in the right position. You know, if your arm is too low or too high, you're going to get an inaccurate reading. Your arm really needs to be- the cuff needs to be right at the level, uh, of your heart. Um, you- you have to pay very close attention to where the cuff tells you to put it. You know, you want to be about an inch above the break in your arm, and th- there's a- a cu- a good cuff will tell you where the- how to line it up with the brachial artery in your arm. Um, you don't want to have just had coffee right before you do it. You don't want to be sitting like I am with your legs crossed. Your legs need to be uncrossed. So, there's a whole protocol for how to do this, and there was a very good study called the SPRINT study that- that really established the- the measurement standard for how to establish, um, a m- a- a proper measurement for blood reading, which was, you know, five minutes sitting stationary without doing anything stimulating, measurement, five minutes of, you know, doing nothing again, repeat measurement, five minutes, repeat measurement. So, 15 minutes to get three measurements, taking the average. That's a blood pressure. Now, we don't ask our patients to do that. We ask them to do it once, but two to three times a day.

Chris Williamson 42:28 So you should even out any inconsistencies?

Dr Peter Attia 42:31 Yeah, and you'll also notice trends, like are you normal in the mornings but elevated in the afternoons? And, um, you know, the data are really clear that-...anything above 120 over 80, uh, has long-term risk associated with it. And so when we see people that have an elevated blood pressure, we want to make sure we're addressing that, and there's lots of ways to address it before you have to go down the pharmacologic path. But if you have to go down that path, you're much better off going down it to protect your kidneys, your brain, and your heart.

Chris Williamson 42:56 What is good and what is bad about different types of cuffs? Are automatic cuffs okay?

Dr Peter Attia 43:03 Yeah, so the gold standard is, of course, a manual cuff. So having a, an actual person, yeah, who's, who's got a stethoscope on the brachial artery and measuring your blood pressure. The problem is unless you're, you know, you have s- like, for me, that's what I do typically 'cause my wife can measure my blood pressure, even I can measure my own blood pressure.

Chris Williamson 43:21 So marry someone who is trained for taking blood pressure.

Dr Peter Attia 43:25 (laughs) Right.

Chris Williamson 43:25 That's what you're saying.

Dr Peter Attia 43:25 But the automated cuffs are pretty good. Um, in me, they run high. So across the board, automatic, um, or automated cuffs tend to run 10 to 15 millimeters per mercury high systolically and they're accurate diastolically. That's just a glitch. I have never been able to come up with a compelling explanation for why, but I'm not unique in this. Um, I, uh, we do see this, uh, i- in a number of people where the, the gold standard runs lower than the, than the cuff. Um, so the challenge of doing an au- a, a, a manual cuff when you're at your doctor's office is the challenge of having your blood pressure checked at the doctor's office. For some people, it produces this syndrome called-

Chris Williamson 44:11 White coats.

Dr Peter Attia 44:11 ...white coat hypertension, where-

Chris Williamson 44:12 My mom's got that.

Dr Peter Attia 44:13 Yeah, they just, you, you, you sort of get, you know... And, and by the way, the other thing is most of the time you walk into the doctor's office, they don't even adhere to this principle, right?

Chris Williamson 44:21 Five minutes.

Dr Peter Attia 44:21 Yeah, yeah, yeah. You sort of run in from the parking lot, run up the flight of stairs, sit down in the waiting room-

Chris Williamson 44:25 "When was the last time you had a coffee?"

Dr Peter Attia 44:27 Yeah, yeah, yeah.

Chris Williamson 44:27 Blah, blah, blah.

Dr Peter Attia 44:28 So, so, so again, I'm, I'm, I think that blood pressure is a very difficult thing to, to accurately glean in the doctor's office for all those reasons, and that's why I just think everybody should, you know, buy one. I, I, I don't have any affiliation (laughs) with any company that makes these things, but I, there's a brand that I like called Omron, O-M-R-O-N. That's the one we tell our patients to get. You can get these things on Amazon and, um...

Chris Williamson 44:49 What are the most common, uh, lifestyle interventions? Let's say that someone does get to, what, that 120 over 80.

Dr Peter Attia 44:56 Yep.

Chris Williamson 44:57 Where should they go first would you think?

Dr Peter Attia 44:59 Exercise is, is a big one. Aerobic exercise is an enormous way to lower blood pressure as is weight loss. So weight loss is gonna be mostly driven by nutrition and then aerobic exercise, and, and sleep. So i- because I track my blood pressure pretty regularly, um, w- two of the most obvious things that show up when I'm not well slept is, you know, higher blood glucose and higher blood pressure.

Chris Williamson 45:22 I went to, uh, Medellin, I went to BioXcellerator down there and got a ton of stem cells for a week. Medellin's at altitude, and they were coming in and testing my blood pressure three, four times a day, f- f- f- f- using that, and I had a nurse doing it. Which was nice to, you know, to have, uh, the sense that a team's there for your health. That was, I really enjoyed that part and felt like I was being cared for. Uh, but at altitude, and I'm a heavy guy, uh, at altitude, my blood pressure was not happy. Um, so I came back and I thought, "Right, I really need to, I really need to make a change here, I really need to..." Uh, 'cause e- even if it is at altitude, et cetera, et cetera, I was in there with, uh, Aljamain Sterling, who is, um, the current UFC 135 champ. Uh, and yes, elite athlete, yes, best in the world literally at what he does, but he wasn't struggling. And I figured, "Uh, I probably could do with making a change here." So-

Dr Peter Attia 46:13 What's the, what's the altitude there?

Chris Williamson 46:15 I don't know. I don't know. High, higher than, higher than I'm used to, I presume. Um-

Dr Peter Attia 46:21 And you were getting stem cells for what?

Chris Williamson 46:23 So they reached out and suggested, um, that I go in and get a procedure. I've got two bulging discs, L3-L4 and L5-S1, uh, that's been, uh, an issue for a while. Although it is, uh, I, I managed to get it to a, a very manageable place now, which I'm very happy with. Um, little bit of rotator cuff, it just bro injuries, you know, like sometimes my knee's, uh, a little bit achy. I had a full Achilles detachment playing cricket, uh, a couple of years ago-

Dr Peter Attia 46:49 Mm-hmm.

Chris Williamson 46:50 ...most, most British way that you can do it. Um, so I went in and I had, uh, 110 million, uh, through IV, two separate ones, uh, oxygen chamber twice, two sessions of that, a bunch of vitamin IVs, two intra-articular, uh, shots into the shoulder, uh, quadriceps tendon above and below the patella, uh, and then straight into the Achilles. And then a intradiscal injection into L3-L4 and, uh, every facet joint as well, down my lumbar spine. Um, under general for the, uh, spine stuff, which was great, under nothing for the, uh, local injections, which were, uh, spicy, but, um, that was seven, eight, seven, eight weeks ago now, uh, and three months is around about the, the time when this stuff's supposed to kick in. So I'm very much looking forward to seeing, uh, how that works. I'd enjoyed, psychologically, it was neutral, physically slightly difficult. Um, the s- sort of, uh, is it cytokine inflammation response is something to behold, um, for the next 24 hours. It felt like anyone that's had DOMS after a, a three-month break from the gym, imagine that kind of stiffness, but exclusively in the tendons of the places that have been touched. Oh God, it was so localized and so I was laughing in, in, uh, for the next day as I sort of tottered around like a robot. Um, it was a very interesting experience.

Dr Peter Attia 48:20 Mm-hmm.

Chris Williamson 48:23 What about

Chris Williamson 48:25 health metrics that people are overlooking? So we've mentioned, you know, e- even the stuff that you've given there in terms of top line, probably your VO2 maxes, your HRV, your resting heart rate, your blood, your blah, blah, blah. Is there something that most people haven't-

Dr Peter Attia 48:36 Well, think about how many, wha- how many people listening to us today do you think know their VO2 max?

Chris Williamson 48:40 (pause) Very few.

Dr Peter Attia 48:42 Yeah, very few. Yet there is no metric, that I am aware of, that is more highly correlated with the length of a person's life than their VO2 max.

Chris Williamson 48:50 Wow. Why?

Dr Peter Attia 48:51 Not even close.

Chris Williamson 48:52 Why? Why that particular metric?

Dr Peter Attia 48:54 Well, there's probably two things going on, right? One, it actually does matter a lot. It's an amazing proxy for health. Um, if you think about it, have you had a VO2 max test done recently?

Chris Williamson 49:03 Not recently. I had one done, last one was probably four years ago.

Dr Peter Attia 49:06 Okay. So you, you, think about how miserable it is, right? Like, what is it testing, right? It is testing your maximal consumption of oxygen. Well, to get to that level, we are stressing you to the highest degree possible. It's, it, it is, as its name suggests, it is a maximal VO2 max test. So, the higher that number is, the more oxygen your muscles can utilize, the more fit you are, the healthier you are, the more capacity you have, uh, to avoid illness. And, um, so, so I think there's the biological reason for it. I think the other reason for it, as opposed to, say, your zone two threshold, which I think would probably be equally predictive, um, is that it's a metric that is so ubiquitous. It's very standardized. It's easy to test for conceptually, not necessarily physically. And so you have a metric that we can easily capture. So it's, for example, it's better than, like, a deadlift.

Chris Williamson 50:08 Mm-hmm.

Dr Peter Attia 50:08 Right? In deadlift, there's variability of form, there's too much risk of people getting hurt. It would be a harder metric to track. So you have this metric that you can track, and then the, having a high number tells you something about the person, right? To have that number, you must be ex- to have a high number, you must be exercising a lot. And we know the benefits of exercising a lot. Right? The person who has a VO2 max at the top 2% of their age, I mean, by definition, they're doing a lot of exercise, and exercise has more benefit than probably any other single intervention we can do. So again, it's, I throw that out there because I say like, yeah, we know those things. We know exercise matters, but when it comes right down to it, most people don't know if they're fit enough. Most people don't know their VO2 max. Most people don't know their ALMI, appendicular lean mass index. They don't actually know how much muscle mass they have, and they don't know where they stack up for other people their age and sex. And yet, that's also a highly, highly predictive metric of how long you're going to live. They don't actually know how strong they are. They don't know if they're in the top 25% of their age or sex for strength. So, uh, I think it just comes kind of back down to the basics, but like, we have to know these things. If we, you know, what gets measured gets managed. And if you, if you're not measuring these things, there's, I don't know what you're managing.

Chris Williamson 51:30 What is the best protocol that you have found for improving VO2 max, in terms of training?

Dr Peter Attia 51:38 Uh, it's two things, right? So, so you want to think of the, the, the way I think of cardiorespiratory fitness is it's a pyramid. So you have a base to a pyramid and you have a peak to the pyramid, and you want the biggest possible pyramid. So the area of the pyramid is your total cardiorespiratory fitness.

Chris Williamson 51:53 High, but also wide.

Dr Peter Attia 51:53 Exactly. So the width of the pyramid is your zone two, that's your sort of aerobic efficiency metric. So if you, and your VO2 max is the height of the pyramid. So if you want a high pyramid, you also need a high base. So you have to do training that widens the base and raises the peak. So the base widening training is what we call zone two training. So again, there's lots of ways to do that, but the simplest way to do it is to train at an RPE that barely allows you to, uh, maintain a conversation. So, um, the way I describe it to people is, I do my zone two on a bike, uh, on a trainer indoors, right? I'm listening to podcasts and, and audiobooks. It's a, it's a pace of training where I'm mostly able to breathe through my nose. Um, but that just speaks to the fact that I have pretty good airways. A better metric is if my wife comes in and talks to me, or if the phone rings and it's important and I pick it up, I can carry on a conversation, but it's strained. The person absolutely knows I'm exercising.

Chris Williamson 52:59 Or doing something else.

Dr Peter Attia 53:00 There's no confusion. Um, but I can speak. If it, if I'm at the point where I can't speak, I'm outside of zone two, I'm into zone three.

Chris Williamson 53:08 What, uh, heart rate is that? Have you got any idea for you?

Dr Peter Attia 53:11 Yeah. For me, it's, uh, typically a heart rate in the high 130s.

Chris Williamson 53:16 Okay. That's a little higher...

Dr Peter Attia 53:17 Yeah.

Chris Williamson 53:17 ... than I would have guessed, but I guess that might speak to your cardiovascular fitness.

Dr Peter Attia 53:20 Yeah, yeah. But it, it vary. Well, but it also varies day by day. So yesterday, I was having such a lousy day, uh, probably 'cause I didn't sleep really well, that that ended up being a heart rate of about 131 to 132.

Chris Williamson 53:33 Mm.

Dr Peter Attia 53:33 So it varies. I've had it days where it's as low as 130, and days where it's as high as 145.

Chris Williamson 53:39 And how old are you?

Dr Peter Attia 53:40 50.

Chris Williamson 53:41 Wow. So that is, that's still very fit. I'm gonna guess that'll speak to the fitness that you've got.

Dr Peter Attia 53:45 Um, well, I think it just speaks to, the, the bigger point, I think, is that it just speaks to kind of the variability you have in heart rate between individuals.

Chris Williamson 53:53 Hm.

Dr Peter Attia 53:53 Um, but then to train the peak of the pyramid, I think the most efficient way to do that is kind of, uh, so, so VO2 max training is maximized between three and eight-minute intervals. So if an interval, you will train VO2 max if you're doing something harder than that. If you're only doing something you can hold for 30 seconds or one minute, that will still give VO2 max benefit, but not nearly as much as if you can push it closer to three, four, five minutes, et cetera. So for me personally, I mo- I mostly do that at four minutes. So I'll do four minutes very hard, four minutes of recovery. Four minutes very hard, four minutes of recovery. So I do those also on a bike usually, and I'll do those outside on a hill. So there's another-

Chris Williamson 54:38 Oh, so you're roads cycling this.

Dr Peter Attia 54:39 Yeah, yeah. So there's a hill near my house that is...... up. It's a, it's a, just a, a straight hill that's not so steep, like meaning I'm in the saddle, I don't have to be out of the s- uh. I'm just in the saddle, looking at my power meter and my heart rate and just going very, very hard for four minutes, getting to the top, feeling like I want to puke, going back down, doing it again. Just repeat, repeat, repeat.

Chris Williamson 55:00 Two sets?

Dr Peter Attia 55:01 No, I'll typically do four to six.

Chris Williamson 55:03 Okay. How often per week?

Dr Peter Attia 55:05 I just do that once a week.

Chris Williamson 55:06 Okay. And that seems to be...

Dr Peter Attia 55:08 Well, again, it's remember what I'm training for now. When I was training as a cyclist, I was doing those types of workouts three times a week.

Chris Williamson 55:15 Mm-hmm.

Dr Peter Attia 55:15 Y- and they were much longer and much more grueling. But again, I was optimizing for a much broader array of fitness. But for today, for all I'm doing is, no, I'm just, you know, I'm just trying to be a good, I'm just trying to be fit as a person, not as an athlete. Um, so yeah, once a week of doing a very hard VO2 max set, four times a week doing those lesser zone two sets.

Chris Williamson 55:37 How long on zone two?

Dr Peter Attia 55:38 Uh, 45 to 60 minutes a session.

Chris Williamson 55:41 Okay. So you're looking at, what, 180 to 240 minutes cumulatively per week?

Dr Peter Attia 55:46 Correct. So I'm basically doing four to five weeks of cardio training a week, which is, you know, depends who you ask. Like, for s- by my historical standards, that's very, very low. Um, obviously, for some people, that would still be considered a lot. Um, I, I think, you know, I think it would be crazy not to want to capture the benefits of something like exercise. Um, so we do, you know, sort of sit down with everybody and say, "Okay, how much time are you willing to put into exercise?" And then that's how we sort of think about how to allocate time across all endeavors: strength, um, you know, stability, aerobic efficiency, peak aerobic power. We, we, we do take kind of a portfolio approach to that. But starting through the lens of how much time are you willing to put into it. So someone like me who's willing to put in 10 to 12 hours a week, that's, you know, you can see-

Chris Williamson 56:36 Cover all of the bases as much as you want, basically.

Dr Peter Attia 56:38 Absolutely, yeah.

Chris Williamson 56:38 Okay, so you've got four pillars: strength, stability, VO2 max, zone two.

Dr Peter Attia 56:43 Yep.

Chris Williamson 56:44 Strength and s- stability. Talk to us about that.

Dr Peter Attia 56:46 Um, so strength is probably the easier one for people to understand. Um, you know, that's basically your ability to generate force. Um, and of course, within strength, you have different, you know, different areas of strength. So I don't do a lot of maximal stuff anymore. So in other words, I'm rarely, if ever, I don't think I really ever go below three reps. So the, the heaviest I will go is five reps stuff. So I'll do, you know, I'll do deadlifts that are-

Chris Williamson 57:15 Maybe 5%ish?

Dr Peter Attia 57:17 Um, it's a good question.

Chris Williamson 57:18 Well, you don't, you don't know your 1RM because you're not doing it, but...

Dr Peter Attia 57:20 I can sort of predict it because I do use a velocity tracker. So have you seen these?

Chris Williamson 57:24 Yeah, yeah, the bar speed things.

Dr Peter Attia 57:25 Yeah, yeah.

Chris Williamson 57:26 Yeah.

Dr Peter Attia 57:26 So I do measure bar speed. Um, so I can have a prediction of it.

Chris Williamson 57:29 Okay.

Dr Peter Attia 57:29 I can have a prediction of 1RM. Um, but yeah, usually I'm sort of in the five to 15 rep range-

Chris Williamson 57:36 Hm.

Dr Peter Attia 57:36 ... when I'm training. So I'm basically... But, but what I'm always trying to do is make sure I'm somewhere between zero and two reps in reserve.

Chris Williamson 57:46 Hm, okay.

Dr Peter Attia 57:47 So that's... I'm really training off reps in reserve.

Chris Williamson 57:49 Okay.

Dr Peter Attia 57:49 That's my overarching principle of training, is... So, so even if I'm at five, I'm probably training to one to two rep in reserve. If I'm at 15, I'm still one to two reps in reserve.

Chris Williamson 58:02 There's the bodybuilders out there that want to do supersets and dropsets to failure that are tearing their hair out at the moment.

Dr Peter Attia 58:07 Yeah, I'm sure. U- Uh, and, and again, I, there are absolutely sets where I do go to failure. But the truth of it is, it's very hard to go to failure all the time. I, I j- I think, I think if people are being brutally honest with themselves, like...

Chris Williamson 58:20 They still had another one or two set, uh, reps left in the tank.

Dr Peter Attia 58:23 Yeah. Uh, uh, yeah. I, I, I don't, I, I, I mean, I, I, I know what it's like to go to failure. Um, and I, you don't h- You, you only have so many of those matches every day. Um, so I don't even try to play that game. I just sort of say, like, "I kn- I, I've learned that I've got... If I stop now, there's only two more I would get before I would violate my form so badly that I would either injure myself or, you know, just effectively-"

Chris Williamson 58:45 Transcending ego lifting is, uh, one of the most difficult things that you can do. Forget about the consistency and all of that. It's transcending ego lifting. Um, strength. Formulating a strength protocol across the week. What are you prioritizing? Are you prioritizing large lifts? Are you prioritizing session length? Et cetera, et cetera.

Dr Peter Attia 59:03 Yeah, it, it... First of all, there's, there's quite a bit of, um, variability in my, in my training. Um, but generally, I'm doing four days a week. Uh, not generally. I'm always doing four days a week, and it's two days lower body, two days upper body. Now, I, I used to... I've, for years, also done three days of mixed longer sessions, but I prefer what I'm doing now. I prefer doing two lower body days, two upper body days. And, uh, yeah, I prioritize big lifts, and I'm sort of working on... Like, so today, I had 24 working sets, uh, of, of upper body. Uh, you know, on Monday, I had 18 sets of lower body, 18 working sets of lower body. And probably on Friday, it'll be a little bit more volume. It'll probably be 22 to 24 sets of lower body, uh, working sets.

Chris Williamson 59:50 In that 5 to 15?

Dr Peter Attia 59:52 Yes.

Chris Williamson 59:52 Uh, which is, uh, -ish, RPE 8, E8, eight and a half.

Dr Peter Attia 59:57 Eight to nine, yeah.

Chris Williamson 59:57 Yeah.

Dr Peter Attia 59:57 Yeah. Sometimes maybe as little as seven on some things.

Chris Williamson 1:00:00 The... Especially if you've had a shit night sleep-

Dr Peter Attia 1:00:02 Yeah.

Chris Williamson 1:00:02 ... the night before.

Dr Peter Attia 1:00:03 Yeah.

Chris Williamson 1:00:03 Um, what... Uh, when you're looking at movements, for instance, what was your session this morning? Can you remember in terms of exercises?

Dr Peter Attia 1:00:10 Yeah. So, uh, I did floor presses.

Chris Williamson 1:00:13 Mm-hmm.

Dr Peter Attia 1:00:14 Uh...

Chris Williamson 1:00:14 Dumbbells?

Dr Peter Attia 1:00:15 Yep.

Chris Williamson 1:00:15 Yep.

Dr Peter Attia 1:00:16 I did, um, pull-downs.

Chris Williamson 1:00:18 Mm-hmm.

Dr Peter Attia 1:00:19 I did incline press. I did row. I did, um, um, like incline curl, uh, overhead tricep extension.... and, um, and then a preacher curl. You know what? It's not a true preacher bench, but hanging over a bench doing a preacher to create the same angle.

Chris Williamson 1:00:39 Yep.

Dr Peter Attia 1:00:39 And then, uh, laying tricep extension. And then always in between them, I'm doing stability work. So, we didn't come to stability-

Chris Williamson 1:00:47 Mm-hmm.

Dr Peter Attia 1:00:47 ... but I'm doing, I do two dedicated days of stability a week. So Tuesday, Thursday I do a full dedicated hour of stability training, and then on the off-days, that's not Tuesday, Thursday, I'm getting in at least 20 minutes of stability per day on, on either side of the exercise, like throughout the workout.

Chris Williamson 1:01:05 So, the stuff that we've gone through so far, the gym bros will still understand what cardio is. The cardio bros will still understand what lifting is. Nobody understands what-

Dr Peter Attia 1:01:15 What stability is.

Chris Williamson 1:01:15 ... balance training is.

Dr Peter Attia 1:01:16 Yeah.

Chris Williamson 1:01:16 No one understands. What, what are the principles behind this? No one's ever thought about stability training before. Uh, how do you integrate it into your workouts, and then also, what does a dedicated session look like?

Dr Peter Attia 1:01:28 Yeah, it's very difficult to explain. Um, it's, it's actually, I think it was the hardest chapter in the book to write, truthfully, um, because it's, it's not, it's- it's hard enough to show people in videos, or to have friends over who want to work out with me and put them through the exercises. That's actually very difficult. Um, so, you know, I lead with an analogy in the book where I talk about the difference between street cars and track cars, 'cause I'm a car nut, and I, being on the racetrack is probably one of my favorite things to do. And, um, so- so the analogy I give is- is this, which is, um, if you took- if you take a street car with very high horsepower and you put it on a track, and you let it race against a track car which is lighter, less horsepower typically for a given engine size or for a given class size, slick tires on it, which one's going to be faster? I mean, it's no comparison, right? The track car rips the street car into oblivion even though, by the way, the street car will go faster in a straight line. Um, so the example that I use in the book is a real example. I compare at the time, this is, you know, seven or eight years ago, my street car at the time was like a- a- an actually a modified E92 M3.

Chris Williamson 1:02:42 Mm-hmm. Nice, quite nice.

Dr Peter Attia 1:02:44 So I mod- I- I- I modified it, changed all the air flow. That thing was putting out 475 horsepower.

Chris Williamson 1:02:51 Big German beast, yep.

Dr Peter Attia 1:02:52 Yep. And at the time, my track car was a spec E30 M3. I'm sorry, a- not even an M3, just a spec E30.

Chris Williamson 1:03:03 Okay.

Dr Peter Attia 1:03:04 Right?

Chris Williamson 1:03:04 But everything's stripped out, roll cage is in, stiff as hell-

Dr Peter Attia 1:03:07 Stiff as hell.

Chris Williamson 1:03:08 ... tires. 165 horsepower versus-

Dr Peter Attia 1:03:11 What engine's in it?

Chris Williamson 1:03:12 Oh, just the stock engine. Yeah, it's a six in line.

Dr Peter Attia 1:03:16 Right, okay.

Chris Williamson 1:03:16 Yeah, yeah, yeah. So- so you've got the- the- the stock 165 horsepower engine.

Dr Peter Attia 1:03:21 (laughs) It's very light. The car weighs like probably 2,400 pounds versus the M3's 3,400 pounds.

Chris Williamson 1:03:25 Yeah.

Dr Peter Attia 1:03:26 M3's got street tires on it. This one's, I'm running, you know, probably Hankook slicks on it. But to your point, the chassis, stiff as a button. Suspension, super stiff. And yeah, I was d- going faster in the straightaways in the M3 but my lap time was two seconds faster, which on a track is- might as well be a day-

Chris Williamson 1:03:46 Yeah.

Dr Peter Attia 1:03:46 ... um, in the spec E30. And of course, what does it come down to? It's cornering speed. What does cornering speed come down to? It comes down to, of the 165 paltry horsepower in that engine, every little bit of it is making it where it belongs. Remember, what is the name of the game in driving a race car? It's all about friction. It's all about power loss. It's all about transmitting what's happening in the crankshaft to the tire, tire to the street. That's it. You only have four points of contact with the outside world. Nothing else matters. And so again, we're not talking about aerodynamics 'cause these aren't aero cars, right? So in the- in the street car, first of all, I have much more slippage at the tires 'cause I've got- I'm not running slicks. Secondly, the chassis is so loose, right? So-

Chris Williamson 1:04:36 Wallowing all over the place.

Dr Peter Attia 1:04:36 ... I've got all this- m- all this energy loss with energy leaking out of that car not making it to the surface of the track.

Chris Williamson 1:04:44 It's like having laxity in a joint.

Dr Peter Attia 1:04:46 That's right. So every time you're hurting your knee, you're hurting your elbow, something's hurting, that's an energy leak. So again, even if one doesn't care about performance, just from an injury perspective, this is something we want to avoid. We want to avoid it. And again, my introduction to stability only came the hard way. It's not like I was born out of the womb realizing this was an important thing. I mean, I had to go through horrible injuries to finally arrive at this place where I said, you know, "I'm tired of being in pain. I'm tired of the fact that my elbow hurts when I do pull-ups. And you know, oh, like half the time I deadlift or squat, my back hurts, you know, my- my SI joint hurts the next day." Like, was just kind of tired of that, and then I got very fortunate in that I landed, um, in the- in the company of a guy named, who I write about in the book briefly, his name is Michael Stromness, and, um, he's a practitioner of something called DNS, dynamic neuromuscular stabilization. And the very first time I met him, you know, at the time I was like, uh, my main complaint was, uh, basically my right SI joint and my right elbow. I had tennis elbow having never played tennis.

Chris Williamson 1:06:00 Mm.

Dr Peter Attia 1:06:01 And he said, "All right, you know, take your shirt off and hop up on the bar and do some pull-ups." So I- I did, and rattled off, you know, 15 pull-ups or something, which I could do easily at the time. Um, and he's like, "Oh, that's horrible. Like, those are the- those are..." And by the way, these are good form pull-ups. I'm not doing like bro pull-ups where I'm like jerking up and down. I'm doing like full extension, up, like everything perfect. And he's like, "Yeah, you have no capacity to control your scapula. So your scapula is winged, and in doing so, you are transmitting all of that force into your elbows."

Chris Williamson 1:06:34 Mm.

Dr Peter Attia 1:06:35 "You cannot retract your scapula. You don't have the control, you don't have the stability in the scapula, so you're leaking energy through your scapula into your arm." So, to make a very long story short, that-That, which started in 2017, um, just took me so far down the rabbit hole of not just DNS, but other, other schools of thought. Uh, I would later go on to meet someone named Beth Lewis through Michael, who, um, you know, h- has, has her own expertise around, um, other, other disciplines. And we basically just started, piece by piece, rebuilding my movements. And by the way, that meant spending a year not doing pull-ups and not deadlifting as I relearned how to, how to align my body again. And so today, I'll still spend two days a week working with a guy here in Austin named Kyler Brown, who's amazing, um, working on just dedicated DNS things. And again, if you watched the exercises I was doing, you would be thinking, "What is he doing?" You know, like, "Why is he doing..." you know, "Why is he in these baby positions, like, moving in these odd ways?" But a, a lot of what DNS is based on is the idea that up until we were about two years old, we all moved almost perfectly. Um, m- most of our movement patterns that are corrupt, which we all have as adults, only started to kick in once we were about two. Uh, maybe one, but, but generally about two. So, so there's a very predictable, you know, neuromuscular set of, or sequence of movements that are genetically programmed into us. Uh, the abili- you know, the way a child reaches for something, the way a child rolls, the way a child stands, the way a child, you know, gets into a bear position. All of these things are basically hardwired into us, and the goal of this type of training is to basically provide a software update on the crappy software we've ins- you know, we've, we've, we've overridden that system with.

Chris Williamson 1:08:29 Let's say someone doesn't live in Austin, doesn't have access to your very smart friend.

Dr Peter Attia 1:08:33 There are lots of DNS practitioners across the country, um-

Chris Williamson 1:08:36 But you would advise doing this with instruction?

Dr Peter Attia 1:08:40 I think so, yes. I think-

Chris Williamson 1:08:41 Sufficiently complex and nuanced, and you need the...

Dr Peter Attia 1:08:43 I, I think DNS is, um, is very difficult to learn. Um, I, I shouldn't say that. I haven't tried to learn it off, you know, videos and online. And, and there might be ways to do it. But, but I, I think, you know, trying to find a practitioner is a good way to start. Um, and then once you have it going, it's, it's always great to, to, to, you know, continue on your own. And there's a lot of stuff I do with my friend Kyler that's not DNS. I mean, you know, one of the issues I've been having injury-wise, I have very flexible ankles. I think a lot of former swimmers do. And so, one of the drawbacks of that is when I do... For ex- I love doing box step-ups.

Chris Williamson 1:09:22 We're both cut from the same cloth. I knew that you were a massive fan of these. They're my favorite movement for the lower body.

Dr Peter Attia 1:09:27 Yeah, I, I absolutely love, um, I love doing them in all regards. I love doing them very, very heavy. I love doing them very, very slowly, all of these things. Well, because my ankles are so flexible and I can really, really dorsiflex, I have a tendency sometimes when I'm... 'Cause I guess, you know, when you're, when you want to do a step-up, the real key to it is pre-loading the glute and the ham.

Chris Williamson 1:09:48 Correct. Not bouncing off the floor.

Dr Peter Attia 1:09:50 That's right. So to, to pre-load, you want to be able to shift forward and glide the femur back.

Chris Williamson 1:09:55 Mm-hmm.

Dr Peter Attia 1:09:55 That creates an enormous stretch, eccentric stretch, so that that front leg is loaded. Boom, you pop up. Okay, well, in doing so, I often will drive my knees so far over my toes 'cause I have the flexibility in my ankles. But sometimes I'll develop a little bit of discomfort there in the front. So one of the things I'm working on with Kyler is soleus strengthening to actually counteract that movement.

Chris Williamson 1:10:19 Bring it back.

Dr Peter Attia 1:10:20 Yeah. And so, the amazing exercises that he has come up with for me to do these, you know, to do soleus strengthening, which, um, again, you have to, you have to be very deliberate about doing that. It's easy to strengthen your gastrocs.

Chris Williamson 1:10:33 Hmm.

Dr Peter Attia 1:10:33 Uh, the soleus requires more effort.

Chris Williamson 1:10:35 I learned this intimately during my rehabilitation.

Dr Peter Attia 1:10:38 During your Achilles, absolutely.

Chris Williamson 1:10:38 Yeah. I overshot it, actually. It was hilarious. So, um, there's not a good time to snap an Achilles, but during COVID wasn't bad. Um, and I overshot it on my right leg, which was the one that snapped, and I ended up having to then work on my left more aggressively to catch it up because I'd ended up building up a, a calf that was bigger. I mean, I learned so much, man, from that. Uh, the first thing was, I had a 13-day wait period because I was doing it on the NHS, although I managed to find, uh, one of the top three surgeons in the entirety of the UK through a friend, uh, who was on the NHS to come and do my reattachment, which was really, really great. It felt like being, um, fitted in at the end of the day with a barber that needs to do their haircut. And I was waiting around all day, all day, all day, and then it got to the very end and we, uh, he had to run it back and I had to go back tomorrow. I'd been fasted all day 'cause I was gonna go into general anesthetic, blah, blah, blah. Anyway, um, a bunch of the things that I learned from that coming out the other side were how important it is to be able to deal with not just strength but plyo, uh, especially for, uh, that ankle position. But what I'm thinking here when, when you're talking about your, um, challenges with box step-ups, there's a guy called Dr. Eddie Joe PhD on Instagram. Now, he took a massive hiatus for like three years, but he did these really great breakdowns of academic literature in infographics, which lend themselves to Instagram very nicely. And I'll never forget this one from maybe four years ago, I think. And there'd been a study done looking at muscle fiber recruitment for glute exercises.

Dr Peter Attia 1:12:07 Mm-hmm.

Chris Williamson 1:12:07 And, you know, you look at, uh, the Glute Factory Bum Lab things for girls that want big glutes, or me, that's increasingly realized that my back gets better the bigger that my bum gets. Um, and glute bridge, donkey kickback, side raises, all manner of fantastical exercises that, that girls do. And he'd ranked them by, uh, the amount of muscle fiber recruitment. And the top five exercises were step-ups or step-up variations.

Dr Peter Attia 1:12:35 Hmm.

Chris Williamson 1:12:35 It was like step-up, cross-body step-up-

Dr Peter Attia 1:12:38 Mm-hmm.

Chris Williamson 1:12:38 ... like, lateral step-up, something, something, something, and then maybe hexde- hex bar deadlift was in the sort of upper middle, uh, deadlift another one, and then you get down toward like glute bridge kickback. And it's a...... 25, and I think it's 95 on this particular scale or this number-

Dr Peter Attia 1:12:57 Mm-hmm.

Chris Williamson 1:12:57 ... with step-up. So for anybody that wants to improve, like lower-body power, I just, I, I absolutely adore that movement, uh, and it's so easy to do.

Dr Peter Attia 1:13:05 We, we, um, you know, in the first iteration of writing the book, I had intended to put so much detail in about instruction on, like, kind of the most important movements. In the end, it was getting too long, so what I did is I ended up creating videos for a handful of them, and one of them is the step-up. So there's a pretty good video, um, on the s- like the book will point people to where to go on our site to see it.

Chris Williamson 1:13:27 Mm-hmm.

Dr Peter Attia 1:13:28 And, um, it's a pr- it's a pr- I just watched it yesterday. It's a pretty good instructional video, um-

Chris Williamson 1:13:32 Is that you doing it?

Dr Peter Attia 1:13:33 It's me doing it, with Beth and I talking through how to do a step-up.

Chris Williamson 1:13:36 Cool.

Dr Peter Attia 1:13:36 Uh, weighted, unweighted, low box, high box, the whole thing. Eccentric, concentric, what are the pitfalls, how do you, you know, how do you unload the ribs to, you know, you know, do the movement correctly and all that stuff, so.

Chris Williamson 1:13:46 Beautiful, yeah. Um, going back to some

Chris Williamson 1:13:49 of the other, uh, we'd spoken about sweeteners. What about vaping? Have you had a look at any of the science around vaping? I, I, it's kind of a little bit of a moral panic at the moment if you look at certain areas of the ancestral paleo world on the internet. Uh, what's your thoughts on vaping and its potential dangers?

Dr Peter Attia 1:14:06 L- let's come back to kind of the risk-reward matrix, right? So again, I, I view everything through this two-by-two. So, what's the risk? Is it closer to getting hit by a tricycle or getting hit by a train? And what's the reward? Is it picking up a dollar or is it picking up a gold coin? So I think that the i- th- I don't think we have sufficient data to say that it's picking up... that it's getting hit by a tricycle. Um, I don't think the industry is standardized enough to be sure that what is being inhaled is sufficiently clean. Maybe it is. Maybe some companies are better than others. I mean, we, we could talk about that all day long, but I'm not personally willing to put my trust in that, in that market, in that infrastructure, in those companies whatsoever. Um, so, so for me personally, this would be a no-brainer. There's no upside in it to me.

Chris Williamson 1:15:00 What would you be concerned about going into your body? It's not just the nicotine. It's the stuff that-

Dr Peter Attia 1:15:04 Oh, no. First of all, nicotine I love. Like, I'm all about nicotine.

Chris Williamson 1:15:07 How do you use nicotine in a safe way?

Dr Peter Attia 1:15:09 Um, I would chew gum or I would use, I use a, like a lozenge or I ch- um, there's like, these little patches that you, you know, kinda suck on.

Chris Williamson 1:15:16 The Zyn pouch?

Dr Peter Attia 1:15:17 Yeah.

Chris Williamson 1:15:17 What have you found is your favorite brand for those?

Dr Peter Attia 1:15:20 Um... I'm blanking on the name of the brand. Um... They come in a little round, colorful thing. I don't remember the name of the brand.

Chris Williamson 1:15:31 Got you, and are you using three mgs, five mgs?

Dr Peter Attia 1:15:33 Um, unfortunately, that's the, maybe... I haven't bought in a while from these guys. I bought so many the first time by accident that I'm still living off the last two years' worth. I literally, just like an idiot, accidentally bought ten times more than I-

Chris Williamson 1:15:45 Like a prepper.

Dr Peter Attia 1:15:46 (laughs) Yeah. So, um, unfortunately, they only come in sevens, which is a-

Chris Williamson 1:15:51 There's no way, dude. I would, that would take-

Dr Peter Attia 1:15:52 No, yeah, you can't do it all at once. Uh-

Chris Williamson 1:15:54 That would be in my mouth for 30 seconds and then I would have to take another one.

Dr Peter Attia 1:15:56 Yeah, yeah. So I go in, out, in, out, in, out, in, out.

Chris Williamson 1:15:59 Yep, yep, yep, yep.

Dr Peter Attia 1:15:59 Um, I think they have a four as well-

Chris Williamson 1:16:01 Got you.

Dr Peter Attia 1:16:01 ... which is a little bit more manageable.

Chris Williamson 1:16:03 Yeah. Zyn-

Dr Peter Attia 1:16:03 But truthfully, like, I think two milligrams is sort of the right dose. One to two milligrams is probably the sweet spot.

Chris Williamson 1:16:07 And then you don't need to dick about taking it in and out as well.

Dr Peter Attia 1:16:09 Yeah, yeah, yeah, yeah, yeah. Um, so, so, no, to be clear, like, uh, the, the, the nicotine is not the problem.

Chris Williamson 1:16:14 Yep.

Dr Peter Attia 1:16:15 Right? Uh, it's the, it's w- uh, just like with cigarettes. Nicotine is not the problem with cigarettes. Yes, there's an addictive component to it. The problem is the toxicity of the vehicle that's delivering the nicotine in the form of tobacco. Well, with vaping, I don't have any sense of what's happening when you have a heated metal filament that is burning combustible products, some of which I may or may not be inhaling through a filter. Like, uh, uh, what I'm saying is not that I know there's something wrong