#144 - Phil Maffetone: Optimizing health and performance through maximal aerobic function

1. 0:00 – 2:30

   Intro

   1. PAPeter Attia0:01

      [upbeat music] Hey, everyone. Welcome to "The Drive" podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, full stop, and we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in-depth content if you wanna take your knowledge of this space to the next level. At the end of this episode, I'll explain what those benefits are, or if you wanna learn more now, head over to peterattiamd.com/subscribe. Now, without further delay, here's today's episode. [upbeat music] My guest this week is Phil Maffetone. Phil is an author, a coach, health practitioner. He wears many hats, and many of you will probably recognize him as he's written a number of books, the '80s, '90s, and today, basically covering a number of aspects of exercise, sports medicine, biofeedback, nutrition. I first probably came across Phil's work when I was in college, and I was interested in aerobic training, trying to improve my cycling performance at the time, and became pretty interested in, in the way he was advocating for a very low intensity relative to what I was doing approach, which of course today in hindsight seems to be quite the logical thing to do. Phil's background is in biology. He has a doctorate in chiropractic, and he also has trained in, in Chinese medicine and kinesiology. He was in private practice for about two decades, and he's now a consultant, along with continuing to write, doing independent research, and lecturing. In this episode, we talk about his journey, you know, how he became interested in this, both as an athlete himself and then ultimately as a coach. We get into what is maximal aerobic function, and this overlaps very closely. In fact, you could argue this is a very similar way to describe zone two, something we speak about in a previous podcast, but coming at it through a sort of different lens and using heart rate as opposed to lactate to measure it. We get into the importance of fuel partitioning in addition to different levels of intensity. We talk a little bit about marathon times and how they've changed over time and what that probably tells us about training. So I hope you'll enjoy this episode, and without further delay, please enjoy my conversation with Phil Maffetone. [upbeat music]

2. 2:30 – 11:00

   Phil’s background in running, and training insights from a six-day race

   1. PAPeter Attia2:34

      All right, Phil, thanks so much for making time so late in your day. You're in, uh, where are you? Are you in Portugal right now?

   2. PMPhil Maffetone2:40

      I'm in Lisbon, Portugal, and you know, they don't have dinner here till 9:00 or 10:00 at night, which I usually skip, so it's just past lunch for me. It's great to be with you, so thanks Peter for, for having me.

   3. PAPeter Attia2:54

      Well, I've been wanting to speak with you for quite some time, and we've got a lot of listeners who have been excited about getting you on. A lot of questions have come about. We've talked a lot about aerobic efficiency on this podcast because obviously it's such an important part of delaying the aging process. So even if you take it out of the context of performance, I think today we'll, we'll sort of talk about both of these things, sort of performance and health. But it's obviously something that you've been working on for such a long time. It's been kind of central to the work you've done. But I, I kinda wanna go back and give folks a, a bit of a sense of how you cut your teeth on this stuff. So you're obviously an avid runner yourself, correct?

   4. PMPhil Maffetone3:34

      I've been running since, yeah, since high school, I guess, and from track and field in high school and college. And then when I got out and into practice, I thought, "You know, this road running stuff looks interesting. I'm starting to see patients. Let me, let me see what's going on." And I, you know, I jumped into a 5K and it was a complete disaster because I was a track runner, and what do we know about distance? And gradually, I progressed to the marathon. I trained for a six-day running race on a track because I had been working with some ultra runners, Stu Middleman in particular, and it looked like such an exciting event. I thought this... You know, "I'm gonna do this." Then I can s- you know, my bio could read I've run everything from 200 meters to six days. I thought that was cool. Of course, I was-- by that time I was so busy with, with treating other athletes that I was just not able to get the time on the training. All the training was on a track because the race was on a track.

   5. PAPeter Attia4:40

      Yeah. Tell people what a six-day race is.

   6. PMPhil Maffetone4:43

      Yeah. A six-day race is a, a running race where you run on the track and the, the person who accumulates the most miles or kilometers is the winner. You can run as you please. You can start and stop any time. You can sleep if you want. If you can stay awake, good luck. And I, I trained some people, and it was, for me, a f- fascinating thing clinically. It was really akin to having a, a mouse in a lab where you, you know, you do something to this mouse and then you put him back in the cage and have him run on the, on the wheel for a while, and then you take him out and you do something else, measure something, and you know. It was such a great learning experience for me, and it was a great opportunity to really hone my skills of observation in terms of gait and talking to an athlete, finding out when they really were tired, unlike what they said. It was just so many really fascinating things. And then the idea of doing the race seemed quite interesting, and I just ran out of training time, and so.

   7. PAPeter Attia5:52

      What is the ideal strategy? In my mind right now, I'm going through multiple ideas for how one could approach a six-day race. And, you know, one idea that comes to mind is you simply walk 18 hours a day and sleep six hours a day, or, you know, you walk 20, sleep four, and never put yourself under incredible duress, but also never go too fast, the sort of slow and steady wins the race approach. And then alternatively, you can see something crazy where you, you know, actually take out a, a reasonable clip and run for, you know, an hour and take an hour off. But of course, in that scenario, you don't really get a full recovery. So what did you discover was the optimal scenario for covering the most amount of ground in six days?

   8. PMPhil Maffetone6:36

      What I discovered was you, you, you start the race by walking, and now you're the only runner who's walking. The gun goes off, everybody starts running, you're left walking, and that was always a kind of a comical scene for me and the runners I worked with, Stu Middleman in particular, who has the-- maybe still has the American record for that distance. They were a little embarrassed in the beginning, but the strategy was to start slow, gradually run faster, start jogging, gradually hit a, a certain plateau using the heart rate, that maximum aerobic heart rate that we can talk a-about at some point. So very easy, relatively easy, relatively low heart rate, and then now you're two hours into the, the first run, maybe three hours, and then you start cooling down, and you take a half an hour to cool down, basically just the opposite of what you did in the beginning. And now you can get off the track and take a very short break, and then get back on the track and do the same thing. And that segment w-would sometimes be elongated in the beginning in particular because people are kind of jittery and they want to do something, and taking a break is not something they want to do. And so there's no hard running. Certainly, there's no high heart rate, high intensity training. You do see that in, in other athletes, and that's how the days go by. That's it. So you spend a, a fair amount of time walking. And with Stu in particular, as an example, Stu really liked the idea of going for 36 hours without sleep. And I said, "Okay, let's try it." And it, it worked out well, so we did that, and then we took a longer break before getting back into a 24-hour cycle. I tell you, the interesting thing for me is that it was exhausting for me because I really had to be awake longer than, than he did because I couldn't sleep when he slept because we had a specific timeframe for him to sleep, sometimes as short as seven minutes. And I needed to be awake when he was waking up because sometimes he [chuckles] didn't know where he was. And so for me, it was quite a stress. It was qui-- I mean, the circa-- you know, you're interfering with your circadian rhythm so much that you could literally hallucinate after day four, by day five potentially, and I've, I've done that. So it's a very different kind of event than most runners have ever experienced.

   9. PAPeter Attia9:17

      Yeah, it sounds a lot like RAAM, the Race Across America in cycling, which I interviewed a guy named Mike Trevino a while ago, who has done RAAM a number of times, and his stories are, are very similar to that. And again, very different strategies that many cyclists will take, but there's nobody at the end of that that's not in, uh, a significant world of pain. And the hallucinations can lead to crashes and all sorts of crazy things, and it's pretty high-stakes racing.

   10. PMPhil Maffetone9:44

       It's a obvious indication of, of significant brain stress. But I think the key is to, l-like with everything else, individualize it with your athlete. And, and like I said, Stu had this idea that he wanted to go for 36 hours, which we had talked about a lot beforehand, and that became part of the strategy because that's something that he wanted to do. And the way we did it seemed like we weren't gonna sacrifice his health much, and so it was okay for me. And I think in, in-- whether you're on a bike or running or whatever, you, you, you need to, as a coach, as a clinician... And in that kind of race, I served as a clinician because I did things like biofeedback, neuromuscular biofeedback. Obviously, there's significant stress in that area of the body. You still wanna allow the athlete to voice, you know, how they would like to do this race, and then you wanna voice how you think it should be done. You come to some meeting of the minds. But for me, it, it was always, I'm not willing to sacrifice the health of this athlete because that's, that's against what I do as a clinician. As a coach, I want him to perform his best, and he was running

3. 11:00 – 18:15

   The difference between being “fit” and being “healthy”

   1. PMPhil Maffetone11:00

      about 100 miles a day for six days. That's, that's not a bad performance.

   2. PAPeter Attia11:04

      Wow. At what point did your thinking start to transition from the training of peak athletes to sort of a broader set of metrics or parameters that could be applicable to health? Or did that not occur in sort of the fashion I've sort of described it?

   3. PMPhil Maffetone11:24

      It occurred the opposite way. I always loved sports. I loved sports myself. I competed at a very high level. I played other sports. And in undergraduate school, my goal was, "Hey, I wanna study and get out into the world, and my goal is to help people." It was my goal was to help people with their health, and I knew there was this fitness thing, and I wasn't sure how it goes together, but I, I, I didn't focus it. The athlete component was not really there in, in those early, early days. When I got into practice and started seeing athletes who were injured, they were local athletes who were You know, they were, they were 5, 10K runners, half-marathon runners. Some of them were marathoners. You know, this was the, the boom in the '70s, and there were a lot of patients because there were a lot of injuries, and so my focus was, "Why are they getting injured?" And I would gradually see better and better athletes locally. That led to two things. One, some of those athletes got really good and, and attained a national class level, and, and then they referred people that they knew who were professionals, and I started seeing pro athletes who were in running, of course, because that was the big thing back then. But there was this thing on the West Coast called the triathlon, which just fascinated me to death because I was a swimmer and I was a cyclist and a runner, and to have three events to work with was just... It was exciting. And I started seeing some local people who were... You know, I was in the New York City area, so I was on the East Coast, where it took a while for the word of triathlon to get there. And when it did, there were some athletes, and that was a lot of fun as well.

   4. PAPeter Attia13:19

      So this is now sort of late '70s, right? When the triathlon movement starting in Hawaii b- kind of migrating over to California and the West Coast?

   5. PMPhil Maffetone13:30

      Yep, and it was still new. It was crazy, and all we, all we really knew about it were these, these three guys in a bar who were arguing about who's the better athlete, the swimmer, the cyclist, or the runner, and, you know, blah, and that... I don't know how accurate that story is, but supposedly that's, that's how the event started. And interestingly enough, early on, there was a double Ironman.

   6. PAPeter Attia13:53

      Mm-hmm.

   7. PMPhil Maffetone13:54

      I worked with somebody who, who did that. But yeah, that was late '70s and then into the '80s, and by then I was seeing some professionals in most sports by then. Certainly by the m- by the mid-'80s, I had seen professionals in all sports.

   8. PAPeter Attia14:09

      And by the mid-'80s, what fraction of your practice is professional athletes or athletes competing at a very high level versus normal people who are coming to you saying, "I'm overweight," or, "I have diabetes," or something like that?

   9. PMPhil Maffetone14:25

      Gosh, I, I'd have to... You know, by then my clinic was so busy I was taking on associates, so I had other doctors in the clinic. You know, my goal was for them to treat the local patients I had because I was now starting to travel with athletes, which I hadn't, hadn't done. Mark Allen was a patient of mine by that point in, I think it was '83. I had been doing some sports clinics, uh, on the road in various cities. San Diego was one, and that's where I first met Mark and Paul and Newby Fraser and some of those other folks who were just getting going. And so by the mid-'80s, I was on the road a lot, and certainly by the mid-'80s, I was in Boulder every summer because that's where a lot of athletes went, and so I went there. So by that point, most of the patients I had were competitive athletes who I was working one-on-one with, uh, and I was doing a lot of lecturing, starting to do a lot of writing as well.

   10. PAPeter Attia15:30

       So at what point did you sort of, I would say, congeal the idea that said, "Hey, we need to train at a lower level of intensity for longer periods of time"? You know, we're gonna get into obviously the methodology, but I, I wanna talk even broader than that, which is did you look at athletes and say, "Wait a minute, something's amuck here. These people are training too much," or e- either, either volume is too high or intensity is too high, but something is off and we need to do something that's sort of counterintuitive, which is dial this back in one or both of those metrics. Was there-- Did you sort of see that in the '80s?

   11. PMPhil Maffetone16:10

       Oh, I saw it before the '80s. I saw it quite early because I was seeing these people who were, were able to run a marathon in whatever time, and that was like, "Wow, this guy could run a marathon. What an example of optimal health." Well, it, it wasn't, 'cause they were broken down. They were getting sick. You may remember, I mean, back then, you know, it was a badge of courage to have a high white blood count because you were a runner.

   12. PAPeter Attia16:38

       [chuckles]

   13. PMPhil Maffetone16:39

       And I, I started putting all these things together, and it was pretty clear that something wasn't right. Cooper's Aerobic revolution was not... Something wasn't working. You don't just go out and train and, and everything falls into place. These people were falling apart. So that, that was in the '70s when I started seeing that, and I was having a hard time understanding that relationship between being healthy and being fit. And when I ran the, the New York City Marathon in 1980 and I crossed the finish line, it just hit me, these athletes are fit but unhealthy, and that whole concept of fit but unhealthy, and fitness and, and health are two separate definitions, and they need to be balanced, whether you're a grandmother who goes out for a walk four or five times a week, or you're training for the race of your life as a professional. It's all the same. And many of the things that I developed, like the, the MAF test, for example, were never meant for athletes. They were meant for the average person because I thought, "Whatever we're doing to this person to help them get healthier, we need an indication, not just a blood test." We don't wanna know if their blood picture looks better.

   14. PAPeter Attia17:54

       You want a functional test.

   15. PMPhil Maffetone17:56

       We want a functional test that at the time didn't really exist. And so the functional test for me was that they were gonna be able to walk faster at the same low heart rate than they could a month or two earlier, and that was, that was the big thing. And then, uh, soon after that I said, "Hey, wait a minute. These guys are running faster now at the same

4. 18:15 – 24:00

   Defining the aerobic and anaerobic systems, and why VO2 max doesn’t predict performance

   1. PMPhil Maffetone18:15

      heart rate and I, I thought, "Wow, this is, this is interesting." [chuckles]

   2. PAPeter Attia18:21

      Can you give folks an explanation? Let's assume that people aren't entirely clear on the nomenclature between aerobic and anaerobic fitness. This will allow us to, I think, more accurately talk about what submaximal means and maximal and all of these things. People have heard the term VO2 max, but I think it's important to give a bit of a context for where that'll fit on the spectrum. So can you explain to folks what we mean by aerobic and anaerobic systems?

   3. PMPhil Maffetone18:48

      Yeah, and, and, and I don't wanna go into the, the microbe, uh, definition, which is where a lot of us have learned those terms. You know, there are aerobic microbes and anaerobic microbes. So the anaerobic microbes are without oxygen. And when patients would say, "Well, I, I, I wanna do some anaerobic training," I'd say, "Well, what is, what is that?" They said, "Well, it's without oxygen." I said, "You mean you can hold your breath while you're doing the intervals?"

   4. PAPeter Attia19:15

      [chuckles]

   5. PMPhil Maffetone19:15

      And so we need a better definition, and my definition became fat burning was, was associated with aerobic and all of the factors that are associated with fat burning, so the aerobic muscle fibers in the mitochondria and the ability to convert fatty acids into energy, into ATP. And anaerobic was the glucose side. And that was simple enough. It wasn't scientific enough, but it was simple enough for what people needed to understand, and especially when we can come up with a heart rate that says, "Well, if you go over this heart rate, you're drifting into that anaerobic state, and if you stay under it, you're in an aerobic state. And therefore, you're training your body to burn more fat as an energy source. And therefore, you're gonna store less fat and, and you're gonna get rid of any excess fat," and so on and so forth.

   6. PAPeter Attia20:11

      Can you explain to folks what the VO2 max is? Because I wanna spend some time explaining why it's not a great predictor of much, despite the fact that it certainly produces boasting rights.

   7. PMPhil Maffetone20:23

      It produces, [chuckles] for sure, boasting rights. It's a number that people talk about. Everybody talks about it and hardly anybody gets tested, and almost nobody gets tested with some regularity so they could do something with the numbers. We can define it academically, which doesn't tell you much, but it's a test that is, was developed a long time ago, and so there's a lot of tests around. And the real question is what does it really mean? And I'm not sure it means a whole... I didn't do many of those tests. So I, you know, I had an academic education and, and I knew about VO2 max and I knew about all this traditional stuff, the 220 formula which I used in the very beginning because I thought that was the science of, of exercise physiology and quickly learned it wasn't. And VO2 max was right there and, and VO2 max became the tradition. I think it was the tradition back then. I don't remember when it was first developed. It was by Hill, wasn't it? Back in-

   8. PAPeter Attia21:30

      I actually don't know who developed it

   9. PMPhil Maffetone21:31

      ... the 1920s maybe

   10. PAPeter Attia21:33

       But for listeners, I think it's, it's a relatively straightforward test to administer provided you have the machinery. And the machinery is complicated because you have to be able to isolate gases very well, specifically oxygen and carbon dioxide. So the test is normally done on either a treadmill or a stationary bike where you can control the resistance or the, the load that the athlete is under. The challenge is creating an airtight seal around their nose and their mouth because what you're really doing with the test is you want to measure how much oxygen is coming out of their respiratory system and how much CO2 is coming out because you know how much is going in. And therefore, the difference is the amount of oxygen consumed. Now, if you're sitting here at rest, you have a VO2, an amount of oxygen that's consumed. And the purpose of the test is to ramp up the level of exertion until you reach the maximum level of oxygen consumption. So VO2 max is simply the maximum amount of O2 consumed. And the difference between a very fit person and a non-fit person is the fitter you are, the more oxygen you're able to consume, and that's basically a function of your muscles. It's what can the muscles do? So I think a lot of people erroneously think this is a, a test of the heart and lungs, but it's not really a test of the heart and lungs, right? The lungs is where the gas exchange is happening. The heart is the circulatory pump. It's really a test of what your muscles can do in terms of utilizing that oxygen. And to your point, it's how much fat oxidation can happen because that's where you're utilizing the oxygen is in the mitochondria to oxidize fat. But all of that said, the research actually says that you can't predict marathon finish time by VO2 max.

   11. PMPhil Maffetone23:37

       You're right, and people don't like hearing that because they have this idea that this set, now this VO2 max is directly associated with performance. So they need to rev up their VO2 max by doing hard training which will get them performing better and that, you know, that's where the whole system breaks down. That's the problem we have. This VO2 max

5. 24:00 – 37:30

   Defining maximum aerobic function (MAF), determining your MAF heart rate with Phil’s 180 Formula, and why a strong aerobic system is crucial to health and performance

   1. PMPhil Maffetone24:00

      is a, it's something we, we have been worshiping and we're worshiping the wrong thing.

   2. PAPeter Attia24:07

      So tell folks what MAF stands for.

   3. PMPhil Maffetone24:11

      MAF stands for maximum aerobic function. And in essence, the goal of being healthy or the goal of being fit is to develop the aerobic system. This is what our ancestors did. This is how we got here. We developed a really incredibly powerful aerobic system by doing the things in our lifestyle that drive that aerobic system to develop, which includes eating more fat, not eating much carbohydrate, eating moderate amounts of protein, maybe even relatively small amounts of protein for the earlier humans because we were, we were not the hunters in those early stages. But we, we certainly ate a, a, a large amount of fat. And we didn't sprint after animals, we jogged after animals. And so all of that is how we, we developed. We developed bigger brains, bigger bodies. We developed bodies that had great longevity and a higher level of health to match that longevity. And it doesn't take long when you start reading about this, and, and, and it was really an anthropology course, I think, that I first started reading this kind of stuff. And it was really quite fascinating 'cause I said, "Well, if that's what they were doing, why are we doing all this other stuff now?" And that sort of got me thinking about this as an undergraduate student because it seemed pretty clear what our ancestors were doing, and the fact that they were doing it for so long, you know, just what happened between some time ago and now? How did we get into the mess we're in? And so the concept of maximum aerobic function has been really with me for, for quite some time. When I was working with runners, which is almost all the athletes I worked with certainly in the '70s, I started talking about the pace that these athletes could run at with this given heart rate that I had come up with, this aerobic heart rate, and I called it the maximum aerobic heart rate. And so the pace they were running was the maximum aerobic pace.

   4. PAPeter Attia26:30

      And how did you come up with that heart rate?

   5. PMPhil Maffetone26:33

      That heart rate was derived in combination of a physical exam in my office. I wanted to know how healthy they were. I wanted to know about their history. What did their labs look like? Their posture, their strength, and so forth. And then they... I would go out to the track, and I would monitor their heart rate. I'd monitor their gait while we used different heart rates. And so I'd see them at a 120 heart rate. I'd look at their gait. I'd say, "This is some pretty good gait." And then we'd go to 130. "That's a pretty good gait, maybe even a little better." And then they'd go to 140, and I'd start seeing irregularities. And then I'd bring them back to 130, and I'd see a, a nice smooth gait again. And I'd put all that together, and I'd assign them a certain MAF heart rate, and they would go train, and then I would test them again to see if it correlated, and it was a long process, and it was-- it would not be for two or three years when I developed a formula, which I never used personally because I always wanted to do it manually. But they correlated so well. And you may have heard me say I was lecturing one day about this and how I came up with this heart rate and what it meant and how people were benefiting from it. And somebody said, "Well, how do we come up with that heart rate?" And I, I didn't have an answer. And I started realizing that, well, there's probably some simple mathematical process that I can go through to use the, the athletes I had. I already know their heart rate. Let's plug in the numbers. And the 180 formula was born. I tweaked that for a couple of years, and the formula you see today is basically the same formula that existed in the early '80s.

   6. PAPeter Attia28:25

      Let's go through it in a bit more detail just to make sure folks understand what we're saying. You're saying that a person is going to be at their maximum aerobic output, so meaning they're gonna be maximally fat oxidizing, at an approximate heart rate of 180 minus their age, plus or minus a few modifications. So I believe there are a handful of these. If you're recovering from an illness or you're kind of in an overtrained situation, you might actually need to discount that by another 10, right? It might be 170 minus your age.

   7. PMPhil Maffetone29:02

      Correct. The key is that you want to individualize it. So you b- you begin with 180 minus the age, which has no meaning, like the, the 220 formula that, you know, you subtract your age from 220, and they say it's your-

   8. PAPeter Attia29:15

      Maximum heart rate or whatever, yeah

   9. PMPhil Maffetone29:16

      ... your max heart rate, and of course it's not most of the time. So 180 minus the age has no meaning. It's just a means to the end. But you now wanna individualize it to your health and fitness needs. So if you're recovering from an illness, if you're severely overtrained, if you're in rehab, you wanna subtract another 10 from that. But if you're not in that category and you only have the typical two or three colds a year, you might have asthma or seasonal allergies, you might be overfat, you might be training for a while, and then you kind of, you lose time, you can't train, and then you get back into it. And in that, in that category, you subtract another five, all the way to the competitive athlete who has no health problems, who has been progressing quite well, they can add five to that number. So in the, you know, that formula, what's important for people is to follow the formula and be honest. That's the hardest part is to be honest. So if you're on medication, for example You've got to subtract your age from 180, and you've got to subtract another 10.

   10. PAPeter Attia30:30

       And what kind of meditation? Does, does it matter?

   11. PMPhil Maffetone30:33

       Doesn't matter. That's the thing. People will say, "Well, I'm, I'm only on this, and that's not really affecting my heart rate," or, or, "I don't have to be on it," or I w- I don't know what. You know, if you're on medication, you subtract 10. And if you get healthy along the way by training this way, and now you can get off your medication, well, now you could redo the formula 'cause now you're no longer on medication. You're healthier. Let's have a look at the 180 Formula again and modify it as needed. You know, it's like doing a, a, a history on a patient. The most important thing is that they be honest because if you don't get the right information, you're, you're in trouble.

   12. PAPeter Attia31:14

       So it's kind of amazing to me, by the way, that you were able to do so much with heart rate back in the '70s and '80s. What, what did you even use for heart rate monitors, or were people just manually checking their heart rate doing these tests?

   13. PMPhil Maffetone31:27

       Well, yeah, I began manually checking heart rates. Uh, there were some finger units that were not very accurate. There were some clips you put on the ear.

   14. PAPeter Attia31:37

       Mm-hmm.

   15. PMPhil Maffetone31:37

       They were not accurate, unlike the earbuds that are used today, picking up the heart rate in the ear, in the ear canal is, is a good measure. And I finally got a heart monitor that was used in cardiac rehab in hospitals, and it was a big, obnoxious, you know, double strap. One went over the shoulder, one went around the chest, and it had this box that was in the middle, and it-- you know, all you got was the heart rate. You could see it in this tiny window, and you can hear the thing beeping. And it would be several years before the wireless monitors came out, which I think was, mm, late in '83 maybe. And when I first started using this heart monitor, I had one in my office. It was like having, you know-- I, I had a stethoscope, okay? And I used it when I needed to use it, and so I had this heart monitor, and I would use it, go to the track, put it on a, on an athlete. We'd use it, take it off, put it on another athlete. And I-- silly me, I thought, "Well, okay, once they feel what 130 heart rate or 150 heart rate is like, they'll be able to train that way." Well, that didn't work. So then I started lending out the heart monitor, and then I had to buy another one.

   16. PAPeter Attia32:57

       [chuckles]

   17. PMPhil Maffetone32:58

       And then I had, like, three of them. You know, it was like, "You have three heart monitors?" "Yeah, I have three in my office." It was like the old, you know, 1950s. People had one television, and if somebody had two television, it was like, "You mean you have two TVs? Wow, that's r-" you know. You know, then people started buying them. They said, "I, I'm gonna train with this 'cause when I train with it, I feel better. I'm not tired. I'm-- you know, my back doesn't hurt anymore," and blah, blah, blah. It progressed that way, and then when the wireless heart monitors came out, everybody wanted to buy one, which was interesting.

   18. PAPeter Attia33:34

       So the formula, the MAF formula of 180 minus age and then adjusted based on all the factors, is a way to basically gauge the intensity. How did you then prescribe volume, and how did you not only prescribe the volume there but determine how much volume to add in that was at a higher intensity?

   19. PMPhil Maffetone34:00

       That's an interesting question. It really began early on when I had no intention of coaching. I didn't want to be a coach. I, I, you know, I wanted to be a clinician and fix people's knees and help them, you know, get off blood pressure medications or whatever. And with athletes, I thought if I could just keep them from getting injured, they'll just perform better because, you know, that seemed to be the thing that slowed them down, getting some physical injury. And I realized that I was treating symptoms. I was, I was really-- You know, it was against my nature to, to do that. I was, I was fixing some runner's knee, and they'd go out and train, and then I'd see them again in my clinic a month later with the same knee problem. I said, "Well, what, what did you do?" He said, "Well, I just did my normal training." And, you know, eventually I said, "Well, let me look at your training." And people would write down their schedules, and I would start looking at it, and I realized that I needed, I needed to have some input on this schedule because what they're doing was excessive. They were literally over-training. And so I became a coach. And I didn't wanna be like a regular coach where I give out a schedule. I wanted them, like I said earlier with, with, with Stu Middleman, I wanted the athlete to be part of the process, you know? I wanted to say, "Well, what would you like to do with your training?" And they'd bring in their schedule, and I'd look at it, and I would just say, "Let me get this straight. You work 60 hours a week, you have three kids and a house, and you do all these social things, and you're trying to run 100 miles a week. That doesn't make sense. You either have to get rid of your kids, get rid of your family, get rid of your job, or reduce the number of miles you're running." And so, you know, I, I got a lot of laughs, and we, we, uh, went on, and I found that people could do a lot less training at a lot less intensity and perform in a race a whole lot better, and it didn't take long to see that. You know, it's like a taper. When you taper, you get stronger. Well, when you cut somebody's schedule down, they can get more out of their training. And so it, it, it worked that way. And so the, the big issue was really this aerobic system stuff. How do you build the best aerobic system? Of course, I had been familiar with Arthur Lydiard, who was a patient in my clinic actually at one point. And so I knew about this concept of the aerobic base and, and it just seemed to make a lot of sense. And what I found through working with a number of patients that if they, if they do their traditional two days a week of interval training on the track, they never got faster at the same heart rate like these other people did, who seemed to excel quite quickly from, from one month to the next. They could be running, starting at a nine-minute-a-mile pace at their MAF heart rate. They might be running 8:30 a month later, same heart rate. A month later, now they're running

6. 37:30 – 40:00

   Using the MAF test to track and improve your aerobic fitness

   1. PMPhil Maffetone37:30

      at a eight-minute pace.

   2. PAPeter Attia37:31

      Okay, so I want, I wanna pause there for a sec. So when the athlete makes progress, when they're doing their MAF test, which again, I just wanna remind everybody 'cause we're, we're talking about both an MAF heart rate, but then the MAF test, and these are very important concepts. So let's go back. So I figure out either through a very bespoke manner or using the formula that my MAF heart rate is 130. I go out and I'm gonna do my training at 130, and I'm running a nine-minute mile. The question becomes, while keeping my heart rate at 130, can I get faster? Can I go from a nine-minute mile to an 8:30 mile to an eight-minute mile? And if I can do that while staying at 130, by definition, I have become aerobically fitter and more efficient, correct?

   3. PMPhil Maffetone38:22

      Correct.

   4. PAPeter Attia38:23

      Now, is there a point at which you begin to adjust up the heart rate and say, "Peter, I want you to now train at 132," or do you keep me at 130 and see how far we can drive that down until I plateau? How do you make that decision?

   5. PMPhil Maffetone38:41

      I keep you at 130 because I've determined that 130 is a good number for you because you're progressing now. Can we cheat a little bit up to 132 and 1, 133 and only to find out two months later that you're back to where you were? I don't wanna spend that time because at some point I've had enough experience to know that's not a, a good use of our time. So we're gonna stay at 130, and we're gonna allow your body to develop that aerobic system. The question people often have is, "Well, how do I run faster at the same heart rate? It doesn't make sense." And the answer is that you're, you're able to generate a lot of energy from fat.

   6. PAPeter Attia39:24

      Mm-hmm.

   7. PMPhil Maffetone39:24

      You're, you're, you're building the aerobic system, so you're, you're increasing fat burning. Now you have more energy. You have, uh, you have this steam engine. The more wood or coal you throw in there, the more that engine can, can go and the faster it can go. And you will progress, and you'll month after month get faster and faster. At some point, you will hit a plateau, and, and early on I realized it, it took three, four, five, six months before people hit a plateau. So there are two issues. One is

7. 40:00 – 43:00

   How increasing your sub-max pace at a given heart rate can increase your maximum pace

   1. PMPhil Maffetone40:01

      do we keep allowing the body to get faster and faster, which for an endurance athlete is the greatest benefit they can obtain. 'Cause if they can go faster at a sub-max pace, they can go faster at a max pace.

   2. PAPeter Attia40:15

      Let's unpack that for a minute. That- let, let's unpack that. That's a very, very important statement. Can you talk about some of the experiences you've had to establish that? And again, actually, before we do that, Phil, let's talk about why that's relevant. You're running a 10K. Let's say at the very competitive level, a 10K is, you know, depending on how competitive, obviously, can be sub 30 minutes, but if you're kind of a recreational athlete who's running competitively, you're gonna be in the, you know, 32, 33, 34-minute range. By definition, you're running well above your MAF target. Is it necessarily true that if you take the top 10 finishers of that race and then a week later have them run at their MAF heart rate, they'll cover greater distances as a function of what they ran in the 10K race? In other words, do you-- do we have evidence that that's true? 'Cause if it is, it's a remarkable statement, right?

   3. PMPhil Maffetone41:19

      We do have evidence that that is true. Hypothetically, you have the outlier who's this guy who can't run nine minutes without hitting a 180 heart rate. These are the people who are over-trained enough to be in that sympathetic state. They get into a 10K and they run a PR, an amazing feat. How could... You know, I've run a minute and a half faster in my p- you know. These are the people that are ready to fall apart at any minute, and I've seen them. These are also the people who are ready to drop dead of a heart attack. And so if we take those outliers away, then yes, we have this hierarchy of, of athletes who have a increasingly better sub-max condition that corresponds to their race pace.

   4. PAPeter Attia42:12

      If that's true then, Phil, it would really lend credence to the idea that even if you're training for a 5K or a 10K, you still wanna push your MAF protocol. It still matters how much you can, how f- how much distance you can cover at that lower heart rate and lower intensity where you are running at your maximum fat oxidation and maximum aerobic capacity.

   5. PMPhil Maffetone42:40

      Yeah, and I think it's pretty clear now that sub-max performance predicts maximum performance. How far down, uh, can you go even for a miler? I think it comes down to how much fat burning do we need, and even for a mile, there's a lot of fat burning

8. 43:00 – 51:45

   The impact of nutrition on one’s ability to use fat as fuel while exercising

   1. PMPhil Maffetone43:00

      taking place in a one-mile race.

   2. PAPeter Attia43:03

      I want to ask you about fat. When I was in medical school, the conventional wisdom was that fat oxidation could not exceed one gram per minute. Now, I didn't think much of it, but many years later when I underwent an enormous dietary switch and I went from being a kind of ultra-distance athlete, basically mainlining carbohydrates, so probably consuming, I would say, five bottles of Powerade a day. So let's say if I was training four hours a day, I would go through five liters of Powerade plus Cytomax plus Hammer Perpetuum, like basically all of these very high carbohydrate formulas, you know, rotting my gut. And when I would do my VO2 max testing, which I did pretty frequently, you get a lot of data on the way up to VO2 max. You're getting all of your fuel partitioning data because you're getting VO2 and VCO2, so I know how much, I know how many calories I'm expending at every level of intensity, and I know what the mixture is of carbohydrate versus fat. So clearly in that state, I was nowhere near oxidizing one gram of fat per minute. In fact, I was pretty much only oxidizing glucose the entire level. In other words, even at my low intensity, I was still a glucose oxidizer. Fast-forward years, several years, I've tried something totally radical. I've gone on a ketogenic diet. I've done it for not just a while, but actually for three years, and I've become very adapted to it such that I can function at high and low intensity, and I'm now doing the same thing. I'm repeating VO2 max testing, but on this ketogenic diet, and I hit a fat oxidation which is still submaximal, so it's just below my VO2 max, but my max fat ox was 1.73 grams per minute.

   3. PMPhil Maffetone45:12

      Wow.

   4. PAPeter Attia45:13

      And I remember thinking, "How is that even possible?" Now, of course, I would go on to learn that world-class athletes training on a very low carbohydrate diet were able to hit 2, 2.1, even 2.2 grams per minute, which I found interesting. It basically said that this conventional wisdom we have about sports nutrition and sports science is largely predicated on assumptions of what people are eating that aren't necessarily the optimal way to go about doing it.

   5. PMPhil Maffetone45:44

      It's a very good point, and I mean, you and I came to that, that same conclusion in different ways, and we also had the same studies to look at, the same lab tests to do. And unfortunately, we had a lot of the same subjects, or we read about studies that used the same subjects, which were big carbohydrate eaters that distorted the research completely. But all along the way, I, I, I knew there was something about fat, and the question is, "Well, how could we really measure it?" And I knew we could do it in the lab. My clinic was in the middle of... I mean, I was in the New York City suburbs at the time, so I occasionally had access to a lab, occasionally could get somebody in there to test, and occasionally they would say, "Wow, this is amazing. How could this person burn so much fat? We don't understand this. It must be a problem." And then, you know, as the months and years went by, you know, it was not a problem anymore. This was great. And so all along the way, for me, it was always, "I know what's going on. I'm, I know this athlete's getting healthy. I know they're burning more fat because they're running faster at the same MAF heart rate." And now we're starting to see it be measured. And it was a point where I said, "I can't be the scientist. I'm not really a scientist. I do wear that hat, but I'm too busy being a clinician and coming up with all these crazy tests." And still, my primary concern was helping people get healthy and, and fit. And if it was an athlete, it meant they were gonna perform better, but not by sacrificing their health. And if they were not an athlete, we still had a lot of work to do. And, and it was only after a while that I started thinking more scientifically. I always thought scientifically. Depending on who you ask, you know, if you ask a scientist, they would say, "Well, I'm not, I'm not being very scientific when I explain this MAF heart rate." And if I ask a clinician, they say, "You know, you're, you're too scientific about this." So I gradually became more and more scientific only because, A, it was fun, especially reading the new research, and B, it was much better for me as a clinician to explain things in scientific terms. I still had that scientific mentality of this is how we communicate to the rest of the world from a scientific standpoint. So the fat burning component became that factor that we can measure more and more, and like the s- the story you told of the changes you made and how it affected fat burning. You know, I, I started gathering that kind of data and started writing more. As a clinician, you can't publish papers. You just can't... You know, your brain is unable to, to spend time doing that because you're spending so much time doing other things. And it wasn't until after I left my clinic, because healthcare was getting so bad I, I just couldn't do that anymore, and I, I ended up only working with, with athletes, and so healthcare was really out of the picture in, in many ways. And then I was able to spend more time thinking and writing scientifically and start publishing more. I, I wrote a textbook. I started publishing more scientific papers and talking about all this with a scientific hat on rather than merely a clinical hat. Although a lot of the scientific things I've written are clinical-oriented, because that's still my goal is to help people, and one of the ways of helping people is to help other clinicians who can then in turn help their patients.

   6. PAPeter Attia49:48

      There's something about this nutritional component that I think creates a lot of confusion for people, which is that it tends to be in flux. So it's not constant. When I was young, so call it the first athletic phase of my life, which I would say is about age 13 to 18. So between the ages of 13 to 18, I was indestructible, just like most 13, you know, to 18-year-olds are. You can do anything. There is no such thing as over-training, nor is there such a thing as overeating. I could consume such comical amounts of food, and they were really not of high quality at all, right? So, you know, breakfast would be a box of cereal and a large Tupperware bowl, the entire box. I mean, six or seven sandwiches for lunch every day. So a whole loaf of bread turned into sandwiches, plus french fries, plus a one gallon thing of orange juice. I mean, just disgusting quantities of food. But absolutely no impairment of performance or health, at least by any measurable amount. But by the time I'm in the sort of second and third phase of my life, into my late 20s and my 30s, my tolerance for that amount of carbohydrate went down. And so even though I was still exercising a lot, uh, certainly by, by any normal standard, you know, I metabolically became quite sick. And I became the example of that guy who can't outrun his bad diet. Uh, although in my case, I was out-swimming it. I was trying to out-swim it or out-ride it. And so how did you then, either as a coach or as a clinician trying to help just a normal person, calibrate not just the intensity of exercise, not just the duration of exercise, but now this

9. 51:45 – 58:00

   Phil’s nutritional approach with patients, the concept of “carbohydrate intolerance”

   1. PAPeter Attia51:45

      third layer, which is specifically what is the carbohydrate tolerance of the individual, given that, one, two people can be, uh, similar and very n- in a number of ways, and yet be different in that regard, and secondly, any given individual is likely going to see a, a, a deterioration of that over time?

   2. PMPhil Maffetone52:04

      Sure, and we, we all become more insulin resistant as the years go by. I, I like to call it carbohydrate intolerance, because as soon as you say insulin resistance to the average person, they either shut down, or they panic, or they totally ignore you because that's a hard... It's a hard term to relate to because they can't relate to it. Carbohydrate intolerance, at least when you say, "You're not tolerating the level of the amount of carbohydrates you're eating, so you need to cut down," they can relate to that. They may not be happy, but they can relate to that. But the, the more important factor was one that I already knew about, although I didn't know how to apply it to patients. But I already knew going... Again, going back to undergraduate school where this idea of holism, you know, it came from philosophy really for me. This holistic idea showed up one day, and I think out of that came this idea that we're all individuals, and we all have uniquenesses, and I carried that with me into my clinical world. And there wasn't much to do. You know, to measure insulin resistance back then meant going into the hospital and having a glucose clamp test. You... That, that was just unheard of. They laughed at me when I sent patients to the cardiologist 'cause I wanted to see... I want to measure heart rate variability in this patient because I think there's an autonomic problem. Well, half of them didn't have any problem, but the other half did, and they said, "Well, gee, how do you know that?" You know these things as a clinician because you do a good evaluation. You assess the patient, and you spend a lot of time talking to the patient, something that's not done n- anymore. Wasn't done much back then either. But by doing that, you learn about the patient. You learn about so many things, including insulin resistance. How sensitive are, are they to insulin? How do they respond? An obvious example is a New York City executive, works in an office all day, training for a marathon, goes out for lunch, comes back, and is so tired that he has to put his head on the desk and literally fall asleep. Obviously, "Bob, what did you have for lunch?" Well, you start putting two and two together, and it's, it's not that hard. And then just like the MAF test, where you want to see what is this person capable of doing at this given heart rate- I came up with a, another challenge, which was a food challenge called the two-week test. "Okay, Bob, I want you to not eat those things at lunch anymore. I don't even wanna have you eat those things for breakfast. In fact, let's take away all the junk food from your diet and take-- and cut way down on the natural carbohydrates like lentils and beans and rice and fruits and fruit juice, et cetera, and we'll do it just for two weeks. It's a challenge. We wanna see how you respond." So we gather all the signs and symptoms that are not normal. "I fall asleep after meals. I fall asleep easily at night because I'm so exhausted, but I wake up at 2:00 A.M.," et cetera, et cetera. "Okay, let's, let's put these things on the table. Let's do this two-week test. After the two weeks of eating that way, let's look at all these signs and symptoms. Are any of them better? Are any of them worse?" "Well, yeah, three-quarters of them are better." Of all the miracles I've seen in, in clinical practice, the two-week test is one of them, because you see these people become new people after a very short period of time, and it's really amazing. I mean, it's because insulin is involved. Insulin has immediate effects. Carbohydrates have immediate effects. The two-meal effect with... You know, it's just, it's an almost an instant change. So now you've, you've gathered more information. You're still assessing the patient, but now we can start individualizing things more and more, and that process was just ongoing. And again, I, I always wanted to enlist the patient, so I, I wanted to say, "Okay, you've done this two-week test. You're feeling so much better after two weeks. Now we want you to add some lentils to your midday meal or add a, a small piece of fruit at breakfast or whatever, and let's see how you feel. Let's see if some of those signs and symptoms come back with just one piece of fruit or let's see if you've lost 10 pounds, you're, you're starting to gain after a couple of weeks of only having a little bit of carbohydrate," whatever. But I want to enlist them in the process. I want them to use their instincts and intuition, which we all have, to understand what it feels like to eat too much carbohydrate before you've gotten there. "One more bite of this apple and I'm in trouble." I want you to know that. I think it's a very important thing. It's a very human thing. And so that holistic component, that individualizing aspect of my work has always been there, and it, in many ways, it makes it easier. People might say, "Well, if you just give somebody a diet, it doesn't get any easier than that." Well, it doesn't get any rewarding when you do that either. So it was a very important part, and it still is a very important part, even though I'm not sitting with patients one-on-one anymore, usually. I may do some consulting, but I am writing. I am still lecturing and, and I could take that

10. 58:00 – 1:04:45

    Assessing the impact of a low-carb diet on high intensity exercise and anaerobic performance

    1. PMPhil Maffetone58:00

       component of individualization, of holism, and get those points across to people so they can take that and run with it, so to speak.

    2. PAPeter Attia58:11

       Now, I, um, again mentioned that, you know, spent all this time on a very low carbohydrate diet and saw, you know, enormous improvements in my aerobic fitness. When it was all said and done, my anaerobic fitness, my higher level intensity fitness did not deteriorate, but it took a very long time for that to come around, and the conclusion I drew from that was athletes who were heavily involved in glycolytic activity really ought not restrict carbohydrates as much as, say, athletes who are doing things that can be done at a much more aerobic level. Now, a couple of years ago, you were part of a study that sort of flew in the face of my assumptions, because it was a very short study. It was a four-week study, and it put athletes on a very low carbohydrate diet. They averaged less than 10% and maybe 15% protein, so they were, you know... If they weren't on a ketogenic diet, they were very close to it, and they were doing high intensity interval training, and you guys didn't find any difference between the groups, suggesting that this amount of carbohydrate restriction did not impair performance. What can you say about that study?

    3. PMPhil Maffetone59:28

       It was a good study. Part of it, actually, we published a separate paper on, on it showing that the, the high fat diet did not have any adverse effect on inflammation. But that study really came from this idea that athletes can still burn high amounts of fat when they do interval training. Paul Larson did... You know, that's how I met Paul. They did a study some time ago. They showed that high intensity training can still produce large amounts of, relatively speaking, fat burning, as opposed to, you know, burning 100% carbohydrate like you were mentioning earlier. I sent him an email and I said, "Yeah, well..." I sent him a, an athlete I had worked on who we had done some, some lab studies on, and at, I don't remember the numbers, but at about a 180 heart rate in this 36-year-old athlete, he was burning a lot of fat, relatively speaking. And I said, "Yeah, here, you know, here's a, here's an example of what I found clinically and, you know, and so we've known this for a long time. It's good to see that you're doing this." And, and, uh, he wrote me back and w- you know, we've been colleagues ever since, and he was in that study. So it was a study that showed what we al- already knew clinically in, in a sense, and we want to, we want to demonstrate it from a lab standpoint.

    4. PAPeter Attia1:00:53

       Do you remember how many participants were in that study?

    5. PMPhil Maffetone1:00:56

       I want to say 20, but I, I-- that seems so long ago. [chuckles]

    6. PAPeter Attia1:01:01

       Okay. Yeah. So, I mean, it would be interesting to see if with a larger sample size that is still the case, and obviously at different levels of the athletes incoming, right? In other words, is that true of recreational athletes only? Is it also true of high-level athletes?

    7. PMPhil Maffetone1:01:19

       Yeah, these were students. I think Jeff has done, Jeff Volek has done some, some studies with the higher level athletes, with some ultra-athletes. Again, they're, they're not running as fast, but they're running at a max level. These were students, and these were subjects who, the ones who, who were on the very low carbohydrate diet were only there for a month. And my feeling is we really should have gone longer. I think we could have seen different results, but, but they were only there for a month. A month is long enough for some people, but not long enough for others, and there's a g- good argument to make that, you know, it should be two months or even three months to really stabilize that metabolic change. But whatever. It was a good study and, you know, like other studies, somebody will see it and say, "Hey, this should be done with more people," just like you said. Let's get more numbers. Let's get a wider age group. Let's get beginners, athletes, you know, middle of the pack runners, professional athletes. Professional athletes are really hard to get 'cause they don't wanna do this. They don't wanna go into a lab and do that. But from a clinical standpoint, I love all these studies. I love being involved with them. But for me, the bottom line is, can you, the athlete, run faster at the same submax heart rate? In fact, I don't care what you do with your training or your diet, if you could run faster at the same heart rate as the months go by, whatever you're doing is working. Keep doing it. So that MAF test is so powerful that that's really the only thing you have to sell people on. And then when they start seeing that they're, they're not getting faster, or when they see they've gotten faster and now they're gonna start doing some weight training, fatiguing type weight training, or they're doing some intervals, and then they get slower, you know, now you've got their attention. Now you say, "Yeah, see, do you understand what's happening?" And, you know, they, they start feeling it because they say, "Well, you know, I, I felt it wasn't quite right," or, "I didn't feel comfortable doing that," or, "I didn't..." You know? So when I first started using a heart monitor, I thought, "This is, this is interesting. This is biofeedback by definition. We're, we're gonna listen to or we're gonna look at our heart rate, and we're gonna respond to what that heart rate does." And the goal is to be able to do that without this heart monitor. So I thought really these heart monitors were just a one use, maybe for, maybe spend a whole week doing it. Now you, you know how to run at 130 heart rate. It never happened. Once in a while, I see an athlete who knows exactly where they are. They know exactly w- when they could run at that max fat burning level, and I've always been amazed by that, and there are some good ones and some mediocre runners who, who are able to do that. But most people, we are in a no pain, no gain world, and we're seeing injuries because someone watches the New York City Marathon on TV, and the next day they go out and they wanna run like that

11. 1:04:45 – 1:13:30

    Extracting insights from world-class marathoners

    1. PMPhil Maffetone1:04:45

       lead pack runner. They wanna stride out like... You know, come on, man, you can't even break four hours in the marathon. No wonder you got injured. [chuckles]

    2. PAPeter Attia1:04:55

       Speaking of the marathon, I, I wanna talk about this, this book you wrote in 2014, which was just such a brilliant idea. The title of the book is "1:59: The Sub-Two-Hour Marathon Is Within Reach. Here's How It Will Go Down and What It Can Teach All Runners About Training and Racing." And of course, five years later, in October of 2019, Kipchoge goes and runs 1:59:40. Now, we can explain to people who care about the nuance that it was not technically a sub-two in a world record pace. It was sort of a contrived example of what could be done under the most optimal conditions. It was not a, a, a race. But there's simply no denying that what Kipchoge did was unbelievable. He had tried a year earlier, and I believe came very close, was probably 2:00, I don't know, 40 seconds or something close, I think, right?

    3. PMPhil Maffetone1:05:51

       Yeah, yeah. He was, he was, he was pretty close.

    4. PAPeter Attia1:05:53

       He was under 2:01. So let's put aside the, the technicality of how this wasn't a, you know, a world record in the typical sense of how world records are run in marathons, but instead just focus on what you thought needed to happen in 2014, why you thought this was achievable, and, and maybe what we learned from Kipchoge.

    5. PMPhil Maffetone1:06:16

       Well, I had originally written an article called "The 1:59 Marathon" back in the '90s. It was half-- I wouldn't say that it was a, a kind of a joke, but it was half goof but half serious because the lead pack runners were running faster and faster. World records were, were being broken all the time. There was no evidence that said, "This is gonna stop. We're gonna hit a plateau, and we're not gonna get any faster." There were people who thought that. I don't know where they got those ideas from. But we started seeing the fact that age group runners were not getting faster, and I thought that was interesting. And, and when you start putting Numbers together, such as what if you wore a lighter shoe, or what if you were three pounds lighter, or what if you were shorter, or what if your body type was this? And of course, what if you were a better fat burner? How much more energy would you have? And then again, the next obvious step is, well, what does your MAF test need to be to run under two hours? And I was getting some runners who were, who were starting to hit five-minute pace for their MAF test. They were running five minutes a mile at their MAF heart rate. And so I thought, there's no indication that, that they're reaching a limit, that they're hitting a plateau in, in performance, so why couldn't it keep going? And that's really where the idea went, and it turned into a book, and I'm not sure it was a book that sold very well. I think, you know, in the '90s when I wrote that article, a lot of people just asked me why I even wrote it. You know, "This is silly. What-- You know, we're not gonna see a 159 marathon in our lifetime." And I said, "Well, how long do you plan on living?" [chuckles] So I think what this runner did was amazing. I don't like what he did. I don't like the whole idea behind it. I still know that a runner's gonna do it in Berlin or, or London on the right day, and it's relatively soon it's gonna happen, and I'll be much happier to see that.

    6. PAPeter Attia1:08:49

       And you're just saying you're not happy with the way it was done because of the sort of contrived nature of it.

    7. PMPhil Maffetone1:08:55

       Yeah, it was, it was an advertisement. I'm not opposed to advertising, but it was, it was more like a circus, and I think it took away from professional running as a sport. That's what I didn't like about it.

    8. PAPeter Attia1:09:11

       Yeah, it was, it was a Nike commercial, for sure. Do we know much about Kipchoge's nutrition or other factors that, that we could, you know, extrapolate from? Uh, for example, in a two-hour race, you know, even at the level he's exerting himself, he technically didn't-- doesn't really need calories. Fluids should be enough. Do we know if he actually consumed glucose during that race?

    9. PMPhil Maffetone1:09:39

       I'm not aware of what, what he consumed, if anything. You know, if properly trained, obviously he was burning a lot of fat. If properly trained, he wouldn't have needed any added nutrition, maybe not even water. You know, water is this interesting thing because it, it has a lot of weight, and if you dehydrate a small amount, the time factor is significant enough where you're, you're running faster. There's this window, and I don't know if it's, if it's 2% dehydration from a weight standpoint or, or what it might be. You have this game of dehydrating but not impairing performance, and as a result, you're getting lighter, and so you're gonna, you're, you're gonna run, be able to run faster. It's all about performance. If you can prevent impairment of performance, that's where you wanna be. But I don't have information. My, my impression with the, the Kenyans, with the East Africans, is that if you look back in history, we've got all these areas of the world that have taken their place on the world stage of great runners, and now it's the Kenyans. The question is, number one, who's gonna be next? 'Cause somebody else will be next. But the real question is, why have all these countries come and gone? And my feeling is that in Kenya, you know, it's a very poor country. These young men and women have a opportunity to become kings in their own country with the money they make on racing, and they go from race to race, and they race all the time, and they burn out. And it's really sad, but I think that's what's happened. And the ones I've met along the way at, you know, at the races and at different events, a lot of them are, are burned out. But they're gonna make as much as they can make. It's a job, and, and that's it. Imagine being able to take one of those athletes and train them, uh, I don't wanna say properly, but train them more effectively. I think you'd have a two-hour marathon broken already in a real race.

    10. PAPeter Attia1:11:58

        When you look at somebody like Kipchoge or guys at this top level, though, there is a longevity to them, which is they're-- You know, I've spoken with really world-class marathoners, and, and many of them will sort of acknowledge they might only have a dozen marathons in them, you know, in their entire career where they're gonna really be able to run at a certain level. And that's, you know, that says, "Look, I might only have 12 marathons over 15 years in me that are truly world-class performances." And that's, that's sort of a different philosophy than the churn-and-burn philosophy. Like look at Meb when he won the Boston Marathon. I mean, he was, what, 39? How old was Kipchoge when he went under two? I mean, he was in his mid-30s, wasn't he?

    11. PMPhil Maffetone1:12:42

        Yeah, and that's what, that's what I-- You know, in the book I wrote this. This is the makeup of a 159 marathoner, someone who's in their 30s, not someone who's, who's in their 20s, not somebody who could run a great 10K. They had, almost had to have run a great 10K when they were younger, but now that they're 35 and they've, they've built this great endurance base, now they've got the best of everything. And so yeah, I th- my feeling is that y- you're, you're in your mid to late 30s and maybe even 40s. Man, I've just-- I've worked with some incredible 40-year-olds who have won some races, and, you know, history has shown these people, and people are, you know, often say, "Well, these are amazing people. They're outliers." I don't think they're outliers. I think it's, I think it's the

12. 1:13:30 – 1:22:18

    How being “overfat” affects health and performance, and ways to decrease excess body fat

    1. PMPhil Maffetone1:13:30

       norm.

    2. PAPeter Attia1:13:31

       So I wanna talk a little bit about a term that you were-- You've used it a couple times today, and I, and I have heard you, you know, or seen you write about it before, which is you don't like the term overweight. You like the term overfat. You, you, you're, you're very clear to talk about it's adipose tissue we should be concerned with, not mass. How do you think about that in the overall context of health? You know, we, we tend to focus on weight. You know, if we get one more layer sophisticated, we look at body mass index, which of course is a highly flawed metric. But where do you see the trends in fatness, and how does that factor into maybe what you said earlier, which is at the level of recreational athletes, we're not really seeing much improvement in performance? D- are those related?

    3. PMPhil Maffetone1:14:22

       I think they're related in terms of the diminishing performance of age group athletes. The problem, clearly the overfat condition can typically add weight to the body, so that's gonna affect, uh, running performance. But more significantly, those people with excess body fat have some downstream problems that can be very serious. We're talking about chronic disease. So along the way to chronic disease, you have blood fat abnormalities, blood sugar abnormalities, blood pressure abnormalities, and these things then lead to chronic diseases. So of course, in that situation, people are not gonna be performing their best. Overfat, excess body fat also impairs the immune system, so people tend to get sick more often. And Paul Larson and I wrote a paper on this regarding COVID early, early on, uh, in the, in the spring, actually. And people with excess body fat also have physical impairment problems more frequently. And so we're talking about the basic simple injury, that plantar fasciitis or-- and also pain patterns, so low back pain on the less serious, all the way to the, the arthritides that are affecting runners. But again, in an injured athlete, you're not gonna perform your best. So these things are gonna, over the years, show diminishing performance in age groupers. And it's, number one, that's really sad to see. Number two, it's even more sad to not be acknowledged. I just don't see people talking about this. I don't understand why.

    4. PAPeter Attia1:16:11

       I think people are starting to acknowledge that it always takes longer. I guess someone like you who's sort of been clinically at the forefront of a lot of these things, it seems like what's taking so long because, you know, you're, you're seeing these things many years before. But for example, uh, you know, sugar consumption is actually declining, but it sometimes takes a while for this decline to necessarily translate into some of the health benefits. And furthermore, these things are so multifaceted, right? I, I think that-- I don't actually know the data on this, so I'm kind of making this up, but I would guess that you can sometimes see an improvement in one parameter and a deterioration in others. For example, activity levels might be declining even while certain elements of nutrition improve, and so the net effect of that could be a reduction or something we didn't talk about, sleep. Quality of sleep could be declining, and that can sort of offset any benefit that we see. But this idea that health and performance are not necessarily the same thing is something I, I see a lot of people struggle with it, right? I see a lot of people who are not very healthy believe that the key to getting healthier is to train for a marathon, or train for an Ironman, or train for this bike race, or train for this event. And it, it usually puts me in a bit of an awkward position because on the one hand, I'm so grateful that they have found something to do to be active and to train for, and I don't want to discourage that. But I also want them to understand that there's nothing especially healthy about doing an Ironman, and that one doesn't need to do that to be healthy. So do you have a message for folks around that?

    5. PMPhil Maffetone1:17:58

       Well, I have a lot of messages for them around that, but the main one is that they don't have to do it, just like you said. And in fact, all they have to do is start walking around the block, and the benefits, the fat-burning benefits that they'll get from that are, are huge. But also that the food is more important, and so they need to look at the big picture. And of course, they need to look at stress also, but the food is such a, such a, a key factor in all of this. And going back to the, the question you asked me, what is MAF, maximum aerobic function? How can we maximize our aerobic system? Well, two of the components of lifestyle are food and exercise. And sure, stress, stress is a very important factor. And yeah, you can't smoke cigarettes and drink too much alcohol. But food and, and exercise are keys, and it's really, really simple. Just don't eat junk food, and take it easy out there.

    6. PAPeter Attia1:19:00

       Well, Phil, on that note, I think we've given folks a lot to think about today, and I want to, uh, I want to thank you for your time. You're gonna be ready for dinner soon, which it sounds like you skip anyway, right?

    7. PMPhil Maffetone1:19:09

       [laughs] Yeah. I'm, I'm, I'm, I'm here when they will be starting to eat dinner soon, and I'll be watching-

    8. PAPeter Attia1:19:17

       [laughs]

    9. PMPhil Maffetone1:19:18

       ... which is okay because I'm not hungry. But thank you, Peter. I enjoy your work. I have for quite some time, and, um, thanks for having me on. It's been great.

    10. PAPeter Attia1:19:28

        Thank you, Phil. Thank you for listening to this week's episode of The Drive. If you're interested in diving deeper into any topics we discuss, we've created a membership program that allows us to bring you more in-depth, exclusive content without relying on paid ads. It's our goal to ensure members get back much more than the price of the subscription. Now to that end, membership benefits include a bunch of things. One, totally kickass comprehensive podcast show notes that detail every topic, paper, person, thing we discuss on each episode. The word on the street is nobody's show notes rival these. Monthly AMA episodes or ask me anything episodes, hearing these episodes completely. Access to our private podcast feed that allows you to hear everything without having to listen to spiels like this. The Qualies, which are a super short podcast that we release every Tuesday through Friday, highlighting the best questions, topics, and tactics discussed on previous episodes of The Drive. This is a great way to catch up on previous episodes without having to go back and necessarily listen to every one. Steep discounts on products that I believe in, but for which I'm not getting paid to endorse. And a whole bunch of other benefits that we continue to trickle in as time goes on. If you want to learn more and access these member only benefits, you can head over to peterattiamd.com/subscribe. You can find me on Twitter, Instagram, and Facebook, all with the ID PeterAttiaMD. You can also leave us a review on Apple Podcasts or whatever podcast player you listen on. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take conflicts of interest very seriously. For all of my disclosures and the companies I invest in or advise, please visit peterattiamd.com/about, where I keep an up-to-date and active list of such companies. [outro music]

Episode duration: 1:22:19